by Dr Steven Arrowsmith.
Recently, women's health issues have begun to receive long-deserved attention from the international community. However, one of the greatest tragedies facing women in the developing world today remains relatively unknown. It is well known that women in poorer countries in the world face an appalling risk of death during childbearing. However, for every woman who dies in labour, many more are injured.
Danger in childbirth
Among childbirth injuries, the most devastating is obstetric fistula. This injury occurs when a long labour, for whatever reason, goes untreated. For many hours or even days, the baby’s head grinds against the pelvic tissues of the mother, eventually interrupting the blood flow to these tissues. Soon these tissues die, leaving a large hole leading directly from the vagina to the bladder or even the rectum. Permanent, constant leakage of urine (from the bladder) or stool (from the rectum) results.
In over nine out of ten cases, the baby does not survive this long labour. Because the victim of this horrible injury smells of urine all the time, she is often rejected by her husband and family. Obstructed labour is more common in young women who have not yet reached adult size. So often these women find themselves in their mid-teens, mourning the loss of their first baby, deeply hurt from their rejection by husband and family, cast off to an uncertain future of looking after themselves and facing a long life in complete isolation from all that was once dear to them.
No one really knows how many fistula victims there are in the world. There are thought to be at least 1.5 to 2 million sufferers in Africa alone. Up until the beginning of this century, obstetric fistula was feared all over the world. The first fistula hospital built especially for these women was in New York City, where thousands of women were cured in the late 1800s. But as medical advances in childbirth improved, this problem all but disappeared from wealthier nations in the world. Sadly, these advances have passed the developing world by. In poorer areas of Africa, Asia, and South America, there are millions of women quietly suffering this tragedy.
The costs of caring
Why is this problem so common? Global economics are very important. Many countries simply cannot afford to have enough well equipped, well staffed centres where women in obstructed labour can go to have a caesarean section. Neither can they afford the huge cost of developing good highways and transport systems that allow these women to reach a hospital for emergency help.
Cultural factors are very important as well. Some ethnic groups practice early marriage, which increases the risk of obstructed labour. When the mother has not grown to full size, there is often simply not enough room in the pelvis for the baby to be delivered normally. Some cultures apply tremendous pressure on the pregnant woman to deliver at home. Those who go to the hospital to deliver are often considered to be weak or abnormal. So they choose to suffer in obstructed labour at home. Female excision, when practised in the severe form of infibulation, can cause terrible scarring which leads to obstructed labour.
Meeting the needs
Repair of obstetric fistula can be difficult, but in the hands of experienced surgeons, success rates of over 90% are possible after a single operation. Successful repair requires both the closing of the hole created during the long labour and the restoring to normal function of the bladder. Fistula patients often suffer from other complications of their long labour, including difficulty from nerve injury in walking, infertility because of damage to the uterus, and inability to have sexual relations with their husbands because of the damage and scarring to the vagina. So the fistula surgeon must be ready to try to meet all of these special needs that fistula victims have. A major effort is underway to organise a network of training centres which would allow physicians working in fistula areas to be properly trained in this special technique.
A handful of hospitals
Although fistula surgery is being performed in general hospitals throughout the developing world, there are very few centres in the world today which are dedicated to the care of these special patients. Fistula hospitals are currently in operation in Ethiopia, Sudan, and Nigeria. Why are there so few fistula hospitals? Most often the women are so poor that they are completely unable to pay hospital bills, so special help with the costs is usually necessary. This means that fistula hospitals must be constantly seeking assistance from government and private donors to give care to their patients. These hospitals can never hope to be financially self-supporting.
At the Addis Ababa Fistula Hospital we have performed more than 11,000 fistula repairs since 1974. Our highly efficient staff is made up almost entirely of patients who stayed with us when they could not be completely cured. Our patients come from all over Ethiopia and from other countries in the Horn of Africa, often walking for many days just to reach the nearest road to journey to Addis Ababa. We train gynaecologists from our local medical school and physicians who come from all over the world to learn fistula surgery.
The hope of health
No work could be more rewarding than to reach out in love to these women who for so long have had no hope. With just a single trip to the hospital, the vast majority of these women can be restored back to a normal life. We hope and pray that the new attention focused on the plight of women in the developing world will bring about improvements in childbirth services throughout the world that will make fistulas a thing of the past. As we wait for this to happen, we also hope that this new attention will enable many more hospitals like our own to be established, and that thousands of surgeons throughout the world would have the training and resources to deal with this great human tragedy.
Dr Steven Arrowsmith, Addis Ababa Fistula Hospital, PO Box 3609, Addis Ababa, Ethiopia.