The danger of obstetric fistula

WHEN Nina, a striking-looking young Tanzanian was put on the cover of Faces of Dignity, the publication of the United States-based Women's Dignity Project, it was not to promote cosmetics or a beauty contest, but to tell the story of her struggle with a little known affliction - obstetric fistula.

Between 50,000 and 100,000 young women are afflicted worldwide by obstetric fistula every year. Though the ailment is not heard of in Western societies since the Middle Ages, it is still extensively prevalent in Asia and sub-Saharan Africa. In Nigeria alone, as many as a million women remain untreated, and the United Nations estimates some two million cases worldwide.

A disorder of the bowels and bladder, obstetric fistula is usually the result of obstructed childbirth in young pregnant women. During prolonged labour, the soft tissues of the pelvis can get compressed between the baby's head and the mother's pelvic bone - constricting blood flows to these tissues and creating an opening between the mother's vagina and bladder, or vagina and rectum, or both. This hole causes the mother to lose control over her bladder and bowels and thus remain soaked in her own fluids. The horrific nature of the condition prompts husbands, children, relatives and friends in many cases to abandon these women, leaving them destitute.

According to Family Care International, a non-profit organisation headquartered in New York, 14 million babies are born to girls under 19 years every year, accounting for 10 per cent of all births. Pregnancy-related deaths are the leading cause of mortality among those in the 15-19 age group (married and unmarried) worldwide. In the least developed countries, one in every six births is to girls aged between 15 and 19; 33 per cent of women in less developed countries give birth before the age of 20 - ranging from a low of 8 per cent in East Asia to 55 per cent in West Africa - compared to about 10 per cent in more developed countries. Interestingly, in the U.S. about 19 per cent of women give birth before they are 20.

Teenage girls over 15 are twice as likely to die at childbirth as women in their 20s, while girls under 15 are at five times greater risk. In Niger, 88 per cent of women with obstetric fistula were aged between 10 and 15 at marriage. Every year, a quarter of all unsafe abortions - approximately five million - are performed on girls aged 15-19, thereby increasing their risk of obstetric fistula.

Global health experts say child marriage - an age-old custom in many nations - is the major cause of serious health risks for women in the developing world, doubling the likelihood of death during childbirth and leading to lasting reproductive health problems such as obstetric fistula. In India, the mean age at marriage is less than 18. Over 70 per cent of women in India are married before 20; 54 per cent before 18; and 26 per cent before 15.

In developing countries, some 82 million girls between the ages of 10 and 17 marry before their 18th birthday, disrupting their education and limiting their opportunities. Expectations from parents, in-laws and society pressure them to produce a child as soon after marriage as possible. Many young wives feel pressured to bear sons. This typically results in many pregnancies, too soon and too close.

According to Geeta Rao Gupta, head of the International Centre for Research on Women, child marriage is a serious problem with deep cultural and economic roots, especially in the developing world. Poverty causes many families to force early marriage on their daughters. With proper resources obstetric fistula can be treated, and inexpensively too. In most cases a repair of the vaginal hole caused by the condition is required. According to the U.N. report, a simple surgery can be effective in 60-90 per cent of the cases, depending on the severity of the fistula.

But currently, the cost of treatment starts from Rs.5,000, a sum that most poor people in the developing world find unaffordable. U.N. Population Fund Executive Director Thoraya Ahmed Obaid says: "While there are many doctors in the West who are capable of treating this ailment, there are very few qualified professionals in, say, India, Bangladesh or Nigeria where the need is very high."

According to Mary Ellen Stanton, Senior Reproductive Health Adviser, Bureau for Global Health, women who suffer from obstetric fistula also suffer in many cases from neurological damage that can affect their ability to walk.

The women who are most at risk include the very young going through their first childbirth and women whose growth has been stunted owing to malnutrition and childhood illness. Women who live in the rural areas without access to healthcare services and those relying on the delivery of the baby at home and on traditional care are also at high risk.

While most women suffering from fistula can be treated with surgery, medical expertise needs to be coupled with good post-operative care, including quality nursing and psycho-social support. In India, the surgical infrastructure to provide such repair is inadequate at the primary health centre (PHC) level.

Experts working with fistula patients have found imparting knowledge and training to identify the problem and psycho-social reintegration for social rehabilitation essential. Focus should be on creating public awareness that urges women to postpone marriage and childbearing until after teenage and community awareness about the problem of prolonged labour, and preparedness for emergencies.

Access to skilled care, including surveillance during labour, is important in preventing obstetric fistula. Whether a woman delivers at home or in a health facility, there is time to detect prolonged labour and take action before the mother suffers continued pressure on soft tissues that leave her urinary, intestinal and reproductive systems damaged.

One proven tool is the partogram that assists midwives and doctors in plotting the progress of labour as well as the condition of the mother and the foetus. If a partogram reveals any deviation from the normal, the birth attendant is given a visual cue to be on the alert and to take action. This tool can be used in all settings where there is a skilled birth attendant and will allow timely transfer of the mother, if necessary, to a place where assisted delivery can be performed.

In addition to skilled attendants and the availability of emergency obstetric care, a functioning referral system must be in place so that timely transfer to life-saving medical care - in most cases, a caesarean section - can be given.

The role of education is important in reducing maternal disability and death. For instance, in developing countries each additional year of schooling is associated with a 5 to 10 per cent drop in child deaths. Education is second only to family planning in lowering family size.

For every Nina we know, there may be thousands of unknown Ninas suffering in silence, alone.