Programmatic and Policy Recommendations for Addressing Obstetric Fistula and Uterine Prolapse
Obstetric fistula is “not just a medical issue, but a human issue,” said Dr. Luc de Bernis, senior maternal health advisor at UNFPA, during a September 27 panel discussion at the Wilson Center. Obstetric fistula, a hole in the birth canal that can develop between the vagina and the bladder and/or rectum during prolonged labor without proper medical intervention, is preventable and treatable but continues to affect more than two million women worldwide, mostly in developing countries where women lack access to cesarean services. Women stricken with it face severe pain and suffering, social stigmatization, and usually give birth to a stillborn child.
Root Causes and Effects
For Gillian Slinger, a nurse, midwife, and coordinator of UNFPA’s Campaign to End Fistula, the fact that there are 50,000 to 100,000 new cases of fistula every year is a sad reminder of the inequalities that exist between developing and developed countries.
Although the women and girls affected by obstetric fistula may not die, the impact on their quality of life is awful, said Slinger. Many become social outcasts because of the “constant and humiliating” incontinence that often accompanies fistula, and in many traditional societies, the inability to give birth also unfortunately alienates these women from their husbands. In addition, fistula can also lead to other health issues, Slinger said, such as kidney disease, severe dehydration, and paralysis through a condition known as foot drop in which nerves in the limbs are damaged by prolonged labor.
Childbirth for these women literally breaks their bodies, leaving them completely helpless. “In a world of unequals, the most unequal of unequals are the women and girls with obstetric fistula,” Slinger said.
While UNFPA’s Campaign to End Fistula focuses on prevention, treatment, and reintegration into society, the Fistula Foundation’s primary function is to provide surgeries. Kate Grant, executive director of the foundation, stressed that the incidence of obstetric fistula is “a symptom of a system that either doesn’t exist or failed for women when they needed it most.” Malnourishment causes stunted pelvis growth in young girls, she said, which in turn increases the likelihood of obstetric fistula when they give birth as adults. The foundation was working exclusively in Ethiopia but is now funding projects in 19 countries.
Synergizing Care or Splitting Resources?
Dr. Lauri Romanzi, clinical associate professor at the New York University Langone Medical Center, suggested including uterine prolapse in the discussion with fistula. Romanzi sees patients that have experienced both, since fistula can often lead to prolapse. While there are several key differences between the two conditions, namely that obstetric fistula can be eradicated and uterine prolapse cannot, both produce comparable symptoms and require a related set of surgical skills.
Celia Pett, a midwife and medical associate for fistula care at EngenderHealth, said there is a strong case to be made for integrating resources and advocacy efforts for obstetric fistula and uterine prolapse and believes it could be more cost-effective and sustainable in the long-run. But, she is skeptical about the short-term feasibility of such an approach, especially in already fragile health systems. Based on her experience in Nepal, where uterine prolapse is exceptionally high, she said practitioners found it difficult to translate the rhetoric of integration into reality.
Pett said she is also concerned about competition between the two for limited resources and attention, and the demand for services outweighing the supply of medical practitioners who can actually deliver treatment.
However, she remains optimistic about the role that midwives – “the specialists in childbirth” – can play to prevent and treat obstetric fistula and uterine prolapse in developing nations, where they are often the health professionals best placed to ensure continuing care for women’s health.
Dealing with Challenges and Engendering Solutions
Despite the fact that obstetric fistulas are preventable, there are a great many challenges to their complete eradication.
One is building infrastructure. Fistula is a traumatic injury which requires considerable medical expertise and facilities. Training surgeons from the countries in which fistula persists (mostly in sub-Saharan Africa and Asia) is the best solution for building up human capacity, said Grant. Investing in Western surgeons who would effectively be “medical tourists,” she says, is not the way to go. De Bernis echoed this sentiment by saying that the only way to solve the problem in a sustainable way is to train people to deal with the issues in their own communities instead of giving them temporary aid or assistance.
Following along these lines, Romanzi spoke about an exciting development at the Korle Bu Teaching Hospital in Accra, Ghana, that she sees as the future for training in fistula and pelvic floor disorders in developing and middle-income nations. Without any external funding or assistance, Korle Bu recently launched a residency-level urogynecology program, based on the model of the American Urogynecologic Society and British Society of Urogynaecology’s fellowship programs. The International Urogynecological Association has since become involved, but only after being invited to participate by Korle Bu and after the program had already started. It is a three-year training program and that is exactly what is needed to learn the full range of skills, said Romanzi.
Funding, however, is also an issue. It is difficult to raise money to address maternal morbidities in general, said Pett, since many resources are devoted to maternal mortality instead. There is usually a backlog of women who require treatment but are unable to receive it because of a lack of financial and human resources, said de Bernis. In places where the medical infrastructure is poor and funding lacking, Pett suggested focusing on strengthening midwives and nursing in the short term.
The UNFPA’s strengthening midwifery program has done a lot to add fistula prevention strategies to midwife training, she said. In Nepal, for example, UNFPA has created specific modules on fistula and prolapse prevention for its midwifery training program. Similarly, EngenderHealth has collaborated with the East, Central, and Southern Africa Health Community to create a nursing curriculum that focuses on prevention, treatment, and care for fistula and prolapse.
In addition to training and infrastructure building efforts, Slinger said that continued advocacy and awareness-raising is critical to helping to end fistula. A key strategy that works for mobilizing communities and raising awareness is working with grassroots community networks as well as using women and girls who have suffered from fistula to deliver the message of prevention.
De Bernis agreed, stressing that ending obstetric fistula must be a global campaign undertaken through joint collaboration by small and big NGOs, governments, and others. When UNFPA began its Campaign to End Fistula in 2003, “it was very clear for all that piecemeal efforts will never achieve anything seriously,” he said. The diversity of the speakers on the panel showcased this type of coordinated effort and augurs well for continued collaboration around women’s health issues in the future.
Drafted by Payal Chandiramani and edited by Schuyler Null.
Kate Grant //Executive Director, Fistula Foundation
Technical Specialist Obstetric Fistula and Coordinator of Campaign to End Fistula, UNFPA
Senior Maternal Health Advisor, Technical Division, UNFPA