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Evidence-Based Programming : Research :


Determinants of Postoperative Outcomes in Fistula Repair Surgery

To better understand the factors that affect the outcomes of fistula repair, Fistula Care conducted a multicountry prospective cohort study, in partnership with local organizations.

The study was carried out between September 2007 and September 2010 at 11 facilities in five countries: Bangladesh, Guinea, Niger, Nigeria, and Uganda. The effort represents one of the largest data collection initiatives to date that assessed fistula repair outcomes and documented the experiences of women with fistula across multiple countries. It is also one of few studies that monitored women after discharge from the repair facility to determine the factors that affect longer-term outcomes.

The study identified key factors affecting the outcome of fistula repair surgeries and examined the social and structural factors associated with fistula. These factors include preoperative bladder size, a history of prior repair attempts, and the degree of vaginal scarring and urethral involvement.


  • Determinants of Postoperative Outcomes in Fistula Repair Surgery: A Prospective Facility-Based Study (Study Protocol)
    · File: English (PDF, 82KB)
    · Abstract: French (PDF, 561KB)
  • Factors Influencing Urinary Fistula Repair Outcomes in Developing Country Settings: A Systematic Review
    · Link: English
    · Abstract: French (PDF, 561KB)
  • Determinants of Postoperative Outcomes of Female Genital Fistula Repair Surgery
    · Link: English
  • Factors Influencing Choice of Surgical Route of Repair of Urinary Fistula, and the Influence of Route of Repair on Surgical Outcomes: Findings from a Prospective Cohort Study
    · Link: English
    · Abstract: French (PDF, 561KB)
  • Development and Comparison of Prognostic Scoring Systems for Surgical Closure of Genitourinary Fistula
    · Link: English
    · Abstract: French (PDF, 233KB)
  • Profiles and experiences of women undergoing genital fistula repair: Findings from five countries
    · Link: English

Current Practices in Treatment of Female Genital Fistula: A Cross-Sectional Study

In 2009, 40 surgeons who provide fistula treatment services in Africa and Asia at private and government hospitals completed questionnaires about treatment practices for fistula patients. Respondents were asked about three issues: prophylactic use of antibiotics before, during, and after fistula surgery; urethral catheter management; and management practices for patients with urinary incontinence following fistula repair. 

The results provide a snapshot of current practices in fistula treatment and care. There was consensus in some treatment areas, while there were wide variations in practice in other areas (e.g., duration of catheter use, surgical treatments for postsurgical incontinence). The findings were based on a small sample and do not allow for recommending changes in clinical care, but they point to issues for possible clinical research that would contribute to more efficient and effective fistula care.


  • Current Practices in Treatment of Female Genital Fistula: A Cross Sectional Study
    · Link: English

Randomized Controlled Trial on Short-Term Catheterization

Fistula Care and the World Health Organization collaborated on a randomized controlled trial to assess the efficacy and safety of using short-term catheterization after fistula repair rather than longer-term catheterization. Short-term catheterization has the potential to reduce hospital stays for women, decrease postsurgery complications, free up bed space at facilities, and lower costs, potentially allowing more women to receive clinical care. The study was conducted at eight sites in eight countries (DRC, Ethiopia, Guinea, Kenya, Niger, Nigeria, Sierra Leone, and Uganda) between 2011 and 2013. A total of 507 women were enrolled in the study.


  • Non-Inferiority of Short-Term Urethral Catheterization Following Fistula Repair Surgery: Study Protocol for a Randomized Controlled Trial
    · Link: English
    · Abstract: French (PDF, 561KB)

Piloting a Community Screening Model for Fistula in Nigeria

To help fistula treatment centers and state and federal ministries of health reduce the backlog of women needing fistula repair, Fistula Care, in partnership with state and community stakeholders, conducted this study to quantify the backlog of cases within two local government areas in Kebbi and Cross River states via community-based clinical screenings. In addition, the study explored the feasibility of reporting minimum estimates of prevalence and incidence of fistula (at the individual district level, and, if possible, extrapolated to the state level) and assessed the questions in the Demographic and Health Survey fistula module by comparing women’s self-reported fistula symptoms to results from the medical assessment. The community screening intervention model is based on the experiences in Ebonyi State, which are described in a technical brief.


  • Community-Based Screening for Genito-Urinary Fistula in Nigeria:  A Novel Approach
    · Files: English (PDF, 940KB) and French (PDF, 248KB)

Multi-Center Retrospective Review of Data Collection Procedures and Data Quality of Indications for Cesarean Deliveries

Obstructed labor is a major cause of maternal and neonatal mortality and morbidities, including obstetric fistula. Quality and timely cesarean delivery services can ease the obstruction and prevent fistula. Although data are available about cesarean rates, few data are available about the factors that lead clinical staff to recommend cesarean sections. This retrospective record review sought to determine the leading indications for cesarean delivery, as well as to assess the quality of services provided. Results from this study helped facilities to better understand and document cesarean section indications and improve record keeping.

Data collection was completed in 2010 at 11 facilities that received support from Fistula Care in five countries (Bangladesh, Guinea, Niger, Nigeria, and Uganda). In total 2,941 cesarean delivery records from 2008 were randomly selected and reviewed.


  • Key Findings and Recommendations: A Multi-Center Retrospective Review of Data Collection Procedures and Data Quality of Indications for Cesarean Deliveries
    · Files: English (PDF, 833KB) and French (PDF, 315KB)

Guinea Program Evaluation

In 2011, Fistula Care conducted a two part in-depth evaluation of the Guinea program to examine the supply side of the program and the community-level fistula prevention efforts.

The supply side evaluation was carried out to determine the readiness of supported sites to provide fistula treatment and prevention care.  The community evaluation was undertaken to explore whether the establishment and support of the Village Safe Motherhood Committees in the intervention areas had led to measurable outputs in terms of enhanced community capacities and social capital related to maternal health, as well as whether enhanced community capacity and social capital were associated with outcomes, such as fistula prevention knowledge, birth preparedness and maternity care-seeking at the population. The study methodology included facility assessments, a community survey, and key informant interviews.


  • Evaluation of Community-Level Fistula Interventions in Guinea
    · Files: English (PDF, 978KB) and French (PDF, 1.0MB)
  • Guinea Fistula Care Program Evaluation
    · Files: English (PDF, 2.2MB) and French (PDF, 339KB)

Assessing the Costs of Fistula Treatment Services

Fistula Care collaborated with selected sites in Nigeria and Ethiopia to undertake a study to determine the cost of fistula care services in 2011. The study was designed to assist facilities in identifying, allocating, and managing resources for the provision of quality fistula care services. Findings, analysis, and implications were discussed with site staff and with local and national authorities. The results can facilitate improved coordination with other donors and provide standardization in the approach to calculating the costs of fistula care services.


  • Estimating Costs to Provide Fistula Services in Nigeria and Ethiopia: Key Findings
    · Files: English (PDF, 297KB) and French (PDF, 311KB)

Literature Reviews

Outcomes in Obstetric Fistula Care: A Literature Review
Consensus about basic definitions of clinical success does not yet exist. Opinions vary widely about the prognostic parameters for success or failure. Commonly agreed upon definitions and outcome measures will help ensure that site reviews are accurate and conducted fairly. To properly compare technical innovations with existing methods, agreement must be reached on definitions of success. Standardized indicators for mortality and morbidity associated with fistula repair will improve the evidence base and contribute to quality of care.
Link: English

Use of the Partograph: A Literature Review on Effectiveness, Training, Modifications, and Barriers
The purpose of the review was to identify and summarize the available literature on the use and efficacy of the partograph (including information on the attitudes of health care providers toward the partograph) and to identify and evaluate training strategies and barriers to its use.
Files: English (PDF, 342KB) and French (PDF, 236KB)

Strengthening Health Systems Through the Levels of Fistula Care Framework
This paper presents findings from a literature review of the peer-reviewed and grey literature, exploring the application of Fistula Care’s Levels of Fistula Care Framework (repair, prevention and reintegration) as a health systems strengthening group of interventions. The methodology offers a comprehensive approach for reviewing the literature that can inform how to address institutionalization of rationalized health systems strengthening for fistula services.
Files: English (PDF, 486KB) and French (PDF, 83KB)

Traumatic Gynecologic Fistula as a Consequence of Sexual Violence: A Literature Review
This literature review surveys the landscape of information on traumatic gynecologic fistula in conflict settings. Though limited in scope by the lack of documented evidence, the literature review makes it clear that future efforts to address traumatic fistula should include increased surveillance to assess wither this problem exists in all countries where systematic sexual violence has occurred and confirms the need for collective discourse on traumatic fistula.
Files: English (PDF, 42KB)

© 2013 EngenderHealth.

This resource was made possible by the generous support of the American people through the U.S. Agency for International Development (USAID), under the terms of the cooperative agreement GHS-A-00-07-00021-00. The information provided on this resource is not official U.S. Government information and does not represent the views or positions of the USAID or the U.S. Government.