Obstetric Fistula: A Problem of Poverty and Culture

Obstetric fistula having been nearly eradicated in the West, many people here never hear the phrase, let alone know what it is. Yet in other parts of the world, obstetric fistula can be a common and tremendously devastating complication of childbirth. It's counterpart--traumatic fistula--is caused by sexual violence and affects even more women.

What is a fistula?
A fistula is a hole where one should not exist.¹ In the case of obstetric fistula, this means that because of obstructed labor, living tissue loses its blood supply, dies, falls away, and leaves a hole between a woman's vagina and bladder, or sometimes between her vagina and rectum. This results in incontinence.

What causes fistulas?
The two main causes of fistula are labor obstruction and severe sexual trauma. Many other factors play into these two causes.

In countries where obstetric fistula is common, several other important factors are also common. In these countries, malnutrition is the norm for most people throughout their life. For girls, this means stunted growth and often deformed pelvic bones. If a pelvic opening is deformed enough, it can prevent vaginal birth, and the pressure of the baby's head for many hours (or several days) in the same spot because of this labor obstruction can cause a fistula.

In some of these countries, early marriage also may contribute to fistula rates, as newly menstruating young girls are married off and become pregnant in their very early teens. If their body is not fully developed because of age, or deformed due to malnutrition, their very first pregnancy may doom them to a life of incontinence and social rejection.

Obstetric fistula can also occur when a woman's labor is obstructed for other reasons. Labor obstruction has a variety of causes. In the Western world, we have access to emergency medical care, including Cesarean section. In countries where obstetric fistula is common, a woman may be days away from any kind of medical care, or she may not have the money to purchase care, or there may be cultural reasons keeping her from seeking emergency medical care when it becomes obvious that there is a problem with her labor.

The focus of this article is obstetric fistula, but traumatic fistula deserves at least a brief mention, as it often occurs in the same countries as obstetric fistula, and has the the same (or worse) long term effects on women. Traumatic fistula is caused by the most physically brutal forms of rape, often involving objects or even weapons. It is a particular problem in areas of conflict, political instability, or war.² The horrendous situation in the Democratic Republic of Congo has begun to bring this kind of tragedy to light, as the world becomes aware of the brutal sexual violence being used as a weapon to destroy families and communities and thus subdue them.³

The Effects of Obstetric Fistula
As previously mentioned, obstetric fistula causes severe urine incontinence, and occasionally fecal incontinence. In many countries, a woman with a fistula faces lifelong ostracism and rejection if it is not repaired. In terms of health, it is somewhat understandable that humans tend to avoid a person whose smell is offensive and who leaves a puddle of urine wherever they go. Even a loving and supportive family may have difficulty living intimately with a person so afflicted, particularly when the ability to maintain cleanliness is limited by poverty or geographical location.

However, oftentimes this natural avoidance of odor and excretion becomes intensely personal and a matter of shame and humiliation. Instead of offering to help a woman suffering in this way--by helping her stay clean, getting her medical assistance, offering food when she cannot work for her own--husbands, families, and villages may simply turn their backs on her.⁴ In some worldviews, such a dreadful condition can only be the result of personal failing or sin, making the woman's suffering her fault, or a punishment from the divine.

Physically, the constant flow of urine or feces can cause severe discomfort for a woman, cause rashes and infections, make her more vulernable to disease-carrying flies, and the existence of the fistula itself leaves her open to infection. The obstructed labor itself may have killed her baby or damaged her uterus. If she is fortunate enough to have the fistula repaired and be re-accepted into society, if she has more children she is at risk of the fistula re-opening and thus is recommended to give birth only by c-section. This in turn leads to yet another psychological and social problem--the desire to have children but lack of money or access to the necessary healthcare that would prevent a reoccurance of this devastating problem.

What is Being Done to Help?
There are several organization as well as independant doctors and hospitals that are working tremendously hard, and sometimes at great risk, to provide help and healing to women suffering from fistula.

Surgical repair of an uncomplicated fistula has as high as a 90% success rate. For more complicated cases, the rate of success is still as high as 60%.⁵ Recognizing the social and emotional aspects of this problem, many of these places also provide supportive community for women who's repairs were not successful, prevention education, and community education.

Pioneering fistula repair centers and hospitals exist in Ethiopia, Nigeria, Mali, Sudan and Tanzania, among others. The Addis Ababa Fistula Hospital (Ethiopia) was founded in 1974 and has provided treatment for more than 25,000 women. The Panzi Hospital in the Democratic Republic of Congo seeks to provide treatment and hope for the many women in the DRC devastated by obstetric fistula and fistula caused by sexual violence. In Afghanistan, where the health care system has completely broken down, the CURE International Hospital and is a hopeful starting point for expanded care for women in the war-torn country.

The Future of Obstetric Fistula
That obstetric fistula can be eradicated or nearly so by the history of childbirth in the West. Obstetric fistula's decline in this part of the world was a direct and demonstrable result of health education and access to emergency medical care during childbirth.

Many organizations and missions are working to make this a world-wide reality. Some work directly with fistula patients. Others are seeking the social changes that will lower the incidence of this problem in the first place--better nutrition, protection of women, rejection of child marriages, health education, and workable healthcare infrastructures.

It is hopeful that with time and major social changes, women around the world who suffer from obstetric fistula today can see their daughters and their grandaughters deliver children in safety and in good health, free of fear and physical trauma.

¹Fistula, Free Dictionary-Medical Dictionary
²Traumatic Gynecologic Fistula, fistulacare.org
³Stop Violence Against Women in the DRC, Amnesty International
⁴The Challenge Of Living With Fistula, Campaign to End Fistula
⁵Fistula Can Be Surgically Repaired, Campaign to End Fistula