benfield 5.19.11
TRANSCRIPT
Conflict, Fistula, and Family Planning
Eastern Democratic Republic of Congo
Nerys Benfield MDUniversity 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
•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
12th largest country by geographic area in the world
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 Conflict1994: 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
In DRC:
•>150,000 in refugee camps
•>2 million internally displaced
• 70-80% of refugees are women and children
•Social disruption•Armed conflict•Population displacement•Collapse of public health infrastructure•Food shortages
UNHCR Global Report DRC 2009
Al Gasseer J Midwif Women Health 2004
Reproductive Health in Complex Humanitarian Emergencies
Waiting for USAID food distribution
Fertility rates can increase or decrease
McGinn HPN paper 45 2004
•Replace lost children
•No access to contraception and safe abortion
•Malnutrition
•Destruction of family unit
•Economic challenges
• 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
Maternal Mortality increases
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
• Total number of women affected is unknown– >40,000 reported
rapes by 2004
• Epidemic of Rape - Used as a “weapon of war” to destabilize and intimidate communities- Culture of impunity
My Research
Contraceptive and fertility desires and the impact of contraception counseling in genital fistula patients in Eastern DRC
Conflict
Large fistula burden
Sexual ViolenceNo Healthcare
Access to Family Planning
Traumatic birth experience
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 SafetyActive 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
Un-affected 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 FistulaObstructed 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
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”
Etiology of Fistula
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 1982Vangeenderhuysen D. Int J Gyncol Obstet 2001.
Meyer L. Am J Obstet Gynecol 2007
Risk Factors for Obstetric Fistula
- Average labor - 2-4 days
DRC 2008: 25% labored 4-7 daysDRC 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.”
• Lack of Access to Obstetrical Care
How does conflict affect direct fistula risk factors
Conflict
↓ Access to Obstetrical Care
↑ Sexual Violence
↓ Surgical capacity and knowledge
Fistula causes
Obstructed labor
Trauma
Iatrogenic
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
Goh JT BJOG 2005 112:1328
Browning A Int J Gynecol Obstet Aug 31 2007
Nigeria: 74% were divorced or separated
Ethiopia and Bangladesh: 40% had considered suicide
DRC 2008:56% rejected by their community
Genital Fistula Classification
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, repeat repair
The Goh Classification is the most commonly used system.
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
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
Surgical closure is generally very successful.
Fistula Treatment
• Bulbocavernosus Flap
• Ureteral reimplantation or ileal conduit
• Neo-urethra from bladder or labial tissue
• Sub-urethral sling
Complicated and large fistulas can require more complex surgical techniques
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 2002Carey MP Am J Obstet Gynecol 2002
MacDonald P Int J Obstet Gynecol 2007
Fistula Prevention
• Avoid PregnancyAccess to Family
PlanningDRC 2008: 22% fistula-causing pregnancies were undesired
Improve the status
of women
International Women’s Day at HEAL Africa
• Safe Delivery Access to Obstetrical
Care
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 difficultiesHakamies N Repro Health Matters 2008
Heal AfricaCongolese NGO
• 300 bed hospital• Community education
and training programs
1300 fistula repair surgeries since 2004
Hospital Grounds
Women with FistulaDemographics: (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 ViolenceRate 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 IntentionsDRC 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
Patient demonstrating cycle beads
•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
Post-CounselingContraceptive Knowledge
Changes in Contraceptive Knowledge
• After counseling:
• Only 1 woman could not describe birth control
• Average number of methods recalled = 5.2
• Proportion who knew ≥5 methods : 2%→94%
Knowledge of modern birth control
Knowledge of any specific methods
≥1 question correct for >50% of methods
Pre-counseling
52.4% 24.6% 40%
Post-counseling
97% 97% 84%
Post-CounselingContraceptive 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.