With last week's global health summit in London focussing on family planning, it seems timely to focus on obstetric fistula - one of the many problems caused by pregnancy in the developing world. It is also a condition of pregnancy that we rarely see here at home.
“Obstetric fistula occurs when women experience prolonged, obstructed labour and cannot get to a medical facility.
Put simply, when a baby gets stuck in the birth canal for too many days or too many hours, the pressure of its head against the mother’s pelvic bones causes tissue to disintegrate between the vagina and the bladder and/or rectum. A hole forms, and the resulting condition is somewhat akin to incontinence: the mother leaks urine, and sometimes feces, uncontrollably from her vagina.” Kristina Graff, Associate Director of the Centre for Health and Wellbeing
The acid in the urine, faeces, and blood can cause severe burn wounds on the legs, and nerve damage from the leaking can also lead to women struggling with walking - eventually losing mobility. It is not uncommon for women to try and avoid the constant dripping by limiting their intake of water and liquid, and many have actually died from dehydration. Ulcerations and infections are other side effects, as well as kidney disease and kidney failure. Further, only a quarter of women who suffer a fistula in their first birth are able to have a living baby, and therefore have miniscule chances of conceiving a healthy baby later on.
Who does it affect?
Cephalopelvic disproportion is considered the main culprit of obstructed labour, when the pelvis is literally too small for the baby’s head to pass through. With one in four Tanzanian girls having their first child before they are 18, and malnutrition and stunted growth slowing development, a high percentage of fistula sufferers are young girls. They simply aren't developed enough to allow the passage of a baby, or in some cases female genital mutilation has made delivery more difficult. All of them could have delivered via caesarean section, but in almost every case the decision to find medical attention was out of their hands. They may have survived, but their babies died and they were left believing what many African women accept as true – that illness, injury and death is the price they must pay for giving birth.
Dr. Ng'walida, a surgeon at the government hospital laments the power imbalances underlying the incidences of fistula, commenting, “Because parents have the final say, girls get married before they want to and have children before they are ready. They are also powerless in their marriages, where the husband controls the household’s money, and the wife is dependent on him to obtain medical care.”
Susie Anthony, Work the World Operations Manager, comments that “for Tanzanian women the effects of the condition are not just physical, they also include ridicule and exclusion from the community, as well as rejection from their husbands because of their ‘unclean state’. In most circumstances they are left to live, work and sleep on their own.”
Obstetric fistula can only be treated by reconstructive surgery. The surgery has a 90% success rate for uncomplicated cases and 60% for more complicated. For those that cannot be treated, it is possible to perform a urostomy so that patients can use a bag for the collection of urine. In almost all cases, treatment of any form (with the appropriate and sometimes lengthy aftercare), means women are accepted once again into society. It is life-changing for them.
The big problem in developing countries is access to treatment - specialist surgeons are required and there simply isn't enough of them. For the many Tanzanians who live on $2 a day and have never left their villages, it would not be able to arrange an operation that costs $250 - $300 in a hospital more than 500km away. Most would not even be able to afford the $9 bus journey to get them there. And even if they did have the money for the surgery - in a large number of cases they do not even realise it is possible to treat it.
What experience have our students gained?
Students in our Tanzania destination are getting the most access to cases of fistula. It is a fairly new placement for us, but students have recently been involved in fistula surgery as part of a charitable project set up in 1997. The "Fistula Project" was created at the large referral hospital that most of our placements are based - Tanzanian doctors have been trained and visiting surgeons help keep on top of the huge demand for surgery. It is funded by charitable organisations that cover the cost of transport and surgery, supporting women before, during and after the process. As many are hidden away from society, they also advertise far and wide to make sure women suffering in small villages get the message they are not alone and can be helped.
Let's hope that the new pledge of $2.6 billion dollars at the global health summit will help young girls understand the risks of early pregnancies and the need for adequate care when they deliver their babies.