On June 3rd, 2010, I posted a guest blog post from Dr. Fatouma Mabeye of WAHA International on a recent meeting in Benin of midwives from West and Central Africa. Dr. Mabeye explained that the goal of the meeting was to explore the role of midwives in preventing and treating fistula—and to discuss the use of catheters to treat new fistula cases. Later that day, I asked Dr. Joseph K. Ruminjo, Maternal Health Task Force Editorial Committee member, obstetrician-gynecologist, and the clinical director for the Fistula Care project, to share his thoughts on Dr. Mabeye’s post. Dr. Ruminjo wrote a response and raised several questions. In this post, Dr. Mabeye responds to Dr. Ruminjo’s very important questions.
Written by Dr. Fatouma Mabeye
Thank you Dr. Ruminjo for your comments!
We strongly agree with you that there are several interventions that should go hand-in-hand to help prevent new fistula cases from occurring, including family planning, complete antenatal screening, skilled attendance at delivery and access to comprehensive emergency obstetric care.
However, in terms of urethral catheterisation for women, we like to distinguish between i) prevention of obstetric fistula and ii) (early) treatment of obstetric fistula.
In terms of preventing a fistula from occurring in the first place, the use of a catheter during and after prolonged labour can help by decompressing the bladder and reducing distension of the bladder wall. This allows the bladder wall, which was subject to devascularisation and subsequent ischemia, to repair, thus preventing the onset of fistula in some cases.
However, a catheter can also be used as a first step in a treatment plan for new fistula cases. Its use may reduce the diameter of the fistula or close small fistulas completely.
Concerning your specific questions –
Dr. Ruminjo : What is the process for selecting appropriate cases or those that are most likely to succeed?
If the patient is in the presence of a trained surgeon, then cases can be selected with the highest chances of success after a detailed clinical and physical examination. For example, the cases that are most likely to succeed are smaller fistulas where there is a fresh, single, and relatively small communication between the vagina and the bladder. Complicated cases, including larger or multiple communications are less likely to be effective.
Dr. Ruminjo : What is the actual percentage of that selection that will then go on to heal spontaneously?
In the cases treated and documented by Dr. Kees Wakdjik in Kano and Katsina 2031 patients (under 75 days post partum) were selected and treated by indwelling bladder catheter immediately upon arrival, of them 1,579 (78%) were cured completely by catheter, all without antibiotics.
However, in the vast majority of settings, the patient will not be assessed by a trained fistula surgeon within 75 days post-partum, but by a midwife. As midwives may not be able to make the same well-defined selection of cases, it is suggested that they use a more simple decision tree for selecting cases. Although this will result in more women receiving the catheterisation with lower chances of success, it is estimated that the cure rate will still reach at least 25%. Even if it does not completely cure the fistula, it may help to reduce its size. For patients who are not cured after this intervention, referral for surgical treatment can then be undertaken. Having patients in follow up during their catheterisation will help identify women for this referral.
Dr. Ruminjo : What does all of this translate to in terms of cost-effectiveness and safety? For instance, you might need to have the catheter in-dwelling for many weeks; in most but not all facilities, this translates into the woman being an in-patient for all those weeks.
Once the catheter is inserted, it needs to remain in place for four to six weeks. However, the vast majority of women will not need to remain as inpatients in a health facility for all of this time, because the catheter can safely be used in the home environment under certain conditions and the catheterisation can be followed up on an outpatient basis. This means that the intervention is also accessible for women who have delivered at home. The important thing is for the woman to have access to a midwife in order to fit the catheter, and to ensure that it is collecting urine, and at least every 15 days thereafter. A midwife would also need to be called in the event of any problems such as if urine fails to collect in the catheter and it needs to be removed.
Ideally the woman should drink 6 litres of clean water per day. The catheter needs to be regularly emptied, and the woman should be given a high protein diet for the period of the catheterisation eg/ a diet that includes pulses, beans, chicken, meat, eggs or fish. Where it is impossible for these conditions to be met, women should remain as an inpatient for the 1 month duration.
More generally in terms of safety, it is certainly the case that urethral catheterization is a less risky procedure than undergoing fistula surgery.
In terms of cost-effectiveness, the calculations are fairly apparent. A catheter costs around 1 USD versus the approximate 300 USD of a surgical intervention for obstetric fistula. Even the additional cost of the disinfectant material and gloves for the midwives bring the total cost of the intervention to a maximum of 5 USD. The recovery time spent in hospital with a catheter (where this is deemed necessary) will not be more expensive per day than the costs associated with keeping a recovering surgery patient in hospital. While a woman with a catheter may have to remain in hospital for a few weeks if her home conditions do not permit her to return early, the additional cost per inpatient per night will still be far from reaching the total of 300 USD for a surgery.
Let us also consider the opportunity costs that will be saved: For example, women for whom the catheterisation technique is effective will be able to work after the catheter is removed, to manage their household, and to participate in social activities. Indeed, it is difficult to put a cost value on avoiding the high risk of psychosocial problems that often follow the onset and typically long duration of obstetric fistula.
However, the greatest argument in favour of the catheter intervention is that for many women, this will be their only chance to avoid the misery of living with obstetric fistula. After all, the vast majority of women who will develop a new fistula case this year have a far higher probability of being in contact with a midwife than they have of ever seeing a fistula surgeon.
Dr. Ruminjo : With regard to training midwives or any other health personnel to do the actual catheterization (rather than the case selection) there is no great mystery to the procedure; indeed, most midwives will already know how to do a safe, clean, urethral catheterization for women from their midwifery training.
As you say, most midwives will have already been trained to do a safe, clean, urethral catheterization for women.
Nevertheless, the 1st International Conference of Midwives from Central and West Africa held in Benin this year did highlight several important concerns expressed by the Presidents of the National Midwife Associations:
1. Many midwives have never seen a case of obstetric fistula and are not aware of the indications of fistula
2. Many midwives completed their initial training many years ago, and have not actually regularly practiced urethral catheterisation since that time
3. Many midwives are competent at catheterisation but do not have access to the necessary materials including gloves or disinfectants in the settings where they work
4. Many midwives expressed the need for additional training or the development of medical protocols to help them to recognise when catheterisation for fistula prevention and treatment is appropriate. This should cover; how to minimise the risk of infection when using a catheter; what advice to give to the patient regarding how to manage the catheter, especially within the home, including advice on diet and hygiene practices; indications for early removal of the catheter; assessment of the success of the catheterisation in repairing the fistula; and indications for referral for further fistula care if catheterisation is unsuccessful.
Dr. Ruminjo: Foley’s catheter was mentioned in today’s blog post, but the catheter need not specifically be Foley’s.
Yes, that’s a good point! In Dr Kees Waaldijk’s project, Foley catheters have been used, but the important thing is that the catheter should have a balloon to keep it in place so that the patient is able to walk.
Thank you for theinsightful comments and questions! It is with thoughtful and helpful debate that we can all move forward together to help prevent and treat fistula more effectively!