Epidemiological and Clinical Aspects of Obstetric Fistulas Managed in Six Health Structures in the Central African Republic ()
1. Introduction
Obstetric fistulas (OF) are defined as an acquired communication between the vagina and neighboring organs occurring during a prolonged or obstructed delivery (mechanical or dynamic) resulting in a permanent loss of urine and/or feces through the vagina [1]. According to the World Health Organization (WHO), OF affect more than two-million women worldwide, the majority of whom live in sub-Saharan Africa (including CAR) and Southeast Asia and constitute a major public health problem due, among other things, to its social consequences, represented by the exclusion of fistula patients due to permanent loss of urine and/or feces [2]. A study carried out on urogenital fistulas in Bangui (RCA) found that 86% of these are of obstetric origin [3]. The United Nations Population Fund (UNFPA) has financed several campaigns for the treatment of this condition which brought together patients from both urban and rural areas [4]-[6]. We therefore proposed to carry out this study in order to address the epidemiological, anthropological, clinical and therapeutic aspects based on the files of the patients treated with the aim of contributing to reducing the cases of OF in the CAR.
2. Patients and Methods
The study was carried out in six (06) health facilities in the CAR:
The Sino-Central African Friendship University Hospital Center (CHUASC) in Bangui;
The Bambari Regional University Hospital (HRUB);
Three (03) Health District Hospitals (Mbaïki, Sibut, Kaga-Bandoro);
Castors Maternity also in Bangui.
This was a retrospective, descriptive and analytical study covering OF cases treated from January 2009 to January 2018, a period of nine (09) years in the aforementioned health facilities. The study population consists of fistula patients treated and followed at these centers. All patients with vesicovaginal fistulas (VVF) of obstetric origin treated and followed up in the selected sites and having complete files were included. On the other hand, all patients presenting a no-obstetric fistula (iatrogenic, pathological); VVF lost to follow-up and VVF cases with unusable records were not included in our study.
After obtaining the various authorizations (Deanship of the Faculty of Health Sciences of the University of Bangui, different chief doctors of the health facilities concerned), the data was collected using pre-established survey sheets in the files and registers of patients with OF (operating room registers and department registers in which the cases are recorded). The sampling was exhaustive. Anonymity was requested. Data entry and analysis were carried out using Epi Info version 7 software. The statistical test used was Chi2 with a significance threshold of p = 0.05.
3. Results
In total, two hundred and forty-five (245) cases of OF were recorded.
3.1. OF Repair Centers
Most cases (111 or 45.3%) were treated at the Friendship University Hospital Center (Table 1).
Table 1. Distribution of patients according OF repair centers.
OF repair centers |
Numbers (n) |
Percentage (%) |
Friendship University Hospital Center |
111 |
45.3 |
Regional University Hospital of Bambari |
38 |
15.5 |
Sibut District Hospital |
16 |
6.5 |
Kaga-Bandoro District Hospital |
23 |
9.4 |
Mbaïki District Hospital |
40 |
16.4 |
Beavers Urban Health Center |
17 |
6.9 |
Total |
245 |
100.0 |
3.2. Age Group
There were more patients aged 15 - 24 and 25 - 34. The average age was around 31 years old (Table 2).
Table 2. Distribution of cases according to age group.
Age group |
Numbers (n) |
Percentage (%) |
≤14 |
1 |
0.4 |
[15 - 24] |
79 |
32.2 |
[25 - 34] |
79 |
32.2 |
[35 - 44] |
57 |
23.3 |
[45 - 54] |
20 |
8.2 |
≥ 55 |
9 |
3.7 |
Total |
245 |
100.0 |
3.3. Level of Education
The majority of patients (53.9%) were illiterate (Figure 1).
Figure 1. Distribution of patients according to level of education.
3.4. Parity
First-time mothers were the most represented (38%) (Figure 2).
Figure 2. Distribution of patients according to parity.
3.5. Prenatal Fellow-Up
Most patients (73.1%) had made fewer than four contacts during prenatal follow-up (Table 3).
3.6. Duration of Work
The average working time was 3.16 days or approximately 75 hours (Table 4).
Table 3. Distribution of patients according to the number of contacts made during prenatal follow-up.
Number of contacts |
Numbers (n) |
Percentage (%) |
<4 |
179 |
73.1 |
≥4 |
66 |
26.9 |
Total |
245 |
100.0 |
Table 4. Distribution of patients according to approximate duration of labor (in hours).
Hours |
Numbers (n) |
Percentage (%) |
[12 - 23] |
4 |
1.6 |
[24 - 47] |
71 |
29.0 |
[48 - 71] |
56 |
22.9 |
≥72 |
114 |
46.5 |
Total |
245 |
100.0 |
The extremes were 0 days and 6 days, the maximum frequency corresponded to 3 - 4 days in 46.5% of cases.
3.7. Mode of Delivery
Most patients had delivered vaginally (64%) (Figure 3).
Figure 3. Distribution of patients according to the mode of delivery of the causal pregnancy.
3.8. Types of OF
The fistulas were of vesico-vaginal location in 25.3% on a soft vagina in 23.5% (Table 5).
Types V and I dominated in 17.4% and 9.2%, respectively.
3.9. Approaches
In the majority of cases (50.2%), the fistula was treated via the upper route (Table 6).
Table 5. Distribution of patients according to types of OF.
Classification of fistula |
Answers |
Numbers |
Percentage |
Fistula on soft vagina |
164 |
23.5% |
Fistula on sclerotic vagina |
55 |
7.9% |
Fistula associated with perineal tear (1st, 2nd, 3rd degree) |
8 |
1.1% |
Type I: fistula of the vesico-vaginal septum |
64 |
9.2% |
Type II: vesico-cervico-urethral fistula |
6 |
0.9% |
Type IIa: without destruction of the urethra |
6 |
0.9% |
Type IIb: cervico-urethro-vaginal fistula |
2 |
0.3% |
Type IIab: partial cervico-urethral desinertion |
7 |
1.0% |
Type IIc: with destruction of the urethra |
4 |
0.6% |
Type III: trigono-cervico-uterovaginal fistulas |
28 |
4.0% |
Type IV: complex fistulas |
22 |
3,2% |
Type V: high fistulas (retro-trigonal) |
121 |
17.4% |
Vesico-vaginal |
176 |
25.3% |
Vesico-cervico-uterine |
15 |
2.2% |
Vesico-uterine |
11 |
1.6% |
Vaginal ureter |
8 |
1.1% |
Total |
697 |
100.0% |
Table 6. Distribution of patients according to surgical approach.
Surgical approach |
Number (n) |
Percentage (%) |
Low |
93 |
38.0 |
High |
123 |
50.2 |
Mixed |
29 |
11.8 |
Total |
245 |
100.0 |
4. Discussion
4.1. OF Repair Centers
All areas of the CAR were represented: urban and rural. Bangui, an urban area, represents 52.2% (CHU de l’Amitié and Castors Health Center) and rural areas, 47.8%. This rate shows that the majority of fistulas are repaired in Bangui, where medical infrastructure is less poor, security relatively acceptable and qualified personnel available (gynecologists, urologists, anesthesiologists).
4.2. Level Education
Educational level is a direct reflection of occupation and socio-economic level [7]. Indeed, 53.9% of our patients were illiterate and therefore unemployed with low income [8]. This lack of financial means for treatment in the event of a health problem would be the cause of prolonged working hours, thus causing OF. Our results are superimposable to those of Sheilla MY et al. Bangui [9] who found that 70.9% of patients were illiterate and 85.5% carried out household activities.
4.3. Parity
In our series, fistula occurred much more in primiparous women (38%) then in pauciparous women (30%). These results can be superimposed on certain data from the literature. Sanda in Niger also reports a predominance of first-time mothers (67.3%) without children among OF carriers [10] [11]. The same observation was made by Ouattara in Bamako in Mali, including 76.4% of carriers of vesico-vaginal fistulas were primiparous [12].
4.4. Prenatal Follow-Up and Duration of Labor
The majority of patients (73.1%) had made fewer than four contacts during pregnancy compared to 26.9% of patients who had not followed a prenatal consultation. The average duration of work was 3.16 days or approximately 75 hours. The extremes were 0 days and 6 days, the maximum frequency corresponded to 3 - 4 days in 46.5% of cases. This poor performance of prenatal monitoring coupled with the poor quality linked to the absence of qualified personnel would be the cause of prolonged labor and other negative consequences due to lack of last contact during which the prognostic delivery plan of the child is established. In some studies, this average duration is similar, varying between 2.5 and 4 days [13]-[15].
4.5. Mode of Delivery
In relation to the mode of delivery, cesarean section was the most incriminated mode in our series with 64% of cases or 157 patients. The same observation was made following a previous study carried out in Bangui in the Central African Republic in 2005 by Nguembi et al. which reports the occurrence of OF caused by technical errors during cesarean section [16]. During the second conference of fistula surgeons in November 2009 in Yaoundé, the iatrogenic nature of obstetric fistulas was the subject of concern among the speakers [17]. Other authors have made the same observation with respectively 57.72% and 54.03% of cesarean sections [18] [19]. In our study, the high proportion of iatrogenic OF could be explained on the one hand by the insufficiency of the qualified personnel throughout the territory with a high concentration of competent personnel in urban areas [20]. On the other hand, the late arrival of parturients in the reference centers after several days of attempts of deliveries constitutes a significant factor in the genesis of fistulas of obstetric origin. Caesarean section being performed for maternal rescue. In health facilities, unqualified medical personnel could assist with acute deliveries but are sometimes unable to detect an obstetric emergency or obstructed labor that could prompt evacuation to a reference center [18].
5. Conclusion
The study carried out six (06) OF treatment sites in the CAR and allowed us to conclude that OF are common in the country and constitute a real public health problem because of its multiple consequences (social, medical, psychological, economic). OF mainly affected women of childbearing age, uneducated, and primiparous. Vesicovaginal fistula was the frequently encountered type and was manifested by urine loss clinically with a positive methylene blue test. Strong social mobilization coupled with broad awareness (community prevention) as well as the practice of good obstetrics will constitute effective measures to reduce the prevalence of OF.