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Raising awareness of obstetric fistulas

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Zoe Vowles, guest blogger
Zoe Vowles, guest blogger
11.21, 23 April 2010

Obstetric fistula is an extremely debilitating condition that causes serious physical and psychological morbidity for women who are affected by it. It is something that many people in the UK possibly have little awareness of and, as a midwife working in the UK, it is something that I would never expect to see. Sadly, in Sierra Leone many women are living with the health problems and stigma associated with this preventable condition.

A fistula is most commonly caused by obstructed labour. When the blood supply to the soft tissues of the vagina and bladder (and possibly rectum) are cut off during prolonged obstructed labour the tissues die, resulting in a hole either between the bladder and vagina or rectum meaning that women are continually leaking either urine, faeces or both. In many cases the baby will have died during the labour too. Women with fistula are often ostracised by their husband, families and communities, meaning that a woman who was already likely to be very poor becomes even more poverty stricken. Fistula is a result of many direct and indirect causes that include lack of use or provision of adequate health services, coupled with a need to improve opportunities for education and economic empowerment for women.


An organisation called Mercy Ships operates in Sierra Leone. Based in Freetown, it gives many women the opportunity to return to normal life through surgical repair of the fistula and also seeks to identify women living with this condition through outreach work.


Health Poverty Action is collaborating with Mercy Ships in a project to raise awareness of the causes of fistula, how to prevent it and how to access treatment through the training of women from remote villages in Northern Bombali (and soon also the more urban western area that includes Freetown) who have had surgical fistula repair, to become ‘fistula advocates’.


These women and also many of the people in their communities may be illiterate, traditionally women had little access to education and the war meant that education for many people of school age at that time was disrupted, so the advocates use a picture book that powerfully depicts the story of Fatu a young girl who develops a fistula following a long labour and many delays in seeking, reaching and receiving appropriate health care. In 12 pictures, the book captures what Fatu endures during her long, difficult labour and her ensuing stigmatisation and isolation. It goes on to show Fatu learning about her condition when a fistula advocate comes to her village, her regained confidence following successful treatment followed by becoming an advocate herself to help other women. 


With any project which is implemented, it is clearly important to evaluate the impact. I am working with an epidemiology intern to plan our baseline survey, focusing mainly on indicators relating to prevention of fistula such as awareness of obstructed labour, pregnancy complications and birth preparedness alongside the availability, use and quality of health services in our operational area. I am learning a huge amount as we plan the survey and enjoying the challenge of new and different aspects of my work. Planning the survey complements my other work to develop and strengthen emergency obstetric care guidelines and the documentation system at Kamakwie Wesleyan Hospital with the hospital staff. It is helpful that there is good collaboration between organisations here and sharing of locally developed resources makes this work easier and more relevant.      

                           

 From 27 April, free healthcare for pregnant women is being introduced by the government. I hope that this important step, to improve outcomes for mothers and babies, supported by the work of theDepartment for International Development, UNICEF and the other organisations including Health Poverty Action, who are working in Sierra Leone to improve maternal health, will be a step towards fistula becoming a thing of the past.


The RCM is also using this year’s International Day of the Midwife on 5 May to raise awareness of obstetric fistulas.


COMMENT

1. At 10.39 on 30 April 2010, Tony wrote:

There is a free obstetric fistula surgery service being set up in Cambodia, where HPA also works. Many of the indigenous people of the northeast define 'prolonged delivery' as more than 4 days, so there is a demand...


2. At 17.23 on 1 June 2010, Kate de Rivero wrote:
 
Thank you for raising awareness about obstetric fistula through your blog.
 
At Women and Health Alliance (WAHA) International, we support many fistula care projects across Africa.(http://www.waha-international.org)
 
In Ethiopia, Cameroon, and Nigeria, we work in partnership with local university teaching hospitals, which ensures that free fistula surgery is continuously available. Furthermore, a permanent fistula treatment service within the hospital exposes medical students (including trainee surgeons and gynaecologists) to as many cases as possible such that they are better equipped to identify and treat fistula cases once they have qualified and are working in smaller hospitals around the country.
 
In rural settings with a high prevalence of cases and no locally available fistula surgeon or referral hospital, we organise fistula ‘treatment camps’ at district hospitals. This strategy enables a high number of cases to be treated over a short period of time (e.g. 1-2 weeks) by visiting surgeons and a fistula care team, with a follow up ‘camp’ normally organised to assess the outcomes 4-8 weeks later. So far this year, we have co-organised several treatment camps with local partners in Kenya, South Sudan, Cameroon, Tanzania, Zambia, Somaliland and Senegal. In June, we will be present at treatment camps in Guinea Bissau, Eritrea, Bangladesh and Afghanistan – all settings with high rates of maternal mortality and low utilisation of health services, suggesting a high prevalence of untreated fistula.
 
However, despite the efforts of fistula surgeons across Africa, the backlog of up to 2 million cases continues to grow. For every fistula surgery performed, 5 new cases occur!
 
Nevertheless, there is new hope that midwives could potentially play an important new role in substantially reducing the number of new fistula cases that occur every year. A new campaign has been launched by WAHA International and Dr Kees Waaldijk (President of the International Society of Fistula Surgeons and director of the Nigeria National Fistula Programme) to promote systematic use of Foley catheters by midwives for all women who are leaking urine following delivery.
 
Data from the Nigeria National Fistula Programme show that up to 37% of new fistula cases could be cured through using a Foley catheter, if the procedure is started within 75 days post-partum.
 
So how does it work? To put it simply, the indwelling Foley catheter drains urine from the bladder. This decompresses the bladder wall so that the wounded edges come together and stay together, promoting spontaneous healing - at least of the smaller fistulas.
 
This promising data represents a potential change in the role that midwives can play in the fight to eradicate obstetric fistula. If guidelines were developed such that midwives were trained and equipped to carry out this procedure (which costs a couple of US dollars compared to the 300 USD for a surgical intervention), then this could be a cost-efficient and highly effective way to reduce the incidence of fistula cases. This would also permit early identification of the other 75% of women who did not heal and who need to be referred for surgical treatment in short delay in order to reduce the risk of being marginalized within their community.
 
These data were shared in the first International Conference for Midwife Associations from French speaking Africa which was held on the 18th and 19th of May in Benin, organised by WAHA International. The midwives present at the conference all called on their greater involvement through the use of Foley catheters - an approach which was also endorsed by the many gynaecologists, fistula surgeons, and representatives from the Ministry of health, WHO and UNFPA who attended.
 
You can find out more about the Foley catheter campaign, our fistula projects and the conference in Benin on our website: www.waha-international.org or by contacting Kate at kate.derivero@waha-international.org
 

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