Bladder and bowel health

Intro

After a friend or family member gives birth we want to know all the details. Is the baby healthy? How long was she in labor? What’s the gender of the baby? What’s the baby’s weight and length? Was the birth vaginal(and if so did she use an epidural) or was it a cesarean section? In America, as in most wealthy and developed countries, the answers to these questions may be slightly different from woman to woman, but little overall variability is expected and it’s seldom that the answer to any of these questions is jaw-dropping. But how would we react to a friend who tells us that she was in labor for seven days, her baby died in her womb during birth, and now she has fecal and urinary incontinence?

This scenario describes how each year, an estimated 50,000 - 100,000 women in developing countries incur obstetric fistulas during childbirth, a complication that results in a hole between the vagina and bladder and or rectum leading to constant leaking of urine and or stool. To Americans this situation may seem unfathomable, but obstetric fistula used to be a prominent issue in the United States, as well. In 1852 James Marion Sims, an American surgeon, developed a technique to cure obstetric fistulas and became a leader in fistula care. Dr. Simms helped set up the world's first fistula hospital in New York City in 1855. Eventually advances in obstetric care and increased accessibility to maternal healthcare eliminated the need for fistula hospitals in the US and now the former location of the world’s first fistula hospital is the Waldorf Astoria hotel (operationOF.org).

This brief introduction to fistula may have sparked a few questions for you such as: Where are fistulas currently a problem? What causes a birth to lead to an obstetric fistula? Can fistulas be prevented? And where can I learn more about this issue? The answers to these questions and education about obstetric fistulas can help abolish the occurrence of fistulas during childbirth, So please keep reading!

What causes a birth to result in obstetric fistula? Is one population more susceptible than another?

An obstetric fistula occurs between the vagina and bladder, the vagina and rectum, or both, causing leakage between the tissue and results in incontinence (the inability to control the flow of either urine or feces) (WFF). Either a small pelvis or malpositioning of the baby within the uterus can predispose a woman to obstetric fistula if adequate medical care during her labor is not available. Dr. Steven Arrowsmith, a renowned American urologist, surgeon, and Vice President of the Worldwide Fistula Fund, describes the “road to obstetric fistula” which includes risk factors that increase the likelihood that young women will experience obstructed labor. This “road” unfolds as follows: a young woman grows up without access to adequate nutrition, as a result her musculoskeletal growth is stunted and she does not reach musculoskeletal maturity until later than expected, however, she is married soon after her first menstrual cycle, becomes pregnant before adulthood, and gives birth at home without any skilled obstetric care during pregnancy or labor. This situation is most common in the rural areas of poor countries where access to good nutrition during development and sound maternal healthcare are rare, and pregnant teens are not. An obstructed labor usually lasts for days, during which time the baby is stuck inside the mother’s womb. Pressure develops that cuts off circulation to the tissues between the vagina and bladder and/or rectum. The loss of blood to these areas causes tissue death and leads to the formation of a hole, or a fistula

A Walk to Beautiful, an Engel Entertainment documentary, follows the story of a 25-year-old Ethiopian woman named Ayehu and her journey to the Addis Ababa Fistula hospital. Ayehu was in labor for a week, ending only after her baby was delivered stillborn. After the labor Ayehu described a persistent leaking from between her legs; she started to smell of urine and eventually her husband left her to marry another woman. She had to return to her parent’s home with her older daughter, but due to the smell and stigma associated with fistula, she was not allowed to sleep in the house. She built herself a hut beside the house to keep her safe from hyenas, while she waited for what she believed to be certain death. Ayehu was finally encouraged to seek help at the Hamlin Fistula Hospital in Addis Ababba by a friend who had previously been treated there for her obstetric fistula. Ayehu suffered for six years with urinary incontinence, as a result of a 2 by 3 cm hole between her bladder and vagina, before she sought help.

The stigma associated with fistula permeates life for those living with the condition. Women are often ridiculed for smelling of urine and feces, are abandoned by their families and husbands, must grieve the death of the baby lost in childbirth and are doing so without means to provide necessary housing and food for themselves and any surviving children for whom they are responsible. Many also feel alone as Ayheu did - believing that they are the only woman suffering from incontinence and that their condition will result in death. The Hamlin Fistula Hospital in Addis Ababa provides hope and has been a model for other organizations active in fistula care and prevention. It unites them with other women who are suffering from the same condition and helps them heal from the physical, psychological, and social scars associated with fistula. This comprehensive approach to fistula care is espoused by other hospitals in Africa, including Heal Africa and Panzi Hospitals in DR Congo and the Danja Fistula Hospital in Niger (WFF).

Where are obstetric fistulas currently a problem?

Although obstetric fistulas have been virtually eradicated in America and in other wealthy countries, they still remain an incredible problem in much of the developing world. The World Health Organization cites that between 50,000 and 100,000 women worldwide suffer from obstetric fistulas each year. The exact statistics of fistula occurrence are unavailable because there are many undocumented cases. In 2010 the Word Health Organization estimated that there were more than two million young women in Asia and sub- Saharan Africa living with un-repaired fistulas. Fistulas are prevalent in countries and areas where necessary gynecological and obstetric care is unavailable or overlooked. Obstetric fistulas have been reported most commonly in Asia, Africa, and the Middle East (WHO).

Can fistulas be prevented? How are fistulas repaired?

Fistulas can be prevented if a woman receives adequate obstetric care before and during pregnancy and childbirth. This may not be possible globally, so women must be educated on when to seek medical help to ensure a safe pregnancy. It is also crucial that poor, young, and petite women in rural areas are educated about their increased likelihood of obstructed labor. The use of medically-necessary cesarean section helped eradicate obstetric fistulas in the US, and is a procedure that could be made more widely available globally for women with increased susceptibility to fistulas.

Fistulas are preventable and repairable. To repair a fistula an obstetric surgeon must perform an exam to identify the location and size of the hole. The surgeon can then suture the hole while the woman is anesthetized under local anesthesia - approximately 90% of fistulas are successfully sutured using this procedure. However, the patient’s journey does not stop there. Due to the extensive trauma to the tissue each patient must then rebuild the strength of her pelvic floor muscles by performing exercises prescribed to her by healthcare professionals.

What can I do to help women who suffer from obstetric fistulas?

This year, The Women’s ACTION Initiative, sponsor of the Share MayFlowers project is also helping to fund the development of two educational videos regarding fistula and fistula rehabilitation that will be used to educate hospital-based and rural healthcare and social service providers in Africa. You can make a tax-deductible donation directly to this project, by donating to WAI and specifying your gift to the Fistula Video Projects.

HEAL Africa is a nonprofit health and social services organization whose services include free fistula repair surgery, rehabilitation, and social services for women in the Democratic Republic of Congo (DR Congo). HEAL Africa has a 155-bed hospital that comprises 20% of HEAL’s impact around Africa. The other 80% is implemented through smaller, more remote clinics, throughout the DR Congo. Programs addressing public health and health education, gender-based violence, law and justice training, and other topics are provided at these centers. Visit them online for more information about their services and for ways to donate and get involved.

The Worldwide Fistula Fund provides free fistula repair surgery for women in Niger. Without these services thousands more women would still be suffering from the awful consequences of obstructed labor. Visit them online for more information about ways to donate and get involved.

Shereen Sairafi, SPT
Boston University