Prevention of Obstetric Fistula

What Is an Obstetric Fistula?

Obstetric fistula is a condition characterized by an abnormal opening between a woman's genital tract and her urinary tract or rectum, leading to urinary and fecal incontinence, anemia, ongoing genital infections, and neurological symptoms in the lower limbs. The primary cause of obstetric fistula is prolonged obstructed labor, often resulting in stillbirth. In cases of severe obstruction, there is a risk of cervical damage, potentially affecting future fertility. This condition has a profound impact on mental health, as well as social and marital relationships, due to the stigma associated with it. Estimates suggest that between 50,000 to 100,000 women worldwide are affected by obstetric fistula each year. Additionally, more than 2 million young women in Asia and sub-Saharan Africa are living with untreated obstetric fistula.

What Are the Causes of Obstetric Fistula?

The most common cause of obstetric fistula is prolonged, obstructed labor lasting up to five days.

1. Social factors contributing to obstructed labor include:

• Limited access to maternal health services.

• Poverty.

• Lack of education.

• Women's limited role in decision-making.

• Early marriage.

• Harmful traditional practices like Female Genital Mutilation (FGM).

• Limited access to and utilization of family planning services, resulting in inadequate spacing of pregnancies.

2. Obstructed labor can be prevented by:

• Delaying the age of the first pregnancy ensures full development of the pelvic ring, providing more room for the fetal head to pass through the pelvic canal.

• Eliminating harmful traditional practices.

• Ensuring timely access to maternal and obstetric care, addressing the three delays: prompt decision-making to seek medical care, timely transportation to the nearest medical facility, and access to treatment by appropriately skilled healthcare providers upon reaching a medical facility.

3. In low-resource settings, other (less common) causes of obstetric fistula include:

• Sexual abuse and rape.

• Complications of unsafe abortions.

• Surgical trauma, most commonly injury to the bladder during cesarean section.

4. In high-resource settings, other (less common) causes include:

• Crohn’s disease.

• Gynecological cancer and infection.

• Unintended consequences of medical interventions such as colorectal anastomosis, anorectal operations, or radiation therapy (rare in low-resource settings).

How Does Obstetric Fistula Happen?

Obstetric fistula resulting from obstructed labor occurs due to necrosis of the surrounding tissue in the birth canal caused by the pressure of the baby's head against the pelvis. Reduced blood flow to the soft tissues surrounding the bladder, vagina, and rectum leads to tissue necrosis. In cases where the mother survives, labor often ends when the fetus dies and decomposes enough to be expelled from the vagina. The necrotic pelvic tissue then disintegrates, leaving a hole or fistula between adjacent organs.

Compression of the lumbosacral plexus can cause nerve injury, leading to decreased sensation and muscle power in the lower limbs. If treatment intervention is delayed after the injury occurs, secondary musculoskeletal problems such as contractures and significant muscle weakness may develop.

What Are the Symptoms of Obstetric Fistula?

• Urinary or fecal incontinence.

• Persistent genital infections.

• Anemia.

• Low mood or psychological distress.

• Neurological symptoms affecting the lower limbs, such as foot drop, altered gait, and significant muscle weakness.

How Is Obstetric Fistula Managed?

Treatment for obstetric fistula involves various interventions:

• Surgery: Repairing fistulas requires surgeons to have specialized training. Specialized fistula hospitals, found in areas with high prevalence, such as Ethiopia, Sierra Leone, and the Democratic Republic of Congo, offer this treatment.

• Supportive Nursing Care: This includes pre-and post-operative care, catheter management, and patient education.

• Physical Rehabilitation: Addressing nerve injuries, musculoskeletal issues, gait disturbances, and pelvic floor deficiencies.

• Education: Providing information about the causes of injuries and incontinence, treatment options, and necessary rehabilitation.

• Psychological Support: Offering individual and group support whenever possible.

How Is Obstetric Fistula Prevented?

Several of the strategies used to prevent obstetric fistula are also effective in improving overall maternal health and safety during childbirth. Some of the preventive strategies include:

• Family Planning: Family planning enables couples to postpone early pregnancies, space desired pregnancies and control family size. Access to contraception could have prevented up to one-third of all maternal deaths and injuries. Additionally, family planning can support women who have undergone fistula repair by allowing them to delay future pregnancies until they have fully healed. Following fistula repair, women are usually advised to abstain from sexual intercourse for a period to facilitate healing, but adherence to this recommendation can be challenging for some women. Furthermore, some women may require additional time before they are physically ready to sustain a pregnancy, and family planning methods can assist couples in determining the most suitable time for conception.

• Encouraging the Use of the Partograph: The partograph is a simple yet effective tool used to prevent and manage prolonged or obstructed labor, which is a significant cause of maternal morbidity and mortality. It consists of a preprinted one-page form where observations of labor progress and information about the maternal and fetal condition are recorded. Acting as an "early warning system," the partograph alerts healthcare providers, including doctors, midwives, and nurses, to the need for timely interventions such as referral to a labor augmentation, cesarean section, and higher-level facility. Consistent and accurate use of the partograph has the potential to reduce the incidence of obstructed labor and its adverse consequences, including obstetric fistula.

• Prompt Catheterization: In cases where a woman with obstructed labor is admitted to the hospital and is deemed to be at risk of developing an obstetric fistula, immediate catheterization can help prevent fistula formation. The catheter should be left in place until well after the completion of labor.

• Cesarean Section: For women experiencing obstructed labor, timely cesarean section is crucial. The healthcare providers performing the cesarean delivery must be skilled to prevent the inadvertent creation of an iatrogenic fistula.

• Community-Based Prevention: Community-based prevention activities may involve social mobilization and awareness campaigns, as well as dramas and broadcasts highlighting the importance of antenatal care and assisted delivery. Additionally, support for transportation and referrals is provided.

Conclusion

Preventing obstetric fistula requires a multifaceted approach addressing both medical and social factors. Timely access to skilled obstetric care, including cesarean sections when necessary, along with family planning education and services, is essential. Additionally, efforts to eliminate harmful traditional practices and promote women's education and empowerment are crucial. With comprehensive interventions, obstetric fistula can be significantly reduced, ensuring safer childbirth and better maternal health outcomes.