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Fistula: Healing the Pain of Obstructed Labor

   Joe DeCapua  March 07, 2011

Photo: MSF

   Women rest following surgery to repair fistulas at the Doctors Without
   Borders' clinic in Boguila, Central African Republic

   A medical aid group says many pregnant African women suffer needlessly
   from  complicated  or  prolonged labor. As a result, theyâre forced to
   live  with obstetric fistula â a condition that scars them physically,
   emotionally  and  socially.   Doctors Without Borders is highlighting
   the problem as the world marks the 100^th anniversary of International
   Womenâs Day on March 8.

   Obstetric  fistula  is a problem rarely seen in western countries, but
   it  can be all too common in developing nations.  Itâs a hole between
   the  vagina  and  bladder. Itâs caused when the babyâs head places too
   much  pressure on soft tissue in the pelvis.  The blood supply to the
   tissue is cut off, causing it to die and leave a hole.  It happens in
   labor lasting days, not hours.

   Surgeon   Michiel   Lekkerkerker,  the  groupâs  medical  advisor  for
   reproductive  health,  says,  âIt  is  of  course  certainly a medical
   problem,  but  maybe  even  [a]  bigger social problem because many of
   these  women  are  just  ostracized  by their families or their social
   fabric,  so to say, because they are wet all the time. But they smell,
   too.   And  since they donât want to be wet all the time, these women
   also  tend to limit their water uptake.  And therefore the urine gets
   more  concentrated  and  they may be less wet, but they start to smell
   even more.â

   It gets worse.

   âThey lose their husbands.  Theyâre kicked out of their house.  They
   often  have to fully take care of themselves because they have dropped
   out  of their [social] system and they even have to resort to becoming
   whatever, sex workers or something,â he says.

   Doctors  Without  Borders,  also  known as MSF, has fistula repair and
   treatment projects in Burundi, Chad, Nigeria, DRC, and Central African
   Republic.   It  estimates  that  two  million  women  worldwide  have
   fistulas, most of them in Africa.

MSF

   Esther  Feibouko of CAR developed a fistula in 2008. She says, "When I
   walked, I would leak urine, and it made me feel bad."

   Surgery  to  repair  the  damage  during childbirth is complicated and
   requires  great  skill.   It  can  take  anywhere from a half hour to
   several hours, depending on the damage.

   âThe  majority is quite difficult,â he says, âIt is of course delicate
   surgery in a very confined environment because 95 percent is operating
   within the vagina.â

   Dr.  Lekkerkerker  says  obstetric  fistula usually occurs among young
   women.   But  there  are cases of women who have been living with the
   condition for 20 years.

   Fistula is just a symptom of a much bigger problem.  And that is lack
   of  access  to obstetric care.  There may be many more women that die
   as  a consequence of a lack of access than you have women that survive
   with the price of a fistula,â he says.â

   He  says we may never know just how many poor women die from a lack of
   obstetric care.

   Whatâs being done

   The  good  news  is  that  with  proper  medical  care  fistula can be
   prevented.  And with surgery, repaired.

   Prior  to  surgery,  while  women are at MSF clinics, they are told to
   drink  a lot of clean water.  Usually something they avoid because of
   their incontinence.

MSF

   Fistula patients wait outside the operating room for a consultation.

   Lekkerkerker  says,  âYou  want to kind of clean the system.  And the
   less  the  whole  environment  is, letâs say, infested or contaminated
   with  bacteria  the better.  So, ideally, you only operate [on] these
   women  when they produce colorless and odorless urine.  And indeed in
   a good fistula repair environment you have many women that are waiting
   to  be  operated [on], but there is no stench of urine.  There may be
   puddles of basically water everywhere that those women lose, but it is
   so unconcentrated that there is no urine stench.â

   Once  the  fistula  is  repaired,  recovery  may  take  several weeks.
   Patients  will  probably  need  to use a catheter to urinate, so there
   isnât much pressure on the surgical area.

   However,  women  still  may  be  incontinent  after the surgery.  Dr.
   Lekkerkerker  says  that  may  disappear  with  rest  or  pelvic floor
   exercises.    Sometimes  the catheter will be left in for a few more
   weeks and in some cases more surgery may be needed.

   An  African  proverb  says, âThe sun should not rise or set twice on a
   woman in labor.â  Doctors Without Borders says the best way to ensure
   that holds true is to improve medical care for African women.

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