Etiology and factors associated with urogenital stula among ...

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Etiology and factors associated with urogenital�stula among women who have undergoneCesarean section in the Democratic Republic ofCongoRaha Maroyi  ( [email protected] )

Université Evangélique en AfriqueMadeline Moureau 

University of Wisconsin–MadisonHeidi Brown 

University of Wisconsin–MadisonRane Ajay 

James Cook UniversityGloire Byabene 

Panzi General Referral HospitalDenis Mukwege 

Université Evangélique en Afrique

Research Article

Keywords: female, obstetric �stula, Cesarean section, obstructed labor, fetal demise, Democratic Republicof Congo

Posted Date: July 25th, 2022

DOI: https://doi.org/10.21203/rs.3.rs-1871568/v1

License: This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full License

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Abstract

BackgroundThe prevalence and impact of �stulas is more common in developing countries with limited access toemergency obstetric care. As a result of �stulas, women in these settings often experience adversepsychosocial factors. The purpose of this study was to describe characteristics of Democratic Republicof Congo (DRC) women who developed urogenital �stula following Cesarean sections (CS) and todetermine the characteristics associated with �stula related to obstructed labor or CS.

MethodsWe abstracted data from all patients with urogenital �stula following CS who received care during a DRCoutreach surgical campaign. Urogenital �stula etiology was designated as related to (1) prolongedobstructed labor; or (2) a complication of CS. Descriptive analyses characterized patients with �stularelated to obstructed labor versus CS. Logistic regression identi�ed factors associated with �stulaetiology.

ResultsAmong 125 patients, urogenital �stula etiology was attributed to obstructed labor in 77 (62%) andcomplications following CS in 48 (38%). Women with a �stula attributed to obstructed labor developedthe �stula at a younger age (p = .04) and had a lower parity (p = .02). Attempted delivery prior to hospitalarrival was associated with an increased risk of obstetric �stula (p < .01).

ConclusionCS are commonly performed on women who arrive at the hospital following prolonged obstructed laborand fetal demise, and account for almost 40% of urogenital �stula. Obstetric providers should assessmaternal status upon arrival to prevent unnecessary CS and identify women at risk of developing a�stula.

IntroductionAn obstetric �stula is de�ned as an opening between the genital tract and bladder or rectum that resultsin chronic urinary or fecal leakage [1, 2]. Prolonged obstructed labor is the leading cause of obstetric�stulas globally and is more common in settings with limited access to emergency obstetric care [3]. Withlimited healthcare resources to repair obstetric �stula, women in these settings often experience chronicleakage leading to negative societal impacts including divorce, loss of income, and social isolation [1, 4].As a result of the prevalence and impact of obstetric �stula on women in developing countries, the United

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Nations has called for the end of obstetric �stulas by 2030 as part of the Sustainable Development Goals[5].

In the absence of skilled medical care, prolonged obstructed labor can continue for days, resulting in fetaldeath and ischemic necrosis of the genital tract that can lead to the development of an obstetric �stula[6]. The co-occurrence of obstetric �stula and fetal death has previously been described as a doubleburden of tragedy [7]. When women with an obstetric �stula seek care, they often present with a history ofCesarean section (CS) at the time they developed the �stula [8]. Recently, studies have found that theprevalence of iatrogenic �stula associated with CS is increasing as CS rates increase; this suggests thatwhen women present to a tertiary care facility following prolonged obstructed labor, the CS itself mayincrease morbidity and create an additional burden [8, 9].

We sought to describe the characteristics of Democratic Republic of Congo (DRC) women who developedurogenital �stula following CS to determine characteristics associated with two different �stulaetiologies: (1) obstructed labor; and (2) CS following obstructed labor.

MethodsThis study was approved by the DRC National Health Ethics Committee (UCB/CIE/NC/10/2013). In 2011,a surgical outreach program was developed by Panzi General Reference Hospital in the South Kivuprovince [10]. The program was initiated to provide specialized �stula care to women in remote,underserved areas who are not able to travel to Panzi Hospital for treatment. Each year, approximately700 women receive surgical �stula repair through the surgical outreach program.

We conducted a cross-sectional study on patients who developed urogenital �stula following CS andreceived care from the surgical outreach program in 2016. Patients were provided informed consent, andthose who consented to participate in the study were interviewed regarding their medical history. Datacollected during the interview included (1) patient demographics (age, profession, education level, andmarital status); (2) obstetric history (parity, characteristics of labor); (3) characteristics of �stula; and (4)medical conditions. The type of �stula was con�rmed during pre and postoperative clinical exams, and atthe time of surgical �stula repair, urogenital �stula etiology was designated as either related to (1)prolonged obstructed labor; or (2) surgical complication of CS.

Descriptive analyses characterized patients with urogenital �stula related to obstructed labor versus CS.Univariate and multivariate logistic regression identi�ed factors associated with �stula etiology. Variableswere included in the logistic regression models based upon biological plausibility: age, parity, days inlabor, whether labor started at the hospital, and whether delivery was attempted before hospital arrival. Ap-value of less than .05 was considered statistically signi�cant. Analyses were performed using SPSS26.0.

Results

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Among 125 patients who consented to participate, the median age was 30 years, with 76% being farmers,66% being married, and 46% having never received formal education (Table 1). The etiology of theurogenital �stula was attributed to obstructed labor in 77 (62%) and to complications of CS in 48 (38%).Women whose �stula was attributed to complications of CS were more likely to be single, while womenwhose �stula was related to obstructed labor were more likely to be married or widowed. There were noother signi�cant demographic differences between the two groups. Overall, 41.6% of women reported aseparation or divorce-related to their CS, fetal demise, or �stula (45.8% among women with �stula due toCS and 39.0% with �stula due to CS, p = .448).

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Table 1Sample Description Strati�ed by Etiology of Fistula

Characteristic Totalsample

(N = 125)

Etiology of Fistula P-Value

Cesarean Section (N = 48)

Obstructed Labor (N = 77)

Age in years (median,IQR)

30 (24.5–42.5)

32 (26.25-45) 30 (24-40.5) .209

Education level

None

Some primary

Completed primary

Some secondary

Completed secondary orabove

58 (46.4)

44 (35.2)

5 (4.0)

15 (12.0)

3 (2.4)

21 (43.8)

16 (33.3)

2 (4.2)

9 (18.8)

0 (0)

37 (48.1)

28 (36.4)

3 (3.9)

6 (7.8)

3 (3.9)

.540

Profession

Farmer

Housekeeper

Teacher

Merchant

Other

95 (76.0)

19 (15.2)

1 (0.8)

5 (4.0)

5 (4.0)

34 (70.8)

8 (16.7)

0 (0)

4 (8.3)

2 (4.2)

61 (79.2)

11 (14.3)

1 (1.3)

1 (1.3)

3 (3.9)

.323

Marital status

Married

Single

Divorced/separated

Widowed

82 (65.6)

5 (4.0)

29 (23.2)

9 (7.2)

29 (60.4)

5 (10.4)

12 (25.0)

2 (4.2)

53 (68.8)

0 (0)

17 (22.1)

7 (9.1)

.024

IQR = inter-quartile range

Table 2 describes �stula characteristics strati�ed by �stula etiology. The median age at presentation was30 years (range 16–80) and the median age at �stula development was 24 years (range 11–51). Morethan half of the participants had a �stula for 6 years or more prior to undergoing surgical correction.

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Table 2Characteristics Related to Urogenital Fistula Strati�ed by Etiology of Fistula

Characteristic Totalsample

(N = 125)

Etiology of Fistula P-Value

CesareanSection (N = 48)

ObstructedLabor (N = 77)

Age when �stula developed (median, IQR) 24 (18-30.5)

26 (19.25–36.5)

23 (18–30) .043

Years with �stula (median, IQR) 6 (2–15)

4.5 (1-15.75) 6 (2-13.5) .614

Years with �stula

0–5

6–15

15+

61(48.8)

35(28.0)

29(23.2)

26 (54.2)

10 (20.8)

12 (25.0)

35 (45.5)

25 (32.5)

17 (22.1)

.368

Parity at �stula (median, IQR) 3 (1.5-5)

4 (2–5) 2 (1-4.5) .020

Days in labor (median, IQR) 2 (1–3) 2 (1–3) 2 (1–3) .318

Where labor started

Home

Health center

Hospital

55(44.0)

45(36.0)

25(20.0)

13 (27.1)

19 (39.6)

16 (33.3)

42 (54.5)

26 (33.8)

9 (11.7)

.002

Individual that helped in labor

Family member

Medical worker

55(44.0)

70(56.0)

13 (27.1)

35 (72.9)

42 (54.5)

35 (45.5)

.003

Delivery attempted before arriving athospital

100(80.0)

32 (66.7) 68 (88.3) .003

Type of Cesarean Section

Fetal extraction

Cesarean Section (fetus alive)

119(95.2)

6 (4.8)

42 (87.5)

6 (12.5)

77 (100.0)

0 (0)

.001

Number of days post CS that urineleakage occurred (median, IQR)

2 (1–4) 2 (1–7) 2 (1–3) .055

IQR = inter-quartile range; CS = Cesarean section

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Characteristic Totalsample

(N = 125)

Etiology of Fistula P-Value

CesareanSection (N = 48)

ObstructedLabor (N = 77)

Number of days post CS that urineleakage occurred – grouped

1–2

3–6

7+

74(59.2)

27(21.6)

24(19.2)

25 (52.1)

7 (14.6)

16 (33.3)

49 (63.6)

20 (26.0)

8 (10.4)

.005

Fistula type and location

Ureterovaginal

Left

Right

Vesicouterine (intracervical)

Vesicovaginal

Mid or low vagina

Apical (juxtacervical)

Complex

10(8.0)

3 (2.4)

35(28.0)

38(30.4)

39(31.2)

4 (3.2)

10 (20.8)

3 (6.3)

35 (72.9)

0 (0)

0 (0)

4 (8.3)

0 (0)

0 (0)

0 (0)

38 (49.4)

39 (50.6)

0 (0)

< .001

Surgical route

Abdominal

Vaginal

49(39.2)

76(60.8)

46 (95.8)

2 (4.2)

3 (3.9)

74 (96.1)

< .001

IQR = inter-quartile range; CS = Cesarean section

Women with a �stula attributed to obstructed labor developed the �stula at a signi�cantly younger agethan women with a �stula related to CS (23 versus 26 years, p = .04) and had a lower parity (median 2versus 4, p = .02). While both groups were in labor for a similar duration, women whose �stula wasattributable to obstructed labor were more likely to have started labor at home (p = .002) and attempteddelivery prior to arrival at the hospital (p = .003). Women whose �stula was related to the CS were morelikely to develop urine leakage delayed from delivery (p = .005). The vast majority of �stulas related toobstructed labor were repaired vaginally, while �stulas related to CS were repaired abdominally (p < .001).

Factors associated with obstetric �stulas are displayed in Table 3. On univariate logistic regressionanalysis, age (p = 0.02) and parity (p = 0.043) were associated with decreased risk of obstetric �stula;attempted delivery prior to hospital arrival (p = .005) was associated with increased risk. Only attempteddelivery prior to hospital arrival was signi�cant in the multivariate logistic regression model (p = .003).

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Table 3Factors associated with obstetric �stula

Variable Odds Ratio

(95% CI)

Adjusted Odds Ratio (95% CI)

Age when �stula developed .953 (.915-.992) .974 (.928-1.022)

Parity at �stula .862 (.747-.995) .922 (.778-1.094)

Days in labor 1.169 (.855-1.597) 1.146 (.865-1.518)

Labor started at hospital .778 (.369-1.642) .449 (.187 − 1.080)

Delivery attempted before arriving athospital

3.778 (1.508–9.464)

5.156 (1.773–14.998)

CI = con�dent interval

DiscussionIn this study of 125 patients with a history of urogenital �stula following CS in DRC, over one-third had a�stula attributable to their CS and all of these �stulas required abdominal surgery to repair. Women with a�stula attributable to obstructed labor were more likely to attempt delivery prior to arriving at the hospitaland were more likely to undergo vaginal surgery for repair. Upon multivariate analysis, women whoattempted delivery prior to arriving at the hospital were at an increased risk of developing an obstetric�stula.

Previous studies conducted in Sub-Saharan Africa have found that obstetric �stulas are more common inuneducated women [11, 12]. In 2013, Hawkins et al reported that 45% of women in Kenya who developedan obstetric �stula had no prior education, similar to our �ndings in this study that 46% of women with anobstetric �stula had no prior education [11]. With more than half of the participants waiting six years ormore to seek treatment for their obstetric �stula, future analyses should explore women’s knowledge ofobstetric �stulas and their treatment options in the DRC.

Of signi�cance, 42% of women in our study reported experiencing a separation or divorce as aconsequence of their urogenital �stula, obstructed labor, or CS. Khisa et al previously analyzed theexperiences of women with obstetric �stula in Kenya, and found similar adverse societal impacts,speci�cally noting the high prevalence of divorce, stigma, and psychological trauma [13]. Unfortunately,even after �stula repair, women continue to experience social isolation from their families andcommunities and are referred to as “spoiled and not accepted”, indicating that even if their �stula isrepaired residual effects may persist [13, 14].

While the association between younger age at marriage and �rst birth and development of obstetric�stula has been documented in other sub-Saharan African countries [15–17], the median age at

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symptom development in our cohort was relatively old (24 years). It is possible that our unique sample ofpatients who participated in a surgical outreach campaign accounts for this difference.

The only variable that remained signi�cantly associated with developing an obstetric �stula in themultivariate logistic regression model was attempted delivery prior to arriving at the hospital. Althoughwomen in this study were from remote, underserved areas, there were still accessible hospitals withskilled physicians and nurses and adequate capacity, that women could have sought care at when they�rst began labor. This supports a previous literature review concluding that obstetric �stulas can bereduced in developing countries if women seek timely care in labor [18]. However, it is likely that thispopulation of patients still faces signi�cant barriers to hospital birth, and future research should seek tounderstand how these barriers may be overcome.

Of the 125 patients in this study that experienced prolonged obstructed labor, 119 (95%) resulted in fetaldemise. The �stula etiology, among women who had a stillbirth, was later attributed to CS in 42 (35%)and obstructed labor in 77 (65%). This calls into question why healthcare providers are removing stillbornbabies via CS as opposed to fetal extraction. Similar �ndings have been reported by Ngongo et al in aretrospective review of nine sub-Saharan African countries (not including the DRC) [8]. Ngongo et alfound that in women delivering a stillborn baby, CS increased while assisted vaginal delivery decreased[8]. Instead of potentially inducing a triple burden of tragedy on women, including fetal demise, CS, andurogenital �stula, fetal extraction should be considered to limit maternal morbidity and mortality.

This study contributes meaningful information that may help us progress towards the ambitious goal ofending obstetric �stulas in developing countries by 2030. Determining the etiology and factorsassociated with urogenital �stula is crucial in achieving the Sustainable Development Goals, identi�ed asa priority due to the high prevalence in developing countries as a result of inequities [5]. With limitedresearch examining the etiology and factors associated with urogenital �stula in women from the DRC,this study provides meaningful insight on strategies to combat the development of urogenital �stula inlow-resource settings. Although the cross-sectional methodology used for this analysis limits theconclusions we are able to make, this study provides invaluable insights into the etiology and factorsassociated with urogenital �stula that will aid in combatting this preventable medical condition in theDRC. Future studies should explore barriers experienced by birthing people from the DRC and how thoseare similar to or different from barriers to care-seeking faced by those from other sub-Saharan Africancountries. Understanding why the majority attempt vaginal delivery before arriving at the hospital iscritically important to implementing interventions to prevent �stula development.

ConclusionIn conclusion, in the DRC, CS are commonly performed on women who arrive at the hospital followingprolonged obstructed labor and fetal demise. These women are already at high risk for urogenital �stula,and CS increases the risk of complex �stula requiring an abdominal approach to repair. We propose thatobstetric providers conduct an assessment on women who present with fetal demise to determine

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whether patients are at risk of developing an obstetric �stula. Obstetric providers can then determine if avaginal delivery or CS is more appropriate for the patient in an effort to reduce maternal morbidity.Training obstetric providers and staff to assess maternal status upon arrival may prevent unnecessaryCS and decrease women’s risk of developing a urogenital �stula.

AbbreviationsDRCDemocratic Republic of CongoCSCesarean section

DeclarationsEthics approval and consent to participate

This study was approved by the Democratic Republic of Congo National Health Ethics Committee(UCB/CIE/NC/10/2013). All study procedures adhered with institutional ethical standards and theDeclaration of Helsinki and its later amendments. Upon enrollment in this study, informed consent wasobtained from participants.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding authoron reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Author contributions

RM contributed to the study design, planning, data collection, data analysis, and manuscript writing. MMand HB contributed to the data analysis and manuscript writing. RA contributed to study design andplanning. GB contributed to study planning. DM contributed to the study design, planning and datacollection.

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Acknowledgements

The authors thank the patients and staff at Panzi Hospital for their participation in this study.

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