The Fetal Outcome and Fetal Wastage Pattern among Different Types of Obstetric Fistula at the National Obstetric Fistula Centre, Abakaliki, Nigeria

BACKGROUND: Obstetric Fistula is a major public health problem in developing world. It is associated with a high fetal wastage rate. The objective of this study was to evaluate different types of obstetric fistula and their fetal wastage rate. METHOD: A retrospective population study was done at the National Obstetric Fistula Centre, Abakaliki between 1 st January-31 st December, 2016. The calculated minimum sample size was 3, however, the total number of 203 patients were studied. The case notes of all the women who had obstetric fistula repairs over the period were analyzed. RESULTS: The mean age from this study was 38 ± 12.1 years. The fetal wastage rate from this study was 82.76% while the live birth was 17.24%. Seventy percent of the stillbirth were delivered via SVD, while 11% of stillbirth


Introduction
Obstetric Fistula is a form of genital fistula resulting from the process of delivery. It is an abnormal communication between the female genital tract and the lower urinary tract forming the urogenital fistula with consequent leakage of urine through the vagina and/or the lower gastro-intestinal tract forming the faecal genital fistula which allows leakage of faeces through the vagina. The commonest of the fistulas is the vesico-vaginal fistula (VVF) [1].
Obstetric fistula is a public health issue in the developing world. It is a major public health concern in Nigeria. It is a disease with tremendous socio-economic and health implications and consequences [2]. It tells the untold story of high rate of maternal mortality in developing countries. Generally, the obstetric fistula patient is often poor, uneducated, unhappy and abandoned. The disease takes away their dignity and is often associated with great psychological burden. Other associated problems may include infertility, menstrual irregularities, vaginal stenosis dyspareunia, apareunia, difficulty in walking, begging and cheap prostitution [1]. Generally, victims often end up as destitute if the incontinence is not relieved. They are socially, mentally, emotionally and sometimes physically challenged [1].
Obstetric fistula is associated with a high fetal wastage rate, leaving victims in a profound state of despair from childlessness, incontinence and abandonment.
Obstetric fistula practice manual in Nigeria reported a fetal wastage rate of 96% [1].
This childlessness often arose from fetal distress and consequent stillbirth resulting from prolonged obstructed labour, intrapartum neglect and different levels of delays in labour.
The problem with prolonged obstructed labour is that it causes squeeze between the fetal bone and maternal pelvic bone anteriorly and the sacrum posteriorly leading to ischaemia which subsequently leads to necrosis and sloughing off of the tissue thereby causing fistula. The halt in labour progress, the long duration of labour with increase squeeze of the fetal skull results in fetal hypoxia/anoxia and consequent fetal distress which results to stillbirth. A cross-sectional retrospective study done in Kassala hospital, Sudan showed perinatal mortality of 35.7% [3]. A retrospective case review study done at Kitovu hospital in Uganda showed stillbirth of 69% and early neonatal death of 12%.
A hospital based cross-sectional study done at Jimma University Teaching Hospital in Ethiopia showed stillbirth rate of 85.7%.
Despite all these findings, few if any study have described the fetal wastage pattern for different types of obstetric fistula. Open Journal of Obstetrics and Gynecology The general aim and objective of this study is to evaluate the fetal wastage pattern among different types of obstetric fistula at the National Obstetric Fistula Centre, Abakaliki. The specific objective will be to evaluate the overall fetal wastage pattern for obstetric fistula during the study period and to evaluate specific fetal wastage pattern for different types of obstetric fistulae.

Materials and Method
A one year retrospective study was conducted at the National Obstetric Fistula Calculated minimum sample size = 3.22. A 10% attrition rate was allowed giving a total of 5 patients for the minimum sample size. However, the case notes of 203 patients were reviewed during this study period to give a better representation.
Sampling Technique: Population study was done using the case notes of all the patients that were treated in the hospital for the year 2016.
Data collection: The data was collected and analyzed using SPSS version 22.

Ethical Consideration
Ethical approval was obtained from the ethical committee of the National Obstetric Fistula Centre, located in Abakaliki, for the study. The study adhered to the tenets of Helsinki declaration.

Results
The mean age from this study is 38 ± 12.1 years. Majority of the patients are in the reproductive age group (78.8%), the highest age range is between 30 -39 years which is 39.4%, the least age range is 70 -79 years which is 2.9%. Majority of the patients are in a monogamous marriage setting (56.2%). Most of the pa-Open Journal of Obstetrics and Gynecology tients did not have any formal education (24.1%), while majority had senior secondary education (32.5%). Majority of the patients are Ibo (73.4%), followed by Urhobo & Ibibo (5.4%) respectively. Majority of the patients are farmers (35%), which is followed by self employed (32.5%) ( Table 1).  The table below showed types of obstetric fistula and the fetal outcome. From the table, the incidence of intracervical fistula was highest (17.2%), followed by circumferential defect 14.8%. The incidence of RVF was 9.4%. The least was urethral loss 1%. There was high fetal wastage (82.76%) amongst the obstetric fistula patients. The fetal wastage was highest with patients with large extensive fistula, Urethral loss and multiple fistula which were 100% respectively. There was only 15% fetal wastage rate among women with rectovaginal fistula ( Table 2).

Discussion
The mean age from this study was 38 years. This age falls within the reproductive age group. This falls within the age ranges of related studies done in Abakaliki [5] and Ethiopia [6]. However, it is different from the mean age of 16 years recorded in the North-Central part of Nigeria [7].
The fetal wastage from is study was 82.76% while the livebirth was 17.24%. This is similar to the work done in Ethiopia [6] and Uganda [8]. It is also similar to the documentation in the Obstetric Fistula Manual Doctor's version in Nigeria. However, it is different from the findings in Sudan [3] which was 35.7%. Seventy percent of the stillbirth were delivered via Spontaneous vertex delivery (SVD), while 11% of the stillbirth were delivered through Emergency Caesarean Section (EMCS). This is because most patients with prolonged obstructed labour present with intrauterine fetal death (IUFD), hence, the preferred choice of SVD.
Twelve different types of fistula were identified in this study using anatomical classifications by Lawson. This is similar to the findings in the studies done at Abakaliki, Kano, and Sokoto in Nigeria. It is also similar to studies done in Sudan and Ethiopia. Large extensive fistula, urethral loss and multiple fistula had the highest fetal wastage of 100% respectively. This could suggest that the magnitude of tissue loss and organ damage connotes severity and adverse fetal outcome. The fetal wastage in patients with mid-vaginal fistula was 95.7%. This was followed by Juxtaurethral fistula 94.4%, Juxtacervical fistula 88.5%, Intracervical fistula 85.8%, Ureteric fistula 85.7%, Vesicouterine 84.2%, Vault fistula 62.5%. Rectovaginal fistula had the least fetal wastage of 15.8% and the highest livebirth of 84.2%. This could be due to reduced impact on the fetus in RVF because of the presence of more maternal soft tissues and reduced maternal bony impact [5].

Conclusion
The findings showed a high fetal wastage rate amongst women with obstetric fistula. There is high fetal wastage across different types of obstetric fistula. Rectovaginal fistula had the best outcome in terms of livebirths.