Literature Review on Studies of Obstetric Fistula Cases
Cathleen A. RueckeisObstetric fistula (OF) is an abnormal passageway between two organs or an organ and the exterior, usually in the form of a tear due to an injury during childbirth. In rural parts of African countries such as Niger, Tanzania and Sierra Leona, many women become pregnant at a young age, sometimes as early as their first monthly bleeding, because of cultural traditions, where older men marry young virgins. Due to their young age, these girls hips are not fully developed and if they become pregnant, they often have obstructed labor, in which the baby’s head does not fit through the birth canal, presses against the hip’s bones and inhibits blood flow to the tissue in between, causing the tissue to die. If the women survives childbirth, the tissue wears away leaving a hole most commonly between the bladder or the rectum and the vagina. Often, women with OF are ostracized by their communities, because of the bad smell resulting from the constant leakage of urine and/or feces through their vaginas. Some also suffer from infections. Due to the lack of health care facilities and transport, many women live with an OF for months or years before getting surgical repair. There are many cases where women die of health issues resulting from fistulae and there are also cases of suicide. Though fistulae do occur in Western countries, they are very rare due to the network of extensive health care systems, which offer women preventive measures, such as C-sections, as well as immediate repair surgeries. Additionally, the average age of childbirth is significantly higher in first world countries than in most third world countries, making obstructed labor a less likely occurrence. Obstructed labor is also a result of malnutrition, which is prevalent in many part of rural Africa, but not in Western countries.
Various studies have been conducted that analyze the impact of OF on women’s lives, what physical characteristics most frequently lead to OF development and, accordingly, ways to determine what women are most at risk for having OF, as well as methods for reducing OF occurrences and future goals in the field.
Obstetric Fistulae have profoundly negative impacts on women’s lives. Many women are ostracized or marginalized by their local communities, because of the horrible smell they generate due to urinary and/or fecal incontinence. Separation, divorce, absence of sexual intercourse and depression are all common results of fistulae. A study by Hannah Krause in Uganda, which involved 150 women, showed that 42% of women were rejected by their husbands and all women were exposed to abandonment by family members. Additionally, the study looked at the mean duration of their condition with OF, which was 13.1 months, and the average age of first delivery, which was 17.1 years. In this way, Krause’s study demonstrates that on average these women were teenage girls, who spent over a year suffering from their condition. It must be noted that this study worked with hospitalized women and thus centered exclusively on women who eventually found medical attention for their condition, as opposed to those who might have struggled with an OF longer and never been healed.
OF cases occur most prominently in rural areas, because of lacking medical health care options for women outside the city. A study conducted by Kathryn Siddle in Tanzania, sought to investigate additional demographics of women most frequently affected by OF. The study shows that women were more likely to develop OF if they chose natural delivery, had no family support and lived in isolated areas with little access to health care or education. Though the study itself does not propose a method for reducing OF rates, it does provide a foundation for targeting women most in need of health care opportunities, especially as it claims to be the largest study of its kind in Tanzania.
Several methods have been proposed for preventing or at least reducing the frequency of OF occurrences. Browning’s 2014 study on women in Sierra Leona and Tanzania developed a method for predicting women at risk for OF occurrences. A woman’s age, height, and knuckles, which measure pelvic diameter and indicate the possibility of obstructed labor, were put together to create a ‘fistula index,’ a number which estimates potential complications during childbirth and resulting fistula development. The fistula index is noninvasive, not technology based and can be applied at the village level. This is important for working in resource-limited communities. In this way, the fistula index can indicate which women are at a higher risk for developing fistula and health care precautions, such as the presence of a midwife or transportation preparation to a nearby hospital, can be made prior to these women’s deliveries.
Additional methods have been devised for the reduction of OF rates. Anders Seim conducted an experiment where he introduced community mobilization into an isolated, rural part of Niger and reported a decrease in maternal and perinatal mortality, though the OF rates remained constant. Two individuals were selected from each of the 305 villages and trained in maternal health education and instructed as to how to behave in complications prior to, during and after childbirth. According to Seim, lack of data prevented possible proof of OF rate reduction. This decline was, in fact, significant enough (between 40 % and 60%) that it cannot be attributed to chance. The program’s success owes also to the improved mobile-phone coverage and the addition of staff members to the local district hospital. The legitimacy of this program is emphasized by the variety of its sponsors, including the government of Niger and United Nations Population Fund. This experiment illustrates that by increasing awareness and accessibility of health care can decrease the rates of mortality due to obstructed labor.
Africa is not the only continent with widespread fistula occurrences. A. H. Jokhio conducted a study to determine the prevalence of OF in rural Pakistan. A random sampling strategy was used to collect data, by interviewing women at local health care clinics and at home. The results showed that 0.39% of all women and 0.45% of all women with previous births had OF. Most of the women with OF were less than 20 years old and 40% had lived with their condition for longer than five years. The study interviewed a total of 5064 women and was funded by the Aga Khan University in Pakistan, thus demonstrating reliability. Clearly, OF is not a problem solely on the African continent, but also in other underdeveloped areas.
Efforts have been made by international organizations to increase the world’s attention to OF. Babatunde Osotimehin outlines the 2014 UN Commission on Population and Development, which addresses the health issues related to OF in rural parts of Africa as well as future goals, though the methods for achieving these goals are not stated. According to the article, OF is to be eliminated by 2030 and there now is an annual Day to Ending Obstetric Fistula on May 23rd, where the global community is enlightened to the nature and consequences of OF.
Multiple factors, including teenage pregnancies, malnutrition and a lack of health care facilities, contribute to the high obstetric fistula rates in certain developing countries around the world, such as Tanzania, Niger and Pakistan. The studies examined in this literature review showed that fistulae can have many profound negative impacts on women’s lives, like marginalization by society. Different techniques can be applied to determine the likelihood of fistula development and prevention. The ‘fistula index’ and community mobilization are examples of successful methods of determining the chance of fistula occurrence and its reduction. All studies agree that more attention needs to be focused on improving access to health care for women in order to effectively reduce OF rates in developing nations.
Works Cited
Browning A., Lewis A, Whiteside S. “Predicting women at risk for developing obstetric fistula: a Fistula index? An observational study comparison of two cohorts”. Wiley Online Library. BJOG, 10 January 2014. Web. 07 Sept. 2014
Johkio, A. H. “Prevalence of Obstetric Fistula: A Population-based Study in Rural Pakistan.” Wiley Online Library. BJOG, 30 Mar. 2014. Web. 28 Sept. 2014.
Krause, Hannah G., et al. “Treatment-seeking Behavior and Social Status of Women with Pelvic Organ Prolapse, 4th-degree Obstetric Tears, and Obstetric Fistula in Western Uganda – Online First – Springer.” Springer Link. International Urogynecology Journal, 01 June 2014. Web. 08 Sept. 2014.
Seim, Anders R., et al. “Pilot Community-mobilization Program Reduces Maternal and Perinatal Mortality and Prevents Obstetric Fistula in Niger.” Science Direct. International Journal of Gynecology & Obstetrics, 30 July 2014. Web. 08 Sept. 2014.
Siddle, Kathryn, Lisbeth Vieren, and Alison Fiander. “Characterising Women with Obstetric Fistula and Urogenital Tract Injuries in Tanzania – Springer.” Springer Link. International Urogynecology Journal, 01 Feb. 2014. Web. 07 Sept. 2014.
Osotimehin, Babatunde. “Seizing the Moment to End Obstetric Fistula.” Science Direct. The Lancet Global Health, July 2014. Web. 09 Sept. 2014.