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Abstract
BackgroundAn obstetric fistula is a traumatic childbirth injury that occurs when labor is obstructed and delivery is delayed. Prolonged obstructed labor leads to the destruction of the tissues that normally separate the bladder from the vagina and creates a passageway (fistula) through which urine leaks continuously. Women with a fistula become social outcasts. Universal high-quality maternity care has eliminated the obstetric fistula in wealthy countries, but millions of women in resource-poor nations still experience prolonged labor and tens of thousands of new fistula sufferers are added to the millions of pre-existing cases each year. This article discusses fistula prevention in developing countries, focusing on the factors which delay treatment of prolonged labor.DiscussionObstetric fistulas can be prevented through contraception, avoiding obstructed labor, or improving outcomes for women who develop obstructed labor. Contraception is of little use to women who are already pregnant and there is no reliable screening test to predict obstruction in advance of labor. Improving the outcome of obstructed labor depends on prompt diagnosis and timely intervention (usually by cesarean section). Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. This time interval is often extended by delays in deciding to seek care, delays in arriving at a hospital, and delays in accessing treatment after arrival. Communities can reasonably demand that governments and healthcare institutions improve the second (transportation) and third (treatment) phases of delay. Initial delays in seeking hospital care are caused by failure to recognize that labor is prolonged, confusion concerning what should be done (often the result of competing therapeutic pathways), lack of women’s agency, unfamiliarity with and fear of hospitals and the treatments they offer (especially surgery), and economic constraints on access to care.SummaryWomen in resource-poor countries will use institutional obstetric care when the services provided are valued more than the competing choices offered by a pluralistic medical system. The key to obstetric fistula prevention is competent obstetrical care delivered respectfully, promptly, and at affordable cost. The utilization of these services is driven largely by trust.
Highlights
An obstetric fistula is a traumatic childbirth injury that occurs when labor is obstructed and delivery is delayed
An obstetric fistula is formed when the tissues that normally separate the vagina from the bladder and/or rectum are destroyed by the prolonged impaction of the presenting fetal part against the soft maternal tissues that are trapped between the fetal head and the woman’s boney pelvis
The destruction of these tissue barriers joins these adjacent structures through a fistula, which results in continuous incontinence of urine or stool and turns the affected woman into a social outcast
Summary
Reducing maternal mortality and severe obstetric morbidity It has been obvious for many years that reductions in maternal mortality and serious maternal morbidity can only be accomplished through three mechanisms [10]: 1. The risk of becoming pregnant can be reduced. The laboring woman should be transported rapidly to an emergency obstetric care facility where proper treatment (often cesarean section) can be provided At this point, there are many possible and very divergent therapeutic pathways that can be chosen by the actors involved. . A caesarean section, which in Burkina Faso is performed almost exclusively as a life-saving intervention, was widely held to presage unaffordable costs, potentially accompanied by social calamity if it meant that a woman was divorced or abandoned on account of being ‘too expensive’” [130] The result of these economic factors is that large segments of the population in the world’s poorest countries have almost no access to cesarean section and it is among these women that the obstetric fistula problem is most pressing [141]. The terse observation that “inequities in maternal mortality are largely shaped by social, economic and political vulnerabilities that disproportionately affect the world’s poor” is quite accurate [130]
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