Obstetric fistula: current practicalities and future concerns

Abstract

Wubenesh is a typical young woman in Ethiopia. She was married at 10 and became pregnant soon after menarche. She actually had three normal deliveries and three live children before she turned 20. However, on her fourth delivery she developed an obstructed labour and remained in labour for 4 days. She eventually delivered a stillborn child but by this time she was unconscious from exhaustion. Three days after her delivery she started to leak uncontrollably from her bladder and bowel due to vesicovaginal and recto-vaginal fistulae forming by ischaemic injuries from the impacted presenting part. Her family looked after her for 2 weeks, but it was obvious that she was not getting better, and, still unconscious, she was carried for 2 days to the Barhirdar Hamlin Fistula Centre in northern Ethiopia. On arrival she was in a critical state, unresponsive, in respiratory distress, no blood pressure, low heart rate, she had ascites, full-body oedema, paralysed from the waste down, blind from corneal ulcerations from having her eyes open during that period, retained products, and fistulas from her vagina to both her bladder and rectum. Medical care in developing countries is scant at best: There is often no monitoring equipment, poor laboratories that only do basic testing and little available medicine. Wubenesh embarked on a hazardous recovery. With basic medical common sense and some good luck, she fully recovered with a mixture of frusemide, potassium and calcium, whole blood (blood products were not available and the blood transfusion took 5 days to arrange), antibiotics, drainage of her ascites, oxygen from an oxygen concentrator and eventually surgery for the retained products and for the fistulae. After 3 months of basic medical care she had fully recovered, she was able to walk, her sight was restored and her fistulae were cured. She was able to return to her husband and three children in good health and resume her previous life. The obstetric fistula is a devastating condition. Caused by a long obstructed labour, resulting in a stillborn child and rendering the patient completely incontinent with a vesico-vaginal fistula and sometimes a recto-vaginal fistula as well, it causes social isolation, ostracism and often depression and suicide. No-one really knows howmanywomen are living with this condition or how many new cases occur a year. Conservative estimates put the figure at about 50,000–100,000 new cases each year and at least 2 million patients still waiting for treatment across Africa [1]. Some estimate that there could be as many as 500,000 new cases each year [2]. There has been some media attention to this problem and more people from the west have become interested in helping these women, but even so only about 7000 thousand cases are being treated per year across the world. Most, if not all, cases of obstetric fistulae occur in areas with poor medical resources and training. By definition, unrelieved obstructed labour results in obstetric fistula simply because the patient has no access to emergency obstetric care, no means of reaching people with facilities and training to repair these injuries. The above case illustrates the complexity of some of the cases and some of the struggles that practicing in resourcepoor areas can bring, but also the rewards of bringing dignity and healing to such debilitating conditions. More and more doctors from western medical systems are interested in helping to treat these women, but when Int Urogynecol J (2008) 19:333–334 DOI 10.1007/s00192-007-0543-1