5.1 Introduction
This chapter looks into explaining the results institute in Chapter 4. This chapter allows the data collection procedure outcomes to be interpreted and explained and allowing it to give a better understanding of the hysterectomy profiling in Northern Zimbabwean women.
5.2 Discussion
Frequency and distribution outcomes of hysterectomy in Northern Zimbabwe
Of a total of 316 reports, 103 (32.59%) were in the 41-50 years age group. There is a higher frequency of hysterectomy in women between 41 and 50 years, with a mean age of 42.19 years possibly due to most women having passed the child bearing age. A study in Cameroon on the epidemiology profile and complications of hysterectomy revealed that the 41 to 50 years age group was the most represented with a mean age of 46.39 years. Most of the women are nearing or are post-menopausal and can undergo a hysterectomy as they are past childbearing age (Ngaroua, 2019).
The hysterectomy procedure is also not encouraged as a first line treatment for lower age groups since it is irreversible hence it is less frequent and should be undergone as an emergency. Whilst the older age groups undergo it to manage prolonged discomfort, pain and management of a gynecological conditions ,presumably, fully aware it is irreversible and a lasting solution or treatment to their conditions. This suggests that the 41-50 years age group is at higher risk of having a hysterectomy performed. This is supported by a study on the prevalence, sociodemographic determinants and self-reported reasons for hysterectomy in India. It concluded that one of the reasons of the likelihood and percentage of undergoing hysterectomy was relatively high in women between the ages of 45 and 49 (Shekhar, 2019).
There is a small correlation (p=0.1594) between the age group and the type of hysterectomy. A population based study in rural China of the epidemiology profile of hysterectomy done by (Fangfang, 2017) had similar results. The hysterectomy prevalence differed by age and the cause. Women over the age of 40years had a higher prevalence of prior hysterectomy than those between the ages of 25 to 39. 84% of the women that provided further information had undergone a total abdominal hysterectomy and the procedure was for the leiomyomata.
The 1 to 20 age group had 25 samples in the group however, 20 of the samples were all aged between 1 to 2 years. Hysterectomy is not a medical procedure done in toddlers. Therefore 6.33% of the histological reports had incorrect ages. 13 of these reports were from Sally Mugabe Central Hospital, 4 from Mutare Provincial Hospital, 2 from Parirenyatwa Group of Hospitals and one from Bindura Hospital. The reports were included as there were complete but presented the issue of a possible clerical error or insufficient information sent in by the hospitals.
Women between the years of 31 to 40 are at a greater risk of postpartum hemorrhaging followed by 21 to 30. Women between the ages of 41 to 50 being at greater risk of leiomyomata although the values of leiomyomata hysterectomies were high in all age group except 21 to 30years of age. The indicators for a hysterectomy show prevalence of diseases varying with age group however there is a small correlation (p=0.1594). Hysterectomy prevalence differed by age.
In Cameroon, 94% of the hysterectomies were total abdominal hysterectomy (Ngaroua, 2019) whereas in Zimbabwe 59.81% were total abdominal hysterectomy. 79.5% of the retrospective study underwent total abdominal hysterectomy (Egbe, 2018). 84% had a total abdominal hysterectomy procedure (Fangfang, 2017). Many factors determine the type of hysterectomy procedure that will be used starting from the ailment that is being treated, surgical skills of the Doctor, patient health and cost. There is a low count of total abdominal hysterectomy procedure that requires an understanding of whether it is the best method for indicators of hysterectomy and how the Doctor chose the procedure. All values of p‹0.5 indicating small correlation over the variables studies.
Epidemiology profile of hysterectomy outcome and its patterns in occurrences
The epidemiology profile of hysterectomy in Zimbabwe followed closely to a similar study done in Cameroon. 41 to 50 years was the most represented group with a mean age of 46.39 and extremes of 18 years and 83years. The indications for hysterectomy was dominated by a polymyomatous uterus and uterine cervix cancer at 47.9% and 11.3% respectively (Ngaroua, 2019). The prevalence for hysterectomy in India was among women between the ages of 30 and 49years. These figures were for India as a whole. (Prusty, 2018). There is common ae in hysterectomy is frequent.
Total abdominal hysterectomy was the most common type of hysterectomy procedure used (59.81%) for women who had their samples sent at Parirenyatwa Group of Hospitals. (Fangfang, 2017) reported that the majority of the hysterectomies reported were performed abdominally and also for leiomyomata cases for the rural women in China. 79.5% of the retrospective study underwent total abdominal hysterectomy (Egbe, 2018).
Geographically, Parirenyatwa is the central hospital and all Northern Zimbabwean public hospitals send their Histology samples there. It is situated in the capital city and that could explain the high number of uterine samples. Mutare Provincial Hospital has the second highest number of samples. It could be that it serves the Manicaland region and hence the high number of samples. However, Chinhoyi Provincial and Bindura do not send as many samples as Mutare Provincial. The samples received are higher from major towns in Zimbabwe, with smaller towns sending less than 5 samples each. Perhaps a variable or a determinant exists, such as accessibility, cost, availability of Doctor skills, hospital capacity and awareness levels, that could explain the high number of hysterectomy sample when hospitals are compared regionally.
The p value ‹0.25 for all variables indicating a small correlation between hysterectomy with age, type of hysterectomy, possible indicator and the referring hospital.
Direct indicators outcomes of hysterectomy among women
Multiple leiomyomata (58.2%) and heavy vaginal bleeding (60.6%) were the main causes for having a hysterectomy performed (Egbe, 2018). The self-reported causes of hysterectomy are excessive menstrual bleeding/pain (56%), by the presence of fibroids/cysts (20%) and uterine ruptures or postpartum hemorrhages (14%) (Shekhar, 2019).
Hysterectomy procedures for postpartum hemorrhaging are emergency procedures. 18.67% of the procedures performed were postpartum hemorrhaging hysterectomies making the prevalence rate of postpartum hemorrhaging is 18.67%. This is high considering Denmark is at 2.6 per 10 000births and 10.7 in Italy (Kallianidis, 2020). Post-partum hemorrhaging is the leading cause of maternal mortality. (Smith, 2018) It is further risked by weight gain, pregnancy induced hypertension and other factors, commonly witnessed in pregnant women.
The indicators of hysterectomy should be noted in the clinical notes. However, in the event the data was unavailable, the Pathologists report could be used to determine the cause of having a hysterectomy performed. However, the Pathologists findings and therefore the report data may not necessarily be the reason the patient had their uterus removed and so the lack of clinical information effects a bias on the indicators noted.
The marital status and employment status was undocumented. A PGH histology report patient profile shows the patient name and laboratory number, age, sex, requesting Doctor, ward and hospital number, referring hospital and clinical notes. This information is transposed from the laboratory form. It also shows the date and time sample was processed and reported. The marital status, employment status, method of payment are undocumented and became a hindrance in the assessment of the predictors and therefore the epidemiology profile of hysterectomy in Northern Zimbabwean women. “Exploratory analyses suggest state-level factors associated with prevalence include caesarean section, female illiteracy and women’s employment.’ (Desai S, 2019). Therefore, the prevalence of the indicators could be supported by socio-economic factors that affect hysterectomy being performed.
5.3 Conclusion
Conclusively, the study reveals that the prevalence of hysterectomy is 9.78% with the most represented age group being that of 41-50 years. It also shows that most common determinant for having the procedure was leiomyomata. It also reveals that 31- 40 years age group is the second most represented group that is commonly treated for postpartum hemorrhage. The total abdominal hysterectomy is the most performed type of hysterectomy. Parirenyatwa Group of Hospitals and Mutare Provincial Hospital perform the highest number of hysterectomy, respectively.
There is need for more variable consideration to allow for a better understanding of the factors that determine hysterectomy procedure among women.
5.4 Implications
Incomprehensive hospital check in forms give little or no data for further use or research. The factors associated with hysterectomy could have been more comprehensive to give a clear picture on the epidemiology profile of hysterectomy in Northern Zimbabwean women. Determinants of disease could have been supported better by the race, education, health insurance, parity, religion and caste, clinical/medical history, socioeconomic status to give a better understanding on the environments associated with hysterectomy. The small number of reports could have affected the precision of the research assessment on the predictors of hysterectomy.
This looks into the improvement of data that should be requested when patients check in for hysterectomy procedures and all surgeries in general. There is need for a collective review or evaluation of hospital forms to ensure all parties that require, use or update hospital forms can collectively edify the documents for filing and further use. There is need for appropriate data access to the laboratory when needed to ensure laboratory findings are supported by clinician notes and all other supporting staff.
The results were not as complete due to poor data capturing resulting in a portion of the data having errors, such as an incorrect hospital number and so could not be retrieved, incorrect age, mismatched data between specimen entry book and report and missing clinical data. The determinant of hysterectomy was then retrieved from the report after Pathologists report. However, the reason a hysterectomy is done and the pathology report could be different distorting the result pool again. An example are 10 specimens excluded due to wrong hospital numbers. These might not have been reported, could have the hospital number clerically captured differently during or after processing or not entered into the system after reporting
The majority of the forms lacked clinical data and any laboratory tests that supported the need for the procedure to be performed. This questions the role of the laboratory work pre, during and post-surgery. This suggests the need for a set algorithm in laboratory testing before a hysterectomy can be performed. This is supported by the findings of normal uterus that were removed and showed no indication of any medical conditions and no supporting data provided by the hospitals and operating physicians or why the hysterectomy was performed. It further supports the use of alternative measures which should be introduced before undertaking the procedure. This is evident by patients with choriocarcinoma undergoing hysterectomy procedure as a treatment option.
Its implication in the laboratory profession is on the importance of laboratory testing pre, during and post decision making.
Postpartum hemorrhage indicates the need for further studies on hysterectomy and the complications of post-partum hemorrhaging and initiatives in the fight to lower the maternal rates. There are an indicator of emergency procedures that are constantly done during child birth that can be evaluated for better mother and child care.
The Doctors strike resulted in irregularities from September to December with no reports being done in December. This affected the number or reports received for the year and could have altered the result pool. All the samples received within that period were only processed and done in 2020 removing them from the 2019 data. The events of 2019 might mean the study might be a partial representation of the population.
5.5 Recommendations
Hysterectomy is one of the leading gynecological procedures all over the world with growing numbers in Africa and Zimbabwe. There is need for the Ministry of Health and Child Care to raise awareness on the procedure and the determinant medical conditions that precede it. There is need for further studies to determine the socioeconomic determinants of hysterectomy to allow for better awareness levels depending with the results of the study. Different social-economic classes have different habits and so this gives targeted social awareness methods.
Hysterectomy reveals the importance of sexual and reproductive health issues and the need for its constant awareness and new initiatives. The number of cases in 21-30 year old age group shows the need for sexual and reproductive education and rights advocacy in age groups even younger.
There is need to determine the incidence levels of hysterectomy in different regions to determine where the need is. Also, the data required to make a better population study is not noted on the laboratory or report forms making it harder to collect it in retrospective studies. There is need for the collection of reports including those of Mpilo Hospital and other hospitals that are receiving public hospitals for histology samples. This will give a snapshot of the holistic picture at a specific time nationwide.
Lack of clinical data and history does not allow for better procedure assessment and knowledge of other possible laboratory tests that could have assisted in decision making before choosing hysterectomy. This is especially critical for patients that underwent the hysterectomy procedure but where found to have normal uterus with no malignancies or benign disorders seen. This is emphasizes the need for laboratory testing before the procedure for the cases that were not emergencies. Hysterectomy performed on patients who had disorders such as choriocarcinoma further supports laboratory testing and histology processing before an irreversible procedure is performed.
5.6 Suggestions for further research
On comparison, Mutare Provincial Hospital has high numbers of hysterectomy procedure derived samples sent to PGH. Its numbers tally with the central hospitals and hence there is need to further research on what can be done to determine justification on high numbers of hysterectomy from Mutare Provincial Hospital. The reasons can be from socio-economic factors, region the hospital serves, doctors’ expertise, determinants of hysterectomy, hospital capacity and many others factors to influence the decision.
As mentioned earlier, the determinants of hysterectomy could have been supported better by the race, education, health insurance, parity, religion and caste, clinical/medical history, socioeconomic status to give a better understanding on the environments associated with hysterectomy. Further studies can be done to incorporate other factors giving a more comprehensive epidemiology profile of hysterectomy.
Research studies from all Histology centers in Zimbabwe would give a holistic picture on the epidemiology profile. This reduces the chances of error as the profile is determined on data than an inference from the results of Northern Zimbabwean women.
The manifestation of post-partum hemorrhage as one of the main causes of the hysterectomy procedure allows for the research into the epidemiology profile of hysterectomy and its complications. It can also allow for studies in deriving its contributions in maternal health management.
A case study analysis can be done on the samples that were viewed and reported as normal uterus in determining what errors, misjudgments or cause of the hysterectomy procedure on specimens later found to be normal. This further queries the algorithm that is used by surgeons in conjunction with laboratory testing in determining need for surgery.