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Obstetric Fistula in Developing Countries:A Review Article
OBSTETRICS OBSTETRICS
Obstetric Fistula in Developing Countries: A Review Article Mulu Muleta, MD, MDC Obstetrician-Gynecologist, Addis Ababa Fistula Hospital, Addis Ababa Ethiopia
Abstract Obstetric fistula, one of the most devastating consequences of prolonged obstructed labour, is a historical issue in the developed world. However, it is still prevalent in resource poor countries like Ethiopia. The objective of this review article is to describe the epidemiology of obstetric fistula and its management, with specific emphasis on the experience of the Addis Ababa Fistula Hospital. Published and unpublished literature on obstetric fistula was reviewed, and expert opinions are used in augmentation. Most obstetric fistulas result from neglected obstructed labour, often affecting very poor, young, illiterate, rural women and girls. The women are often in labour for days, helped by unskilled family members. They deliver a stillborn child, become incontinent of urine and/or feces, and become outcast and divorced as a result. Surgical repair mends the lives of thousands of women, although not all injured cases have access to treatment. Although prevention should be the ultimate goal, the need for curative care services for the sufferers is shown to be significant.
Résumé Les fistules obstétricales, l’une des conséquences les plus dévastatrices d’une interruption prolongée du travail, sont une curiosité historique dans les pays développés. Toutefois, elles demeurent omniprésentes dans des pays à court de ressources comme l’Éthiopie. L’objectif du présent exposé de synthèse est de décrire l’épidémiologie des fistules obstétricales et leur prise en charge, en mettant un accent plus particulier sur les cas rencontrés au Addis Ababa Fistula Hospital. Des articles publiés et non publiés sur les fistules obstétricales ont été passés en revue, et les opinions de spécialistes sont utilisées à titre de documentation d’appoint. La plupart des fistules obstétricales sont attribuables à une interruption du travail qui n’a pas été prise en charge. Les filles et les femmes qui en sont victimes sont souvent très pauvres, jeunes et analphabètes, et vivent en région rurale. Les femmes connaissent un travail qui dure souvent plusieurs jours, et n’ont pour seule aide que la présence de membres de la famille n’ayant aucune compétence en matière d’accouchement. Elles donnent naissance à un enfant mort-né, sont frappées d’incontinence (urinaire ou fécale), et sont délaissées par leur époux et leur communauté. La chirurgie permet à des milliers de femmes de reprendre une vie normale; toutefois, toutes les femmes atteintes de ce trouble n’ont pas nécessairement accès au traitement. La prévention devrait être le but ultime à atteindre; il Key Words: Obstetric fistula, epidemiology, incontinence, urogenital Competing Interests: None declared. Received on May 1, 2006 Accepted on May 24, 2006
962
l NOVEMBER JOGC NOVEMBRE 2006
n’en reste pas moins qu’il est très important de mettre en œuvre des services de soins curatifs à l’intention des victimes. J Obstet Gynaecol Can 2006;28(11):962–966
INTRODUCTION
bstetric fistula is an opening between the vagina and the bladder and/or the vagina and the rectum resulting from prolonged obstructed labour.1 Obstetric fistula leaves women with leakage of urine or feces or both and has been observed since women first began delivering children.
O
The oldest evidence of obstetric fistula can be found in the remains of an Egyptian queen’s mummy from around 1550 BC.2–4 Over time, physicians have attempted to describe and resolve this problem: the Persian physician Avenica made the connection between obstructed labour and vesico-vaginal fistula in the 11th century; Dr John Peter Mettauer of Virginia reported success in closing a vesico-vaginal fistula using wire sutures in 1838.3 In 1845, Dr J. Marion Sims of America encountered his first case of obstetric fistula, and on his 30th operation on the same patient in 1849, managed to close the fistula. In 1852, he published his article on the principles of fistula repair, and he has subsequently been called “the father of American gynecology.” In May 1855, he opened the first fistula hospital in New York. On the site of the hospital today, however, is the Waldorf Astoria Hotel, as there is now no need for a fistula hospital in America.5 In 1959, Dr Catherine Hamlin and Dr Reginald Hamlin left Australia to establish a midwifery training hospital in Ethiopia. However, the horrendous physical and social damage endured by fistula patients attracted their attention, and their efforts focused on helping these patients. They opened the fistula hospital in Ethiopia in May 1974, built exclusively for fistula patients. The hospital now operates on more than 1200 cases a year and has a success rate of 92%. Because there are many women who continue
Obstetric Fistula in Developing Countries: A Review Article
suffering in shame, Dr Catherine Hamlin continued the work with her team after the death of her husband in 1993.6,7 Obstetric fistula is completely preventable if high quality basic and comprehensive maternal health services are available to all. The Hamlin’s wish for the future is that, like the fistula hospital in New York, the fistula Hospital in Addis Ababa will eventually no longer be required. However, there is a huge backlog of unrepaired cases in the country, and the absence of adequate maternal health care and emergency obstetrical services means that large numbers of new cases are continually occurring. Once the condition has occurred, the difficulty fistula patients go through is enormous, although the tragedy is neglected and very little has been done to address the issue. If the efforts to meet the Millenium Development Goals (MDGs) are to be fruitful, the plight of fistula patients must be seriously considered. This review article thus provides an overview of the epidemiology of obstetric fistula and its management in developing countries with emphasis on the experience of the Addis Abbada Fistula Hospital (AAFH). This will shed light on the plight of women and the magnitude of the problem, and hopefully thereby inspire professionals, decision makers, and interested donor organizations to take steps to help. METHODS
Accessible publications from Ethiopia and other developing countries were identified from Medline and Google using the key words “obstetric fistula,” “epidemiology,” “incontinence,” and “urogenital.” This was augmented by unpublished literature and relevant reports obtained by contacting experts in the field. The review focuses on experience, information, and literature from Ethiopia, although similar or different experience and reports from other developing countries were used as well. EPIDEMIOLOGY OF OBSTETRIC FISTULA
Although there are many problems associated with the collection of maternal mortality and morbidity statistics in developing countries, recent unpublished national prevalence data in Ethiopia indicate that for every 1000 women in the reproductive age group (15–49 years) there are 2.2 fistula patients in rural Ethiopia, making more than 26 000 cases awaiting repair.6 The 2005 demographic health survey (DHS) in Ethiopia (unpublished) also showed national prevalence of obstetric fistula being 1% of ever married women.7 Other reports stated that of the two million women estimated to suffer from obstetric fistula in the world, between 100 000 and one million reside in Northern Nigeria and over 70 000 in Bangladesh.8,9 Reports from Kenya and Nigeria have shown that, about 1/1000
deliveries are complicated by obstetric fistula.10,11 From 50 000 to 100 000 women are expected to develop a fistula each year, although this figure is said to be underestimated. Typical fistula patients in Ethiopia are young peasant girls who are married in their early teens to farmers with little or no education. The girls are given heavy tasks in the household and are poorly educated. They have no access to any health institution during pregnancy and labour, are often helped during labour by women of the village at home, and deliver a dead baby after being in labour for days. Although obstructed labour kills many of these young girls, the survivors develop urogenital fistulae. Because they are soon deserted by their husbands, ostracized by their village friends, and excluded from their social life, they often wish they had died with the baby. Many commit suicide. Even though detailed community-based research is lacking, several hospital-based studies support this profile of fistula patients.10–18 Structured interviews of 639 fistula patients treated at the AAFH between May 1999 and February 2000 revealed that the mean age of fistula patients at presentation to the hospital was 22 years, mean age at first marriage was 14.7 years, and mean age at the causative delivery was 17.8.15 More than 83% had their causative delivery when they were under 20 years old, 64% were primiparous, and the average length of labour was 3.8 days (range 1–10 days). The principal cause of obstetric fistula in the developing world is prolonged obstructed labour beyond the reach of medical help.14,19–24 Access to a health institution is a major problem for fistula patients, chiefly because of the long distances to reach care, poor transportation networks, and lack of money, and because parturition is regarded as something that can be managed at home.12,15,16,18 A report from Ghana identified obstructed labour as a cause of fistula in 91.5% of cases and difficult gynaecological surgery in the remaining 8.5% of cases. Approximately 53% of these women were under 25 years of age, and 43% developed a fistula during their first delivery.25 Other important causes of urogenital fistula include injuries from difficult surgery, radiation therapy, sexual abuse, penetrating injuries (for example from a cow’s horn or stick), infection, and malignancies.19,26,27 Malnutrition and high physical workloads in adolescence and childhood might interfere with growth and contribute to the high prevalence of obstetric fistula in the developing world, but this requires further research. Harmful traditional practices responsible for 6% to13% of fistulas include gishiri cutting in northern Nigeria.11,13,14,28 This is a series of random cuts through the anterior vagina, involving urethra and the bladder neck, as a traditional NOVEMBER JOGC NOVEMBRE 2006 l
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Figures
remedy for a variety of gynaecological complaints such as dyspareunia, infertility, genital prolapse, and obstructed labour. Although fistulas are common in communities where various forms of gishiri cutting is practised, there is no evidence suggesting that gishiri cutting is a major cause of fistula formation or even that it is causatively associated. In addition to urinary and fecal incontinence and the loss of their baby, women who experience obstructed labour are also more likely to suffer bony abnormalities, perineal nerve injury (including findings of a foot drop), nerve damage to the bladder, and dermatologic injuries. Reports from the AAFH showed that more than 93% of the deliveries to women with fistula were stillborn, and more than 50% of fistula patients were divorced.15,19,29 In India and Pakistan the divorce rate is 70% to 90%.30 MANAGEMENT
Treatment of obstetric fistula can be conservative or surgical. Placing an indwelling urinary catheter for all mothers who have survived obstructed labour can prevent fistula formation, and newly formed fistulas can heal spontaneously in 60% of cases if the margins of the fistula come together and continuous urinary drainage using a Foley catheter is used; however, the great majority of women will need surgical management.31,32 Every fistula is unique, and no single surgical technique can be used to close different types of fistula. Surgical experience and skill are required to deal with unexpected findings. The quality of nursing care and the extent of the damage will also influence the outcome of fistula repair. Although there are some controversies regarding timing, approach, and antibiotic use in obstetric fistula repair, the generally accepted principles of fistula closure technique include mobilization of the bladder from the vaginal wall, identification of the ureters, closure of the bladder wall, testing for integrity of closure by instilling dye (methylene blue) into the bladder, placing a graft between the bladder and the vagina, and closing the vaginal skin (see figures).33–36 Adequate exposure of the operative field is attained by an exaggerated lithotomy position, and a vaginal relaxing incision in cases where there is a narrow scarred vagina. Spinal anaesthesia is the cheapest and easiest type of anaesthesia for use in developing countries. Success rates after fistula repair vary from 85% to 92%, and the best chance for success is with the first operation.26,37 If there is complete destruction of the urethra, a closed or scarred vagina, complete or near complete destruction of the bladder, or involvement of ureters, the repair is very difficult and the prognosis poor. 964
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Obstetric Fistula in Developing Countries: A Review Article
In large and high fistulaes surrounded by dense scarring in the vagina, the ureteric orifices should be identified and catheterized under direct vision so that they are readily identifiable throughout the course of the operation. Freeing the bladder from the vaginal wall allows a tension-free bladder closure. When this has been accomplished, the ureteric catheters can be passed through the bladder and brought out through the urethra to keep them out of the operative field. The bladder is then closed using interrupted, absorbable sutures. Ideally, the bladder is closed in a two-layer approach; however, this is not always possible with urethral and very large fistulas. The second layer stitch is to reinforce the first layer, if at all possible. The Martius graft (in which the bulbo-cavernosus muscle is inserted between the bladder and vaginal sutures to improve the fistula repair) is an important technique used by most surgeons to enhance successful repair.38–41 The success rate of fistula repair has shown a significant improvement in the past few years, although depending on the severity of injury and the amount and site of tissue loss, there may be residual incontinence. Very few women require urinary diversion.42 The most satisfactory solution to the problem, however, is to prevent it.43 CONCLUSION
Although advances in obstetric care have made obstetric fistula a rarity in the developed world, it remains common in the developing world. Affected women are suffering from untold misery, and the great majority of these are poor and disadvantaged peasant women and girls. The problem has been neglected by governments in the developing world and by the MDGs, which fail to capture the problem of obstetric fistula. Fistula patients are living indicators of poor maternal health care and failed health systems, but they are largely ignored by the world.
death or to developing obstetric fistula. The calamities these young girls and mothers face must inspire us in this enormous task of preventing the injury, treating the affected, and searching for the best approaches to both prevention and treatment. ACKNOWLEDGEMENT
I am grateful to Dr Catherine Hamlin and Dr Biruk Tafesse for sharing their experience and their generous support. My special thanks to Dr André Lalonde for his confidence in me to write this article. REFERENCES 1. World Health Organization. Obstetric fistula. A review of available information. WHO/MCH/91.5. Geneva: WHO; 1991. 2. Mahfouz NP. Atlas of Mahfouz’s obstetrics and gynecological museum. 1949;2:580. 3. Zacharin RF. Obstetric fistula. New York: Springer-Verlag/Wein;1988:2–124. 4. Hilton P. Sims to SMIS–historical perspective on vesico-vaginal fistula. In: The yearbook of the Royal College of Obstetricians and Gynaecologists. Regent’s Park London: RCOG press;1994:7–16. 5. Zacharin RF. James Marion Sims (1813–1883) and the first fistula hospital. In: Zacharin RF, ed. Obstetric fistula. New York: Springer-Verlag/Wein;1988:22–64. 6. Prevalence of Obstetric Fistula in Rural Ethiopia; by the Addis Ababa Fistula Hospital. Unpublished document. 7. Demographic and Health Surveys of Ethiopia 2005. Unpublished document. 8. Proceedings of South Asia Conference for the Prevention and Treatment of Obstetric Fistula, 9–11 December 2003, Dhaka, Bangladesh. New York: UNFPA; 2004. 9. Wall LL. Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of northern Nigeria. Stud Fam Plann 1998; 29:341–59 10. Hillary M. Characteristics of women admitted with obstetric fistula in the rural hospitals in west Pokot, Kenya. Postgraduate training course in reproductive health 2004. Available at: http:/www.gfmer.ch. Accessed: August 4, 2006. 11. Liskin LS. Maternal morbidity in developing countries: a review and comments. Int J Gynaecol Obstet 1992;37:77–8. 12. Haile A. Fistula—a socio-medical problem. Ethiop Med J 1983;21:71–7.
The solution to the fistula problem will ultimately come from the provision of essential obstetric care service; however, the needs of those who have already developed fistula cannot be ignored. Reports from dedicated centres have shown how surgery transforms the lives of these victims and restores their dignity. The need for specialized and dedicated fistula centres derives from the special nature of the injury produced by obstructed labour. This includes the stigmatizing and socially isolating nature of the injury, the long period of rehabilitation needed before surgery, and the lengthy nursing care required after surgery. Obstetricians and gynaecologists must lead the way to liberate young women who are already on the road to maternal
13. Ampfo K, Out T, Uchebo G. Epidemiology of vesicovaginal fistulae in Northern Nigeria. West Afr J Med 1990;9(2):98–102. 14. Tahzib F. Epidemiological determinants of vesicovaginal fistulas. Br J Obstet Gynaecol 1983;90:387–91. 15. Muleta M. Socio-demographic profile and obstetric experience of fistula patients managed at the Addis Ababa Fistula Hospital. Ethiop Med J 2004;42:9–16. 16. Kelly J, Kwast BE. Epidemiological study of vesicovaginal fistulas in Ethiopia. International Urogynecology Journal 1993;4:278–81. 17. Hilton P, Ward A. Epidemiological and surgical aspects of uro-genital fistulae: a review of 25 years’ experience in south east Nigeria. Int Urogynecol J Pelvic Floor Dysfunct 1998;9:189–94. 18. Murphy M. Social consequences of vesicovaginal fistulae in northern Nigeria. J Biosoc Sci 1981;13:139–50. 19. Kelly J. Vesico Vaginal and rectovaginal fistulae. J R Soc Med 1992;85:257–8.
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20. Amr MF. Vesico-vaginal fistula in Jordan. Eur J Obstet Gynecol Reprod Biol 1998;80:201–3.
33. Hilton P. Urogenital fistulae. In: MacLean AB, Cardozo C, eds. Incontinence in women. London: COG Press 2002;163–80.
21. Arrowsmith SD. Genitourinary reconstruction in obstetric fistulas. J Urol 1994;152:403–6.
34. Margolis T, Mercer LJ. Vesico-vaginal fistula. Obstet Gynecol Surv 1994;49:840–7.
22. Goh JTW. Genital tract fistula repair on 116 women. Aust N Z J Obstet Gynaecol 1998;38:158–61.
35. Edwards JN. Principles of management of the vesicovaginal fistula. S Afr Med J 1982;62:989–91.
23. Lawson JB. Rectovaginal fistula following difficult labor. Proceedings of the Royal Society of Medicine 1972;65:283–6. 24. Waaldijk K. The surgical management of bladder fistula in 775 women in Northern Nigeria [thesis]. Netherlands: University of Utrecht;1989. 25. Danso KA, Martey JO, Wall LL, Elkins TE. The epidemiology of genitourinary fistula in Kumsai, Ghana, 1977–1992. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:117–20. 26. Muleta M. Obstetric fistula: a retrospective study of 1210 cases at the Addis Ababa Fistula Hospital. J Obstet Gynaecol 1997;17(1):68–70. 27. Muleta M, Williams G. Postcoital injuries treated at the Addis Ababa Fistula Hospital, 1991–97. Lancet 1999;354:2051–52. 28. Tahizib F. Vesico-vaginal fistula in Nigerian children. Lancet 1985;2:1291–3. 29. Wall LL, Arrowsmith S, Briggs NS, Lasey A. Urinary incontinence in the developing world: the obstetric fistula. Proceedings of the Second International Consultation on Urinary Incontinence, Paris, July 1–3, 2001. Committee on Urinary Incontinence in Developing World. Available at: http://www.wfmic.org/chap 12.pdf. Accessed May 1, 2006. 30. Cottingham J, Royston E. Obstetric Fistula. A review of available information. Geneva: WHO;1991: 39.
36. Tomlinson AJ, Thorton JG. A randomized controlled trial of antibiotic prophylaxis for vesicovaginal fistula repair. Br J Obstet Gynaecol 1998;105:397–9. 37. Elkins TE. Surgery for the obstetric vesico-vaginal fistula: A review of 100 operations in 82 patients. Am J Obstet Gynecol 1994;170:1108–20. 38. Elkins TE, DeLancy JOL, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesico-vaginal and rectovaginal fistula repair. Obstet Gynecol 1990;90:727–33. 39. Hamlin RHJ, Nicholson EC. Experiences in the treatment of 600 vaginal fistulas and in the management of 80 labors which have followed the repair of these injuries. Ethiop Med J 1966;4(5):189–92. 40. Baines REM, Orford HJL, THeron JLL. The repair of vesicovaginal fistulae by means of omental slings and grafts. S Afr Med J 1976;50:959–61. 41. Punekar SV, Buch DN, Soni AB, Swami G, Rao SR, Kinne JS, et al. Martius’ labial fat pad interposition and its modification in complex lower urinary fistulae. J Postgrad Med 1999;45:69–73.
31. Waaldijk K. Step by step surgery of vesicovaginal fistula. Edinburgh: Campion Press;1994.
42. Hamlin EC, Woldemichael A, Muleta M, Tafesse B, Aytenfesu H Browning A. Obstetric Fistula in the 21st century. In Hillard T, Purdie D, eds. The yearbook of Obstetrics and Gynaecology. Regent’s Park London: RCOG press 2004;11:210–23.
32. Waaldijk K. The immediate management of fresh obstetric fistula. Am J Obstet Gynecol 2004;191:795–9.
43. Murphy M, Baba TM. Rural dwellers and health care in Northern Nigeria. Soc Sci Med 1981;15:265–71.
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Obstetric Fistula in Developing Countries: A Review Article Mulu Muleta, MD, MDC Obstetrician-Gynecologist, Addis Ababa Fistula Hospital, Addis Ababa Ethiopia
Abstract Obstetric fistula, one of the most devastating consequences of prolonged obstructed labour, is a historical issue in the developed world. However, it is still prevalent in resource poor countries like Ethiopia. The objective of this review article is to describe the epidemiology of obstetric fistula and its management, with specific emphasis on the experience of the Addis Ababa Fistula Hospital. Published and unpublished literature on obstetric fistula was reviewed, and expert opinions are used in augmentation. Most obstetric fistulas result from neglected obstructed labour, often affecting very poor, young, illiterate, rural women and girls. The women are often in labour for days, helped by unskilled family members. They deliver a stillborn child, become incontinent of urine and/or feces, and become outcast and divorced as a result. Surgical repair mends the lives of thousands of women, although not all injured cases have access to treatment. Although prevention should be the ultimate goal, the need for curative care services for the sufferers is shown to be significant.
Résumé Les fistules obstétricales, l’une des conséquences les plus dévastatrices d’une interruption prolongée du travail, sont une curiosité historique dans les pays développés. Toutefois, elles demeurent omniprésentes dans des pays à court de ressources comme l’Éthiopie. L’objectif du présent exposé de synthèse est de décrire l’épidémiologie des fistules obstétricales et leur prise en charge, en mettant un accent plus particulier sur les cas rencontrés au Addis Ababa Fistula Hospital. Des articles publiés et non publiés sur les fistules obstétricales ont été passés en revue, et les opinions de spécialistes sont utilisées à titre de documentation d’appoint. La plupart des fistules obstétricales sont attribuables à une interruption du travail qui n’a pas été prise en charge. Les filles et les femmes qui en sont victimes sont souvent très pauvres, jeunes et analphabètes, et vivent en région rurale. Les femmes connaissent un travail qui dure souvent plusieurs jours, et n’ont pour seule aide que la présence de membres de la famille n’ayant aucune compétence en matière d’accouchement. Elles donnent naissance à un enfant mort-né, sont frappées d’incontinence (urinaire ou fécale), et sont délaissées par leur époux et leur communauté. La chirurgie permet à des milliers de femmes de reprendre une vie normale; toutefois, toutes les femmes atteintes de ce trouble n’ont pas nécessairement accès au traitement. La prévention devrait être le but ultime à atteindre; il Key Words: Obstetric fistula, epidemiology, incontinence, urogenital Competing Interests: None declared. Received on May 1, 2006 Accepted on May 24, 2006
962
l NOVEMBER JOGC NOVEMBRE 2006
n’en reste pas moins qu’il est très important de mettre en œuvre des services de soins curatifs à l’intention des victimes. J Obstet Gynaecol Can 2006;28(11):962–966
INTRODUCTION
bstetric fistula is an opening between the vagina and the bladder and/or the vagina and the rectum resulting from prolonged obstructed labour.1 Obstetric fistula leaves women with leakage of urine or feces or both and has been observed since women first began delivering children.
O
The oldest evidence of obstetric fistula can be found in the remains of an Egyptian queen’s mummy from around 1550 BC.2–4 Over time, physicians have attempted to describe and resolve this problem: the Persian physician Avenica made the connection between obstructed labour and vesico-vaginal fistula in the 11th century; Dr John Peter Mettauer of Virginia reported success in closing a vesico-vaginal fistula using wire sutures in 1838.3 In 1845, Dr J. Marion Sims of America encountered his first case of obstetric fistula, and on his 30th operation on the same patient in 1849, managed to close the fistula. In 1852, he published his article on the principles of fistula repair, and he has subsequently been called “the father of American gynecology.” In May 1855, he opened the first fistula hospital in New York. On the site of the hospital today, however, is the Waldorf Astoria Hotel, as there is now no need for a fistula hospital in America.5 In 1959, Dr Catherine Hamlin and Dr Reginald Hamlin left Australia to establish a midwifery training hospital in Ethiopia. However, the horrendous physical and social damage endured by fistula patients attracted their attention, and their efforts focused on helping these patients. They opened the fistula hospital in Ethiopia in May 1974, built exclusively for fistula patients. The hospital now operates on more than 1200 cases a year and has a success rate of 92%. Because there are many women who continue
Obstetric Fistula in Developing Countries: A Review Article
suffering in shame, Dr Catherine Hamlin continued the work with her team after the death of her husband in 1993.6,7 Obstetric fistula is completely preventable if high quality basic and comprehensive maternal health services are available to all. The Hamlin’s wish for the future is that, like the fistula hospital in New York, the fistula Hospital in Addis Ababa will eventually no longer be required. However, there is a huge backlog of unrepaired cases in the country, and the absence of adequate maternal health care and emergency obstetrical services means that large numbers of new cases are continually occurring. Once the condition has occurred, the difficulty fistula patients go through is enormous, although the tragedy is neglected and very little has been done to address the issue. If the efforts to meet the Millenium Development Goals (MDGs) are to be fruitful, the plight of fistula patients must be seriously considered. This review article thus provides an overview of the epidemiology of obstetric fistula and its management in developing countries with emphasis on the experience of the Addis Abbada Fistula Hospital (AAFH). This will shed light on the plight of women and the magnitude of the problem, and hopefully thereby inspire professionals, decision makers, and interested donor organizations to take steps to help. METHODS
Accessible publications from Ethiopia and other developing countries were identified from Medline and Google using the key words “obstetric fistula,” “epidemiology,” “incontinence,” and “urogenital.” This was augmented by unpublished literature and relevant reports obtained by contacting experts in the field. The review focuses on experience, information, and literature from Ethiopia, although similar or different experience and reports from other developing countries were used as well. EPIDEMIOLOGY OF OBSTETRIC FISTULA
Although there are many problems associated with the collection of maternal mortality and morbidity statistics in developing countries, recent unpublished national prevalence data in Ethiopia indicate that for every 1000 women in the reproductive age group (15–49 years) there are 2.2 fistula patients in rural Ethiopia, making more than 26 000 cases awaiting repair.6 The 2005 demographic health survey (DHS) in Ethiopia (unpublished) also showed national prevalence of obstetric fistula being 1% of ever married women.7 Other reports stated that of the two million women estimated to suffer from obstetric fistula in the world, between 100 000 and one million reside in Northern Nigeria and over 70 000 in Bangladesh.8,9 Reports from Kenya and Nigeria have shown that, about 1/1000
deliveries are complicated by obstetric fistula.10,11 From 50 000 to 100 000 women are expected to develop a fistula each year, although this figure is said to be underestimated. Typical fistula patients in Ethiopia are young peasant girls who are married in their early teens to farmers with little or no education. The girls are given heavy tasks in the household and are poorly educated. They have no access to any health institution during pregnancy and labour, are often helped during labour by women of the village at home, and deliver a dead baby after being in labour for days. Although obstructed labour kills many of these young girls, the survivors develop urogenital fistulae. Because they are soon deserted by their husbands, ostracized by their village friends, and excluded from their social life, they often wish they had died with the baby. Many commit suicide. Even though detailed community-based research is lacking, several hospital-based studies support this profile of fistula patients.10–18 Structured interviews of 639 fistula patients treated at the AAFH between May 1999 and February 2000 revealed that the mean age of fistula patients at presentation to the hospital was 22 years, mean age at first marriage was 14.7 years, and mean age at the causative delivery was 17.8.15 More than 83% had their causative delivery when they were under 20 years old, 64% were primiparous, and the average length of labour was 3.8 days (range 1–10 days). The principal cause of obstetric fistula in the developing world is prolonged obstructed labour beyond the reach of medical help.14,19–24 Access to a health institution is a major problem for fistula patients, chiefly because of the long distances to reach care, poor transportation networks, and lack of money, and because parturition is regarded as something that can be managed at home.12,15,16,18 A report from Ghana identified obstructed labour as a cause of fistula in 91.5% of cases and difficult gynaecological surgery in the remaining 8.5% of cases. Approximately 53% of these women were under 25 years of age, and 43% developed a fistula during their first delivery.25 Other important causes of urogenital fistula include injuries from difficult surgery, radiation therapy, sexual abuse, penetrating injuries (for example from a cow’s horn or stick), infection, and malignancies.19,26,27 Malnutrition and high physical workloads in adolescence and childhood might interfere with growth and contribute to the high prevalence of obstetric fistula in the developing world, but this requires further research. Harmful traditional practices responsible for 6% to13% of fistulas include gishiri cutting in northern Nigeria.11,13,14,28 This is a series of random cuts through the anterior vagina, involving urethra and the bladder neck, as a traditional NOVEMBER JOGC NOVEMBRE 2006 l
963
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Figures
remedy for a variety of gynaecological complaints such as dyspareunia, infertility, genital prolapse, and obstructed labour. Although fistulas are common in communities where various forms of gishiri cutting is practised, there is no evidence suggesting that gishiri cutting is a major cause of fistula formation or even that it is causatively associated. In addition to urinary and fecal incontinence and the loss of their baby, women who experience obstructed labour are also more likely to suffer bony abnormalities, perineal nerve injury (including findings of a foot drop), nerve damage to the bladder, and dermatologic injuries. Reports from the AAFH showed that more than 93% of the deliveries to women with fistula were stillborn, and more than 50% of fistula patients were divorced.15,19,29 In India and Pakistan the divorce rate is 70% to 90%.30 MANAGEMENT
Treatment of obstetric fistula can be conservative or surgical. Placing an indwelling urinary catheter for all mothers who have survived obstructed labour can prevent fistula formation, and newly formed fistulas can heal spontaneously in 60% of cases if the margins of the fistula come together and continuous urinary drainage using a Foley catheter is used; however, the great majority of women will need surgical management.31,32 Every fistula is unique, and no single surgical technique can be used to close different types of fistula. Surgical experience and skill are required to deal with unexpected findings. The quality of nursing care and the extent of the damage will also influence the outcome of fistula repair. Although there are some controversies regarding timing, approach, and antibiotic use in obstetric fistula repair, the generally accepted principles of fistula closure technique include mobilization of the bladder from the vaginal wall, identification of the ureters, closure of the bladder wall, testing for integrity of closure by instilling dye (methylene blue) into the bladder, placing a graft between the bladder and the vagina, and closing the vaginal skin (see figures).33–36 Adequate exposure of the operative field is attained by an exaggerated lithotomy position, and a vaginal relaxing incision in cases where there is a narrow scarred vagina. Spinal anaesthesia is the cheapest and easiest type of anaesthesia for use in developing countries. Success rates after fistula repair vary from 85% to 92%, and the best chance for success is with the first operation.26,37 If there is complete destruction of the urethra, a closed or scarred vagina, complete or near complete destruction of the bladder, or involvement of ureters, the repair is very difficult and the prognosis poor. 964
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In large and high fistulaes surrounded by dense scarring in the vagina, the ureteric orifices should be identified and catheterized under direct vision so that they are readily identifiable throughout the course of the operation. Freeing the bladder from the vaginal wall allows a tension-free bladder closure. When this has been accomplished, the ureteric catheters can be passed through the bladder and brought out through the urethra to keep them out of the operative field. The bladder is then closed using interrupted, absorbable sutures. Ideally, the bladder is closed in a two-layer approach; however, this is not always possible with urethral and very large fistulas. The second layer stitch is to reinforce the first layer, if at all possible. The Martius graft (in which the bulbo-cavernosus muscle is inserted between the bladder and vaginal sutures to improve the fistula repair) is an important technique used by most surgeons to enhance successful repair.38–41 The success rate of fistula repair has shown a significant improvement in the past few years, although depending on the severity of injury and the amount and site of tissue loss, there may be residual incontinence. Very few women require urinary diversion.42 The most satisfactory solution to the problem, however, is to prevent it.43 CONCLUSION
Although advances in obstetric care have made obstetric fistula a rarity in the developed world, it remains common in the developing world. Affected women are suffering from untold misery, and the great majority of these are poor and disadvantaged peasant women and girls. The problem has been neglected by governments in the developing world and by the MDGs, which fail to capture the problem of obstetric fistula. Fistula patients are living indicators of poor maternal health care and failed health systems, but they are largely ignored by the world.
death or to developing obstetric fistula. The calamities these young girls and mothers face must inspire us in this enormous task of preventing the injury, treating the affected, and searching for the best approaches to both prevention and treatment. ACKNOWLEDGEMENT
I am grateful to Dr Catherine Hamlin and Dr Biruk Tafesse for sharing their experience and their generous support. My special thanks to Dr André Lalonde for his confidence in me to write this article. REFERENCES 1. World Health Organization. Obstetric fistula. A review of available information. WHO/MCH/91.5. Geneva: WHO; 1991. 2. Mahfouz NP. Atlas of Mahfouz’s obstetrics and gynecological museum. 1949;2:580. 3. Zacharin RF. Obstetric fistula. New York: Springer-Verlag/Wein;1988:2–124. 4. Hilton P. Sims to SMIS–historical perspective on vesico-vaginal fistula. In: The yearbook of the Royal College of Obstetricians and Gynaecologists. Regent’s Park London: RCOG press;1994:7–16. 5. Zacharin RF. James Marion Sims (1813–1883) and the first fistula hospital. In: Zacharin RF, ed. Obstetric fistula. New York: Springer-Verlag/Wein;1988:22–64. 6. Prevalence of Obstetric Fistula in Rural Ethiopia; by the Addis Ababa Fistula Hospital. Unpublished document. 7. Demographic and Health Surveys of Ethiopia 2005. Unpublished document. 8. Proceedings of South Asia Conference for the Prevention and Treatment of Obstetric Fistula, 9–11 December 2003, Dhaka, Bangladesh. New York: UNFPA; 2004. 9. Wall LL. Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of northern Nigeria. Stud Fam Plann 1998; 29:341–59 10. Hillary M. Characteristics of women admitted with obstetric fistula in the rural hospitals in west Pokot, Kenya. Postgraduate training course in reproductive health 2004. Available at: http:/www.gfmer.ch. Accessed: August 4, 2006. 11. Liskin LS. Maternal morbidity in developing countries: a review and comments. Int J Gynaecol Obstet 1992;37:77–8. 12. Haile A. Fistula—a socio-medical problem. Ethiop Med J 1983;21:71–7.
The solution to the fistula problem will ultimately come from the provision of essential obstetric care service; however, the needs of those who have already developed fistula cannot be ignored. Reports from dedicated centres have shown how surgery transforms the lives of these victims and restores their dignity. The need for specialized and dedicated fistula centres derives from the special nature of the injury produced by obstructed labour. This includes the stigmatizing and socially isolating nature of the injury, the long period of rehabilitation needed before surgery, and the lengthy nursing care required after surgery. Obstetricians and gynaecologists must lead the way to liberate young women who are already on the road to maternal
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20. Amr MF. Vesico-vaginal fistula in Jordan. Eur J Obstet Gynecol Reprod Biol 1998;80:201–3.
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35. Edwards JN. Principles of management of the vesicovaginal fistula. S Afr Med J 1982;62:989–91.
23. Lawson JB. Rectovaginal fistula following difficult labor. Proceedings of the Royal Society of Medicine 1972;65:283–6. 24. Waaldijk K. The surgical management of bladder fistula in 775 women in Northern Nigeria [thesis]. Netherlands: University of Utrecht;1989. 25. Danso KA, Martey JO, Wall LL, Elkins TE. The epidemiology of genitourinary fistula in Kumsai, Ghana, 1977–1992. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:117–20. 26. Muleta M. Obstetric fistula: a retrospective study of 1210 cases at the Addis Ababa Fistula Hospital. J Obstet Gynaecol 1997;17(1):68–70. 27. Muleta M, Williams G. Postcoital injuries treated at the Addis Ababa Fistula Hospital, 1991–97. Lancet 1999;354:2051–52. 28. Tahizib F. Vesico-vaginal fistula in Nigerian children. Lancet 1985;2:1291–3. 29. Wall LL, Arrowsmith S, Briggs NS, Lasey A. Urinary incontinence in the developing world: the obstetric fistula. Proceedings of the Second International Consultation on Urinary Incontinence, Paris, July 1–3, 2001. Committee on Urinary Incontinence in Developing World. Available at: http://www.wfmic.org/chap 12.pdf. Accessed May 1, 2006. 30. Cottingham J, Royston E. Obstetric Fistula. A review of available information. Geneva: WHO;1991: 39.
36. Tomlinson AJ, Thorton JG. A randomized controlled trial of antibiotic prophylaxis for vesicovaginal fistula repair. Br J Obstet Gynaecol 1998;105:397–9. 37. Elkins TE. Surgery for the obstetric vesico-vaginal fistula: A review of 100 operations in 82 patients. Am J Obstet Gynecol 1994;170:1108–20. 38. Elkins TE, DeLancy JOL, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesico-vaginal and rectovaginal fistula repair. Obstet Gynecol 1990;90:727–33. 39. Hamlin RHJ, Nicholson EC. Experiences in the treatment of 600 vaginal fistulas and in the management of 80 labors which have followed the repair of these injuries. Ethiop Med J 1966;4(5):189–92. 40. Baines REM, Orford HJL, THeron JLL. The repair of vesicovaginal fistulae by means of omental slings and grafts. S Afr Med J 1976;50:959–61. 41. Punekar SV, Buch DN, Soni AB, Swami G, Rao SR, Kinne JS, et al. Martius’ labial fat pad interposition and its modification in complex lower urinary fistulae. J Postgrad Med 1999;45:69–73.
31. Waaldijk K. Step by step surgery of vesicovaginal fistula. Edinburgh: Campion Press;1994.
42. Hamlin EC, Woldemichael A, Muleta M, Tafesse B, Aytenfesu H Browning A. Obstetric Fistula in the 21st century. In Hillard T, Purdie D, eds. The yearbook of Obstetrics and Gynaecology. Regent’s Park London: RCOG press 2004;11:210–23.
32. Waaldijk K. The immediate management of fresh obstetric fistula. Am J Obstet Gynecol 2004;191:795–9.
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