Obstetric fistula

Obstetric fistula is a medical condition in which a hole develops in the birth canal as a result of childbirth. This can be between the vagina and rectum, ureter, or bladder. It can result in incontinence of urine or feces. Complications may include depression, infertility, and social isolation.

Risk factors include obstructed labor, poor access to medical care, malnutrition, and teenage pregnancy. The underlying mechanism is poor blood flow to the affected area for a prolonged period of time. Diagnosis is generally based on symptoms and may be supported by use of methylene blue.

Obstetric fistulae are almost entirely preventable with appropriate use of cesarean section. Treatment is typically by surgery. If treated early, the use of a urinary catheter may help with healing. Counseling may also be useful. An estimated 2 million women in sub-Saharan Africa, Asia, the Arab region, and Latin America have the condition, with about 75,000 new cases developing a year. It occurs very rarely in the developed world and is considered a disease of poverty.

Signs and symptoms

Symptoms of obstetric fistula include:
* Flatulence, urinary incontinence, or fecal incontinence, which may be continual or only happen at night"Women's Health." Vaginal Fistula Causes, Symptoms, & Treatments. WebMD, n.d. Web. 22 Oct. 2012. "Obstetric Fistula." Our Bodies Ourselves Health Resource Center. Our Bodies Ourselves Health Resource Center, n.d. Web. 22 Oct. 2012.
* Foul-smelling vaginal discharge"Rectovaginal Fistula." Mayo Clinic. Mayo Foundation for Medical Education and Research, 29 May 2010. Web. 22 Oct. 2012.
* Repeated vaginal or urinary tract infections
* Irritation or pain in the vagina or surrounding areas
* Pain during sexual activity

Other effects of obstetric fistulae include stillborn babies due to prolonged labor, which happens 85% to 100% of the time, severe ulcerations of the vaginal tract, "foot drop", which is the paralysis of the lower limbs caused by nerve damage, making it impossible for women to walk, infection of the fistula forming an abscess, and up to two-thirds of the women become amenorrhoeic.

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 woman is left with chronic incontinence. Unable to control the flow of urine or faeces, or both, she may be abandoned by her husband and family and ostracized by her community. Without treatment, her 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 severe 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 are able to have a living baby, and therefore have minuscule chances of conceiving a healthy baby later on. Some women, due to obstetric fistulae and other complications from childbirth, do not survive.

Social

Physical consequences of obstetric fistulae lead to severe sociocultural stigmatization for various reasons. For example, in Burkina Faso, most citizens do not believe an obstetric fistula to be a medical condition, but as a divine punishment or a curse for disloyal or disrespectful behavior. 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 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 family, ridiculed by friends, and even isolated by health workers. Divorce rates for women who have an obstetric fistula range from 50% to as high as 89%. Now marginalized members of society, girls are forced to live on the edges of their villages and towns, often in isolation in a hut where they will likely die from starvation or an infection in the birth canal. The unavoidable odor is viewed as offensive, thus their removal from society is seen as essential. Accounts of women who develop obstetric fistulae proclaim that their lives have been reduced to the leaking of urine, feces, and blood because they are no longer capable or allowed to participate in traditional activities, including the duties of wife and mother. Because such consequences highly stigmatize and marginalize the woman, the intense loneliness and shame can lead to clinical depression and suicidal thoughts. Some women have formed small groups and resorted to walking to seek medical help, where their characteristic odor makes them a target for sub-Saharan predatory wildlife, further endangering their lives. This trip can take on average 12 hours to complete.McKinney, T. B. (2006)
Fistula women of Africa: The horror of their lives, and hope for their tomorrow
The International Organization for Women and Development. Lecture presented October 2006, Phoenix, AZ. 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 inability to perform their family roles. Additionally, a fear of developing another fistula in future pregnancies exists.

Obstetric fistula is not only debilitating physically, but 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 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."

Women with obstetric fistula face severe mental health issues. 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 cesarean 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.

Obstetric fistulae can also be caused by poorly performed abortions, 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.The ACQUIRE Project. Traumatic gynecologic fistula as a consequence of sexual violence in conflict settings: a literature review. New York7 The ACQUIRE Project/EngenderHealth; 2005.

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. When available at all, cesarean sections and other medical interventions are usually not performed until after tissue damage has already been done.

Social, political, and economic causes that indirectly lead to the development of obstetric fistulae concern issues of poverty, malnutrition, lack of education, early marriage and childbirth, the role and status of women in developing countries, harmful traditional practices, sexual violence, and lack of good quality or accessible maternal and health care.

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 effectively eradicate obstetric fistulae.Chandiramani, Payal. "Programmatic and Policy Recommendations for Addressing Obstetric Fistula and Uterine Prolapse , Wilson Center." Wilson Center. The Woodrow Wilson International Center for Scholars, 27 Sept. 2012. Web. 27 Nov. 2012.

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. Lack of money and access to proper nutrition, 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. This weak and underdeveloped bone structure increases the chances that the baby will get stuck in the pelvis during birth, cutting off circulation and leading to tissue necrosis. Because of the correlation between malnutrition, stunted growth, and birthing difficulties, maternal height can at times be used as a measure for expected labor difficulties.

Lack of education

High levels of poverty also lead to low levels of education among impoverished women concerning maternal health. This lack of information in combination with obstacles preventing rural women to easily travel to and from hospitals lead many to arrive at the birthing process without prenatal care. This can cause a development of unplanned complications that may arise during home births, in which traditional techniques are used. These techniques often fail in the event of unplanned emergencies, leading women to go to the hospital for care too late, desperately ill, and therefore vulnerable to the risks of anesthesia and surgery that must be used on them. In a study of women who had prenatal care and those who had unbooked emergency births, "the death rate in the booked-healthy group was as good as that in many developed countries, utthe death rate in the unbooked emergencies was the same as the death rate in England in the 16th and 17th centuries." In this study, 62 unbooked emergency women were diagnosed with obstetric fistulae out of 7,707 studied, in comparison to three diagnosed booked mothers out of 15,020 studied. In addition, studies find that education is associated with lower desired family size, greater use of contraceptives, and increased use of professional medical services. Educated families are also more likely to be able to afford health care, especially maternal healthcare.

Early childbirth

In sub-Saharan Africa, many girls enter into arranged marriages soon after menarche (usually between the ages of 9 and 15). Social factors and economic factors contribute to this practice of early marriages. Socially, some grooms want to ensure their brides are virgins when they get married, so an earlier marriage is desirable. Economically, the bride price received and having one less person to feed in the family helps alleviate the financial burdens of the bride's family. Early marriages lead to early childbirth, which increases the risk of obstructed labor, since young mothers who are poor and malnourished may have underdeveloped pelvises. In fact, obstructed labor is responsible for 76 to 97% of obstetric fistulae.

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, and studies find that the doctors and nurses who do exist in rural Africa often do not show up for work.Kristof, Nicholas D., and Sheryl WuDunn. ''Half the Sky: Turning Oppression into Opportunity for Women Worldwide''. New York: Alfred A. Knopf, 2009. Print.

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, 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." In addition, access to health services and education – including family planning, gender equality, higher living standards, child marriage, and human rights – must be addressed to reduce the marginalization of women and girls. Reducing marginalization in these areas could reduce maternal disability and death by at least 20%.

Prevention comes in the form of access to obstetrical care, support from trained health care professionals throughout pregnancy, providing access to family planning, promoting the practice of spacing between births, supporting women in education, and postponing early marriage. Fistula prevention also involves many strategies to educate local communities about the cultural, social, and physiological factors of that condition and contribute to the risk for fistulae. One of these strategies involves organizing community-level awareness campaigns to educate women about prevention methods such as proper hygiene and care during pregnancy and labor. 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 about the nutritional needs of children 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 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. Midwives located in the local communities where obstetric fistulae are prevalent can contribute to promoting health practices that help prevent future development of obstetric fistulae. NGOs also work with local governments, like the government of Niger