Delivery mode for prolonged, obstructed labour resulting in obstetric fistula: A retrospective review of 4,396 women in East and Central Africa

Delivery mode for prolonged, obstructed labourresulting in obstetric fistula: a retrospectivereview of 4396 women in East and Central AfricaCJ Ngongo,aTJIP Raassen,bL Lombard,cJ van Roosmalen,d,eS Weyers,fM Temmermang,haRTI International, Seattle, WA, USAbNairobi, KenyacCape Town, South AfricadAthena Institute VU University Amsterdam, Amsterdam,The NetherlandseLeiden University Medical Centre, Leiden, The NetherlandsfDepartment of Obstetrics and Gynaecology, Ghent UniversityHospital, Ghent, BelgiumgCentre of Excellence in Women and Child Health, Aga Khan University, Nairobi, KenyahFaculty of Medicine andHealth Science, Ghent University, Ghent, BelgiumCorrespondence: CJ Ngongo, RTI International, 119 S Main Street, Suite 220, Seattle, WA 98104, USA. Email: cngongo@gmail.comAccepted 3 December 2019.ObjectiveTo evaluate the mode of delivery and stillbirth ratesover time among women with obstetric fistula.DesignRetrospective record review.SettingTanzania, Uganda, Kenya, Malawi, Rwanda, Somalia,South Sudan, Zambia and Ethiopia.PopulationA total of 4396 women presenting with obstetricfistulas for repair who delivered previously in facilities between1990 and 2014.MethodsRetrospective review of trends and associations betweenmode of delivery and stillbirth, focusing on caesarean section(CS), assisted vaginal deliveries and spontaneous vaginal deliveries.Main outcome measuresMode of delivery, stillbirth.ResultsOut of 4396 women with fistula, 3695 (84.1%) delivered astillborn baby. Among mothers with fistula giving birth to astillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from45% (162/361) in 1990–94 to 64% (331/514) in 2010–14. Thisincrease occurred at the expense of assisted vaginal delivery(overall 18.3%, 676/3695), which declined from 32% (115/361) to6% (31/514).ConclusionsIn Eastern and Central Africa, CS is increasinglyperformed on women with obstructed labour whose babies havealready died in utero. Contrary to international recommendations,alternatives such as vacuum extraction, forceps and destructivedelivery are decreasingly used. Unless uterine rupture is suspected,CS should be avoided in obstructed labour with intrauterine fetaldeath to avoid complications related to CS scars in subsequentpregnancies. Increasingly, women with obstetric fistula add ahistory of unnecessary CS to their already grim experiences ofprolonged, obstructed labour and stillbirth.KeywordsAssisted vaginal delivery, caesarean section, destructivedelivery, obstetric fistula, stillbirth, vacuum extraction.TweetableabstractCaesarean section is increasingly performed inAfrican women with stillbirth treated for obstetric fistula