“When I reflect back over the years, certain faces come swimming unbidden out of the tide of memory. Even though everyone’s story was amazing, some were even more so. One young woman arrived at the hospital and handed us an envelope with a letter inside that had been written by a missionary doctor down near the Kenyan border. It introduced her and asked us to treat her fistula. There was nothing especially unusual about her. Like so many of our patients, she was dressed in rags and weak from hunger. The sealed envelope was so worn and grubby you could hardly read it, but inside the letter was clear and legible enough. To our surprise it had been dated seven years ago.
“Why has it taken you seven years to get here?” I asked. She told me she had been begging at the bus station for her fare. That was how long it took to raise the money.”
The Hospital by the River—a Story of Hope by Dr. Catherine Hamlin with John Little
I just finished my paper on obstetric fistula. I'm sure it could have been better but I must say I've learned so much along the way about the plight of the poor women afflicted with this devastating condition. Dr. Catherine and Reginald Hamlin are PIONEERS in fistula repair and opened the greatest fistula hospital in Ethiopia in the late 1950's. To this day Dr. Catherine Hamlin still works there and in 2007 they opened a midwifery school to help train birth attendants to prevent prolonged labor.
Follow below to read my paper.
A fistula is “an abnormal communication between two or more epithelial surfaces” (Clement & Hilton, 2001). An obstetric fistula is an abnormal communication between the bladder and the vagina and/or the rectum and the vagina (Olivera et al, 2007). This abnormal communication is a hole in the birth canal, which results in the constant leaking of urine and/or feces into the vagina, a condition known as incontinence. Of the two types of obstetric fistula, those between the bladder and vagina (vesicovaginal) are more common than those between the rectum and vagina (rectovaginal). (Miller et al, 2005)
The mummified remains of Queen Henhenit, who lived around 2050 BC, were discovered in 1935 by Professor Derry in Cairo who described a large obstetric fistula (Zacharin, 2000). This mummy illustrates the oldest known obstetric fistula. James Marion Sims, the father of American gynecology, successfully closed the first fistula in Alabama in 1845 after 30 failed attempts on three African slaves without anesthesia. In 1959, Reginald and Catherine Hamlin moved to Ethiopia to open a midwifery school, however, the plight of fistula patients redirected their goals and they opened a fistula hospital (Zacharin, 2000). To this day, the Hamlin’s are seen as pioneers in fistula repair with Catherine still performing surgery in Ethiopia after Reginald’s death in 1993 (http://www.hamlinfistula.org/our-hospital/history.html).
In developing countries, an estimated 90% of fistulas are a result of an obstructed or prolonged labor (Miller et al, 2005). A study from Addis Ababa, Ethiopia noted a 3.9-day average for prolonged labor that resulted in a fistula. (Kelly, 1995) Universal maternal-child mortality and morbidity reporting is not standard in developing countries so exact rates of obstetric fistula are unknown. Most new cases of fistula occur in South Asia and sub-Saharan Africa. Incidence rates have been suspected to be as high as 2-3 per 1000 in countries with high maternal mortality rates (United Nations Population Fund and Engendered Health, 2003).
The World Health Organization states that obstructed labor occurs in 5% of all live births and is responsible for 8% of all maternal deaths (WHO, 2011). Due to easy access to cesarean delivery for an obstructed labor, obstetric fistula is almost unheard of in developed counties where most fistulas are a result of pelvic surgery complication or radiation treatment (Miller, 2005). The same cannot be said of obstetric fistula in developing countries where it remains the “most prevalent and serious gynecological surgical problem” for those countries (Zacharin, 2000).
There are several factors that cause obstructed or prolonged labors with the two of the most frequently sited being malpresentation of the fetus and cephalopelvic disproportion. Malpresentation of the fetus is loosely defined as any presentation that is not vertex with the occiput presenting anteriorly. One of the most common fetal malpresentations is occiput posterior, which accounts for approximately 10% of fetal malpresentations. Face presentations, including mentum and brow, are also fetal malpresentations that can lead to obstructed or prolonged labor. A fetus in a breech or transverse lie is also considered a fetal malpresentation. It has been noted that fetal malpresentation can occur in any woman during any pregnancy; however, it is more common in grand multiparas (five or more deliveries) because of their relaxed uterine muscles (Miller et al, 2005).
Cephalopelvic disproportion occurs when the fetal head is too large to fit through the mother’s pelvis. Disease, malnutrition and immature pelvises due to young age all may result in pelvises that are not adequate for vaginal birth. In Niger, for example, 80% of fistula cases were to girls aged 13-17 years old (Cook, Dickens & Syed, 2004). Cook et al (2004) conclude that one of the easiest and most direct ways to prevent fistulas would be by reducing early marriage and to make sure that women enter into marriage “with free and full consent.”
The number one priority when dealing with a population of women suffering from obstetric fistula is treatment. Hamlin et al (2002) highlight the pre-requisites in offering fistula services as follows: the perceived need and/or demand, the actual need, government permission and government support. There is an estimated 2 to 3 million cases of fistula untreated worldwide (Elneil & Browning, 2009). New onset fistulas are estimated to occur in upwards of 500,000 women per year (Clement & Hilton, 2001) and for every maternal death, twenty women sustain a serious complication related to pregnancy (Ahmed et al, 2007). With such tragically high rates, improved access to quality and sustainable fistula repair needs to be the global goal.
Obstetric fistulas are a result of “pressure necrosis of soft pelvic tissue [occurring] between the impacted fetal presenting part and the bony maternal pelvis” (Goh, 2004). How the fistula is repaired depends on its classification and severity. Currently there is no “standardized method” for the classification of obstetric fistula (Goh, 2004) and their classification is often at the discretion of the surgeon who is seeking to repair them. The Hamlin Fistula Hospital in Ethiopia is the only hospital in the world whose sole purpose is the repair and treatment of obstetric fistulas and they treat approximately 2,500 women a year (http://www.hamlinfistula.org/our-hospital.html).
Immediate management of an obstetric fistula includes catheterization for approximately 6-8 to allow for spontaneous healing (Clement & Hilton, 2001). This step is usually for mild cases of fistula and an antibiotic regime is also encouraged during the catheterization to prevent urogenital infection. Surgical management includes suturing the fistula closed and has a success rate of approximately 60 to 98% after primary operation (Clement & Hilton, 2001). With obstructed labor fistulas obsolete in developed countries, specific training in their repair is often lacking. Specific programs need to be offered to train surgeons in the proper diagnosis, classification and management of obstetric fistulas. It has also been noted that a universal classification system needs to be developed in order to assist in the repair of fistulas cases (Goh, 2004.)
Women who have had fistula repair are encouraged to seek out medical treatment in the 7th to 8th month of pregnancy so that a timely cesarean section may be performed in order to prevent re-occurring obstetric fistula (Browning, 2009). An uncontrolled data sort noted that when women had a vaginal delivery after a fistula repair “all had a reoccurrence of their obstetric fistula” (Browning, 2009). Despite the fact that vaginal birth is possible after a fistula repair, the risk of an “incurable” fistula the second time around shouldn’t be worth the risk or attempting a vaginal delivery. Skilled maternity care with easy and reliable access to a cesarean section needs to be available to all women with a previous fistula repair during subsequent pregnancies (Rizvi, 1999).
Women afflicted with obstetric fistulas are women afflicted with the most “debilitating and devastating” of all obstetric complications. In an attempt to better understand the social and economic consequences of obstetric fistulas, Ahmed & Holtz (2007) conducted a meta-analysis from literature published between 1985-2005. Although it is well known that fistulas are preventable and treatable, Ahmed & Holtz (2007) suggest that “the unmet need for surgical treatment could be as high as 99%.” Ahmed & Holtz (2007) also noted that fistulas account for approximately 22% of all maternal morbidity.
Ahmed & Holtz (2007) cited the phrase, “obstructed labor injury complex,” as an attempt to illustrate the often co-occurring morbidity that accompanies fistulas. It has been observed that nearly 80% of fistula sufferers will develop chronic excoriation of the skin due to irritation from urine incontinence (Ahmed & Holtz, 2007). Other co-occurring morbidity include: amenorrhea, vaginal stenosis, infertility, bladder calculi, infection and foot drop of nerve damage of a presenting fetal part and a prolonged labor (Ahmed & Holtz, 2007).
Not only are obstetric fistulas severely physiologically damaging, they also bare devastating social and economic consequences. Social stigma is intense for those suffering from a fistula. Some studies suggest nearly 50% of women will become divorced as a result of their fistula (Ahmed & Holtz, 2007). As these women are essentially abandoned by their spouses, they are forced to return home to their parents where they are often made to live outside and are not permitted to cook or take part in social events (Ahmed & Holtz, 2007). A survey of Nigerian women with fistulas found that 53% considered themselves “rejected” (Kabir et al, 2004).
Social and economic disadvantage brought forth to those suffering obstetric fistulas are well understood and heavily researched. However, research is lacking in understanding the psychological needs of women suffering from obstructed labor injury (Ahmed & Holtz, 2007). With upwards of 95% of fistula causing obstructed labor resulting in a stillbirth (Olivera et al, 2009), it isn’t hard to imagine that these woman are not only grieving the loss of their normal physiological function but also the loss of their baby. Depression and feelings of embarrassment are commonly reported by those suffering fistula injuries (Goth & Browning, 2005). Access to psychological support needs to be promoted as part of a holistic approach to fistula repair and social reintegration. Also, more studies addressing the mental health needs of women suffering fistulas need to be pursued so that evidence based care can be promoted.
With fistula being the most devastating of all fates, prevention is truly the key. To reduce infant and maternal mortality and ensure optimal birth outcomes, the World Health Organization (WHO) strongly recommends a trained birth attendant at every birth. In Ethiopia, where 95% of births take place without the assistance of a trained birth attendant, there are only 1,000 qualified midwives working in a country with a population over 85 million. Trained, community based midwives are seen as a “bridge” between rural Ethiopian women and much needed maternity care services.
The Hamlin College of Midwives in Desta Mender, Ethiopia began training its first class of midwives in November 2007. The goal of the college is “to provide for every rural community a skilled birth attendant who will provide services for the pre-natal, intra-natal and post natal period for every woman within the predetermined catchment area.” With the success of the midwifery program spreading, hopefully, the incidence of new cases of obstetric fistula will decrease with time. Ensuring a skilled birth attendant for every childbearing woman and maintained adequate facilities where cesarean sections may be performed needs to be priority one to improve maternal and infant health and to reduce the incidence of mortality and morbidity.
References:
Ahmed, S., Genadry, R., Stanton, C., & Lalonde, A. B. (2007) Dead women walking:
Neglected millions with obstetric fistula. International Journal of Gynecology and Obstetrics. 99, S1-S3
Ahmed, S. & Holtz, S. A. (2007) Social and economic consequences of obstetric fistula:
Life changed forever? International Journal of Gynecology and Obstetrics 99, 510-515.
Browning, A. (2009) Pregnancy following obstetric fistula repair, the management of
delivery. British Journal of Obstetrics and Gynecology. Short Communication. 1265-1267.
Clement, K. & Hilton, P. (2001) Diagnosis and management of vesicovaginal fistulae.
The Obstetrician & Gynaecologist. 3 (4), 173-178.
Cook, R.L., Dickens, B.M, & Syed, S. (2004) Obstetric fistula: the challenge to human
rights. International Journal of Gynecology & Obstetrics. 87, 72-77
Elneil, S. & Browning, A. (2009) Obstetric fistula- a new way forward. British Journal of
Obstetrics and Gynecology. 116 (Supplement 1) 30-32.
Goth, J.t. & Browning, A. (2005) Use of urethral plugs for urinary incontinence
following fistula repair. The Australian and New Zealand Journal of Obstetrics and Gynaecology. 45 (3), 237-238.
Hamlin, C. & Little, J. (2001) The Hospital by the River. A Story of Hope. Pan Macmillan
Australia Pty Ltd.: Australia.
Hamlin, E. C., Muleta, M. & Kennedy, R. C. (2002)Providing an obstetric fistula service.
British Journal of Urology. 89 (Supplement 1) 50-53.
Kabir, M., Abubaker, I.S. & Umar, U.I. (2004) Medico-social problems of patients with
vesico-vaginal fistula in Murtala Mohammed Specialist Hospital, Kano. Annals of African Medicine 2 (2), 54-57 .
Kelly, J. (1995) Ethiopia: an epidemiological study of vesicovaginal fistula in Addis
Ababa. World Health Stat Q 48, 15-17.
Miller, S., Lester, F., Webster, M., & Cowan, B. (2005) Obstetric Fistula: A Preventable
Tragedy. Journal of Midwifery & Women’s Health. 50 (4), 286-294.
Olivera, C., Ascher-Walsh, C. & Gligorov, N. (2009) Fistula Experience in Niger: How
We Overcame an Ethical Dilemma. Mount Sinai Journal of Medicine. 76, 71-74.
Rizvi, J. (1999) Genital Fistulae- A continuing Tragedy. Journal of Obstetrics and
Gynecology. 25 (1) 1-7.
The Hamlin Fistula Hospital, Retrieved 2011 From: http://www.hamlinfistula.org/our-hospital.html
World Health Organization. 10 facts on obstetric fistula. Retrieved 2011. From:
Zacharin, R. F. (2000) A History of Obstetric Veiscovaginal Fistula. Australian and New
Zealand Journal of Surgery. 70, 851-854.
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