CLINICAL AND GYNECOLOGY Volume 00, Number 00, 000–000 Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Contemporary Issues in Obstetric

L. LEWIS WALL, MD, DPHIL,*† ITENGRE OUEDRAOGO, MD,‡ and FEKADE AYENACHEW, MD§ *Department of Anthropology, College of Arts and Sciences; †Department of Obstetrics and Gynecology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri; ‡Association Renaissance Arena, Ouagadougou, ; Danja Fistula Center, Danja, ; and §International Fistula Alliance, Terrewode Women’s Community Hospital, Soroti, Uganda

Abstract: We discuss a variety of contemporary issues connected: for example, a vesicovaginal relating to . These include definitions of fistula is an abnormal opening between these injuries, the etiologic mechanisms by which occur, the role of specialist fistula centers in diagnosis the bladder and the . and management, the classification of fistulas, and the Fistulas arise in different ways. A small assessment of surgical outcomes. We also review the number of fistulas are congenital, arising growing need for complex reconstructive surgical pro- from defects that occur during embryog- cedures, follow-up challenges, and the transition to a enesis.1 More commonly, however, fistu- fistula-free world in which other pathologies (such as 2,3 ) will be of increasing importance. las are caused by trauma. Finally, we discuss the need to develop responsive The most common fistulas occurring in systems of care that treat women with females are genitourinary fistulas (vesico- competence, compassion, respect, and fairness. vaginal fistula, , Key words: obstetric fistula, , ’ , etc.) and genito- obstructed labor, women s rights enteric fistulas (especially ). The term “obstetric fistula” refers to a genitourinary or genitoenteric fistula that develops as the result of complica- Definitions tions of the pregnant state (, A fistula is an abnormal passage between labor, delivery, and the puerperium) or 2 epithelialized body cavities that nor- from interventions, omissions, incorrect mally are not connected with 1 another. treatment, or from a chain of events Fistulas are named with reference to resulting from any of the above, just as the structures that have thus become a direct is the death of a pregnant or recently pregnant woman Correspondence: L. Lewis Wall, MD, DPhil, Department of Anthropology, Washington University in St. Louis, from such causes. It is incorrect to use MO. E-mail: [email protected] the terms “obstetric fistula” and “genito- The authors declare that they have nothing to disclose. urinary fistula” interchangeably. The

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 00 / NUMBER 00 / ’’ 2021

www.clinicalobgyn.com | 1 Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 2 Wall et al term “obstetric fistula” should be used Labor is obstructed when the fetus only for fistulas that result from known cannot advance through the canal direct causes of maternal mortality and despite vigorous uterine contractions. The morbidity. In high-resource industrialized presenting part (usually the fetal head) countries, most fistulas are now caused by becomes lodged in the bony , where misadventure during pelvic (com- it compresses the soft tissues of the ves- plications of or urinary icovaginal septum against the maternal stone surgery), by , or by radiation pelvic bones (Fig. 1). The continuing therapy. In low-resource countries (espe- uterine contractions increase the compres- cially those with high rates of maternal sion of the maternal soft tissues that are mortality), most fistulas arise as the result trapped between these 2 bony plates. of delivery trauma.2,3 Eventually this pressure shuts off the blood flow to these tissues completely. If the obstruction is not relieved by prompt Fistula Etiology delivery (such as emergency cesarean When the general public hears about section), a crush injury as described above obstetric fistula, the common belief is that results, and the compressed tissues die and these injuries must arise as the result of slough away, leaving a fistula of varying “tears” occurring during labor and deliv- size. The location and extent of the fistula ery, since most people know that some that forms depends on the location in the degree of tissue-tearing (usually super- ficial) is common during normal child- birth. However, except in rare instances such as difficult forceps deliveries, acute laceration of the vesicovaginal septum is almost never a cause of obstetric vesico- vaginal fistula. Some rectovaginal fistulas result from nonhealing lacerations of the anal sphincter and/or perineum, but rec- tovaginal fistulas account for only a small percentage of the overall obstetric fistulas found worldwide. Most obstetric fistulas are the result of a crush injury occurring during labor. This fact is of fundamental importance in understanding the comorbidities that are often found in association with ob- stetric fistulas. The fact that these lesions originate in a crush injury also explains why obstetric fistulas are frequently diffi- cult to repair. In an acute laceration, the tissues are torn and are separated from 1 another, but they themselves are other- wise normal. In a crush injury, on the other hand, the fistula forms not from tissues being pulled apart, but rather from necrosis of tissues that have lost FIGURE 1. Obstructed labor due to absolute cephalopelvic disproportion. From Smellie, their blood supply at the site where the 4 fistula forms. (public domain). www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Contemporary Issues in Obstetric Fistula 3 pelvis where obstruction has occurred, the care systems, they have increasingly volume of tissues compressed, and related adopted a philosophy of task-shifting, in factors.2,3 which surgical procedures in rural and The tissues that surround the newly remote areas are provided by a cadre of formed fistula from obstructed labor are “surgical technicians” (called by different not themselves normal. Often these tissues names in different countries). Generally, have also been compressed, have lost some these are individuals with less than a of their blood supply, and have been medical degree who have been trained to injured during obstructed labor. Even provide emergency surgical procedures in though these tissues have not died, they rural health care facilities. In some cases, are not healthy. There is often heavy such technicians provide excellent care, scarring, almost always confounded by provided they are adequately supervised, serious and poor tissue perfu- but this issue has not been studied exten- sion, with distortion and retraction of the sively in many countries.7 surrounding structures. The size and scope What may happen in such settings is of the area affected is quite variable, but that the surgeon with the least training may be enormous, affecting other pelvic and experience attempts—under the most organ systems. In such cases, numerous, difficult circumstances and without opti- severe comorbidities may accompany the mal support—to do the most difficult obstetric fistula. The constellation of these cesarean sections: the surgical delivery of comorbidities has been called “the ob- a patient who has been in labor for 2 or structed labor injury complex” (Table 1).5 3 days, is dehydrated and exhausted, with The presence of any of these comorbidities ongoing pelvic sepsis, and a fetal head dramatically affects the care of the woman that is wedged deeply and tightly into the with an obstetric fistula. These women pelvis, with local tissues that may well be often present for care in a condition of already undergoing necrosis at the time of marked general poor health requiring a operation. Under such circumstances, it is long convalescence (both before and after not at all surprising that the number of surgical repair) and the poor and often ureteral injuries and other surgical mis- distorted condition of the local tissues haps increase. Experience from makes the outcome of their treatment strongly suggests that the number of extremely unpredictable. iatrogenic fistulas (such as ureterovaginal The other major cause of obstetric fistulas from surgical injury) have begun fistulas comes from surgical complica- increasing as surgical technicians with less tions, usually during emergency cesarean than full training have been deployed to section, often performed because of ob- rural areas.8 This, in turn, means that structed labor. In many of these cases gynecologic surgeons in low-income and tissue damage will already have occurred middle-income countries must develop before the performance of the cesarean better skill-sets for dealing with these section; but in other cases, the operation complications. Doing this will require itself may independently cause an injury specialized, focused training to deal with that leads to a fistula, particularly if the these specific surgical problems. injury occurs in tissues that have already This phenomenon is sometimes known been partially compromised.6 as the emergence of a “disease of medical progress”; that is, the injury is the result of the introduction of new, often life-saving, Iatrogenic Fistulas technologies that make an important As countries with limited resources try to contribution to medical care, but which expand the reach of their maternal health bring with them at the same time their

www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 4 Wall et al

TABLE 1. The “Obstructed Labor Injury Complex” Acute obstetric injury Hemorrhage, especially postpartum hemorrhage from uterine atony Intrauterine and/or systemic sepsis Deep venous thrombosis Massive vulvar edema Pathologic uterine retraction ring (Bandl ring) Uterine rupture Urologic injury Genitourinary fistulas (vesicovaginal fistula and complex combinations of injuries) Urethral damage, including complete urethral loss Inversion of the bladder through a large fistula, with ulceration of the urothelium Bladder stones Urinary stress incontinence Acute and chronic ureteral injury (hydroureteronephrosis) Acute and chronic (chronic pyelonephritis) Gynecologic injury Cessation of () Vagina scarring and narrowing, leading to loss of sexual capability (gynatresia) Cervical damage, including complete cervical loss Pelvic inflammatory disease and Gastrointestinal injury Rectovaginal fistula and perineal laceration Scarring and narrowing of the Anal sphincter injury and anal incontinence Musculoskeletal injury Injury and of the pubic bone Diffuse pelvic floor trauma Neurological injury Foot-drop and limb contractures from disuse Neuropathic bladder dysfunction Dermatological injury Ulceration due to chronic maceration of the skin by urine and feces Fetal/neonatal injury Over 90% rate with a high death rate among living newborns Neonatal asphyxiation, infection and traumatic birth injuries Psychosocial injury Social isolation Separation and divorce Worsening Posttraumatic stress disorder , sometimes leading to suicide

Modified from Arrowsmith et al.5 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. own set of complications.9 Fistulas aris- the overall-number of obstetric fistulas ing as a of hysterectomy, for from prolonged obstructed labor will fall example, did not occur before hysterec- as access to cesarean section becomes tomy was available as a surgical treat- more widely available. At the same time, ment for uterine disease.10 In the case of the number of fistulas due to surgical cesarean section, one would expect that injuries will also likely rise, even though www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Contemporary Issues in Obstetric Fistula 5 the absolute number of fistulas will be prolonged obstructed labor is often stag- dramatically less overall as the number of gering (Fig. 2). In the worst cases, vir- obstetric fistulas from prolonged ob- tually the entire anterior pelvis, bladder, structed labor decreases in line with the and vagina may be obliterated (Fig. 3), increasing access to cesarean section.11 and there may be almost nothing left with which to attempt to reconstruct a func- tioning bladder and/or vagina. When The Role of Specialist Fistula faced with a pelvic cloaca of this kind, Centers the only viable reconstructive option may be to attempt to create an artificial blad- These 2 etiological factors—complicated der out of reconfigured intestine, with fistulas from prolonged obstructed labor transplantation of the . The new and the injuries resulting from surgical urinary reservoir is then emptied periodi- misadventure—argue strongly for the cre- cally by self-catheterization (Mainz II ation and support of dedicated specialist pouch, etc.).14 Diversion using an ileal fistula units in countries where obstetric conduit has proven less successful in fistulas are common. Although a skilled cases of obstetric fistula. Cases of severe surgeon operating at a district hospital gynatresia where the vagina has been could successfully repair many fistulas, the data are clear that the best opportunity for successful closure of an obstetric fistula is at the first operation.12 Success tends to decline with each ensuing failed operation. As Table 1 clearly indicates, the “hole in the bladder” is not the whole problem when it comes to obstructed labor and obstetric fistulas. There is abundant evidence that womenwhodevelopanobstetricfistulaina resource-poor country come from impov- erished social groups. Once they develop the fistula, their social situation often dete- riorates, making them progressively more vulnerable to exclusion and exploitation.2,3 Domestic violence, marital discord, separa- tion and divorce are all quite common among women with vesicovaginal fistulas. They often require special social programs to help them recover and reintegrate suc- cessfully into society. These programs are more likely to be effective when run as part of specialist fistula centers where a compre- hensive view of the needs of fistula patients are embraced.13 FIGURE 2. Total loss of the following prolonged obstructed labor. Used with per- Complex Reconstructive mission. Copyright [Itengre Ouedraogo], Surgical Procedures [Ouagadougou, Burkina Faso]. All permis- The magnitude of the injuries that a sion requests for this image should be made to woman may sustain in the course of the copyright holder.

www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 6 Wall et al

diagnose and treat potential long-term problems associated with these operations. These operations should only be per- formed at specialist centers where the necessary support and technical capacity can be mobilized.

Fistula Classification and Postoperative Follow-up The diverse presentations that can occur from vesicovaginal fistulas caused by ob- structed labor mean that individual cases will vary extensively in their complexity. To evaluate surgical outcomes accurately, a system of uniform classification and evaluation must be accepted and utilized by clinicians and researchers. This is the only way that therapeutic interventions can be accurately compared. To date, this process remains incomplete. There are 2 widely used classification systems: 1 pro- posed by Waaldijk16 and another 1 pro- posed by Judith Goh (Table 2).17 The latter system has been independently vali- dated among multiple observers.18,19 A prospective study of 202 patients classified using both systems found the Goh classi- fication was better able to predict success- 20 FIGURE 3. Combined vesicovaginal and ful closure than the Waaldijk system. rectovaginal fistula complicated by dense Further such studies involving multiple vaginal scarring and tissue retraction. Used different centers with differing teams of with permission. Copyright [Itengre Oue- surgeons should be encouraged. Attempts draogo], [Ouagadougou, Burkina Faso]. All have also been made to create risk-factor permission requests for this image should be scoring systems to aid prognosis. These made to the copyright holder. show some promise. The important prog- nostic factors appear to include fistula size, degree of scarring, involvement of the obliterated by dense scarring following bladder neck/urethra, whether the fistula sloughing of the vaginal lumen, require is circumferential, number of previous complex vaginoplasty operations or the attempted repairs, and bladder capa- even the creation of a neovagina using city.12,18,21,22 As yet, no risk-factor scoring intestinal segments for reconstruction.15 system has attained a general consensus Operations like these require experi- among operating surgeons. enced, highly specialized surgeons, well- An additional complicating factor is the trained teams of nurses and operating absence of a well-developed methodology room technicians, smoothly integrated lo- for characterizing the potential confound- gistical support, and excellent follow-up to ing influences of other components of the www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Contemporary Issues in Obstetric Fistula 7

TABLE 2. Goh Genitourinary Fistula of discharge from the hospital, typically Classification about 2 weeks after surgery. This is The new classification divides genitourinary clearly inadequate; long-term follow-up fistulae into 4 main types, depending on the studies are required. distance of the distal edge of the fistula from the In the past it was generally assumed external urinary meatus. These 4 types are that successful closure of a vesicovaginal further subclassified by the size of the fistula, “ ” extent of associated scarring, vaginal length or fistula was a surgical success, but it has special considerations since become apparent that a significant Type 1: Distal edge of fistula > 3.5 cm from number of women who undergo success- external urinary meatus ful repair of a fistula continue to have Type 2: Distal edge of fistula 2.5 to 3.5 cm from transurethral from a external urinary meatus Type 3: Distal edge of fistula 1.5 to <2.5 cm from variety of other causes. This discrepancy external urinary meatus between successful fistula closure and the Type 4: Distal edge of fistula <1.5 cm from external attainment of urinary continence has been urinary meatus called the “continence gap.”23 At a mini- (a) Size <1.5 cm, in the largest diameter mum, descriptions of surgical outcome in (b) Size 1.5-3 cm, in the largest diameter vesicovaginal fistula repair should include (c) Size > 3 cm, in the largest diameter the categories “Closed and Dry,”“Failed (i) None or only mild fibrosis (around fistula and/ Repair—Fistula Not Closed,” and or vagina) and/or vaginal length > 6 cm, “Closed, but Wet.”12 Further research is normal capacity needed to determine the best methods for (ii) Moderate or severe fibrosis (around fistula and/or vagina) and/or reduced vaginal length evaluation and treatment for women who and/or capacity have persistent incontinence after success- (iii) Special consideration, eg, postradiation, ful fistula closure, particularly with refer- ureteric involvement, circumferential fistula, ence to the role that should be played by previous repair urodynamic studies and urinary tract 24 As an example, with this proposed classification in a Type 2bi imaging. fistula the ureteric orifice can be close to the fistula edge and it is recommended that ureteric orifices be identified before or during surgery, while the woman with a Type 3aii fistula is probably at a higher risk of postoperative urinary incon- tinence and requires follow-up. Building Responsive Maternal Reproduced with permission from Goh.17 Health Care Systems to Eliminate Obstetric Fistula “obstructed labor injury complex” on the There is nothing particularly complicated outcome of fistula repair. These nonfistula about preventing an obstetric fistula from factors, which are clearly related to the prolonged obstructed labor. All labors underlying pathophysiology that produces should be monitored by skilled birth the injury, may have a bearing on successful attendants, and, at the first indication outcome—certainly they have a major that the progress of labor has stopped, bearing on whether or not patients with the patient should be referred to a higher such co-morbidities have an improved level of care for evaluation and delivery. quality of life after therapy.13 Nobody expressed this better than the There is still no uniformly accepted great American fistula surgeon Thomas definition of surgical “success” in fistula Addis Emmet who, writing nearly repair. Due to the fact that most fistula 150 years ago, said “Since the loss of patients come from remote rural areas tissue is not in proportion to the length of with poor transportation and communi- the labor … and since we cannot judge cation networks, “success” of the fistula of the degree of impaction, there is but repair is still often determined at the time one safe course to adopt, and that is

www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 8 Wall et al speedy delivery. … We must accept the tings where obstetric fistulas are most teaching that vesicovaginal fistula could common, the quality of health care is not occur from a slough if delivery was inadequate at best, and often is disgraceful. always brought about as soon as the head This is particularly true in situations where, ceased to recede after the cessation of an despite deep dissatisfaction, the public per- expulsive effort of the .”25 Emmet ceives itself to be powerless or unable to clearly identified the key issue as one of demand change. Quality improvement in delay in providing appropriate emergency patient care should be led by dedicated, obstetric care once labor becomes ob- empowered hospital administrators, physi- structed. cians, nurses, and midwives who have a Delay has long been understood as a primary ethical responsibility to care for major factor in maternal mortality and patients to the best of their abilities. morbidity. The “3 delays” model popu- With respect to women who have an larized by Thaddeus and Maine includes 3 obstetric fistula, Ruder et al28 have re- sequential points at which delay can occur cently discussed the “fourth delay”—the in the presence of an obstetrical emer- long period of time that many women gency such as prolonged obstructed labor: who have sustained an obstetric fistula (1) delay in deciding to seek care; (2) delay must wait before they can receive appro- in arriving at an appropriate health care priate psychosocial and medical care. facility; and (3) delay in receiving needed This is another compelling reason to care at the facility.3,26 The most difficult promote the development of specialist delay to overcome is the initial delay by fistula centers in parts of the world where the laboring woman and her family in there are large numbers of these cases. deciding to seek care.3,27 There is still a cultural bias in many parts of the world towards home delivery, which exponen- tially increases the chances of delay if Training for the Transition to a labor becomes obstructed. Reluctance of Fistula-free World women to embrace facility-based deliv- As rates of institutional delivery and eries stems in large part from perceptions access to cesarean section increase in of low-quality care at local institutions low-income and middle-income countries, and high rates of patient abuse by nurses the number of obstetric fistulas from and midwives. Laboring women, quite obstructed labor will decrease. This is understandably, do not wish to be sub- already being seen in countries like Ethio- jected to such maltreatment. Overcoming pia, which was long noted for its high rate these problems will require health systems of obstetric fistulas.6,8 As the overall to dedicate themselves to providing com- numbers of fistulas decrease, their place petent care to laboring women, delivered on the spectrum of women’s health needs with compassion, respect, and fairness.3 will be taken by other pathologic condi- Medical professional and nursing organ- tions, most notably pelvic organ prolapse. izations should be leaders in this regard. Recent studies from low-income and mid- Transportation is also problematic in dle-income countries have shown that resource-poor parts of the world. Func- there are now far more cases of severe, tioning infrastructure is a primary govern- symptomatic prolapse than fistulas.8,29 ment responsibility, and local populations There is a pressing need to improve should be adamant about demanding postgraduate medical education in these quality improvements in this area. countries to prepare gynecologists to meet Low-quality health care services are a these new challenges. In particular, a disgrace. In the kinds of low-resource set- major push needs to be made to improve www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Contemporary Issues in Obstetric Fistula 9 training in reconstructive pelvic surgery. 3. Wall LL. Tears for My Sisters: The Tragedy of Existing specialist fistula centers should Obstetric Fistula. Baltimore: Johns Hopkins Uni- expand their capacities in . versity Press; 2018. 4. Smellie W. A sett of anatomical tables. London; When new centers are created, they 1752 (public domain). should strive to encompass the full- 5. Arrowsmith S, Hamlin EC, Wall LL. “Obstructed spectrum of training and treatment for labor injury complex:” obstetric fistula formation pelvic floor disorders from the outset so as and the multifaceted morbidity of maternal birth trauma in the developing world. Obstet Gynecol to provide birth-injured women in these – countries with the highest possible level of Surv. 1996;51:568 574. 30 6. Onsrud M, Sjoveian S, Mukwege D. Cesarean care. delivery-related fistulae in the Democratic Re- public of Congo. Int J Gynecol Obstet. 2011;114: 10–14. 7. Wilson A, Lissauer D, Thangaratinam S, et al. A The Human Rights Dimension comparison of clinical officers with medical doc- of Obstetric Fistula tors on outcomes of in the Above all, the world must develop a shared developing world: Meta-analysis of controlled understanding that injuries are studies. BMJ. 2011;342:d2600. ’ 8. Wright J, Ayenachew F, Ballard KD. The chang- violations of human rights, of women s ing face of obstetric fistula surgery in Ethiopia. Int 3 rights. Childbirth injuries affect women J Womens Health. 2016;8:243–248. exclusively—they are the ones who give 9. Moser RH. Diseases of medical progress. N Engl birth. These injuries occur largely because J Med. 1956;255:606–614. women are denied access to basic, life- 10. Danso KA, Martey JO, Wall LL, et al. The epidemiology of genito-urinary fistulae in Kuma- saving medical services that should be with- si, Ghana, 1977-1992. Int Urogynecol J. 1996;7: in the capacity of every country in the 117–120. world. No woman should lose her life or 11. Raassen TJIP, Ngongo CJ, Mahendeka MM. sustain a crippling life-altering injury just Iatrogenic genitourinary fistula: and 18-year ret- rospective review. Int Urogynecol J. 2014;25: because she gives birth. Not to provide – these services to all women is a form of 1699 1706. 12. Ouedraogo I, Payne C, Nardos R, et al. Obstetric structural, sex-based violence that arises fistula in Niger: 6-month postoperative follow-up from the political decisions of ruling elites of 384 patients from the Danja Fistula Center. Int who choose to divert resources to other, less Urogynecol J. 2018;29:345–351. important but personally preferable pur- 13. Emasu A, Ruder B, Wall LL, et al. Reintegration poses. This is only likely to change needs of young women following genitourinary — fistula surgery in Uganda. Int Urogynecol J. when local populations especially in low- 2019;30:1101–1110. income and middle-income countries— 14. Kirschner CV, Lengmang SJ, Zhou Y, et al. demand justice from their political leaders, Urinary diversion for patients with inoperable and hold them accountable for the poor obstetric vesicovaginal fistula: The Jos, , performance they have shown almost experience. Int Urogynecol J. 2016;27:865–870. 15. Pope R, Hollier PC, Brown RH, et al. A retro- everywhere to date in confronting these spective review to identify criteria for incorporating solvable problems. the Singapor flap and gracilis muscle flap into obstetric fistula repair. Int J Gynecol Obstet. 2020; 148(suppl 1):37–41. 16. Waaldijk K. Surgical classification of obstetric References fistula. Int J Gynecol Obstet. 1995;49:161–163. 1. Escoriza JCM, Marques AMP, Fernandez JAL, 17. Goh JTW. A new classification for female genital et al. Congenital vesicovaginal fistula with or tract fistula. Aus NZ J Obstet Gynaecol. 2004;44: without menouria. Eur J Obstet Gynecol Reprod 502–504. Biol. 2014;175:38–48. 18. Goh JTW, Browning A, Berhan B, et al. Predicting 2. Wall LL. Obstetric vesicovaginal fistula as an inter- the risk of failure of closure of obstetric fistula and national public health problem. Lancet. 2006;368: residual urinary incontinence using a classification 1201–1209. system. Int Urogynecol J. 2008;19:1659–1662.

www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 10 Wall et al

19. Goh JTW, Krause HG, Browning A, et al. 25. Emmet TA. The necessity of early delivery, as Classification of female genito-urinary tract demonstrated by the analysis of one hundred and fistula: inter- and intra-observer correlations. J sixty-one cases of vesico-vaginal delivery. Trans Obstet Gynaecol Res. 2009;35:160–163. Am Gynecol Soc. 1878;3:114–134. 21. Capes T, Stanford EJ, Romanzi L, et al. Com- 26. Thaddeus S, Maine D. Too far to walk: maternal parison of two classification systems for vesi- mortality in context. Soc Sci Med. 1994;38: covaginal fistula. Int Urogynecol J. 2012;23: 1091–1110. 1679–1685. 27. Wall LL. Overcoming Phase I delays: the critical 20. Mukwege D, Peters L, Amisi C, et al. Panzi component in obstetric fistula prevention pro- score as a parsimonious indicator of urogenital grams in low-resource countries. BMC Pregnancy fistulaseverityderived from Goh and Waaldijk Childbirth. 2012;12:68. classifications. Int J Gynecol Obstet. 2018;142: 28. Ruder B, Cheyney M, Emasu AE. Too long to 187–193. wait: obstetric fistula and the sociopolitical dy- 22. Nardos R, Browning A, Chen CCG. Risk factors namics of the fourth delay in Soroti, Uganda. that predict failure after vaginal repair of obstetric Qual Health Res. 2018;28:721–732. vesico-vaginal fistulas. Am J Obstet Gynecol. 29. Ballard K, Ayenachew F, Wrfith J, et al. Preva- 2009;200:578.e1–578.e4. lence of obstetric fistula and symptomatic pelvic 24. Wall LL, Arrowsmith SD. The Continence Gap: organ prolapse in rural Ethiopia. Int Urogynecol a critical concept in obstetric fistula repair. Int J. 2016;27:1063–1067. Urogynecol J. 2007;18:843–844. 30. Nardos R, Ayenachew F, Roentgen R, et al. 23. Nardos R, Phoutrides EK, Jacobson L, et al. Capacity building in female pelvic medicine and Characteristics of persistent urinary incontinence reconstructive surgery: global health partnership after successful fistula closure in Ethiopian women. beyond fistula care in Ethiopia. Int Urogynecol J. Int Urogynecol J. 2020;31:2277–2283. 2020;31:227–235.

www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.