Obstetric Fistula in the Developing World: An Introduction

Obstetric Fistula in the Developing World: An Introduction

While obstetric fistula has been virtually eradicated in the developed world, millions of women and young girls in the developing world are living in poverty as outcasts from their society, rejected by their husband, family and community because they are suffering from the devastating consequences of obstetric fistula. The baby they were expecting will often have died unborn.

Obstetric fistula is a wholly preventable condition, provided that appropriate medical and obstetric facilities including emergency caesarean section are available. The continuing problem of obstetric fistula is a clear sign that the world is failing in its duty to meet the needs of women in developing countries. Its eradication in the developing world needs to be given global priority.

What is a fistula?
A fistula is an abnormal connection (an opening) between two internal organs or between an internal organ and the surface of the body. It may be caused by disease or malignancy, radiation therapy, surgery or traumatic injury. It can lead to abnormal continual leakage of the contents of one organ into another organ or to the outside of the body.

What is an obstetric fistula?
Fistula
In developing countries, obstetric fistula is the result of prolonged or obstructed (blocked) labour, often lasting several days, when the unborn baby cannot pass through the pelvis. The baby may be too big for the pelvis or lying in the wrong position, or the pelvis may be misformed or not fully developed. In developed parts of the world, a woman with this kind of obstructed labour would be given a caesarean section, but in developing countries this may not be available. Consequently, the pressure of the baby’s head for an abnormally long time on the blood vessels supplying the tissue of the vagina, bladder, urethra and rectum cuts off the supply of oxygen (ischaemia) and leads to the death of the affected tissue (necrosis). The dead tissue then sloughs away, leaving a hole between adjacent organs.

Different types of obstetric fistula
There are several possible types of obstetric fistula. These include the following.

  • vesicovaginal fistula (VVF), between the bladder and vagina
  • urethrovaginal fistula (UVF), between the urethra (bladder outlet) and vagina
  • rectovaginal fistula (RVF), between the rectum and vagina
  • ureterovaginal fistula, between the ureters (kidney tubes) and the vagina
  • vesicouterine fistula, between the bladder and the uterus (womb)
  • sometimes more than one type of fistula may occur at the same time, where damage is severe.

Prevalence While obstetric fistula has been virtually eradicated in the developed world due to the availability of good medical care, including emergency obstetric facilities and caesarean section, this is regrettably not the case in developing countries. It is estimated that there may be at least two million women and young girls, living in poverty, who suffer from fistula. This immense number is very concerning. This problem is particularly prevalent in sub-Saharan Africa, parts of Asia (India and Bangladesh), remote rural regions of China and in parts of South America. However, since many of the affected women live in isolation and never seek help, actual prevalence figures may be much higher.

Risk factors for obstetric fistula The primary risk factors for obstetric fistula are:

  • lack of access to medical facilities, obstetric care and emergency caesarean section delivery;
  • lack of adequately trained, skilled medical staff;
  • lack of medical supplies and equipment.

Other contributory risk factors include poverty and malnutrition leading to stunted growth that could make women more susceptible to obstructed labour. Furthermore, in some traditional cultures very young adolescent girls often marry and begin childbearing before their body is sufficiently developed to cope with this. Many of the women have received no formal education and had no access to accurate information about healthcare, family planning, pregnancy and childbirth. Moreover, cultural beliefs and traditions may prevent them from seeking the necessary medical care. In some communities, it is the custom for women in labour to be assisted by traditional birth attendants who have no training in dealing with emergency obstetric situations and may even discourage the woman from seeking medical help. Furthermore, religious or traditional practices may mean that women and girls have undergone forms of female circumcision, infibulation or Gishiri cutting, a cut through the vaginal entrance into the front wall of the vagina against the pubis that is common in parts of Africa. In some cases this may cause scarring that could potentially contribute to obstructed labour and/or obstetric emergencies.

Symptoms
The continual leakage of urine and/or faeces caused by obstetric fistula means that the woman is constantly wet and soiled with an unpleasant odour. This condition can lead to other complications such as infection, kidney disease, genital ulceration and sores, dehydration, pain, damage to vaginal tissue making sexual intercourse impossible or painful, and secondary infertility.

Social and psychological impact of obstetric fistula
Obstetric fistula can have immense social and psychological consequences for the affected women. Since the woman is constantly wet and soiled with a strong, unpleasant smell, she may be socially isolated, stigmatised and discriminated against. She may be excluded from religious practices in the community as being unclean and rejected by both her family and the community. Washing and hygiene is a problem in desert or very dry regions of the world, where water may need to be carried from miles away and is therefore a valuable product that cannot be wasted on frequent washing. Many of these women cannot simply turn on a tap to obtain unlimited water for hygiene.

Being a wife and mother is considered the main role of women in these societies. The inability to have sexual intercourse due to vaginal damage and scarring as well as the unpleasantness of sexual relations due to the leakage and strong smell mean that many husbands divorce and abandon their wives, leaving them alone in extreme poverty without any means of subsistence. The women may also be subjected to both physical and verbal abuse, causing great distress. The death of the unborn child for whom they may still be grieving and the failure to produce other living children also create deep psychological scars in these women. Their important social role in the community as a mother raising children has also been taken away from them.

Stigma
Stigmas and taboos are still associated with incontinence worldwide and particularly in developing countries. Reducing this stigma attached to incontinence would also help prevent these women suffering from incontinence due to obstetric fistula from being rejected by their society.

Treatment
The aim of treatment for obstetric fistula is to:

  • close the hole surgically,
  • achieve continence,
  • restore normal sexual life and fertility,
  • ensure safe delivery in the future
  • reintegrate the patient back into the community.

Successful repair of obstetric fistulas can lead to a dramatic change in the woman’s quality of life. Fistula repair is best carried out by experienced fistula surgeons and at a dedicated fistula centre. Surgical repair ideally has to be successful at the first attempt since the best surgical results are usually obtained with the first repair. Second and third attempts are associated with lower success rate and higher risk of complications. Since follow-up healthcare is essential for lasting results, it is important to have dedicated, skilled surgeons permanently stationed at the location, backed up by trained nurses and physiotherapists. Current problems regarding treatment include: too few locally-based, skilled surgeons, particularly those trained to treat complicated cases, too few medical centres and hospitals and a lack of medical supplies, equipment and the maintenance of this equipment. A lack of follow-up may result in a failure to treat continuing incontinence, to detect complications and to rehabilitate the patient.

Complications
There are many possible complications of obstetric fistula and/or complications of fistula repair and include:

  • recurrent fistula that increases with complicated cases:
    • success rate of uncomplicated à 70-80%
    • success rate of complicated fistula à 50-60%
  • infections: wound, urinary tract infections,
  • other bladder symptoms (overactive bladder, incomplete voiding,)
  • sexual problems
  • obstruction to kidney drainage
  • bladder contracture
  • vaginal narrowing
  • obstruction to bladder drainage, nerve complications (drop-foot)
  • psychological trauma (social isolation, divorce).

Rehabilitation and reintegration into the community
Some women may have been living with fistula for many years, isolated from their community and living in abject poverty. Following fistula repair, they may need a great deal of help in rehabilitating and reintegrating into the community, Acceptance by the community once again will allow the women to participate again in social and religious life. They may be able to marry again and have children, thereby restoring their social status. Rehabilitation projects can help the patient get back her life, restore her self-confidence and provide her with the means and skills to earn money to support herself and her family, thereby regaining or improving her economic status and ensuring a long-term source of income.

Prevention
The immense number of obstetric fistulas occurring in developing countries is of great concern, particularly since they are preventable if the right facilities are in place. Since surgical repair is not always successful even in the very best hands, prevention is paramount. However, prevention means tackling the many different factors which contribute to their widespread occurrence. These factors include:

  • access to skilled maternity healthcare close to the community, such as maternity waiting homes
  • easy access to emergency caesarean section for women in obstructed labour
  • better training of locally based nurses, midwives, doctors and surgeons
  • national and regional policy on maternity care
  • ensuring that healthcare and transportation to healthcare facilities are affordable, with financial support schemes for those needing treatment for fistula
  • ensuring that the necessary infrastructure is in place to facilitate access to medical centres
  • providing girls and women with formal education, including health education concerning family planning, pregnancy and childbirth
  • involvement of the whole local community, including men, in promoting fistula awareness
  • training traditional birth attendants so that they understand the risks of obstructed labour and know what action must be taken
  • raising the legal age of marriage to prevent child pregnancy
  • combating poverty in the developing world.

References

De Ridder D, Badlani GH, Browning A, et al. Fistulas in the developing world. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence, 4th ed.Paris: Health Publications Ltd. UK; 2009. pp. 1419–1458. Singh S, Chandhiok N, Singh Dhillon B. Obstetric fistula in India: current scenario. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Dec;20(12):1403-5. Epub 2009 Sep 30. Safan A, Shaker H, Abdelaal A, Mourad MS, Albaz M. Fibrin glue versus martius flap interpositioning in the repair of complicated obstetric vesicovaginal fistula. A prospective multi-institution randomized trial. Neurourol Urodyn. 2009 May 27 De Ridder D. Vesicovaginal fistula: a major healthcare problem. Curr Opin Urol. 2009 Jul;19(4):358-61. Hassan MA, Ekele BA. Vesicovaginal fistula: Do the patients know the cause? Ann Afr Med. 2009 Apr-Jun;8(2):122-6.. Elneil S, Browning A. Obstetric fistula--a new way forward. BJOG. 2009 Oct;116 Suppl 1:30-2.

Links:
WHO Reproductive Health:
UNFPA
Campaign to End Fistula UNFPA
EngenderHealth
Campaign to End Fistula
Worldwide Fistula Fund
Worldwide Fistula Fund UK
The Fistula Foundation

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