| Obstetric fistula | |
|---|---|
| Classification and external resources | |
| ICD-10 | N82 |
| ICD-9 | 619 |
| MeSH | D014624 |
Obstetric fistula (or vaginal fistula) is a severe medical condition in which a fistula (hole) develops between either the rectum and vagina (see rectovaginal fistula) or between the bladder and vagina (see vesicovaginal fistula) after severe or failed childbirth, when adequate medical care is not available.
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The resulting disorders typically include incontinence, severe infections and ulcerations of the vaginal tract, and often paralysis caused by nerve damage. Sufferers from this disorder are usually also subject to severe social stigma due to odor, perceptions of uncleanliness, a mistaken assumption of venereal disease and, in some cases, the inability to have children.
The fistula usually develops when a prolonged labor presses the unborn child so tightly in the birth canal that blood flow is cut off to the surrounding tissues, which necrotise and eventually rot away. More rarely, the injury can be caused by female genital cutting, poorly performed abortions, or pelvic fractures.
Other potential direct causes for the development of obstetric fistula are sexual abuse and rape, especially within conflict/post-conflict areas, other surgical trauma, gynecological cancers or other related radiotherapy treatment and, perhaps the most important, limited or no access to obstetrical care or emergency services.
Distal causes that can lead to the development of obstetric fistula concern issues of poverty, lack of education, early marriage and childbirth, the role and status of women in developing countries, and harmful traditional practices and sexual violence. Poverty, early marriage, and lack of education place women in positions of severe disadvantage and do not enable them to be advocates for their own health and wellbeing.
Access to obstetric emergency care is one of the major challenges in preventing the development of obstetric fistula. The availability and access to medical facilities that have a trained staff and specialized surgical equipment needed for cesarean births is very limited in certain parts of the world. Factors that may heavily influence an individual's ability or decision to access this emergency care can involve everything from general fear and mistrust of hospitals and healthcare workers, a lack of equipped facilities and trained staff, economic constraints, religious beliefs and practices, cultural norms, and previous birth experiences.
In terms of cultural factors surrounding the birthing process, opinions and practices vary all over the world. In many developing countries, giving birth at home with the assistance of an elder woman or traditional birth attendant is considered the preferred and respected way to give birth. Some consider this point to be controversial and see it more as an economic access issue instead of a cultural issue. Seeking out the option of surgery versus a vaginal birth, in certain places, is also thought to be less womanly and unnatural. This negative perception of surgery can greatly influence a woman's decision to not seek out emergency obstetrical treatment.
Other factors surrounding a woman's ability and choice to access obstetrical care can be rooted in the nature of her relationship with her male partner or male decision makers within her family. This can affect the kind of care and assistance women receive during child labor. In many instances, receiving treatment from a male physician is not pursued or considered a real option due to the religious or cultural violations connected with a male treating a woman who is not his wife or intimate partner. This is an opinion held by both men and women in various parts of the world.
Yet another causal factor is that of logistical access to health care clinics. Many women who suffer from this condition are living in very rural areas and, therefore, access to emergency services often requires some form of travel. The availability of transportation, cost of transportation and road construction can all play a crucial role in the ability of pregnant women to access emergency obstetrical services.
The availability and access to medical facilities that have a trained staff and specialized surgical equipment needed for cesarean births is also very limited in certain parts of the world. In many instances, women do not consider their local hospitals and clinics to be places where they could ever seek such care and therefore do not go when there is an obstetrical emergency.
Primary risk factors are early or closely spaced pregnancies and lack of access to emergency obstetric care; a 1993 study in Nigeria found that 55 percent of the victims were under 19 years of age, and 94 percent gave birth at home or in poorly equipped local clinics. When available at all, cesarean sections and other medical interventions are usually not performed until after tissue damage has already been done.
Early marriage, domestic violence, female genital mutilation, malnutrition which is linked to under-development of the female body, and lack of education/illiteracy also put women at great risk for developing obstetric fistula. Lack of personal knowledge about and experience with childbirth may also put a woman at risk to developing obstetric fistula, especially for women who have previously experienced limited complications with past vaginal births. Women giving birth for the first time and with no real knowledge regarding childbirth may not recognize an emergency situation/complication and therefore not seek out help.
Countries that suffer from poverty, civil and political unrest or conflict, and other dangerous public health issues such as malaria, HIV/AIDS, and tuberculosis often suffer from a severe burden and breakdown within the healthcare system. This breakdown puts many people at risk, specifically women. Many hospitals within these conditions suffer from shortages of staff, supplies, and other forms of necessary medical technology that would be necessary to perform reconstructive obstetric fistula repair.
Prevention comes in the form of access to obstetrical care, support from trained health care professionals throughout pregnancy, providing access to family planning, promoting the practice of spacing between births, and supporting women in education and postponing early marriage. Fistula prevention also involves many strategies to educate local communities about the cultural, social, and physiological factors that condition and contribute to the risk for fistula. One of these strategies involve organizing community-level awareness campaigns to educate women about prevention methods such as proper hygiene and care during pregnancy and labour. Prevention of prolonged obstructed labour and fistula should preferably begin as early as possible in each female’s life. For example, improved nutrition and outreach programs to raise awareness about the nutritional needs of female children to prevent malnutrition as well as improve the physical maturity of young mothers, are important fistula prevention strategies. It is also important to ensure access to timely and safe delivery during childbirth; measures include availability and provision of emergency obstetric care as well as quick and safe caesarean sections for women in obstructed labour. Midwives located in the local communities where fistula is prevalent can also contribute to promoting health practices that help prevent future development of obstetric fistulas. Promoting education for girls is also a key factor to preventing fistula in the long term.
There are currently several organizations that have developed effective fistula prevention strategies. One of them is the Tanzanian Midwives Association, which works to prevent fistula by improving clinical health care for women and delaying early marriages and childbearing years, as well as help the local communities advocate the rights of females.[1]
Treatment is available through reconstructive surgery. This surgery for uncomplicated cases has a 90% success rate, and success rates for more complicated cases are estimated to be 60% successful. The cost for this procedure, which includes the actual surgery, post-operative care and rehabilitation support, is estimated to be US$300 – $450. Successful surgery enables women to live normal lives and have more children, but it is recommended to have a cesarean section to prevent the fistula from recurring. Post operative care is vitally important to prevent infection.
Some women are not candidates for this surgery, but can seek out alternative treatment called a urostomy and a bag for the collection of urine is worn on a daily basis.
Challenges with regards to treatment include the very high number of women needing reconstructive surgery, access to facilities and trained surgeons, and the cost of treatment. For many women, even $300 US dollars is simply an impossible price and they cannot afford the surgery.
The largest challenge that stands between women and fistula treatment is information. Most women have no idea that treatment is available. Because this is a condition of shame and embarrassment, most women hide themselves and their condition and suffer in silence with no relief.
The largest benefit of surgical treatment is that many women can re-join their families, communities, and societies without shame from their condition because the leaking and smell are no longer present.
Fistula cases can also be treated through urethral catheterisation if identified early enough. The Foley catheter is recommended because it has a balloon to hold it in place. The indwelling Foley catheter drains urine from the bladder. This decompresses the bladder wall so that the wounded edges come together and stay together giving it a greater chance of closing naturally, at least in the smaller fistulas.
According to data collected by Dr Kees Waaldijk, Director of the Nigeria National Fistula Programme, out of a case series of 4424 patients with obstetric fistula who were treated within 75 days post partum, 37% (1579 patients) are cured completely with the use of a Foley catheter without the need of surgery. Even without pre-selecting the least complicated obstetric fistula cases, the systematic use of a Foley catheter by midwives after the onset of urinary incontinence could cure over 25% of all new fistula cases each year without the need for surgery.
If left untreated, ulcerations and infections can persist as well as kidney disease and kidney failure leading to death. Urinal and fecal leaking are the major physical side effects and because many women suffering from obstetric fistula do not want to leak, they will limit their intake of water and other liquids. This can lead to a very dangerous case of dehydration. Nerve damage to the legs is also noted as a medical side effect. In some cases, many women struggle to walk from this nerve damage and need physical therapy following the treatment of the fistula.
Most women living with obstetric fistula also struggle with clinical depression, abandonment by their partners, families and communities, and live in isolation because of the constant leaking and odor. Many women report feelings of humiliation, pain, loneliness, shame and mourning for the loss of their lives and the child they lost during delivery. Because of the constant leaking and smell, many women are isolated from food preparation and prayer ceremonies because they are thought to be constantly unclean. Suicide and attempted suicide are also common amongst women with this condition. Social isolation, increased poverty and decreased employment opportunities due to this condition force many women to turn to commercial sex work and begging.
According to the World Health Organization (WHO), an estimated 50,000 to 100,000 women develop obstetric fistulas each year and over two million women currently live with obstetric fistula.[2] The WHO claims that fistula was largely eradicated in developed countries in the late 19th century; it still affects two to three million women in developing countries.
Obstetric fistula was very common throughout the entire world but virtually disappeared within Europe and North America due to improvements in obstetrical care. The surgery to cure it was developed by J. Marion Sims. To this day, the prevalence of obstetrical fistula is much lower in places that discourage early marriage, encourage and provide education of women, and grant women access to family planning and skilled medical teams to assist during childbirth. This condition is still very prevalent in the developing world, especially in Africa and much of South Asia (Bangladesh, Afghanistan, Pakistan, and Nepal).
During most of the 20th century obstetric fistula was largely missing from the international global health agenda. This is reflected by the fact that obstetric fistula was not included as a topic at the landmark United Nations 1994 International Conference on Population and Development (ICPD). The 194 page report from the ICPD does not include any reference to obstetric fistula. However, since 2003 obstetric fistula has been gaining awareness amongst the general public and has received critical attention from UNFPA, who have organized a global campaign to "End Fistula". New York Times columnist Nicholas Kristof, a Pulitzer-prize winning writer, wrote several columns in 2003, 2005 and 2006 focusing on fistula and particularly treatment provided by Catherine Hamlin at the Fistula Hospital in Ethiopia. Increased public awareness and corresponding political pressure have helped fund the UNFPA's Campaign to End Fistula, and helped motivate the United States Agency for International Development (USAID) to dramatically increase funding for the prevention and treatment of obstetric fistula.
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