This study shows that at the onset of fistula, the mean age was 21.4 years and more than half of the patients were adolescent (< 20 years). In Zambia, Holme et al. found that the mean age of patients with OF was 22 years old . Obstetric fistula occurs predominantly in young parturient: the very young age of the patient has been noted by several authors [8–10]. Previous studies have found a high rate of obstetrical complications in teenagers [11, 12]. The increased obstetrical risk in adolescent girls may be partially explained by anatomical immaturity which is responsible for the anomalies of the basin and to more frequent obstetric complications .
The majority of our patients (65.8%) were primiparous at the onset of fistula. Our results are comparable to other studies conducted in Uganda and Zambia where women with OF were primiparous at fistula occurence [8, 14]. This shows that obstetric fistula usually affects primiparas probably because of pelvic insufficiency leading to prolonged and obstructed deliveries (cephalopelvic disproportion) of up to more than two days on average. These deliveries took place at home in most cases (57.9%). In other cases, deliveries are carried out in a health facility (health center or reference general hospital) but this does not fully involve the skills of health professionals. Our patients, mostly rural, live in remote areas, isolated with a poor road network, making emergency obstetric evacuation difficult or late. These patients travel hundreds of kilometers to reach a health center where they arrive with obstructed labor and fistula under development. As shown in several previous studies, deliveries producing fistulas occurred at home in 70.7 to 97.1% [15–18].
The vaginal route was the main route of delivery at the onset of fistula in our study and caesarean section was performed in 4.8% of cases. Diverging results in Zambia and West Africa [2, 8, 19] have been reported with 50% of fistulas occurring during caesarean section.
Regarding the neonatal outcome during fistula delivery, perinatal mortality was 93.7% in our study, ranging from 78.1 to 96% in the literature [8, 20, 21]. This excess neonatal mortality is easily understood if one considers the duration of the labor, which is generally long, which can reach several days, and fistula’s development is only the result of the body's struggle against dystocia. Nsambi et al. highlight the more frequent use of particularly harmful practices during deliveries conducted at home: traditional birth attendants make use of prohibited maneuvers (e.g. use of mortar and pestle pressure on the belly of the parturient) to force the expulsion of the fetus, thus leading to obstetric morbidities such as uterine rupture or obstetric fistula . This situation points to delays in access to emergency obstetric care and the like in all studies that have been conducted in low-resource countries. Reasons for the delayed decision to seek care may include financial, cultural, religious and geographic reasons, with many women living too far from a clinic to receive timely care [15, 16].
One hundred and twenty-three (29.8%) patients in our study were living with their husband despite fistula, and these results appear to be lower than those observed in Zambia , where 75.7% of fistula patients were still married. This differs from our results and previous studies that seemed to suggest that women with obstetric fistula were neglected and abandoned by their husbands [5, 6]. This difference in the proportion of married women is difficult to explain, but perhaps because of differences in culture and religious beliefs in different studies.
A high number of our patients in this study had a very low level of education (only 5.3% had a secondary level). This could be explained by the fact that women with obstetric fistula had dropped out of school to get married or had an early pregnancy. The same is true of other authors who reported a high number of patients without formal education [2, 5, 15, 22]. This could be explained by the low literacy rate in rural areas where these women live .
The majority of patients in our study (92.3%) had a vesico-vaginal fistula alone and 28 patients (6.8%) had a rectovaginal fistula alone or associated with a vesico-vaginal. Our results corroborate those of previous studies where most patients had vesico-vaginal fistula [8, 14, 15]. This high frequency of vesico-vaginal fistulas compared to other fistulas is probably due to the greater likelihood of compression of the anterior vaginal wall by the fetal head against the pelvis resulting in more ischemia of the bladder than the rectum.
The success rate after surgical repair of the fistula varies from one center to another and is determined by many factors such as the fistula site, the degree of healing, previous attempts at repair, the technique of surgical repair, and the expertise of the surgeon, equipment, and post-operative nursing. The success rate in our study was 82.9%. Such high success rates after repair are reported by other authors ranging from 72.9 to 93% [8, 15, 23–25]. But even after successful closure 15–20% of cases may continue to suffer from urinary incontinence related to sphincter deficiency and not to leakage to the fistula site. Closing the bladder is much more important in achieving a successful repair than vaginal closure. As long as these principles are respected, the surgical approach often concludes successfully. In most cases, the choice is essentially dictated by the procedure with which the surgeon is more comfortable and familiar.
In our series, 79% of cases were repaired trans-vaginally. We have personally favored the vaginal approach when the fistula is near the neck of the bladder. The benefits include a low rate of complications, minimal bleeding, rapid postoperative recovery and short hospital stay . We reserved the trans-vesical approach when the fistula could not be correctly visualized (upper fistula located) and when an intra-abdominal disease state requires simultaneous care.