Obstetric fistula

Symptoms of obstetric fistula include: • Flatulence, urinary incontinence, or fecal incontinence, which may be continual or only happen at night • Foul-smelling vaginal discharge • Repeated vaginal or urinary tract infections • Irritation or pain in the vagina or surrounding areas • Pain during sexual activity severe ulcerations of the vaginal tract, "foot drop", which is the paralysis of the lower limbs caused by nerve damage, making it impossible to walk, infection of the fistula forming an abscess, Obstetric fistulae have far-reaching physical, social, economic, and psychological consequences for the women affected. According to UNFPA, "Due to the prolonged obstructed labour, the baby almost inevitably dies, and the parent is left with chronic incontinence. Unable to control the flow of urine or faeces, or both, they may be abandoned by their spouse and family and ostracized by their community. Without treatment, their prospects for work and family life are virtually nonexistent." Physical The most direct consequence of an obstetric fistula is the constant leakage of urine, feces, and blood as a result of a hole that forms between the vagina and bladder or rectum. This leaking has both physical and societal penalties. The acid in the urine, feces, and blood causes burn wounds on the legs from the continuous dripping. Nerve damage that can result from the leaking can cause women to struggle with walking and eventually lose mobility. In an attempt to avoid the dripping, women limit their intake of water and liquid, which can ultimately lead to dangerous cases of dehydration. Ulceration and infections can persist, as well as kidney disease and kidney failure, which can each lead to death. Further, only a quarter of women who develop a fistula in their first birth can have a living baby, and therefore have minuscule chances of conceiving a healthy baby later on. Some, due to obstetric fistulae and other complications from childbirth, do not survive. Other sub-Saharan cultures view offspring as an indicator of a family's wealth. A woman who is unable to successfully produce children as assets for her family is believed to make her and her family socially and economically inferior. A patient's incontinence and pain can also render her unable to perform household chores and childrearing as a wife and as a mother, thus devaluing her. Other misconceptions about obstetric fistulae are that they are caused by venereal diseases or are divine punishment for sexual misconduct. As a result, many girls are divorced or abandoned by their husbands and partners, disowned by their families, ridiculed by friends, and even isolated by health workers. to as high as 89%. Moreover, women are sometimes forced to turn to commercial sex work as a means of survival because the extreme poverty and social isolation that result from obstetric fistulae eliminate all other income opportunities. With only 7.5% of women with fistulae able to access treatment, the vast majority of women end up with the consequences of obstructed and prolonged labor simply because options and access to help is so limited. Psychological Some common psychological consequences that women with a fistula face are the despair from losing their child, the humiliation from their smell, and the inability to perform their family roles. Obstetric fistula is not only debilitating physically, but also emotionally. A woman is presented with an array of psychological trauma that she must oftentimes deal with herself unless provided with ample resources. Oftentimes ostracized by her community, a woman with an obstetric fistula tends to face these issues on her own. In a study of The lived experience of Malawian women with obstetric fistula, the immense psychological trauma is addressed: "For these women, internalizing this constant struggle leads to psychological morbidity." It was striking how many women discussed constant sadness and giving up hope in their interviews." Although the psychological impacts center around the woman experiencing the fistula, others around them, and especially loved ones, feel the impact as well. The same study references this: "This attitude was often shared by their family members, both husbands and female relatives." Among women with obstetric fistula from Bangladesh and Ethiopia, 97% screened positive for potential mental health dysfunctions, and about 30% had major depression. ==Risk factors==

In less-developed countries, obstetric fistulae usually develop as a result of prolonged labor when a caesarean section cannot be obtained. Over the course of the three to five days of labor, the unborn child presses against the mother's vagina very tightly, cutting off blood flow to the surrounding tissues between the vagina and the rectum and between the vagina and the bladder, causing the tissues to disintegrate and rot away. and pelvic fracture, cancer, or radiation therapy targeted at the pelvic area, inflammatory bowel disease (such as Crohn's disease and ulcerative colitis). Other potential causes for the development of obstetric fistulae are sexual abuse and rape, especially in conflict/postconflict areas, and other trauma, such as surgical trauma. In the developed world, such as the US, the primary cause of obstetric fistulae, particularly rectovaginal fistulae, is the use of episiotomy and forceps. Primary risk factors include early or closely spaced pregnancies and lack of access to emergency obstetric care. For example, a 1983 study in Nigeria found that 54.8% of the women affected were under 20 years of age, and 64.4% gave birth at home or in poorly equipped local clinics. Poverty Poverty is the main indirect cause of obstetric fistulae around the world. As obstructed labor and obstetric fistulae account for 8% of maternal deaths worldwide and "a 60-fold difference in gross national product per person shows up as a 120-fold difference in maternal mortality ratio," impoverished countries produce higher maternal mortality rates and thus higher obstetric fistula rates. Furthermore, impoverished countries not only have low incomes, but also lack adequate infrastructure, trained and educated professionals, resources, and a centralized government that exist in developed nations to eradicate obstetric fistulae effectively. According to UNFPA, "Generally accepted estimates suggest that 2.0-3.5 million women live with obstetric fistulae in the developing world, and between 50,000 and 100,000 new cases develop each year. All but eliminated from the developed world, obstetric fistula continues to affect the poorest of the poor: women and girls living in some of the most resource-starved remote regions in the world." Malnutrition One reason that poverty produces such high rates of fistula cases is the malnutrition that exists in such areas. as well as vulnerability to diseases that exist in impoverished areas because of limited basic health care and disease prevention methods, cause inhabitants of these regions to experience stunted growth. Sub-Saharan Africa is one such environment where the shortest women have, on average, lighter babies and more difficulties during birth when compared with full-grown women. This stunted growth causes expectant mothers to have skeletons unequipped for proper birth, such as an underdeveloped pelvis. Lack of healthcare Even women who do make it to the hospital may not get proper treatment. 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 have shortages of staff, supplies, and other forms of medical technology that would be necessary to perform reconstructive obstetric fistula repair. There is a shortage of doctors in rural Africa. Studies find that the doctors and nurses who do exist in rural Africa often do not show up for work. Poverty hinders women from being able to access normal and emergency obstetric care because of long distances and expensive procedures. For some women, the closest maternal care facility can be more than 50 km away. In Kenya, a study by the Ministry of Health found that the "rugged landscape, long distances to health facilities, and societal preferences for delivery with a traditional birth attendant contributed to delays in accessing necessary obstetric care." Emergency cesarean sections, which can help avoid fistulae caused by prolonged vaginal deliveries, are very expensive. Status of women In developing countries, women who are affected by obstetric fistulae do not necessarily have full agency over their bodies or their households. Rather, their husbands and other family members have control in determining the healthcare that the women receive. For example, a woman's family may refuse medical examinations for the patient by male doctors, but female doctors may be unavailable, thus barring women from prenatal care. Furthermore, many societies believe that women are supposed to suffer in childbirth, and thus are less inclined to support maternal health efforts. ==Prevention==

Prevention is the key to ending fistulae. UNFPA states that, "Ensuring skilled birth attendance at all births and providing emergency obstetric care for all women who develop complications during delivery would make fistula as rare in developing countries as it is in the industrialized world." Prevention of prolonged obstructed labor and fistulae should preferably begin as early as possible in each woman's life. For example, improved nutrition and outreach programs to raise awareness of children's nutritional needs 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 the availability and provision of emergency obstetric care, as well as quick and safe cesarean sections for women in obstructed labor. Some organizations train local nurses and midwives to perform emergency cesarean sections to avoid vaginal delivery for young mothers who have underdeveloped pelvises. These survivors help current patients, educate pregnant mothers, and dispel cultural myths that obstetric fistulae are caused by adultery or evil spirits. Successful ambassador programs are in place in Kenya, Bangladesh, Nigeria, Ghana, Côte d'Ivoire, and Liberia. Several organizations have developed effective fistula prevention strategies. One, the Tanzanian Midwives Association, works to prevent fistulae by improving healthcare for women, encouraging the delay of early marriage and childbearing, and helping the local communities to advocate for women's rights. ==Treatment==

in Ethiopia are all treated free of charge. Surgery The nature of the injury varies depending on the size and location of the fistula, so a surgeon with experience is needed to improvise on the spot. Before the person undergoes surgery, treatment and evaluation are needed for conditions including anemia, malnutrition, and malaria. Quality treatment in low-resource settings is possible (as in the cases of Nigeria and Ethiopia). Primary fistula repair has a 91% success rate. and the cost for the entire procedure, which includes the actual surgery, postoperative care, and rehabilitation support, is estimated to cost $300–450. Initial surgeries done by inadequately trained doctors and midwives increase the number of follow-up surgeries that must be performed to restore full continence. Besides physical treatment, mental health services are also needed to rehabilitate fistula patients, who experience psychological trauma from being ostracized by the community and from fear of developing fistulae again. A study on the first formal counseling program for fistula survivors in Eritrea demonstrated positive results, whereby counseling significantly improved women's self-esteem, knowledge about fistulae and fistula prevention, and behavioral intentions for "health maintenance and social reintegration" following surgery. Challenges Challenges concerning 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, US$300 is a price they cannot afford. Access and availability of treatment also vary widely across different sub-Saharan countries. Certain regions also lack maternal care clinics that are equipped, willing to treat fistula patients, and adequately staffed. At the Evangelical Hospital of Bemberéke in Benin, only one expatriate volunteer obstetrics and gynecology doctor is available a few months per year, with one certified nurse and seven informal hospital workers. In all of Niger, two medical centers treat fistula patients. The world is currently severely under capacity for treating the problem; it would take up to 400 years to treat the backlog of patients. plus an increase in financial support and an even higher number of certified doctors, midwives, and nurses needed. Another challenge standing 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. In addition, after receiving initial treatment, health education is important to prevent fistulae in subsequent pregnancies. Another challenge is the lack of trained professionals to provide surgery for fistula patients. As a result, nonphysicians are sometimes trained to provide obstetric services. For example, the Addis Ababa Fistula Hospital has medical staff without formal degrees, and one of its top surgeons was illiterate. She had been trained over the years and now performs successful fistula surgery regularly. Catheterization Fistula cases can also be treated through urethral catheterization 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 fistulae. About 37% of obstetric fistulae treated within 75 days after birth with a Foley catheter resolve. Even without preselecting the least complicated obstetric fistula cases, a Foley catheter by midwives after the onset of urinary incontinence could treat over 25% of all new fistulae. ==Epidemiology==

Obstetric fistulae are common in the developing world, especially in sub-Saharan Africa (Kenya, Mali, Niger, In particular, most of the two million-plus women in developing nations who develop obstetric fistulae are under the age of 30. Obstetric fistulae were very common throughout the world. Since the late 19th century, the rise of gynecology has developed safe practices for childbirth, including giving birth at local hospitals rather than at home, which dramatically reduced rates of obstructed labor and obstetric fistulae in Europe and North America. Adequate population-based epidemiological data on obstetric fistulae are lacking due to the historic neglect of this condition since it was mostly eradicated in developed nations. Available data estimates should be viewed with caution. About 30% of women over age 45 in developed nations are affected by urinary incontinence. The rate of obstetrical fistulae is much lower in places that discourage early marriage, encourage and provide general education for women, and grant women access to family planning and skilled medical teams to assist during childbirth. ==History==

Evidence of obstetric fistula dates back to 2050 BCE, when Queen Henhenit had a fistula. Obstetric fistulae were first described by various Egyptian documents known as the papyri. These documents, including rare medical engravings, were found in the entrance of a tomb located in the necropolis of Saqquarah, Egypt. The tomb belonged to an unknown physician who lived during the 6th dynasty. The translation of this document became possible with the discovery of the Rosetta stone in 1799. In 1872, the Ebers papyrus was discovered in a mummy from the Theban acropolis. This papyrus, 65 feet long, 14 inches wide, consisting of 108 columns each about 20 lines, now resides in the library at the University of Leipzig. The gynecological reference in this papyrus addresses uterine prolapse. At the end of page three, there seems to be a mention of the vesicovaginal fistula, warning the physician against trying to cure it, saying, "prescription for a woman whose urine is in an irksome place: if the urine keeps coming and she distinguishes it, she will be like this forever." This seems to be the oldest reference to vesicovaginal fistula, one which articulates the storied history of the problem. James Marion Sims, in 1852 in Alabama, developed an operation for fistula. He worked at the New York Women's Hospital. ==Society and culture==

During most of the 20th century, obstetric fistulae were largely missing from the international global health agenda. This is reflected by the fact that the condition 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 fistulae. In 2000, eight Millennium Development Goals were adopted after the United Nations Millennium Summit to be achieved by 2015. The fifth goal of improving maternal health is directly related to obstetric fistula. Since 2003, obstetric fistula has been gaining awareness amongst the general public and has received critical attention from UNFPA, who has 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. In 2007, Fistula Foundation, Engel Entertainment, and several other organizations, including PBS NOVA, released the documentary film, A Walk to Beautiful, which traced the journey of five women from Ethiopia who sought treatment for their obstetric fistulae at the Addis Ababa Fistula Hospital in Ethiopia. The film still airs frequently on PBS in the U.S. and is credited with greatly increasing awareness of obstetric fistulae. Increased public awareness and corresponding political pressure have helped fund the UNFPA's Campaign to End Fistula. They helped motivate the United States Agency for International Development to dramatically increase funding for the prevention and treatment of obstetric fistulae. Countries that signed the United Nations Millennium Declaration have begun adopting policies and creating task forces to address issues of maternal morbidity and infant mortality, including Tanzania, Democratic Republic of Congo, Sudan, Pakistan, Bangladesh, Burkina Faso, Chad, Mali, Uganda, Eritrea, Niger, and Kenya. Laws to increase the minimum age for marriage have also been enacted in Bangladesh, Nigeria, and Kenya. To monitor these countries and hold them accountable, the UN has developed six "process indicators", a benchmark tool with minimum acceptable levels that measures whether or not women receive the services they need. One of the UNFPA's initiatives to reduce the cost of transportation in accessing medical care provided ambulances and motorcycles for women in Benin, Chad, Guinea, Guinea-Bissau, Kenya, Rwanda, Senegal, Tanzania, Uganda, and Zambia. The OFWG improves awareness for prenatal and neonatal care and develops strategies for clinically managing obstetric fistula cases. Community organizations People recovering from a fistula in the postoperative period need support to achieve full reintegration into society. In particular, physical labor is limited in the first year of recovery, so women need alternative ways to earn an income. Another organization, IAMANEH Suisse, identifies Malian fistula patients, facilitates operations for those without the financial means, and helps them access follow-up services to prevent recurrence of fistulae in their subsequent pregnancies. Other organizations also help arrange mission trips for medical personnel to visit countries with women affected by fistulae, perform surgeries, and train local doctors to give medical assistance for fistula patients. The International Organization for Women and Development (IOWD) is one such nonprofit organization. The IOWD hosts four to five mission trips per year to provide relief to obstetric fistula patients in West Africa. IOWD mission trip members have evaluated thousands of patients at no cost and performed surgeries for over a thousand women. The World Health Organization has created a manual articulating necessary principles for surgical and pre- and post- operative care regarding obstetric fistula, providing a beneficial outline for affected nations. Treatment centers are crucial for the survival of obstetric fistula patients and well-equipped centers help the emotional, physical, and psychological aspects of their lives. == See also ==