Percent of women presenting with obstetric fistula who have a successful first repair, by facility

 

Percent of OF first repair surgeries, by facility, resulting in fistula closure and urinary continence among all vesico-vaginal fistula first repair surgeries performed in that facility in a given timeframe (generally one year).

The outcomes of vesico-vaginal fistula repair surgeries may be categorized as:

  • closed and dry: fistula closure with no leaking of urine (urinary continence)
  • closed and wet: fistula closure but with urinary incontinence
  • open: non-closure of fistula

The most favorable outcome is closed and dry, which may be evaluated at different times following the surgery. The outcome assessment is best done when preparing for hospital discharge.

This indicator is calculated as:

(Number of first-time fistula repair surgeries performed in a given period resulting in closure and urinary continence after the surgery, excluding women who subsequently died / Total number of fistula first repair surgeries performed in the same time period) x 100


 

Total number of OF repair surgeries performed in a given time period, if the surgery was a first attempt or subsequent surgery, and identified outcome of the surgeries (closed and dry, closed and wet, or non-closure). Ideally, the closure rate should be 85%, of which 90% should be without incontinence (WHO, 2006), but success depends on the complexity of the condition.  Therefore, this indicator should be stratified by the type of fistula repaired (simple or complex).

Some programs may decide to report surgical outcomes separately: closed and dry, closed and wet, or not closed. However, only the patients with fistula closure and urinary continence and only those presenting for surgical repair for the first time should be considered in the numerator of the indicator.  Outcomes followed by death should also be excluded from the numerator regardless of the conditions of the fistula prior to death. Deaths should be captured in a separate indicator: case fatality rate of OF repair surgery. A similar classification system and indicator can be derived for recto-vaginal OFs. Additionally, the number of diagnosed patients treated and the number of successful subsequent surgeries (closed and dry) should be reported separately.


Facility-based surveys; hospital discharge logs; medical records review


 

There is a decreasing possibility of success with each successive attempt at OF repair. Not only does this indicator capture the outcome of fistula repair programs at the individual level, based on the first attempt at repair surgery, it can also serve as a basic quality of care measurement and a powerful advocacy tool reflecting the success of an OF surgical repair program.

For comparability purposes, this indicator should always report the time at which the outcome of surgery was evaluated. When assessed at hospital discharge, calculation of this indicator is straightforward.

Analysis of this indicator over time can be used to assess significant changes in programs. Reductions in success rates that were once high should prompt closer examination of changes in staff, treatment protocols, and/or patient characteristics. Comparison of the indicator across facilities may reflect facility-specific issues that require improvement.


 

Outcome may be evaluated at additional times including:

  • 3 months after discharge,
  • 6 months after discharge, and
  • 1 year after discharge.

Evaluation of outcomes after hospital discharge may require special studies. These evaluations of outcome are important as urinary incontinence can resolve 3 to 6 months following surgery with regular pelvic exercises. This would require adequate postoperative counseling and follow-up visits. Facilities should use these strategies to improve their success rates.

Inoperable cases are excluded in the calculation of this indicator as they would not be candidates for fistula repair surgery, although they may undergo and benefit from other types of surgery such as urinary diversion. These would not be considered fistula repair surgeries.

Surgical outcomes depend on characteristics of the providers, the facility and the patient. The former two include factors such as surgical dexterity and experience of the providers, quality of postoperative care, and infection control practices of the facility, which can be modified. However, patient-specific characteristics such as age, parity, nutritional status, and complexity/severity of the fistula are less modifiable. It is recommended to always disaggregate the surgical success rate by the complexity/severity of fistula.

Another limitation is that the indicator is strictly defined among surgically repaired cases.  A quality of care OF indicator for women who only received catheter treatment for fresh fistula could be included.  Adding the catheter-only treatment has implications for defining the characteristics of OF surgical sites, data sources, and disaggregation.  More practical experience with a more inclusive surgical and catheter treatment indicator is needed.  Until then, success rate should be reported separately for surgical repairs and catheter-only repairs.


safe motherhood (SM), quality, obstetric fistula (OF)
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