Gynecological Fistula Eradication; It’s the Matter of Heart
Obstetric fistulae were very common throughout the world, but since the late 19th century, the rise of gynecology developed safe practices for childbirth, including giving birth at local hospitals rather than at home, which dramatically reduced rates of obstructed labor and obstetric fistulae in Europe and North America and last center was closed in 1927 but the maternal mortality was also the biggest challenge because there wasn’t facility of anesthesia. However, the condition of genital fistula is frequently observed as a maternal morbidity in the regions of Asia and Africa, mainly due to the unavailability of quality surgical equipment and knowledge.1 Although there have been many advances made in the approaches of transabdominal and transvaginal treatment techniques yet the situation remains devastating due to lack of interests of the medical faculty in working for treating the said condition successfully. It is estimated that around 99% of the fistula patients fail to get the required facilities to get the repairing treatment.2,3 The burden of fistula is great in the South Asian region and requires immediate attention specifically for identifying the preventive measures and raising awareness on community level. The utmost devotion is needed for educating the local medical staff, particularly the surgeons and gynecology specialists, about the successful treatment and management of fistula under low cost. Another important factor is the eradication of the obstacles between the patients and the facilities.4 Apart from the lack of facilities, another challenge is the post-treatment status of the patients that includes the persistent urine and fecal incontinence despite the surgical and non-surgical interventions.5 In addition to that a more complex problem of obliterated vagina is also faced by both the patient and the clinician that deprives the sufferer from perceiving normal body functions and performances that burdens them more with psychosocial and sexual complications. Thus, the patients who receive the care for genital fistula are further acknowledged in three groups that includes the first group who recover completely and return back with thorough satisfaction, the second group who face post-operative complications as mentioned before and then the third, the most complicated group of patients who suffer from irreparable fistula. The irreparable state develops mainly when urinary bladder is wasted or urethra is dissolved. Many urologists are working on this issue while many other surgeons have dedicated their work in learning and developing modern techniques of vaginoplasty, transplantation and uterine relocation for dealing with the problem, however, no fruitful results have been attained to date.6,7 Another challenge is the lack of trained professionals to provide surgery for fistula patients. As a result, non physicians are sometimes trained to provide obstetric services. Those who have irreparable fistula we cannot fix them no matter how much we try, although some urologist colleagues of ours are working on repairing the vagina by transplanting and relocating the urethra. You can treat small number of fistula patients but then they get obligated vagina. They get obliterated vagina and loose their normality which creates another psycho sexual issue, for this there are some dedicated fistula surgeons who are doing vaginoplasty with new technology. Obstetrics and iatrogenic genital tract fistula. In Pakistan is another major problem fistula repair surgeons are not available because of reduced interest. The other alarming thing is rising cases of iatrogenic fistula in developing countries like Bangladesh, Pakistan, Nepal etc. because of lack of standardized training of gynecologists for C section and hysterectomy. The precise extent of fistula problem in developing countries is unknown. The available evidence suggests that at a minimum hundreds of thousands of women are afflicted with this condition worldwide, especially in sub-Saharan Africa. The enormous burden of suffering caused by fistula has been seen mostly in young women where the literacy rate is low, they do not have proper health facilities, prosperity, and self-determination. Fistulas are mainly a condition that affects those societies where obstetric practices are poor and the prevalence of obstetric fistula closely tracks world maternal mortality statistics especially in those area where obstructed labor is principal contributing cause of maternal death. The continued prevalence of obstetric fistula represents a tragic waste of young women that are the most precious of the world’s human.
Obstetric fistulas are completely preventable if given complete and adequate obstetric care. Presence of obstetric fistulas is an accusation on the health care system of a particular country. 90% of the obstetric fistula are curable by surgery and technology.
Fistula has been eradicated by countries where it has been a problem, by all kind of local and international organizations like WHO. The fistula problem has been almost uniformly neglected by the world’s Initiatives or slogans like MDGs, Safe motherhood that has been largely in affective in reducing maternal death in developing countries. The fistula problem is still neglected like a child without parents. This situation is intolerable and must be changed. There are very few signs that the world is finally recognizing the problem, however the response has been very low.
Midwifery trainings need to be done especially for prevention of obstructed labor and fistula formation. It has been noted that most fistulas ascend from combinations of obstructed labor and obstructed transportation but much more work is needed to understand the social context in which obstetric emergencies arise and how they are dealt with developing countries. Nonetheless, the urgent needs of pregnant women should not be sacrificed on the alter of epidemiological research; rather, more attention should be paid to improving emergency treatment for obstetric complications at existing referral facilities to provide essential life saving obstetric care to educating the community about the danger signs of obstetric complications, and to working with community leaders to improve access to emergency obstetric care in areas where maternal mortality and obstetric fistula rates are high.
Although the solution to the fistula problem will ultimately come from the provision of essential obstetric services for all the world’s women, the current needs of those women who have already developed an obstetric fistula cannot be ignored. The committee recommends that specialized fistula centers should be created in all countries where obstetric fistula are prevalent. Women with fistula should have access to prompt, high quality surgical reconstruction which should be provided free of charge. It is unlikely that essential obstetric care will be provided to women in foreseeable future therefore development of sustainable clinical infrastructure to deal with the effects of maternal mobility is likely to be essential.
- Ahmed S, Genadry R, Stanton C, Lalonde AB. Dead women walking: neglected millions with obstetric fistula. Int J Gynaecol Obstet. 2007;99:S1–S3. doi: 10.1016/j.ijgo.2007.06.009.
- Arrow smith SD. The classification of obstetric vesico-vaginal fistulas: a call for an evidence-based approach. Int J Gynaecol Obstet. 2007;99:S25–27. doi: 10.1016/j.ijgo.2007.06.018.
- Tancer ML. The post-total hysterectomy (vault) vesicovaginal fistula. J Urol 1980; 123: 839 40
- Fistula Partners' Meeting Report. http://www.fistulacare.org/pages/pdf/accra-meeting/english/meeting-report-final.pdf
- Steven D Arrowsmith, Joseph Ruminjo and Evelyn G Landry. Current practices in treatment of female genital fistula: a cross sectional study. BMC Pregnancy Childbirth. 2010; 10: 73.
- Zafar M, Saira Saeed, Bushra Kant, Badar Murtaza, Muhammad Farooq Dar and Naser Ali Khan. Use Of Amnion In Vaginoplasty For Vaginal Atresia. JCPSP 2007, Vol. 17 (2): 107-109.
- Grudzinskas, Palomino, Armstrong, Lower. Relocation of ectopic pregnancy to the uterine cavity: a dream or a reality? Volume 101, Issue 8, August 1994, Pages 651–653. DOI: 10.1111/j.1471-0528.1994.tb13176.x