Obstetric Fistula



Overview


Obstetric fistula (or vaginal fistula) is a serious medical condition where a fistula (hole) develops between either the rectum and vagina or the bladder and vagina. Obstetric fistula is caused by prolonged childbirth where the pressure of the unborn child in the birth canal cuts off the blood flow to the mother’s internal soft tissue causing it and, at times the child, to die. The dead tissue results in the development of abnormal openings that lead to urinary or fecal incontinence, which causes the uncontrollable passage of urine and feces into the vagina. If left untreated, obstetric fistula can lead to ulcerations and future infections of the kidney, nerve damage, and ultimately death[1] .



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Health Impact


Obstetric Fistula is linked to one of the major causes of maternal mortality: obstructed labor. Though an exact number of those suffering from this condition are unknown and under-reported, the World Health Organization (WHO) estimates that nearly 50,000 to 100,000 women worldwide are affected each year and 2 million women currently live with untreated obstetric fistula[2] . Obstetric Fistula disproportionately affects young, impoverished women and is most prevalent in developing countries, particularly South Asia and Sub-Saharan Africa, where obstetric care/emergency care and treatment is nonexistent and/or inconsistent[3] .

Obstetric Fistula extends well beyond its physical manifestations. The uncontrollable passage of urine and feces produces a foul odor that is difficult to eliminate and hard to ignore. Staying clean becomes a relentless task and women are constantly damp, which leads to reoccurring rashes and infections[4] . Socially, women with obstetric fistula can become stigmatized, isolated from their communities, and deserted by their partners/husbands and families. Seen as “unclean” and their condition as “incurable”, women are often ousted from partaking in daily activities which include religious observances and food preparation. Women also become at increased poverty risk as they face decreased employment opportunities. Social isolation, increased poverty, and decreased employment prospects force many women to turn to commercial sex work and begging[5] .

For many women, the profound social isolation due to obstetric fistula is worse than the physical pain. Many women suffer from clinical depression and report feeling humiliation, loneliness, and shame. The grief of losing a child further exacerbates the feeling of isolation and pain. Thus, suicide and attempted suicide is a common result.


Medical Anthropology Research


Though obstetric fistula has caused devastating effects on women in developing countries, the problem remains overlooked and the provisions needed to resolve the condition have been primarily low on developing countries governmental agendas where obstetric fistula is most prominent[6] [7] . Anthropologists have shed light on this regard by conducting research that addresses: (1) the gap in in the lack of information on the extent of the problem; (2) the absence of comprehension on the underlying causes of obstetric fistula; (2) providing knowledge of treatment capacity for obstetric fistula; and (3) capturing the patient’s experience in dealing with the condition[8] .

Case study: The Campaign to End Fistula: What have we learned? Findings of facility and community needs assessments

Anthropological expertise was utilized to capture information regarding the obstetric fistula problem within 25 countries in Africa and Asia. Information was captured through the use of qualitative and quantitative assessments along with a variety of instruments including needs assessments, key informant interviews, focus groups, and review of medical records. These instruments were key in identifying the situation of obstetric fistula within these countries--which for some--was the first major study on the issue.

The analysis of the assessments contributed in assessing the capacity these countries have in managing the problem and helped identified both existing expertise (e.g. key organizations and individuals) for prevention of obstetric fistula and programmatic gaps (e.g. health system barriers and traditional barriers) that need to be further studied and/or resolved so as to prevent future cases. Additionally, the study identified constraints and the capacity for institutions to provide the necessary and timely preventative services for obstetric fistula and to treat those who have developed the condition (e.g. surgery). Socioeconomic factors (e.g. lack of transportation, developed road systems, geographic locations of clinics) that led to barriers of treatment were also identified within each country, while perceptions of the condition brought to light the psychosocial effects that render women unable to work or able to participate in community life.

The study provided further insight to the broader policy context of obstetric fistula and established a powerful advocacy for mobilizing awareness, political will, and community involvement where there was none. Anthropologists identified that a majority of community members had little knowledge of obstetric fistulas and thought the condition was a result of sorcery or evil spirits. Therefore, communities had a fatalistic attitude toward the condition and ousted women rather than getting them the care they needed. Even when care was provided, it was not comprehensive. Two key elements, rehabilitation and reintegration of women post-operation, were often neglected. Interviews with obstetric fistula patients revealed that in most cases, follow-up care was not undertaken after discharge. The Anthropologists argue that such an aspect needs further emphasis and must be brought to the attention of politicians and doctors alike.






Applied Work


Obstetric fistula can be prevented through adequate prenatal care, where the abnormal progression of labor can be detected and timely interventions can be made before obstructed labor occurs. Use of biomedical technology (e.g. the partograph) by trained birth attendants can prevent prolonged labor and may reduce the need for operative interventions[9] . However, such basic obstetric care is absent throughout most of the developing world and is low on the list of international health care agendas. Most importantly, the health programs that do exist place much importance on providing rudimentary prenatal care and family planning services, all of which have a marginal effect on decreasing maternal and child mortality due to unexpected complications[10] . Thus, there has been little emphasis or awareness placed on what is truly needed in order to prevent obstetric fistulas: the need for emergency interventions. Specifically, there is a need for surgical services to resolve unexpected complications that may occur during labor, including prolonged labor, which can ultimately lead to the development of this condition. However, again, such surgical services are not high on many countries' political agenda[11] .

Anthropologists have played a crucial role in raising awareness towards the increased public health need for surgical reparation and have worked hand-in-hand with Obstetricians, Gynecologists and other public health officials towards increasing greater communication amongst the health community to implement change. A result of raising this awareness has placed fistula on the map. An increasing amount of surgeons from the industrialized world have been traveling to developing countries to perform fistula operations, so much so, that it became apparent that there was a need to develop a uniform plan and code of ethics for how the work of these physicians should proceed. Thus, anthropologists were called upon to assist in a global health initiative to discuss ethical issues surrounding the provision of care to women affected by this child-birth complication and in March of 2007, the American College of Obstetricians and Gynecologists and the Duke Global Health Initiative released the ‘Code of Ethics for Fistula Surgeons’[12] .

Though increased awareness for surgical repatriation is commendable, Anthropologists have also played a critical role in analyzing the effects on such reparations on those women affected, which is often overlooked. Anthropological work has discovered that though the mere surgical repair of a fistula may be successful, it is only but on resolution to a multitude of problems that result from developing the condition. Many women with obstetric fistula develop other injuries, which include vaginal scarring, secondary infertility, and footdrop. Moreover, women must face a long, grueling process of curing their “social injury” through re-establishment of social relationships/partnerships and re-integration to the communities they were ousted from. Thus, anthropologists are contributing towards the identification of what constitutes a “success” in obstetric fistula surgery.[13]

Online Resources


http://www.fistulacare.org/pages/index.php
http://www.engenderhealth.org/our-work/maternal/digital-stories-uganda-fistula.php
www.lovelaborloss.com
http://www.fistulafoundation.org/
http://www.unfpa.org/public/home/mothers/pid/4386


Further Reading


Hamlin Fistula International. Fast facts and FAQS about obstetric fistula. Addis Ababa: Hamlin Fistula Hospital; 2009. Available from:http://www.hamlinfistula.org/what-is-a-fistula/fast-facts-and-faqs.html

Jozwik M.(2000). Clinical classification of vesicouterine fistula. International Journal of Gynecology & Obstetrics. 353-357.

Elkins TE, Thompson JR. Lower Urinary Tract Fistulas. In: Urogynecology and reconstructive pelvic surgery; 2nd ed. Publisher: Mosby; p. 355-366.

Wall LL, Karshima J, Kirschner C, Arrowsmith SD.(2004). The Obstetric Fistula: Characteristics of 899 patients from Jos, Nigeria. AJOG. 1011-1019.

UNFPA and Engender Health.(2003). Obstetric fistula needs assessment report: finding from nine African countries.


References


  1. ^ Creanga, A.A.; Geanadry, R.R. (November, 2007). "Obstetric Fistulas: A clinical review". International Journal of Gynecology & Obstetrics 99 (Supplement 1): S40.
  2. ^ The World Health Organization. (March, 2010). The World Health Organization. Retrieved March 2012, from 10 Facts on Obstetric Fistula: http://www.who.int/features/factfiles/obstetric_fistula/en/.
  3. ^ USAID. (June, 2009). Maternal and Child Health. Retrieved March 2012, from Obstetric Fistula: A devastating injury: http://www.usaid.gov/our_work/global_health/mch/mh/techareas/fistula.html.
  4. ^ UNFPA.(2012). Campaign to end fistula. Retrieved March 2012, from http://www.endfistula.org/public/lang/en/pid/7429.
  5. ^ Wall, L. L. (2006). Obstetric vesicovaginal fistula as an international public-health problem. The Lancet, 1201-1209.
  6. ^ Johnson, K., & Peterman, A. (2008). Incontinence data from the demographic and health surveys: comparative analysis of a proxy measurement of vaginal fistula and recommendations for future population-based data. USAID.
  7. ^ Wall, L. L., & Arrowsmith, S. D. (2007). The "continence gap": a critical concept in obstetric fistula repair. International Urogynecological Journal, 843-844.
  8. ^ Velez, A., Ramsey, K., & Tell, K. (2007). The Campaign to End Fistula: what have we learned? Findings of facility and community needs assessments. International Journal of Gynecology and Obstetrics, 143-150.
  9. ^ Making pregnancy safer -- the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO, Geneva, World Health Organization, 2005. reproductive-health/publications.
  10. ^ Ngoma, Josephine. (2010). Prevention of vesicovaginal fistula. Turku University of Applied Sciences.
  11. ^ UNFPA and Engender Health. Obstetric fistula needs assessment report: finding from nine African countries. 2003. 95 p.
  12. ^ Wall, Lewis, L.; Wilkinson, Jeffrey; Arrowsmith, Steven D.; Ojengbede, Oladosu; Mabeya, Hillary. (2008). A Code of Ethics for the fistula surgeon. International Journal of Gynecology and Obstetrics, 84-87.
  13. ^ Johns Hopkins Bloomberg School of Public Health.(2004). Obstetric fistula: ending the silent, easing the suffering. Baltimore, Maryland: Johns Hopkins Bloomberg School of Public Health. Available from: http://www.k4health.org/system/files/ObstetricFistula.pdf.