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End the Inequity: The Journey to Eradicate Obstetric Fistula

By Lauri Romanzi, M.D.

Obstructed labor can happen to any woman, no matter where she lives. However, it is only in non-wealthy nations that it leads to devastating injuries such as obstetric fistula. While the risk of maternal mortality and injuries is universal, women’s health is not just about women—it is determined by external forces as much as by biology. By looking at how and where we have eradicated obstetric fistula in the past, we hope we can also help illuminate our path forward.

Achieving zero incidence–a look back

Until the early 1900s, obstructed labor was a common occurrence and a top killer of pregnant women everywhere in the world, including women in wealthy nations. As part of the transformation of obstetric care (and anesthesia) in North America and Europe, techniques were developed to treat it early, preventing bodily damage or death. Eventually, the first fistula hospital became obsolete and closed its doors—today it is the site of the Waldorf Astoria Hotel in New York City.

Without intervention, obstructed labor can go on for days, sometimes longer than a week. Left untreated, it will most often result in a stillborn infant, and either kill the mother or, if she survives, leave her body severely damaged. With untreated obstructed labor, the baby is wedged tightly in the mother’s pelvis, compressing the bladder and rectum against the pelvic bones. This pressure destroys the tissues separating the vagina from the bladder or rectum, ending with fistula formation that can only be treated with surgery.

Called “failure to progress” or “arrest of active labor” in wealthy countries, obstructed labor is in large part managed with cesarean delivery.  Among U.S. women pregnant for the first time, for example, obstructed labor is the most common indication for cesarean delivery, accounting for 35% of cesarean indications. “Failure to progress” is simply the pre-morbid phase of obstructed labor.1

The persistence of extreme maternal morbidities in non-wealthy nations showcases a lack of access to quality sexual and reproductive health services across a woman’s lifetime. The key to achieving a zero incidence of new obstetric fistula cases lies in the timely treatment of obstructed labor as part of comprehensive care before, during, and after pregnancy. However, even the prevention of new cases would still not address the roughly 1 to 2 million women and girls living with obstetric fistula today.

Addressing the backlog–looking ahead

Many women with obstetric fistula are waiting to undergo corrective surgery. Meeting this need is crucial to alleviate suffering, restore communities where these women live and create a fistula-free landscape for future generations.

In non-wealthy nations where obstetric fistula persists, women suffering other pelvic floor disorders also contribute to the unmet burden of disease, suggesting there may be an opportunity for improved use of limited resources through holistic care.2 In many busy fistula centers, for instance, three to four women with pelvic organ prolapse come for care for every fistula patient admitted under “single service” programs that only support fistula surgery. Fistula surgeons are best positioned to care for women with other pelvic floor disorders, and in order to do this well, training that integrates prolapse, incontinence and fistula gives the surgeons what they need for their patients and want for themselves.

The skills, facilities, and supplies needed to care for women with these conditions overlap, creating systematic opportunities to integrate fistula care into larger services that gives the doctors, nurses and midwives the capacity to take care of the whole patient and the whole community within the limits of the resources available—a dynamic that resonates in healthcare systems around the world.

At EngenderHealth we support a model that puts women’s rights at the center of our work, to ensure that health care providers and policymakers are listening to what women want, not dictating their needs. Supporting the integration of fistula care into expanded services for female pelvic medicine builds off this notion by demonstrating awareness of and respect for the true needs of women seeking care. It also acknowledges the full potential of the doctors by promoting authentic sustainability of today’s fistula-focused programs into a post-fistula era.2

Holistic approach

As part of Fistula Care Plus, a five-year fistula repair and prevention project from the U.S. Agency for International Development (USAID), we are working alongside doctors, nurses, communities, and policymakers to both reduce incidence of obstetric fistula, and address the backlog of women living with this devastating condition. With appropriate resources, awareness, knowledge, and strong health systems for prevention, treatment, and reintegration, fistula can become a rare event for future generations.

REFERENCES:
1. Boyle A, Reddy U M, Landy HJ. Primary cesarean delivery in the United States. Obstet Gynecol . 2013 July ; 122(1): 33–40

2. Walker GJA, Gunasekera P. Pelvic organ prolapse and incontinence in developing countries: review of prevalence and risk factors.. Int Urogynecol J (2011) 22:127–135

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