tag:theconversation.com,2011:/id/topics/obstetric-fistula-27659/articlesObstetric fistula – The Conversation2019-01-02T09:11:52Ztag:theconversation.com,2011:article/1082062019-01-02T09:11:52Z2019-01-02T09:11:52ZWhy improving access to surgery in childbirth makes economic sense<figure><img src="https://images.theconversation.com/files/251276/original/file-20181218-27758-j579lr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregnant women waiting to see a doctor at a hospital in Uganda. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Maternal mortality remains high around the world, with more than <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00838-7/fulltext">303,000</a> women dying in pregnancy, childbirth or shortly afterwards. The majority (99%) of these deaths occur in developing countries. More than half of these deaths are in sub-Saharan Africa. </p>
<p>A major reason for this is that women in developing countries have no real access to proper medical care and therefore miss out on the help required for difficult births. About <a href="http://apps.who.int/iris/bitstream/handle/10665/255760/9789241565493-eng.pdf?sequence=1">15%</a> of all women experience severe complications when giving birth. Most of these cases require major intervention, including surgery. In developed countries, emergency surgery ensures that women and their babies survive childbirth, and mothers are spared the severe physical and emotional trauma that often follows a complicated birth.</p>
<p>One potentially devastating complication in childbirth is <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula/en/">obstetric fistula</a>. This usually happens during a protracted or obstructed labour that isn’t given sufficient attention. A hole develops in the birth canal between the vagina and rectum or between the vagina and bladder. An estimated <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula/en/">50 000 to 100 000 women </a>in sub-Saharan Africa develop fistula every year. </p>
<p>If women don’t have access to quality emergency obstetric care, the fistula can cause long term damage. This can include incontinence. In turn this can lead to women being stigmatised and isolated from their families and communities among other socio-economic losses.</p>
<p>While conducting <a href="https://www.ncbi.nlm.nih.gov/pubmed/27918334">research</a> in East Africa, I personally witnessed the profound lack of safe anaesthesia. This meant that there was a delay in access to safe and immediate caesarean sections. The lack of access was due to a number of issues. These include few anaesthetists, lack of equipment and emergency drugs, shortage of blood supply and failed referral systems.</p>
<p>In my more <a href="https://academic.oup.com/heapol/article/33/9/999/5106382">recent research</a> I conducted a cost evaluation to see if it made sense to provide women with fistula repair surgery. We looked at it both from the point of view of the long-term cost to women as well as the financial cost. </p>
<p>Our study found that fistula surgery is cost-effective and can significantly reduce disability in women of childbearing age in Uganda.</p>
<p>Our findings were consistent with a previous modelled analysis on the issue in low- and middle-income countries. Increasing access to high quality obstetric and fistula surgery could improve the health of many women in resource-limited settings. </p>
<h2>What we found</h2>
<p>Our study is the first publication on the cost-effectiveness of obstetric fistula repair in the East African region. </p>
<p>We built a model to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery versus no surgery to Uganda’s national health system. </p>
<p>We assessed long-term disability outcomes based on a lifetime Markov model. This involved mapping a sequence of possible events in which the probability of each event depended only on the state attained in the previous event. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula, and mortality rates in the general population in Uganda were based on published sources.</p>
<p>We estimated that the cost of providing fistula repair surgery in Uganda was $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the number of years lost to disability from 8.53 to 1.51. </p>
<h2>What is needed</h2>
<p>Our model found obstetric fistula surgical repair to be the optimal strategy for management of this condition, and one that is highly cost-effective in Uganda. Our study provides data for policy makers to prioritise implementation of this procedure in developing countries. </p>
<p>But this will require significant social and economic attention. The lack of action to date has been because of insufficient political commitment, the low numbers of skilled healthcare providers and the inability to retain skilled birth attendants in priority areas. </p>
<p>Three vital ways to prevent obstetric fistula are to provide access to skilled care during delivery, to closely monitor progress during labour, and to provide emergency caesarean sections. But low and middle-income countries lack sufficient surgeons and resources to treat patients with obstetric fistula. </p>
<p>While the current estimates of the unmet need for fistula surgical repair in low-income countries are not well documented, 10 years ago it was estimated to be as high <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1016/j.ijgo.2007.06.011">as 99%</a>. Therefore, there is an urgent need to strengthen care in low income countries for better maternal and neonatal outcomes. </p>
<p>All this needs to change if countries are going to achieve the goal of making sure that every citizen – whatever their income – has access to universal health care. And priority must be given to investing in medical facilities that are able to provide adequate prenatal care as well as healthy deliveries. Strengthening the option for women to have safe surgery during birth complications would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood.</p><img src="https://counter.theconversation.com/content/108206/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Isabella Epiu received funding from USA National Institute of Health, World Federation of Societies of Anaesthesiologists, University of California Global Health Institute - Center for Expertise in Women, SONKE Gender Justice.</span></em></p>If women don’t have access to quality emergency surgery, they can develop dibilitating complications such as fistula.Isabella Epiu, MD PhD, Postdoctoral Fellow Global Health, University of California Global Health Institute (UCGHI), Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/944282018-06-05T13:44:43Z2018-06-05T13:44:43ZSuffering in silence: how Kenyan women live with profound childbirth injuries<figure><img src="https://images.theconversation.com/files/221387/original/file-20180601-142083-1j8anm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><a href="http://vc.bridgew.edu/cgi/viewcontent.cgi?article=1942&context=jiws">Sasha</a> is 22-years-old. She was married off when she was just nine and by the time she was 11, she was pregnant with her first child, and unprepared for childbirth. </p>
<p>So when labour came, in the middle of the night – in her geographically isolated village in rural Kenya – she was unaware of the painful fate awaiting her. </p>
<p>During childbirth, the baby’s head was too big to fit through Sasha’s pelvis, causing the baby to get stuck in her birthing canal. Traditional birth attendants tried their best to help Sasha but they were not skilled enough to handle the complications. She needed surgery, and quickly. But because she could not access emergency obstetric services, she spent the next six days trying to push out the baby that was stuck inside of her. </p>
<p>In the end, Sasha delivered a dead, rotten baby in macerated form. She was not only in grief of her lost child, but was also traumatised by her experience which left her with profound injuries and a double <a href="https://www.ncbi.nlm.nih.gov/pubmed/8873157">obstetric vaginal fistula</a>. </p>
<p>An obstetric vaginal fistula is a tear between a woman’s vagina and another body part – usually caused by obstructed or prolonged labour. It occurs when the baby’s head is trapped against the pelvic bone and cannot descend further. As the labour intensifies, the blood supply is cut and the surrounding tissues die. Shortly after the baby dies and labour continues until the baby is pushed out.</p>
<p>Across the world, there is an estimated <a href="https://www.booktopia.com.au/tears-for-my-sisters-l-lewis-wall/prod9781421424170.html">two million</a> women and girls just like Sasha who live with vaginal fistulas. There are up to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3937166/#B1">100 000 new cases each year</a>. In Kenya, at least 3000 new cases are reported annually but <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-13-56">research</a> shows that only 7.5% are treated.</p>
<p>But these statistics are bound to be grossly inaccurate
due to under-reporting, poor and non-existent data keeping in most African hospitals. This is made worse by women feeling internalised shame which keeps them from seeking help for their fistulas. It means that the magnitude of the problem on the continent is assumed to be much higher. </p>
<p>Sasha was one of the women I interviewed in <a href="https://www.springer.com/us/book/9789811305641">my research</a> which investigated how Kenyan women with fistulas negotiated the complexities of living with a body that leaks. This included the process of trying to get treatment as well as the journey to recovery from childbirth traumas that rendered their bodies abject, damaged and at times irreparable.</p>
<p>My research revealed a lack of resources and the structural challenges that prevent women from getting the help they need. This is particularly prevalent in remote areas, where access to health services is not available or is very limited.</p>
<p>It also reinforces what <a href="https://www.gfmer.ch/Medical_education_En/PGC_RH_2004/Obstetric_fistula_Kenya.htm">researchers</a> and <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/ajmw.2011.5.2.95">medical professionals</a> in Kenya have established over the years. </p>
<h2>Negotiating the challenges around fistula</h2>
<p>Kenya continues to face enormous challenges as far as dealing with vaginal fistula are concerned. The biggest is the lack of resources to treat fistulas along with a <a href="https://www.reuters.com/article/us-kenya-health-fistula/as-surgeries-triple-kenya-aims-to-end-shame-of-fistula-idUSKBN18L1DN">severe shortage of fistula surgeons</a>. By 2014, Kenya only had three internationally renowned fistula surgeons and less than 10 surgeons who could perform simple obstetric operations.</p>
<p>This has made it logistically impossible to treat all the women who seek treatment every year. It also means that many are left untreated for years adding to the ever increasing backlog.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women awaiting fistula surgery at the Gynocare Women’s and Fistula Hospital in Kenya, which is the only private facility which specifically treats fistulas for free.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/directrelief/11197145265/in/photolist-i4sibH-i4sXtH-9MdDUt-i4spDd-i4ta9P-i4sodN-i4sYRn-i4sp71-i4t9Yt-i4siDA-i4sk2B-i4t6AL-i4sidq-bsqR9F-9MgyxN-i4sg3e-i4seaM-bsqSpe-i4sfQR-i4tHbH-i4srtA-6YgpYi-i4tefW-i4sYja-i4sk2f-i4t5V8-i4tPb8-i4sozY-i4t6Tj-i4siBn-i4taUf-i4t7wo-i4t7M4-75QQSQ-i4tHVi-i4t5Ww-bVLPEU-i4tcgd-bm1xDN-bm1xCW-6YkrxW-byVqGZ-6YgrpP-6YgryX-i4tQUP-8gTYV2-6Ygqra-i4tezJ-i4t8RZ-i4sQ3o">Direct Relief/Flickr</a></span>
</figcaption>
</figure>
<p>But for most women with fistulas, the damage is not only physical, it’s also psychological. They negotiate rejection and social exclusion on a day-to-day basis which can have severe psychological consequences. This can be more destructive than the actual fistula.</p>
<p>The women I engaged with explained how their fistula diagnosis threatened their social and intimate lives. They explained how having a “leaking body” was constructed as being dirty, deviant and contaminated. </p>
<p>Many described that the way they went about their lives was primarily occupied with finding ways to protect themselves from being “outed” or shamed for the pungent smell that they carried with them.</p>
<p>Their stories revealed the structural and sociocultural challenges that explain why women in Kenya are at risk of developing vaginal fistulas and then having adequate treatment delayed or denied them. This is particularly prevalent in remote areas, where there are transport barriers, impassable roads, and limited or unavailable access to health services or emergency obstetric care. </p>
<h2>Responding to fistulas</h2>
<p>In the last decade, the Kenyan government has initiated a programme under which local health workers train traditional birth attendants working in remote areas to mitigate maternal casualties. But despite the fact that the training includes skills to manage birthing complications, some women require immediate medical intervention. </p>
<p>Kenya also rolled out other public health campaigns to end maternal deaths. One was the <a href="https://www.beyondzero.or.ke/official-launch-of-the-beyond-zero-campaign/">Beyond Zero campaign</a> which was initiated by Kenya’s First Lady, Margaret Kenyatta to raise funds and awareness on issues of safe delivery, and obstetric injuries that lead to vaginal fistulas. </p>
<p>Although the initiative was heavily <a href="https://www.pambazuka.org/food-health/beyond-zero-kenyan-first-lady%E2%80%99s-charity-can%E2%80%99t-cure-healthcare-neglect-and-theft">criticised</a> as an attempt to provide a quick fix to structural problems, it raised national awareness about vaginal fistulas and mobilised resources for free surgeries for women with the condition. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/better-maternal-care-in-africa-can-save-women-from-suffering-in-childbirth-59688">Better maternal care in Africa can save women from suffering in childbirth</a>
</strong>
</em>
</p>
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<p>The criticism reflects the importance of addressing the underlying causes of fistula. These causes have been summed by one of Kenya’s most renown fistula surgeons <a href="https://scholar.google.co.uk/citations?user=Cku3H4wAAAAJ&hl=en">Dr Weston Khisa</a>, who says</p>
<blockquote>
<p>Medically, fistula is caused by obstructed labour, but the underlying causes are obstructed transport, obstructed family planning, obstructed emergency care, and obstructed human rights.</p>
</blockquote>
<p>Ending fistulas means eradicating both cultural and structural obstacles that put women at risk of developing preventable tragedies such as fistulas. It requires a complete overhaul of health infrastructure in Kenya to ensure that maternal care and women’s reproductive health are prioritised – and that no woman has to lose her life while trying to give one.</p><img src="https://counter.theconversation.com/content/94428/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathomi Gatwiri PhD does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Each year an estimated 100 000 women have complications during childbirth which leave them with obstetric vaginal fistula.Kathomi Gatwiri PhD, Lecturer, Southern Cross UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/596882016-05-22T10:12:52Z2016-05-22T10:12:52ZBetter maternal care in Africa can save women from suffering in childbirth<figure><img src="https://images.theconversation.com/files/123399/original/image-20160520-30585-x0mny0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women in Africa have poor access to emergency obstetric care during childbirth. </span> <span class="attribution"><span class="source">David Mooring/flickr</span></span></figcaption></figure><p>Every year just over <a href="http://apps.who.int/iris/bitstream/10665/43343/1/9241593679_eng.pdf">500 000 women die</a> from complications in pregnancy and childbirth across the world. Another <a href="http://apps.who.int/iris/bitstream/10665/43343/1/9241593679_eng.pdf">20 million</a> experience severe complications. But many of these complications are entirely avoidable – including obstructed and protracted labour and one of its side-effects, obstetric fistula.</p>
<p>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. </p>
<p>In sub-Saharan Africa for every 100,000 deliveries there are <a href="http://apps.who.int/iris/bitstream/10665/43343/1/9241593679_eng.pdf">about 124 women</a> 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. </p>
<p>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.</p>
<h2>A developing world problem</h2>
<p>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. </p>
<p>About <a href="http://apps.who.int/iris/bitstream/10665/43343/1/9241593679_eng.pdf">two million women</a> suffer obstetric fistulas worldwide. But most are concentrated in the fistula belt, where more than <a href="http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-13-246">6,000</a> new cases are reported each year. </p>
<p>For example, in <a href="http://apps.who.int/iris/bitstream/10665/43343/1/9241593679_eng.pdf">Ethiopia</a> it is estimated that 9,000 women develop a fistula each year, of which only 1,200 are treated.</p>
<p>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.</p>
<p>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. </p>
<p>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. </p>
<p>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. </p>
<p>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. </p>
<p>From a physiological perspective, they suffer from uncontrollable leaking of urine and faeces and are unlikely to bear more children.</p>
<p>The psychological suffering stems from often being rejected by their husbands, shamed and <a href="http://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula-study/en/">socially segregated</a> and ultimately divorced, demoralised and excluded from their family and religious activities. They also face a high risk of worsening poverty and malnutrition. </p>
<h2>Obstructed labour is preventable</h2>
<p>In principle, obstetric fistula can be avoided by:</p>
<ul>
<li><p>delaying the age of first pregnancies; </p></li>
<li><p>removing harmful traditional practices such as child marriages and female genital mutilation; and</p></li>
<li><p>providing access to obstetric medical care with suitably trained surgeons.</p></li>
</ul>
<p>In many instances, young girls do not have pelvises fully developed for childbirth. According to the <a href="http://apps.who.int/iris/bitstream/10665/43343/1/9241593679_eng.pdf">World Health Organisation</a>, more than 25% of the patients with fistula in Ethiopia and Nigeria, for example, became pregnant before the age of 15.</p>
<p>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.</p>
<p>And even if women travel to these facilities, in many instances they must
provide their own <a href="http://apps.who.int/iris/bitstream/10665/43343/1/9241593679_eng.pdf">surgical gloves and dressing</a> for a clean delivery.</p>
<h2>Improving maternal health</h2>
<p>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. </p>
<p>Global health initiatives have taken this call seriously, and maternal health was one of the eight United Nations <a href="http://www.un.org/millenniumgoals/">Millennium Development Goals</a>. Preventing and managing obstetric fistulas was identified as a critical objective to attain this goal. </p>
<p>Maternal health continues to be a focus area that receives attention in the <a href="https://sustainabledevelopment.un.org/?menu=1300">Sustainable Development Goals</a>. </p>
<p>There are many <a href="https://www.fistulafoundation.org/about-us/">organisations</a> 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. </p>
<p>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. </p>
<p>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.</p>
<p>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.</p><img src="https://counter.theconversation.com/content/59688/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kareemah Gamieldien does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More than two million women across the world suffer from obstetric fistula – a hole in the birth canal that makes them incontinent – but this can be avoided.Kareemah Gamieldien, PhD (Human Physiology), Cape Peninsula University of TechnologyLicensed as Creative Commons – attribution, no derivatives.