Transcript Family Planning for Fistula Patients in Democratic

Conflict, Fistula, and Family
Planning
Eastern Democratic Republic of
Congo
Nerys Benfield MD
University of California, San Francisco
Objectives
• Reproductive health in crisis situations.
• Genital fistula - etiology, obstructed labor
injury complex, social impact, and
methods of treatment and prevention.
• Unmet need for family planning in the
fistula population.
Democratic Republic of Congo
12th largest country by geographic area in the world
•Population: 71 million
•Per capita GDP 2nd lowest
in the world - $171
1877-1960: Belgian royal
protectorate then colony
•Infamous for atrocities and
exploitation in extraction of
resources like rubber
1971-97: Zaire
• Mobutu authoritarian regime
Eastern DRC - “Africa’s World War”
1996-Present
• Directly involved DRC,
Rwanda, Burundi, Uganda,
Zimbabwe, Namibia, Angola
• Estimated 5.4 million
conflict-associated deaths
in DRC alone
• More than 3 million
displaced persons
Coghlan B Mortality in the DRC. IRC
History of DRC Conflict
1994: Rwandan genocide
1997: Overthrow of dictatorship of
Mobutu Sese Seko
Alliance of eastern rebel leader
Laurent Kabila with Burundian and
Rwandan armies
1998: Alliance falls apart → lawless
state with multiple armed groups
Land and resource scramble
Failed peace accords 1999 2002 2008
Complex Humanitarian Emergency
•Social disruption
•Armed conflict
•Population displacement
•Collapse of public health infrastructure
•Food shortages
In DRC:
•>150,000 in refugee
camps
•>2 million internally
displaced

70-80% of refugees are
women and children
UNHCR Global Report DRC 2009
Al Gasseer J Midwif Women Health 2004
Reproductive Health in
Complex Humanitarian Emergencies
Fertility rates can increase or decrease
•Replace lost children
•No access to
contraception and
safe abortion
•Malnutrition
•Destruction of
family unit
Waiting for USAID food distribution
•Economic
challenges
McGinn HPN paper 45 2004
Maternal Mortality increases
• Obstetrical
complications
• Hemorrhage, infection
• Obstructed labor, fistula
MMR in Afghanistan 8x MMR
of all neighbors
Maternal + Neonatal →22% of
camp deaths in Pakistan
• Unsafe

abortion
Little available evidence
Burma – 1 in 3 have induced abortion
Camps in SSA – increased complications from abortion
Gender-based Violence increases
• Perpetrators outside the home
• Percentage of women raped during
conflict
• Rwanda 39%
>500,000 women and girls
• Burundi 25%
• East Timor 24%
• Kosovo 26% →
Decreased to 1%
after the conflict
Reproductive Health in DRC
• Healthy life expectancy for women is 39yrs
• Estimated Fertility Rate = 6.7/woman
• Maternal Mortality Rate = 990/100K
– improved from 1837/100K in 2001
• ↑poor pregnancy outcomes with ↑conflict
activity
Sexual Violence in DRC
• Epidemic of Rape
- Used as a “weapon of war” to destabilize and intimidate
communities
- Culture of impunity
• Total number of
women affected is
unknown
– >40,000 reported
rapes by 2004
My Research
Conflict
Sexual Violence
No Healthcare
Large fistula burden
Contraceptive and fertility desires and the
impact of contraception counseling in genital
fistula patients in Eastern DRC
Traumatic birth
experience
Access to Family
Planning
Research Question
• Will the lost years of childbearing and
societal acceptance spur women with
fistula to desire more children or will the
history of serious health sequelae from
reproduction lead patients to want to delay
further pregnancies.
• Are women who would like to defer or limit
future childbearing willing to use
contraception?
• 2008: Needs assessment
– N=78
– Interviews on history, birth
experience, contraceptive
and fertility desires
• 2010: Contraceptive
counseling program and
assessment
– N=61
– Changes in contraceptive
knowledge and use
Security and Safety
Active Conflict Zone
• Secure Housing and
Transportation
– Provided by Congolese
NGO HEAL Africa
• No travel at night without
armed personnel
• No travel to rural areas
without official permission
and appropriate
personnel
• General Awareness is
critical
Our night-time armed guard
Goma
Volcano Nyiragongo
Massive eruption 2002
- destroyed much of the city
- left 120,000 homeless
Unaffected
area of
town
Genital Fistula
• Approximately 3 million women worldwide
are suffering from fistula at this time
• Occurrence worldwide is 1-2/1000
deliveries
• In Africa the incidence of genital fistula is
30,000-130,000 per year.
• Clear indicator of health care disparities
Wall LL. Lancet 2006
History of Fistula
2000BC - EGYPT
“Incontinence of urine in an irksome place."
1000AD - PERSIA
"In cases which women are married too young, and in patients
who have weak bladders, the physician should instruct the
patient in prevention of pregnancy. In these patients the fetus
may cause a tear in the bladder that results in incontinence of
urine. The condition is incurable and remains so until death.”
1840s -
USA
Dr J Marion Sims –
early surgical techniques
Etiology of Fistula
Obstructed labor
The compression of fetal
head against sacrum
and symphysis cuts off
blood supply leading to
pressure necrosis
Largest series of women with
fistula (N=16380)
- 94.4% due to obstructed
labor
Muleta M, Acta Obstet Gynecol 2010
DRC 2008:
71% obstructed labor, 20% trauma, 9% surgery
Etiology of Fistula
Trauma
– Rape and sexual assault
– Direct genital trauma
DRC 2008: 20% caused by sexual assault
DRC 2010: 0%
Iatrogenic/surgical
– Hysterectomy and cesarean section
DRC 2008 - “The soldiers stole me and took me as a
wife. I got pregnant. When I had trouble with my labor
they cut my baby out with a machete in the forest”
Risk Factors for Obstructed Labor
1. Pelvis too small
– Young age at pregnancy
• Large series from Ethiopia and Nigeria >50%
had become pregnant before age of 18
•
DRC 2008: 63% were pregnant before 18
– Malnutrition
2. Fetus too big
– Male fetus – 77% of fistula
Moerman ML Am J Obstet Gynecol 1982
Vangeenderhuysen D. Int J Gyncol Obstet 2001.
Meyer L. Am J Obstet Gynecol 2007
Risk Factors for Obstetric Fistula
• Lack of Access to Obstetrical Care
- Average labor - 2-4 days
DRC 2008: 25% labored 4-7 days
DRC 2010: 60% >5 hours walk from nearest hospital
“Since it was my first, they said it
is normal for this to take a long time.
When they realized it wasn’t going
as planned, they tried to find a car
but couldn’t. So I went on a donkey cart.
The trip took a whole night.”
How does conflict affect direct
fistula risk factors
Fistula causes
Conflict
Obstructed labor
↓ Access to Obstetrical
Care
Trauma
↑ Sexual Violence
Iatrogenic
↓ Surgical capacity and
knowledge
Genital Fistula Complex
• Urological injury
• Gynecological injury
• Gastrointestinal injury
• Musculoskeletal injury
• Neurological injury
• Dermatological injury
• Fetal injury – demise >90%
Genital Fistula Complex - cont’d
• Social injury
Social isolation
Divorce
Worsening poverty
Malnutrition
Depression and suicide
Premature death
Nigeria:
74% were divorced or separated
Ethiopia and Bangladesh:
40% had considered suicide
Goh JT BJOG 2005 112:1328
Browning A Int J Gynecol Obstet Aug 31 2007
DRC 2008:
56% rejected by their community
Genital Fistula
Classification
The Goh Classification is the most
commonly used system.
Site
Type 1: Distal edge of fistula > 3.5 cm from
external urinary meatus
Type 2: Distal edge of fistula 2.5 to 3.5 cm
from external urinary meatus
Type 3: Distal edge of fistula 1.5 to < 2.5 cm
from external urinary meatus
Type 4: Distal edge of fistula < 1.5 cm from
urinary meatus
Size
(a) Size < 1.5 cm
(b) Size 1.5–3 cm
(c) Size > 3 cm
Scarring
(i) No or mild fibrosis around fistula/vagina
and/or vaginal length > 6 cm capacity, normal
capacity
(ii) Moderate or severe fibrosis around
fistula/vagina and/or reduced vaginal length
and/or capacity
(iii) Special consideration, e.g. post-radiation,
circumferential fistula, ureteric involvement,
Fistula Treatment
• Conservative – For recent VVF<1cm
Bladder drainage up to 4 weeks
Spontaneous healing in 12-80%
• Surgical
Surgical closure 2-3 layer
repair
Post-surgical treatment
includes bladder drainage
for 2-3wks, nothing in
vagina for 3 months.
Fistula Treatment
Surgical closure is generally very successful.
Ethiopia: (N=77)
97% of complex fistulas
closed successfully
Nigeria: (N=899)
92% successful closure
Failure associated with
large size, UVJ
involvement, scarring
Roennenburg ML Am J Obstet Gynecol 2006 195:1748
Fistula Treatment
Complicated and large fistulas can require more
complex surgical techniques
• Bulbocavernosus Flap
• Ureteral reimplantation or
ileal conduit
• Neo-urethra from bladder
or labial tissue
• Sub-urethral sling
Eilber, KS J of urology 2003
Browning A. Int J Obstet Gyencol 2006
Challenges after Surgical Repair
• Post-operative incontinence
• Social isolation
– Social reintegration
– Income-generating skills
– Counseling
• Fistula recurrence
– vaginal delivery after repair  11% recurrence
Murray C. BJOG 2002
Carey MP Am J Obstet Gynecol 2002
MacDonald P Int J Obstet Gynecol 2007
Fistula Prevention
• Avoid Pregnancy
Access to Family
Planning
• Safe Delivery
Access to Obstetrical
Care
DRC 2008: 22% fistulacausing pregnancies were
undesired
Improve the status
of women
International Women’s Day at HEAL Africa
Prevention in Conflict Settings
Reproductive Health is often neglected in
complex emergencies
1995 - Minimum Initial Service Package
for Reproductive Health (MISP)
– Set of reproductive health priority actions
meant to save lives in an emergency setting
– Focus on GBV, HIV, and Safe Delivery
– EC and condoms are the only FP methods in
acute phase
Prevention in Conflict Settings
Challenges to MISP implementation
• Views of governments and aid agencies
“We are a catholic agency, conservative. … We don’t need to
have reproductive health as a priority because we’ve so many
other things to do.”
• Multiple priorities
• Lack of collaboration
• Limited resources
• Logisitic difficulties
Hakamies N Repro Health Matters 2008
Heal Africa
Congolese NGO
• 300 bed hospital
• Community education
and training programs
Hospital Grounds
1300 fistula repair surgeries
since 2004
Women with Fistula
Demographics: (2010)
• Age:
• 31 [range 16-46]
• At time of fistula – 19 [range 12-40]
• Access to hospital:
• Median distance of 67.75km
• 59.3% of women walked >5 hrs
[range 10m-3d walking]
• Fistula Etiology:
– 93% obstructed labor, 7% surgical
• Fistula Outcomes:
88% fetal/neonatal demise (71% of women had no live children)
59% divorce or social isolation
• Sexual Violence
Rate decreased from 70% (2008) to 39% (2010)
Birth Experience
• Birth was experienced as traumatic:
DRC 2008:
– 67% rated their last birth experience as “terrifying”
– 69% afraid they were going to be seriously hurt or die
during their last birth
DRC 2010:
– 96.5% afraid they would be seriously hurt or die
during the fistula-causing labor and delivery
“I survived only by the grace of God”.
Post-Repair Intentions
DRC 2008:
• 47% wanted to wait at least 1 yr
• 14% did not want any more children
DRC 2010:
• 64% wanted to wait at least 1 yr
• 18% did not want any more children
Reasons for waiting:
– 62% time to recover
– 15% fear
Knowledge of contraception was limited
DRC 2008:
• Only 2 women had ever used contraception
• Only 17 had ever heard of contraception
DRC 2010:
• No woman had ever used contraception
• 52.4% had heard of contraception /
medicine to prevent or delay pregnancy
• Only 24.6% knew any
specific methods
Condoms, OCPs, Injection
Contraceptive Intentions
• Intent to use
contraception was high
DRC 2008:
• 89% would consider using
contraception
• Those who had been afraid
they were going to die during
their last birth were 3.8 times
more likely to intend to use or
consider using contraception.
(p=0.049)
Contraceptive Counseling
• Group contraception counseling
•Slightly modified from post-partum
contraceptive counseling sessions
•Groups of 10 to 30 women
•Twice monthly
Available contraceptives:
Rhythm beads/fertility awareness method,
condoms, combined and progestin-only
pills, progestin injection, contraceptive
implant(Jadelle),non-hormonal IUD
Provided free of charge by UNFPA
Patient demonstrating cycle beads
Post-Counseling
Contraceptive Knowledge
Changes in Contraceptive Knowledge
Knowledge of
modern birth
control
Knowledge of
any specific
methods
≥1 question
correct for >50%
of methods
Precounseling
52.4%
24.6%
40%
Postcounseling
97%
97%
84%
• After counseling:
• Only 1 woman could not describe birth control
• Average number of methods recalled = 5.2
• Proportion who knew ≥5 methods : 2%→94%
Post-Counseling
Contraceptive Knowledge
“I would like to know
about these medicines
because if you
conceive the first time
you could die, the
second time too… but if
you have these
medicines to prevent
that then you could
help someone, save
their life.”
Contraceptive Uptake
• Amongst women
discharged over the
subsequent 3
months
– 20% of study
participants (5/25)
and 3 additional
women with fistula
left with a modern
contraceptive method
Future Directions
• Study expansion
currently underway to
Panzi Hospital in
Bukavu, South Kivu
• Presenting findings to
UNFPA and funder
agencies to advocate for
FP access
• Working to develop
regional systems for
continued contraceptive
access
Onward to Bukavu
Research Development
• New research committee and IRB at
HEAL Africa
• Clinical research training
• Development and supervision of
independent research projects – Portable ultrasound use, prematurity
outcomes, C/S DDI, delay in antenatal
care,
Conclusions
• Complex emergencies and conflict lead to
destruction of the health care system and
increased sexual violence which greatly
affect women’s lives.
• Genital fistula occurs when access to
family planning and obstetrical care is
limited.
• Women with fistula are interested in
reproductive control and birth spacing, and
will use modern methods if made
available.