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.