Obstetric Fistula

A Labour of Loss: Obstetric Fistula

A fistula is essentially a hole. In both obstetric and traumatic fistula this hole occurs between the women’s birth passage or vaginal cavity and her internal organs such as her bladder. Often this causes the woman to leak urine, feces or both. Obstetric fistula is often a result of obstructed labour and is treatable and preventable. If the baby’s head bears down against the mother’s pelvis for an extended period of time, the blood supply is cut off, eventually causing the tissue to die and wear away, leaving a hole between her vaginal cavity and her bladder, and in some cases, her vaginal cavity and her rectum. The implications of this preventable misfortune are manifold.

Not only has she lost her child, and not only is she leaking urine and possibly feces, she may also be abandoned by her family and community due to the unpleasant smell and social stigma.

A virtually nonexistent issue in North America (the last fistula hospital in the United States closed its doors in 1865), there are an estimated 2 million women suffering from obstetric fistula worldwide, with the majority of cases occuring in lower-resource African countries. In these places, access to skilled birth attendants and cesarean sections are low, and rates of young marriage and child marriage are high. It is the most marginalized members of society – poor, often illiterate women and girls – who are most affected.

“Everyone deserted me - my husband deserted me, my friends deserted me. I know I will never have a husband, I will never have a boyfriend, I will never have a baby. So I just live by myself.”

—Fatmata from Sierra Leone, as quoted by the BBC

While most cases of obstetric fistula can be cured by surgical procedures costing approximately $300-$450, in the developing world, women with fistula may live their entire life with this preventable and treatable condition. Many are unaware that there is a cure and others simply don’t have the financial means or access to the procedure. In many cases, they also lack the most basic of health care services.

“I have to put on heavy clothes. There are painful blisters and itching. I have to continue doing work and it causes increased dribbling of urine. Nobody wants to stay with me because of the smell.”

—A woman from Bangladesh, as quoted in an EngenderHealth report

Preventing obstetric fistula can avoid significant misery and discomfort.

By working with community leaders, health care providers and women in their local settings, we can better educate about the causes of obstetric fistula. While obstetric fistula may be the result of obstructed labour, a root cause of fistula is a lack of sexual and reproductive rights for women.

Things are changing.

“The existence of fistula is the barometer of maternal health in the country. If year by year fistula decreases, we know that maternal health is improving.”

—Dr. Kalilou Ouattara, fistula surgeon, Mali

Obstetric fistula has gained greater attention in the international women’s health community in recent years. The Hamlin hospitals in Ethiopia, the Fistula Foundation and UNFPA’s Campaign to End Fistula have raised the profile of the issue, giving voice to women who have suffered the devastating consequences of fistula. Treating fistula is not limited to a surgical procedure; helping women reintegrate into their communities and providing education about how to prevent fistula are essential. Moreover, most of these women have suffered emotionally and financially due to their condition and require services to help them rehabilitate and reintegrate into society.

There is hope.

Progress has been made in the fight against fistula. In most cases, living with fistula marginalizes women and denies them their human rights. Global campaigns, medical training and greater public awareness have allowed for an increase in services to treat this debilitating condition. No woman should continue to suffer from a condition that is both treatable and preventable. It is important to remember that treating obstetric fistula is more than just a surgical procedure; it is a life-restoring act.

“I will be able to go to church again. I will be able to help a bit in the fields. I will be able to go shopping and to go on the back of someone’s bicycle - all the things that other people normally do! ”

—Rukia from Tanzania, as quoted by the BBC

Preventing Obstetric Fistula

Postponing marriage. Early marriage often leads to high risk pregnancies. Girls under 15 are five times more likely to die from complications in childbirth and are more likely to develop fistula. Their bodies are often not developed enough for childbirth, resulting in obstructed labour.

Spacing births and limiting total pregnancies. Enabling women to access family planning services can greatly reduce their chances of developing obstetric fistula. It gives them more control over the ‘when and how’ of their pregnancies.

Access to skilled birth attendants and emergency obstetric care. Helping women access adequate and timely medical attention will reduce the incidence of the condition by ensuring that qualified help can perform the necessary medical procedures to prevent fistula.

Developing infrastructure. Transportation systems, medical centers with surgical capabilities and the provision of medical training will help women better access the preventative health services and the potential treatment they need, when they need it.

Fighting poverty. Fistula is most common among poor women who cannot access the education and medical services necessary to ensure a healthy pregnancy.

Educating and empowering women and their communities. We see a reduction in maternal injury and mortality when women have access to education and services, and when they are better able to make choices about their bodies and reproduction. Educating communities about preventing fistula and the treatments available will improve the quality of life for women suffering the debilitating condition.

Promoting sexual and reproductive rights. When sexual and reproductive rights are valorized by the state, and when services take a rights-based approach, we see a reduction in maternal death and injury.

Traumatic Fistula

Fistulas can also be the result of direct gynaecologic trauma associated with a violent sexual assault by an assailant(s), or by forced insertion of objects such as gun barrels or sticks into a woman’s vagina. This kind of brutal aggression is unfortunately common in countries at war where such acts may occur with impunity. The effects of the fistula on the women and girls are the same as discussed in the article above; however, their access to health care is all the more challenging given the breakdown of medical services and the possible displacement of populations due to conflict. In this context, the physical and psychological effects of this condition may be even more debilitating.

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“These women suffer agonizing labors and the death of their babies and then, because of their fistulae, are ostracized by their families.”

—Dr. Catherine Hamlin