Obstetric Fistula

Often described as the world’s oldest and greatest hidden epidemic, obstetric fistula affects over two million women in developing countries.^[1] This article provides a brief introduction to this underreported cause of immense physical and psychological trauma.

Definition

Broadly defined, a fistula is an abnormal connection between an internal organ and any other structure. Obstetric fistula is a connection, that is, a hole that develops between the bladder and vagina (vesicovaginal), or rectum and vagina (rectovaginal), as a result of prolonged, untreated, obstructed labor, which often ends with the eventual delivery of a stillborn child.

Implications

Obstetric fistulas are chronic if untreated, and afflicted women suffer from uncontrollable vaginal leakage of urine, feces, or both. This constant leakage of bodily waste causes irritation to the skin and surrounding tissues, which can result in damage to the kidneys, bladder, or other nearby organs. Women suffering from obstetric fistulas also commonly face social ostracism. Rectovaginal fistulas are given a disability weight of .430 for DALY (Disability-Adjusted Life Year) calculations. ^[2]

Causes

Obstetric fistulas are caused by untreated, obstructed labor. Prolonged pressure of a baby’s head on a mother’s pelvis during child labor causes pelvic tissue to die, leading to the formation of a fistula. The average duration of labor for fistula patients is four days, though a duration of one day is long enough for a fistula to develop. Other causes of fistulas in a woman’s pelvic area include traditional “medical” practices such as cutting, coital injury (especially among young girls), violent rape, ritual cleansing, STDs, and cancer. ^[3]

Prevention

Obstetric fistula is almost always preventable. Obstructed labor occurs when the baby cannot pass through the woman’s birth canal, either because it is ill-positioned, or because the woman’s pelvis is not wide enough. Postponing child bearing until the woman’s pelvis has fully developed is one way to lower the risk of obstructed labor. To prevent obstructed labor from leading to fistula, the baby must be delivered via Cesarean section before a fistula develops. Major prevention activities are centered around alerting women and medical personnel to the warning signs for obstructed labor, and improving access to emergency obstetric services. Refer to the Intervention section for details on specific efforts.

Treatment

Approximately 90% of obstetric fistula cases are surgically repairable,^[4] with costs ranging between $100^[5] and $450.^[6] Once medical care is complete, psychological treatment is usually needed to help women socially reintegrate.

There are numerous challenges in providing effective treatment. For example, on the surgical level, medical personnel must have appropriate training, health facilities must be available, accessible, and well-equipped, appropriate follow-up must be ensured, and treatment for postsurgical incontinence must be provided. On the psychological and social level, programs should be established and implemented to provide counseling and support for women to overcome the trauma and stigma associated with obstetric fistula.^[5]

Prevalence and Most Vulnerable Populations

Cases of obstetric fistula are no longer common in mid and high income countries, but are still quite common in low income countries. Specifically, fistulas are most prevalent in Africa, Asian and Pacific countries, and isolated regions of Latin America. ^[7] The higher rates in low income countries are likely due to poorer access to obstetric care, lower rates of attended childbirths (in many countries, women are expected to give birth alone), and higher rates of pregnancy among women in their early teens, whose pelvic bones have not yet fully developed. Risk factors for obstetric fistula include shortness in height, low weight, low level of education, rural location, lack of prenatal care, and low socioeconomic status.^[8]

Additional research is necessary to determine an accurate report of prevalence, but estimates generally indicate that between 2 million ^[9] and 3.5 million women suffer from obstetric fistula with an estimated 100,000 new cases each year. ^[10] Accurate estimates are difficult to obtain due to the severe stigma related to the condition, with underreporting likely. In Ethiopia alone, estimates are as high as 1 million cases.iv Northern Nigeria and Pakistan also carry a large burden of the disease, with estimates approaching 1 million and 700,000 in these regions, respectively. ^[11]

Interventions

Aid organizations working to prevent and repair fistulas are engaged in a wide variety of activities including increasing public awareness of the problem, providing family planning access and education, funding hospitals and specialty centers to provide emergency obstetric care and corrective operations, training surgeons in fistula repair procedures, and funding research to increase knowledge of the subject.

Specific organizations devoted to fistula prevention and treatment include: Fistula Foundation, Bugando Medical Centre, West Africa Institute, EngenderHealth, Worldwide Fistula Fund, Women's Dignity Project, Operation OF, One by One, and UNFPA (End Fistula Campagin)

References

1. ↑ What is fistula? The Fistula Foundation Website. 2009. Available at http://www.fistulafoundation.org/aboutfistula/. Accessed March 22, 2010.
2. ↑ The International Bank for Reconstruction and Development and The World Bank, “Global Burden of Disease and Risk Factors,” 2006.
3. ↑ Other causes of vesicovaginal fistula. Worldwide Fistula Fund Website. 2009. Available at http://www.worldwidefistulafund.org/fistulafund/othercauses.jsp. Accessed March 22, 2010.
4. ↑ Fistula. EngenderHealth Website. 2010. Available at http://www.engenderhealth.org/our-work/maternal/fistula.php. Accessed March 22, 2010.
5. ↑ ^{5.0 5.1} United Nations Population Fund (UNPF) and Engender Health, “Obstetric Fistula Needs Assessment Report: Finding From Nine African Countries.” 2003; 4.
6. ↑ Fistula Fast Facts and Frequently Asked Questions Fistula Foundation Website 2010. Available at http://www.fistulafoundation.org/aboutfistula/faqs.html. Accessed March 28, 2010.
7. ↑ Cook, R., and B. Dickens. “Obstetric Fistula: The Challenge to Human Rights.” International Journal of Gynecology and Obstetrics. 2004; 87: 72-77.
8. ↑ United Nations Population Fund (UNPF) and Engender Health, “Obstetric Fistula Needs Assessment Report: Finding From Nine African Countries.” 2003; 4.
9. ↑ UNPF and Engender Health.
10. ↑ Muleta, M. “Obstetric Fistula in Developing Countries: A Review Article.” Journal of Obstetrics and Gynaecology Canada. 2006; 28 (11): 962-66. Wall.
11. ↑ Muleta.