Obstetric Fistula in Low and Middle Income Countries

Abstract

Vesicovaginal fistula secondary to obstructed labor continues to be an all-too-common occurrence in underdeveloped nations throughout Africa and Asia. Vesicovaginal fistula remains largely an overlooked problem in developing nations as it affects the most marginalized members of society: young, poor, illiterate women who live in remote areas. The formation of obstetric fistula is a result of complex interactions of social, biologic, and economic influences. The key underlying causes of fistula are the combination of a lack of functional emergency obstetric care, poverty, illiteracy, and low status of women. In order to prevent fistula, some strategies include creation of governmental policy aimed toward reducing maternal mortality/morbidity and increasing availability of skilled obstetric care, as well as attempts to increase awareness about its prevention and treatment among policymakers, service providers, and communities. Whereas prevention will require the widespread development of infrastructure within these developing countries, treatment of fistula is an act which can be done "in the now." Treatment and subsequent reintegration of fistula patients requires a team of specialists including surgeons, nurses, midwives, and social workers, which is largely unavailable in developing countries. However, there is increasing support for training of fistula surgeons through standardized programs as well as establishment of rehabilitation centers in many nations. The eradication of fistula is dependent upon building programs that target both prevention and treatment.

Obstetric Fistula: A Narrative Review of the Literature on Preventive Interventions in sub-Saharan Africa

“…In considering regional issues around obstructed labour, only one article detailed that obstructed labour is common in African women due to the narrow build of their pelvis 20 . It was noted in eighteen articles that many African girls get married at an early age, which increases their risk for obstructed labour, which if not managed leads to prolonged labour [1][2][3][4]11,12,[14][15][19][20][21][22][23][24][25][26][27][28] .…”

“…One article relied on the WHO's definition of prolonged labour as labour lasting over 24 hours, while noting that in rural settings there are misconceptions as to the ‗normal' length of labour 21 . Six articles detailed that standards set by the WHO are well understood by skilled birth attendants, however, most women in rural settings either deliver by themselves, in the company of family members, or with the aid of traditional birth assistants and are not aware that urgent obstetric care is needed past that point 1,3,11,14,19,21 . One study showed that in some settings, prolonged labour was not considered of enough importance to seek skilled medical care until two to five days had passed 21 .…”

“…In 15 of the articles, a core focus was on the seminal work by Thaddeus and Maine on the Three Phases of Delay [1][2][3][4][5]11,[15][16][19][20][21][23][24][25]28 , which is a conceptual model that identifies obstacles to the provision and timely utilisation of high quality obstetric care 29 . Consideration of the three phases occurred across these 15 articles [1][2][3][4][5]11,[15][16][19][20][21][23][24][25]28 .…”

“…The articles suggested that the factors greatly affecting the decision to seek care were various, including: distance, cost, sociocultural beliefs, and the perceived quality of care [3][4][5]11,[13][14]19,[23][24]28 . Importantly, one article emphasised that research has shown that an increase in the availability of services does not always increase the use of the services, leaving the issue of delay in decision to seek care an important focus for researchers 29 .…”

“…However, the results of obstetric fistulas are not just physiological. Incontinence often results in women experiencing extensive social stigma and related mental health issues, with these women either marginalised by households and communities, or marginalising themselves 1,5,[11][12][13] . Such isolation and stigma acts to decrease their chances of seeking treatment.…”