Obstetric fistulas

Common in developing countries, obstetric fistulas affect mainly young women, as Ozge Tuncalp and Eddie Sze explain

Imagine you are a 14 year old girl in a society where you are considered mature enough to get married. Imagine you are 15 years old with a belly getting larger every day, and all you can do is try to get used to the idea of becoming a mother. Imagine you are almost 16 and your body is enduring relentless pain, and you wonder how much more you can endure. Just the thought of seeing your little baby soon keeps you going. After several days, there is still no baby. But the pain keeps coming. And then ...

PETER BARKER/PANOS

Over 2 million women have obstetric fistulas.
The women are usually young and very poor

Some of you may assume that this story has a happy ending. Unfortunately for over 2 million women in developing countries, it is just the beginning of a nightmare. Because they have experienced one of the worst complications of childbirth, obstetric fistula—a complication which has been long forgotten in the Western world.

An obstetric fistula is an opening between the vagina and an adjacent organ. Most often it involves the bladder and affects young women who experienced obstructed labour for a prolonged period of time.¹

During normal labour, the anterior vaginal wall, bladder base, and urethra are displaced upward and are compressed between the fetal head and the posterior pubis. This compression causes ischaemia. Soft tissues can recover if the ischaemia lasts for only a relatively short period of time. However, when labour and soft tissue compression continue for days withoutrelief, the ischaemia causes permanent injury. The injuried tissues become necrotic and slough off after three to 10 days,² forming a fistula between the vagina and the bladder. The risk of tissue injury is directly proportional to the length of compression.²

Unclean and ostracised

The results of obstructed labour can be devastating. The baby and mother may both die. If the mother is fortunate enough to survive she may develop a fistula. These women suffer not only from constant leaking of urine, irritation, and terrible odour, they are also considered unclean and are often ostracised from their families andcommunity and abandoned by their husbands.

There are many reasons why obstetric fistula is so prevalent in developing countries. Women often marry at a very young age and begin childbearing before their growth is completed. In countries like Nigeria 90% of girls are married before menarche.³ Many of these young women also have a contracted pelvis because of malnutrition and infection.⁴ Another contributing factor is that many developing countries do not have enough hospitals and obstetricians, which is often exacerbated by a lack of transportation and roads.⁵ Even when such care is available, women often choose to go to traditional healers.

A growing problem

The World Health Organization estimates that some 2 million women have obstetric fistulas. And each year, another 50 000 to 100 000 are affected. Most of these women are young, very poor, and living in developing countries.¹

Is there any solution to this devastating problem? According to a report by the United Nations Population Fund (UNFPA), the solution lies in both prevention and treatment.¹

Vesicovaginal fistulas can be surgically repaired even after many years. Over 90% of vesicovaginal fistulas can be closed successfully, often in as little as 20-30 minutes of operating time.⁶ The success rate for a primary repair is 88-93%.¹ Recurrent fistulas are more difficult to repair, and the success rate declines with each additional attempt.

The sad part is that most young women living with fistulas today are either unaware that treatment is available or cannot afford the surgery. By Western standards fistula repair is surprisingly affordable. According to Naren Patel, former vice president of the International Federation of Gynecologists and Obstetricians (FIGO), repairing a fistula costs around $350 (£195; €293), ranging from $100 to $400.

Fistula repair alone, however, will not completely restore the lives of these young women. According to Ann Ward, an obstetrician and gynaecologist in southeast Nigeria, another important part of the healing process is to persuade these young women that the fistula occurred not because they are bad people but because they could not get to a hospital in time for a caesarian section.

Prevention entails postponing marriage and childbearing for very young girls, assuring adequate nutrition and care, and providing access to adequate medical care for all pregnant women. Such fundamental changes to established customs take time, financial assistance from external sources, and education.

So what is the world doing about obstetric fistulas? Many non-governmental and charitable organisations have recruited doctors from developed countries to donate their time and expertise to help these women. But the most comprehensive approach so far was launched in November 2002 by UNFPA, FIGO, and the Averting Maternal Death and Disability Program of Columbia University and new partners like EngenderHealth and African Medical and Research Foundation. This initiative is a comprehensive programme to combat obstetric fistula in 12 subSaharan countries in Africa including Benin, Chad, Ethiopia, Kenya, Malawi, Mali, Mozambique, Niger, Nigeria, Tanzania, Uganda, and Zambia. This initiative focuses on raising awareness within communities on the causes and consequences of obstetric fistulas, assessing critical needs, empowerment of women, and providing financial and technical support to existing fistula treatment centres in these 12 countries.

Ozge Tuncalp6th year medical student, Istanbul Medical School
Email: ozgetuncalp@hotmail.com

Eddie H M Sze associate professor Department of Obstetrics and Gynecology, Yale School of Medicine
Email: ozgetuncalp@hotmail.com


studentBMJ 2004;12:177-220 May ISSN 0966-6494

1. UNFPA Campaign To End Fistula Fact Sheets: www.unfpa.org/fistula/
2. Cron,J. Lessons From The Developing World: Obstructed Labor and The Vesico-Vaginal Fistula. Medscape General Medicine 2003; 5(3).
3. Murphy M. Social consequences of vesico-vaginal fistula in northern Nigeria. J Biosoc Sci. 1981;13:139-150.
4. Elkins, TE. Surgery for the obstetric vesicovaginal fistula: a review of 100 operations in 82 patients. Am J Obstet Gynecol. 1994;170:1108-1120.
5. Wall, L. Fitsari'Dan Duniya: An African (Hausa) Praise Song About Vesicovaginal Fistulas. OBGYN 2002; 100(6):1328
6. Arrowsmith S, Hamlin EC, Wall LL. "Obstructed Labor injury complex": Obstructed fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Obstet Gynecol Surv 1996;51:568-74.

1. United Nations Population Fund www.unfpa.org
2. Hamlin Fistula Relief and Aid Fund www.fistulatrust.org
3. Matercare International www.matercare.org
4. International Federation of Gynecology and Obstetrics www.figo.org
5. World Health Organization www.who.int
6. Engenderhealth www.engenderhealth.com
7. FIGO endorsed Women's Health Portal www.obgynworld.com