Today is International Day to End Obstetric Fistula, but what exactly is Obstetric Fistula?
Although it affects millions of women, few Canadians know about it because very few women in Canada are at risk of developing this heartbreaking condition.
Obstetric Fistula, also known as Vesico-vaginal Fistula (VVF) is traumatizing. It is a child birth related injury where a hole develops between the rectum and vagina or between the bladder and vagina. Women who survive days of labor and the death of their baby are left incontinent, which means they have no control over constantly leaking urine and feces. This condition affects millions of women around the world, primarily in poverty stricken countries where there is very limited access to healthcare and an emergency caesarean section
Free surgeries are provided for women on board the Africa Mercy and training is given to local & international health care professionals including surgeons, nurses and traditional birth attendants.
Monica Ciolfi from Qualicum Beach, British Columbia, is a nurse who has volunteered with Mercy Ships during two field services and worked closely with ladies suffering from Fistula. We spoke with her recently about her work and what she knows about Fistula.
When did you first hear about Obstetric Fistula?
I first learned about Obstetric Fistula when I was researching Mercy Ships. many years before I applied. When I read specifically on the type of surgeries performed on the ship, I saw that vesicovaginal fistula repair was one of the major ones. I did not know at this time what this was, so I read up on it a bit more on the internet.
When did you first encounter women suffering from Obstetric Fistula?
In 2015 I spent 3 months aboard the Africa Mercy in Madagascar and was so blessed to have spent 6 weeks caring for women after they had corrective surgery for the their Obstetric Fistulas. In 2016 I returned to the ship and worked solely on the VVF ward for 10 weeks.
Was there one particular woman whose story moved you? Can you tell us about her?
Yes. One young woman was 16 years old and her boyfriend/husband accompanied her on the ship because she was under the age of 18, she had to have a caregiver with her. She had an obstructive labour when she was only 14 years old. Her baby died, as most of them do in these circumstances, and she was left childless and with an obstetric fistula. She also had drop foot on one side, presumably from nerve damage as a result of her prolonged labour. Unlike most women with obstetric fistulas, her husband stayed by her side. Despite all she had been through in her young age, she still smiled as if everything was going to be okay. Because of her resilience, I still remember her story and her sweet face.
Another young woman, who I think was in her mid-twenties also remains one of my most memorable patients. As a result of an obstructive labour, she not only had a vesicovaginal fistula (which left her leaking urine), but also a rectovaginal fistula, which left her leaking feces as well. Years before coming onboard the Africa Mercy, she met a doctor who told her he would give her a colostomy to allow her fistula to heal, and then eventually reverse it later on. She was never able to get her colostomy reversed because she was unable to pay for it. I found it so unethical that a doctor would leave this women with a colostomy, in a country where there are no resources or supplies to give her the quality of life she should have at such a young age. She had surgery on her bowel to fix the previous surgery that had been done before she could be considered for a fistula repair. She remained on the ward for weeks and because very well-known by all the hospital staff.
What sort of emotions were brought up while working with these women?
Pretty much every emotion at some point or another. Sadness, after hearing that their families had abandoned them due to their conditions and that their hope of a family of their own had been taken from them so abruptly. Hope, when women would come to the ship and then be cleared by the screening team to have their surgery. Excitement, when women would have their catheters removed and then void on their own for the first time since before their injuries. Happiness and Joy, when the women would go home with fully functioning bladders. Anxiety, when thinking about the women going home and all the post-operative instructions they needed to follow in order to keep their fistula from re-opening. They weren’t suppose to have sex for a minimum of 3 months after their surgery, and a lot of women were fearful that their partners would not be compliant with this. Some also had long journeys home, sometimes 12 hours or more on a truck, and they were afraid that the driver would not stop if they needed to empty their bladders, which were now up to 50% smaller than before.
Overall it was very emotional taking care of these women, but more so in a positive and fulfilling way. They all touched my heart in a different way.
What do you think is the biggest challenge is for these women?
It’s difficult to just choose one. But I would guess that losing a child that had been carried to term would be the hardest part. I am not a mother, but I hear a lot from friends and co-workers who are mothers and how having a child has changed their lives so significantly, but in the end they never regret having their child and are proud to say that it is the best thing they have ever done. I have never heard of a case where a woman with an obstructive labour leaving them with a fistula, had a baby that survived. For many mothers, I think their motivation to find strength and carry on comes from their children, so I can see the greatest challenge for women with fistulas is to have to face each day without their child, and often times, without their husband or family.
What are some of the differences between women in North America and women in Africa when it comes to childbirth and accessibility to healthcare?
In Africa, many women start doing physical work when they are young. In combination with malnutrition, this can cause stunted growth, leaving the women much smaller in Africa than North American women who are generally well nourished and do not do physical labour from a young age. During birth, a baby has a very difficult time getting through the tiny pelvis of a small women. In North America it does happen, but before the newborn baby is at any significant risk, the specialized doctor (in the hospital) or the midwife (potentially at home or in hospital) will intervene and get the birthing mother to a hospital where she can have a C-section to maintain the safety of the mom and baby.
In Madagascar and many other African countries, accessibility to health care is minimal. Most of the population of Madagascar is rural, and without access to a specialist who can perform a C-section (assuming the family can afford it), the odds of intervening on the labour in due time is unlikely. When we discharged patients after their surgeries, we told them to start saving as soon as they found out they were expecting so that they would have enough money to pay for a C-section, which kind of gives you an idea of how much planning and budgeting healthcare costs in countries such as Madagascar.
What needs to change to decrease the percentage of women who develop Obstetric Fistula?
So much. Mostly infrastructure and accessibility to health care services, and subsidized services for at-risk pregnancies. Preventing women from being in obstructive labour would mean changing their roles in their families/villages and ultimately their culture entirely. Ending malnutrition is always on the agenda in less developed countries. But if all women had access to get a C-section when they needed it, and could also afford it, I believe the incidences of new obstetric fistulas would decrease over time.
In Madagascar alone, their is one obstetric fistula clinic. For the majority of the country, it takes greater than 3 days to travel to it. Their is an estimated 80 000 cases of obstetric fistula in Madagascar, with 2 000 new cases every year.
More than 2 million women in sub-Saharan Africa, Asia, the Arab region, and Latin America and the Caribbean are estimated to be living with fistula, and some 50,000 to 100,000 new cases develop annually. Yet fistula is almost entirely preventable. Its persistence is a sign of global inequality and an indication that health systems are failing to protect the health and human rights of the poorest and most vulnerable women and girls. – See more at: http://www.unfpa.org/obstetric-fistula#sthash.535LDJbq.dpuf
A Big thanks to Nurse Monica for sharing with us to help spread awareness around this critical maternal health issue!