Most discussion, research and interventions related to genital fistula have focused on obstetric fistula, an abnormal opening in the upper or lower female genital tract—caused by inadequate medical intervention during prolonged or obstructed labor—which leads to uncontrollable, constant leakage of urine and/or feces. Significantly less attention, however, has been paid to iatrogenic fistula, a similar condition that results from surgical error, often during cesarean section. Given that a growing number of genital fistula cases in low-income countries derive from iatrogenic causes, the fistula dialogue must expand to incorporate its many root causes. To this end, the Fistula Care Plus project at EngenderHealth recently hosted a webinar to review available data, recognize data gaps, identify definition challenges, share successes and discuss next steps in addressing iatrogenic fistula.
An emerging quality of care issue
While more women are delivering in health facilities—according to the World Health Organization, about three-quarters of all childbirths worldwide are now attended by skilled health personnel—maternal and newborn health outcomes are not necessarily improving. As Vandana Tripathi, panelist and Fistula Care Plus Deputy Director, emphasized, “Women are doing what we’ve asked them to do—going to facilities to deliver—yet the care they receive there may not be adequate. Iatrogenic fistula is a really powerful sentinel, an alarm bell, about quality of care.” According to a 2014 publication by Raassen et al., of nearly 6,000 fistula repair cases in 11 countries, approximately 13% were caused by surgical errors performed by all types of clinicians (not just lower-level providers). Other data convey findings of similar or greater magnitude: A recent review of over 2,500 fistula cases at Hamlin Hospital in Ethiopia found that nearly a quarter of women had high bladder fistula, “which predominantly occurs following surgery, specifically cesarean section or emergency hysterectomy.”
To gain a better understanding of the current landscape of iatrogenic fistula, Fistula Care Plus gathered data from 30 project-supported fistula treatment sites in Bangladesh, the Democratic Republic of Congo (DRC) and Niger from October 2014 – March 2016. According to the technical brief, there is wide variation in the prevalence of iatrogenic fistula cases among countries, with the proportion of fistula cases classified as iatrogenic highest in Bangladesh (ranging from 15% to 36% in the six consecutive quarters reviewed) and lowest in Niger, Nigeria and Uganda (10% or fewer classified as iatrogenic).
Fistula Care Plus also conducted an online survey of hospital-based clinicians, primarily obstetrician gynecologists (ob-gyns) and fistula surgeons, to ascertain clinicians’ perceptions of procedures contributing to iatrogenic fistula. According to the survey, cesarean section was considered the most significant cause of iatrogenic fistula, followed by repair of ruptured uterus. Among surveyed clinicians, vaginal gynecological hysterectomy was considered the least important contributor of iatrogenic fistula.
Preventing iatrogenic fistula
As the webinar emphasized, iatrogenic fistula represents a surgical safety system failure. Root causes include gaps in health care worker density, health care worker skill sets and infrastructure. Preventing surgical error is crucial in both high- and low-resource settings. According to Lauri Romanzi, physician and Project Director for the Fistula Care Plus project, although there is low incidence and prevalence of fistula in most high-income countries, most cases are classified as iatrogenic. And cases of iatrogenic fistula are on the rise in low-income countries, which is unacceptable: Women, following instructions to seek care at facilities, should not be subjected to poor quality of care that causes—rather than prevents—health complications.
Romanzi called for changes throughout the ‘surgical ecosystem’ to ensure safe, effective care:
“Whether it is a patient coming for cesarean section or hysterectomy or a patient who arrives with a traumatic fracture or an appendicitis … from reception to post-operative care to discharge from the facility, we need competent administration, accounting, infrastructure, supply chain, utilities, waste management, infection prevention, adequate supplies, adequate pharmaceutical stock and adequate bioengineering.”
Five actions to address iatrogenic fistula
Panelists noted a wide variation in definitions, signs and symptoms used to classify fistula cases as iatrogenic. For example, of the 18 clinicians surveyed by Fistula Care Plus, about a third used the Raassen algorithm, while over half used a different definition or relied on the senior surgeon’s opinion; over 10% were not sure how to classify iatrogenic fistula. The webinar posed persistent questions and complexities such as, “Is fistula caused by female genital mutilation (FGM) or female genital cutting (FGC) traumatic or iatrogenic?” “If a woman experiences prolonged or obstructed labor, and she does eventually make it to the facility to have a cesarean section and develops a fistula, is that obstetric or iatrogenic?”
We must ensure that with the rapid expansion of surgical care in low- and middle-income countries comes high quality care. If rates of iatrogenic fistula continue on the current trajectory, the caseload for fistula will remain steady, even if fistula from prolonged and obstructed labor no longer occurs. Taking swift action will help guard against normalizing iatrogenic fistula. The webinar called for the following five actions to address iatrogenic fistula:
Standardize etiology definitions, signs and symptoms used to classify fistula. This will allow us to analyze trends and make valid comparisons between facilities and settings.
Increase awareness of iatrogenic fistula in the ob-gyn and surgical community to accelerate improvements in surgical workforce training as well as clinical environment.
Effect improvements in surgical/post-operative team training and work environment. This applies to all clinicians, not just lower-level providers.
Improve decision-making regarding surgical obstetrician gynecology procedures. Preventing unnecessary surgeries is crucial to preventing iatrogenic fistula.
Implement routine monitoring and reporting of iatrogenic fistula in settings where surgical ob-gyn care is provided.
Preventing the need for surgery in the first place—by preventing unwanted pregnancy through family planning and preventing unnecessary cesarean sections and hysterectomy surgeries through proper antenatal care and skilled obstetric care—is critical to preventing iatrogenic fistula. When surgery is needed, however, standards, guidelines and accountability mechanisms will help ensure high quality and optimal outcomes for mothers and babies.
Missed the webinar?
Watch a recording and access related resources here.
Photo: “Africa Partnerships Hamlin Fistula 9” © 2009 Department of Foreign Affairs and Trade, used under a Creative Commons Attribution License 2.0