By Doris Obinna
On Tuesday, when the world celebrated the International Day to End Obstetric Fistula, with theme, “hope, healing, and dignity for all,” the pathetic story of women with a hole between the vagina and rectum or bladder caused by prolonged obstructed labour, were remembered. This is understandable. Communities shun such women. The women suffer depression, social isolation and deepening poverty.
Research shows that obstetric fistula are common among women, who live in low-resource countries, who give birth without access to medical help. If a woman’s labour becomes obstructed, she could remain in excruciating pain for days before her baby is finally dislodged. Her baby likely dies and she is often left with an obstetric fistula.
According to Dr. Gabriel Omonaiye, obstetric fistula is an abnormal connection between two epithelial surfaces in a woman arising from difficult delivery.
Said he: “There is a hole between the vagina and the bladder, Vesico Vaginal Fistula (VVF) or the vagina and the rectum, Recto Vaginal Fistula (RVF). or both.
“In VVF, the woman experiences abnormal leakage of urine;, while the sufferer of RVF has leakage of faeces and the patient with both RVF and VVF, surfer the leakage of both faeces and urine.”
He said the consequences of obstetric fistula are many. Hear him: “Due to the inability of the victim to control the effluent of urine (in VVF), excreta (for RVF) and both urine and excreta in individuals with combined VVF and RVF, they suffer from isolation and mental torture, as they have bad body odour from the urine and excreta, which soil them. So mixing freely with other people is restricted. Depression is very common among them. Anaemia is also common, as well as infection.
“It is not uncommon for the husbands of the affected women to abandon, divorce them or stop relating with them sexually. The skin of the perineum can suffer from excoriation from the ammonia in the urine.”
The medical and economic consequences
Research show that if left untreated, fistula can lead to frequent ulcerations and infections, kidney disease and even death. Some women drink as little as possible to avoid leaking and become dehydrated. Damage to the nerves in the legs can leave some women unable to walk. These medical consequences, coupled with social and economic problems, often contribute to a general decline in health and well being that can result in early death.
Omonaiye said economically, the victims are at a disadvantage, as they are unable to engage in economic activities because of the stench of urine and /or faeces. They also tend to be malnourished.
“The social fallouts also include stigmatisation, economic deprivation.
Fistulas occur due to an interplay of several factors: culture, illiteracy, poverty, childhood malnutrition and medical (poor antenatal care and bad delivery practices),” he said.
He explained that all these factors conspire together to produce prolonged obstructed labour and delivery, which is the cause of most cases of VVF and RVF.
“In the northern part of Nigeria, very young girls are given out in marriage. Many of these girls have a very small pelvis, which can easily cause prolonged labour, especially if the fetus is relatively big.
“Cephalopelvic Disproportion (CPD) is a situation in which the pelvis of the pregnant woman is too small for the relatively big head and body of her baby to be easily delivered by the vaginal route.
“But unfortunately, most of these young pregnant girls, with narrow pelvis and CPD have little or no antenatal care in a good hospital. They are rather attended to by the traditional birth attendants, who poorly attend to them.
“The delivery of some lasts for days (prolonged obstructed labour), and in the process cause damage either the bladder or /and the rectum due to prolonged pressure on them by the presenting part of the baby.
“Childhood malnutrition can cause a small or contracted pelvis, which may eventually cause CPD in the future.”
Different researches show that fistula occurs when emergency obstetric care is not available to women who develop complications during childbirth. This is why women living in remote rural areas, with little access to medical care are at risk. Before the medical advances of the 20th century, fistula was quite common in Europe and the United States. Today, fistula is almost unheard of in high-income countries, or in countries where obstetric care is widely available.
The World Health Organisation has called fistula “the single most dramatic aftermath of neglected childbirth.” Malnutrition, poor health services, early marriage and gender discrimination are interlinked root causes of obstetric fistula.
Poverty is the main underlying factor, as it is associated with early marriage and malnutrition, and because lack of funds hinders a woman’s access to emergency obstetric care. Consequently, young and poor women living in rural areas are particularly at risk. Because of their low status in many communities, women often lack the power to choose when to start bearing children or where to give birth.
Childbearing before the pelvis is fully developed, as well as malnutrition, small stature and generally poor health, are contributing physiological factors to obstructed labor. Older women who have delivered many children are at risk as well.
Omonaiye continued: “In so many parts of Nigeria, Caesarean Section (C/S) is still frowned at, and women who deliver by it are seen to be inferior to those who have vaginal delivery. This wrong belief tends to perpetuate prolonged obstructed labour, even in good hospitals as the husbands, family members and the affected women, usually reject vehemently Caesarean section.
“Poverty also deters many pregnant women from accessing good obstetric care (including surgical interventions).
Obstetric fistula are common in primigravida with prolonged obstructed labour, other women with big babies, pregnant women in labour with babies who have abnormal presentation or lie (for example hand presentation or transverse lie at term with an unskilled birth attendant trying to deliver the baby vaginally).”
Can fistula be cured?
Omonaiye notes that the cure of both VVF and RVF is surgical repair after adequate mental, nutritional and medical rehabilitation.
The patient needs to be in an optimal health and nutrition before the surgery to ensure a good outcome.
He said: “There are estimated 400, 000 to 800, 000 women with VVF in Nigeria and about 20,000 new cases being recorded annually. About 90 percent of the affected women do not have access to treatment.”
A study suggests reconstructive surgery can mend the injury, and success rates are as high as 90 per cent. Two weeks or more of post-operative care is needed to ensure a successful outcome. Counselling and support are also important to address emotional damage and facilitate social reintegration.
Omonaiye proposed adequate childhood nutrition. Said he: “Nutrition is needed to enhance adequate growth and having propionate body parts, including adequate pelvis.
“The girl child should be properly educated, empowered, so that she will, in the future (as a pregnant woman), have the resources, knowledge and the wherewithal to make good choices that are favourable to her health.
“The men should give more freedom of movement to their spouses.
Adequate training and retraining of traditional birth attendants are needed, so that immediate referral of difficult delivery cases will be the norm. Cultural practices and beliefs that stigmatise C/S should be discarded.
“The governments at various levels, should subsidise or bear with costs of caesarean section for the poor.”
However, a study said prevention, rather than treatment, is the key to ending fistula. Making family planning available to all who want to use it would reduce maternal disability and death by at least 20 per cent. Complementing that with skilled attendance at all births and emergency obstetric care for those women who develop complications during delivery would make fistula less common.
Also, addressing social issues that contribute to the problem, such as early pregnancy, girls’ education, poverty and women’s empowerment are important areas of intervention as well.