Every year just over 500 000 women die from complications in pregnancy and childbirth across the world. Another 20 million experience severe complications. But many of these complications are entirely avoidable – including obstructed and protracted labour and one of its side-effects, obstetric fistula.
An obstetric fistula is a hole in the birth canal between the vagina and the rectum or between the vagina and the bladder that is largely caused by obstructed and prolonged labour. This can occur when the mother’s pelvis is too small or the baby is too large.
In sub-Saharan Africa for every 100,000 deliveries there are about 124 women who suffer an obstetric fistula in a rural area. Obstetric fistulas predominantly happen when women do not have access to quality emergency obstetric-care services. Antenatal care could help to identify potential problems early but will not have an impact if there is no skilled surgeon to assist with the labour.
Although skilled attendants are necessary, it is the emergency obstetric surgeon who is needed to successfully remove the foetus and save both the baby and mother’s life.
A developing world problem
Obstetric fistulas are more commonly reported in developing countries, including South Africa. But it is predominantly localised to the “fistula belt” – an area spanning the northern half of sub-Saharan Africa from Mauritania to Eritrea, and the Middle East and Asia’s developing countries.
For example, in Ethiopia it is estimated that 9,000 women develop a fistula each year, of which only 1,200 are treated.
A fistula forms when, during prolonged labour contractions, the foetus constantly pushes against the mother’s unyielding pelvic bones. The effect leads to the compression of the blood vessels, which decreases blood flow to this area and deprives the tissue of nutrients.
As a result it weakens the tissue and a hole forms. The baby is unlikely to survive – and if the mother survives and the fistula is not repaired, she is left with both psychological and physiological scarring.
In some cases a woman may experience labour for up to a week. Globally, more than 75% of women with fistulas have endured labour that lasted three days or more.
For most women who live in the developed world, obstetric fistulas are uncommon and are usually promptly repaired. This is primarily due to emergency obstetric care that is readily available.
But women who survive the excruciating ordeal of obstructed labour and develop an obstetric fistula in impoverished countries are often doomed to a life of absolute misery.
From a physiological perspective, they suffer from uncontrollable leaking of urine and faeces and are unlikely to bear more children.
The psychological suffering stems from often being rejected by their husbands, shamed and socially segregated and ultimately divorced, demoralised and excluded from their family and religious activities. They also face a high risk of worsening poverty and malnutrition.
Obstructed labour is preventable
In principle, obstetric fistula can be avoided by:
delaying the age of first pregnancies;
removing harmful traditional practices such as child marriages and female genital mutilation; and
providing access to obstetric medical care with suitably trained surgeons.
In many instances, young girls do not have pelvises fully developed for childbirth. According to the World Health Organisation, more than 25% of the patients with fistula in Ethiopia and Nigeria, for example, became pregnant before the age of 15.
Although access to care is important, accessing suitably equipped facilities for antenatal care and safe childbirth is also integral. In many rural settings this is usually difficult, as health centres that can provide emergency obstetric care may be up to 70km away with no easy or affordable form of transport.
And even if women travel to these facilities, in many instances they must provide their own surgical gloves and dressing for a clean delivery.
Improving maternal health
Improving access to emergency obstetric care is the first and most important step to prevent women from suffering from the effects of an obstetric fistula.
Global health initiatives have taken this call seriously, and maternal health was one of the eight United Nations Millennium Development Goals. Preventing and managing obstetric fistulas was identified as a critical objective to attain this goal.
Maternal health continues to be a focus area that receives attention in the Sustainable Development Goals.
There are many organisations and unsung heroes dedicated to giving hope back to the women who have been demoralised and severely burdened by fistulas. But the obstacles that these women have to overcome to receive treatment – including whether they have access to medical care and what the cost is – need to be addressed.
A compounding factor that could increase the cost of treatment is the time that has lapsed between the formation of the fistula and the surgery.
It is reported that the longer a woman waits for surgery, the greater her scarring and the more complex the surgery. It is not uncommon for women in low-income countries to seek treatment after months, or even decades, further begging the call for trained and experienced surgeons.
As the world moves into the 21st century, boasting advances in science and technology, it stands accused of failing to provide fundamental maternal health care to those most in need of it. To be given the conditions for safe childbirth is the basic human right of every woman.