Obstetric Fistula

Epidemiology of obstetric fistula

The incidence of obstetric fistula has diminished progressively over the years especially in the developed world as results of availability of modern obstetric care which goes parallel with the socioeconomic development of the country, improved communication and education system. In contrast, in developing countries obstetric fistula remains to be a major health problem affecting millions as a hidden or silent epidemic. It is only since the last 3 decades that attention and recognition has been given to this devastating problem.

Global survey to determine the magnitude of obstetric fistula has not been carried out so far. From extrapolated data of hospital records and personal observation it is estimated that about 2 million women are suffering from obstetric fistula worldwide. According WHO estimation, 0.3% of laboring mothers develop obstetric fistula. Based on this estimation 50,000-100,000 new women are affected in the world every year.

There is no analyzed regional or country prevalence of obstetric fistula. However, it is well known that developing world like Asia and Africa have staggeringly high maternal mortality rates. For every maternal death there are about 30 maternal disabilities and obstetric fistula is the most devastating of all these maternal morbidities. Thus, the high maternal mortality ratio is an indirect indicator of the high prevalence of obstetric fistula in these regions

Africa has the highest prevalence of obstetric fistula. In Nigeria alone 800,000-1,000,000 unrepaired VVF cases are estimated to exist. Based on the national survey done in Ethiopia, there are about 26,000 unrepaired fistula cases. In countries like Nigeria and Ethiopia where the population is high the number of new obstetric fistula cases developing every year is significant. In Ethiopia with the population of 110 million with crude birth rate of 38.2 per 1000 births, it is estimated that about 9,000 new obstetric fistula cases develop every year. It is believed that these figures are only the tip of the ice burg of the problem. The figure is much less than the exact number of obstetric fistula on the ground. There are many reasons for the under reporting of obstetric fistula, among which are poor data collection system and the stigma associated with obstetric fistula.

Causes of Fistula

Prolonged obstructed labour

Life giving process is a natural physiological phenomenon that should be a joyful event for mothers and the family. Unfortunately this is not true for many women who live in the developing countries where mothers die or end up with lifelong disability as a result of child birth and obstetric fistula is one of such complications. Even though labour is a natural process, about 15% of labouring women need assistance during their delivery. When these labouring women live far from health facilities it is always difficult for them to get medical help to assist the delivery. Then, their labour can be prolonged for days even for weeks until they reach to the right place and get help. In the process of prolonged labour if the presenting part of the fetus is the head, it compresses the bladder in the front and rectum at the back against the pelvic bone. If the labouring mother stayed in this condition without any intervention that relives the obstruction, the pressure applied by the head of the fetus cuts off the blood supply to the bladder, rectum and adjacent tissues and results in tissue necrosis of the structures around the pelvis. Furthermore, the fetus usually dies and the head decomposes and becomes soft and boggy; finally it slips out through the vagina. The ischemic tissue of the bladder and rectum necrotized sloughs out and leaves a hole that communicates the bladder and/or the rectum to the vagina. Usually the urinary incontinence doesn’t occur immediately, it may occur within 3 - 7 days after the whole necrotized tissue comes out through the vagina.

The degree of injuries usually varies depending on the duration of prolonged labour that is the duration of the compression of tissues and level where the obstruction occurs. The extent of injuries from obstructed labour is not only limited to the bladder, vagina and rectum. It also involves the nerves, blood vessels, soft tissues and bony structure around the pelvis.

As a result of multiple tissue involvement there will be a wide range of clinical problems even in systems that are far from genital tract and these wide range of clinical symptoms collectively referred as “obstructed labour injury complex”. IN addition prolonged obstructed labour caesarean Hysterectomy, ruptured uterus, instrumental and destructive deliveries are causes of obstetric causes.

Backward Communication

In Ethiopia, means of communications are backward. The road is not good especially during the rainy seasons. The rivers will be full and it is difficult to cross it. Ambulances are not available to facilitate the referral of mothers in difficult labour.

Mountainous Landscape

The landscape especially in the Northern part of the country is also another problem. It is mountainous and it makes access to medical care difficult for mothers living in the valley isolated and scattered. Unending civil war in the country becomes a hindrance for the provision of emergency obstetric care. During war time Health facilities will be destroyed, people will be displaced, deployment and retention of skilled birth attendants in the rural areas will be impossible.

Less Opportunity to Education

Moreover, culturally women do not have much say where to give birth; economically they are completely dependent in on their husband. As a result many women suffer from obstructed labour and its consequences. In rural part of the Ethiopia girls always has less opportunity to go to school. They get married at a very young age and get pregnant before their pelvis fully developed and wide enough for the passage of the fetus during labour.