Preventing And Managing Obstetric Fistula To Improve Maternal Health

Each year between 50 000 to 100 000 women worldwide are affected by
obstetric fistula, an abnormal opening between a woman’s genital tractand her urinary tract or rectum. The development of obstetric fistulais directly linked to one of the major causes of maternal mortality.

An obstetric fistula is a hole between the vagina and rectum orbladder that is caused by prolonged obstructed labor, leaving a womanincontinent of urine or feces or both. For women with obstructedlabor, labor that goes unattended, the labor can last up to six orseven days.

It is estimated that more than 2 million young women live withuntreated obstetric fistula in Asia and sub-Saharan Africa. Preventingand managing obstetric fistula contribute to the SustainableDevelopment Goal 3 of improving maternal health.

Obstetric fistula is not only debilitating physically, butemotionally. A woman is presented with an array of psychologicaltrauma that she must oftentimes deal with herself unless provided withample resources. Often times ostracised by her community, a woman withobstetric fistula tends to face these issues on her own.

May 23 is set aside every year as the United Nation’s International Day to End ObstetricFistula, which promotes action towards treating and preventing
obstetric fistula, a condition that affects many girls and women indeveloping countries.

Obstetric fistula is one of the most serious and tragic injuries that
can occur during childbirth. The condition is silently robbingmillions of women and girls of their health, hope and dignity. Yet thecondition is almost entirely preventable. Its persistence is a sign ofglobal inequality and an indication that health systems are failing toprotect the health and human rights of the poorest and most vulnerablewomen and girls.

Those without access to modern maternal health services are more
likely to suffer from obstetric fistula. And girls who are subjected
to child marriage and adolescent pregnancy are also more vulnerable,
since the condition is more likely to afflict those who become
pregnant while still physically immature.

Since May 23 2013, there have been efforts to raise awareness of
this issue and mobilize support around the globe. Obstetric fistula is
one of the most serious and tragic childbirth injuriescaused by
prolonged, obstructed labour without access to timely, high-quality
medical treatment. It leaves women leaking urine, faeces or both, and
often leads to chronic medical problems, depression, social isolation
and deepening poverty. Other causes include injury during childbirth,
cancer, radiation therapy and surgical complications. Depending on the
size and location of the fistula, there may be foul-smelling vaginal
discharge or passage of stool from the vagina. Some such fistulas may
close on their own, but most need to be repaired surgically.

Hundreds of thousands of women and girls in sub-Saharan Africa, Asia,
the Arab States region, and Latin America and the Caribbean are
estimated to be living with fistula, with new cases developing every
year. As the leader of Campaign to End Fistula, UNFPA provides
strategic vision, technical guidance and support, medical supplies,
training and capacity building, as well as funds for fistula
prevention, treatment and social reintegration programmes. UNFPA also
strengthens sexual and reproductive health care and emergency
obstetric services to prevent fistula from occurring in the first
place.

Risk factors
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 inconflict/post-conflict areas, and other trauma, such as surgicaltrauma.

In the developed world, such as the USA, the primary cause ofobstetric fistulae, particularly RVF, is the use of episiotomy andforceps. Primary risk factors include early or closely spacedpregnancies and lack of access to emergency obstetric care. Forexample, a 1983 study in Nigeria found that 54.8 percent of thevictims were under 20 years of age, and 64.4 percent gave birth athome or in poorly equipped local clinics. When available at all,cesarean sections and other medical interventions are usually notperformed until after tissue damage has already been done.

Poverty
Poverty is the main indirect cause of obstetric fistulae around theworld. As obstructed labor and obstetric fistulae account for 8percent of maternal deaths worldwide. Impoverished countries produce highermaternal mortality rates and thus higher obstetric fistula rates.
Impoverished countries not only have low incomes, but also lackadequate infrastructure, trained and educated professionals,resources, and a centralised government that exist in developednations to effectively eradicate obstetric fistulae. All buteliminated from the developed world, obstetric fistula continues toaffect the poorest of the poor: women and girls living in some of themost resource-starved remote regions in the world.

Malnutrition
One reason that poverty produces such high rates of fistula cases isthe malnutrition that exists in such areas. Lack of money andaccess to proper nutrition, as well as vulnerability to diseasesthat exist in impoverished areas because of limited basic health careand disease prevention methods, cause inhabitants of these regions toexperience stunted growth. Sub-Saharan Africa is one such environmentswhere the shortest women have on average lighter babies and moredifficulties during birth when compared with full-grown women. This
stunted growth causes expectant mothers to have underdeveloped pelvis.

Lack of education
High levels of poverty also lead to low levels of education amongimpoverished women concerning maternal health. This lack ofinformation in combination with obstacles preventing rural women toeasily travel to and from hospitals lead many to arrive at thebirthing process without prenatal care. This can cause a developmentof unplanned complications that may arise during home births, in whichtraditional techniques are used.

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

Lack of healthcare
Most times, 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 suffer from shortages of staff, supplies, and other forms
of medical technology that would be necessary to perform
reconstructive obstetric fistula repair and nurses who do exist in
rural Africa often do not show up for work.

Prevention
Prevention is the key to ending fistulae. Prevention comes in the form of access to obstetrical care, supportfrom trained health care professionals throughout pregnancy, providingaccess to family planning, promoting the practice of spacing betweenbirths, 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 organising community-level awareness campaigns to
educate women about prevention methods such as proper hygiene and care during pregnancy and labor.

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