Treating Fistula

Not only physiological damage, pain and discomfort, but also social ostracism

"We have a woman in the ward, she came in obstructed labour, with a ruptured uterus. The baby died, and we had to remove her uterus to save her life. Then we noticed she was losing urine because of an existing hole in her bladder. This has been going on for four years, ever since she had her first child. She constantly leaks urine, stinks, and has been confined to home during this period." Dr Paul McMaster, Somalia

Poor access to health care for pregnant women can have catastrophic consequences. Some women die from difficult and/or unassisted deliveries especially where Caesarean section services are unavailable. Women who survive can develop devastating consequences such as obstetric fistulas which is a result of being in obstructed labour for days.

A fistula is an abnormal or unnatural opening between one hollow organ and another, or between a hollow organ and the skin.

If the labour is prolonged, the baby creates pressure in the birth canal, cutting off blood flow to the vagina and bladder. Women who have narrow or underdeveloped pelvises are at particular risk. The lack of blood and oxygen to these nearby organs result in tissue necrosis creating a hole through which the urine and faeces freely flow. This hole is what is called an obstetric fistula.

Obstetric fistulas result in urinary and/or faecal incontinence. A fistula is not only characterised by physiological damage, pain and discomfort, but also by social ostracism as women are plagued by a pungent smell, and leakage onto their garments. Women are often rejected by their husbands, families, and communities. In treating, or even recommending treatment, great care needs to be taken in order to remain sensitive to the woman, as this is a very private and embarrassing matter.

Fistulas may also form subsequent to extension of cervical cancer or radiation therapy. Trauma-induced fistulas are usually located near the introitus; those induced by cancer tend to be located higher in the reproductive structures. A fistula can also be caused by female circumcision, poorly executed abortions, or sexual assault, although the percentage of fistulas caused by obstructed labour is far greater.

“Obstetric fistulas are as much a result of poverty, lack of education, and early marriage as it is of pregnancy and poor antenatal care,” says Dr Kathryn Chu from the MSF South Africa medical unit.

Pramila, 27, an MSF patient in Nepal has two children. When she was giving birth to her son, at home, she suffered from labour pains for two days. At that time someone from the village health facility, with no formal midwifery training, tried to help her, but in vain. Then her relatives carried her on foot for more than four hours to the nearest hospital.

At last, she safely delivered her son at hospital. But after some time she found that the urine was involuntarily discharged from her vagina. She was diagnosed as having a vesicovaginal fistula.

"Because of this problem, I can only work at home, but not in the field," she said. "I need to change my clothes three times a day. It's very inconvenient. I can't work properly. And I feel a slight pain in my abdomen."

Fistulas require specialised surgery, and as fistulas are rare in more developed countries, they often occur in nations with little or no surgical skills to remedy the condition. Several MSF surgeons have now been trained in the surgical techniques and are transferring the skills in training others as part of the surgical work of MSF.

In 2003 the United Nations Populations Fund (UNFPA) launched a Campaign to End Fistula, with a dedicated website (www.endfistula.org). According to UNFPA treatment costs between US$ 300 and US$ 1,000, and thus not available to all patients in need, many of whom live in poverty; obstetric fistula thus is considered a disease of poverty. The organisation also believes that 85 % of treated cases are successful. Most alarming is that women in sub-Saharan Africa suffer almost twice as much from illnesses relating to sexual and reproductive health than women in the world, as a whole.

“Most women with fistulas are shunned from their communities, but the concept of social reintegration of women who have had their fistulas successfully repaired is unknown,” explains Dr Chu.

MSF has been providing fistula repair in numerous countries, including Liberia, the Republic of Congo (Brazzaville), Ivory Coast, and Chad, and interventions are being considered for other locations. MSF partnered with a Nepalese surgical NGO in that country to help women, organising and managing a "uterine prolapse camp" in 2007. Here, 82 women received the operations they needed and collaboration continues in 2008. At the beginning of 2008, MSF began preliminary work to establish a fistula project in the Tombouctou region in Mali.