Obstetric fistula in Niger: 6-month postoperative follow-up
of 384 patients from the Danja Fistula Center
Avril J. Adelman
L. Lewis Wall
Received: 22 March 2016 /Accepted: 28 July 2016 / Published online: 9 June 2017
The Author(s) 2017. This article is an open access publication
Introduction and hypothesis The impoverished West African
country of Niger has high rates of obstetric fistula. We report a
6-month postoperative follow-up of 384 patients from the
Danja Fistula Center and assess factors associated with oper-
ative success or failure.
Methods The medical records of 384 women who had com-
pleted a 6-month follow-up after fistula surgery were
reviewed. Cases were categorized as Beasy,^ Bof intermediate
complexity,^ or Bdifficult^ based on a preoperative points
system. Data were analyzed using simple chi-squared statis-
tics and logistic regression.
Results The patients were predominantly of Hausa ethnicity
(73%), married young (average 15.9 years), had teenage first
pregnancies (average first delivery 16.9 years), and experi-
enced prolonged labor (average 2.3 days) with poor outcomes
(89% stillbirth rate). The average parity was four. Patients
commonly developed their fistula during their first delivery
(43.5%), but over half sustained a fistula during a subsequent
delivery (56.5%). Prior fistula surgery elsewhere (average
1.75 operations) was common. The overall surgical success
(Bclosed and dry^) was 54%. When the 134 primary opera-
tions were analyzed separately, the overall success rate was
80%. Increasing success was seen with decreasing surgical
difficulty: 92% success for Beasy^ cases, 68% for
Bintermediate^ cases, and 57% success for Bdifficult^ cases.
Success decreased with increasing numbers of previous at-
tempts at surgical repair.
Conclusions These data provide further evidence that clinical
outcomes are better when primary fistula repair is performed
by expert surgeons in specialist centers with the support of
trained fistula nurses.
Keywords Obstetric fistula
Vesi cov agi nal f istula
An obstetric fistula is an abnormal passageway between the
vagina and the urinary and/or gastrointestinal tract arising
from obstetric trauma . In sub-Saharan Africa, these inju-
ries most commonly arise from a crush injury to the
vesicovaginal septum during prolonged obstructed labor .
These injuries are completely preventable provided the diag-
nosis of obstructed labor is made early and prompt interven-
tion takes place before extensive ischemia has occurred.
However, poorly developed systems of maternal healthcare
in West Africa prevent many women from accessing emergen-
cy obstetric services in a timely fashion after labor becomes
obstructed. This often leads to catastrophic injuries [2, 3].
Obstetric fistula is largely a disease of poverty, and West
Africa is extremely poor .
* L. Lewis Wall
WALLL@ wu st l.ed u
The Danja Fistula Center, Danja, Niger
The Worldwide Fistula Fund, Chicago, IL, USA
Department of Obstetrics and Gynecology, Oregon Health and
Sciences University, Portland, OR, USA
Division of Biostatistics, Washington University School of Medicine,
St. Louis, MO, USA
Department of Anthropology, Washington University in St. Louis,
Campus Box 1114, One Brookings Drive, St. Louis, MO 63110,
Department of Obstetrics and Gynecology, Washington University
School of Medicine, St. Louis, MO, USA
Int Urogynecol J (2018) 29:345–351