The Obstetric Fistula - An Unresolved Public Health Problem

Introduction:

The vesicovaginal fistula (VVF) is as old as humanity and has consistently caused suffering for the affected women. In more than 85 ercent of cases, the root cause is obstructed labor that is not promptly alleviated by a cesarean section. Other intravaginal and extravaginal lesions frequently coexist with it. The uterine lesions are pelvic (the base of the abdomen) floor loss, rectovaginal fistula (a connection between the rectum and vagina), and muscular tightness or stenosis in the vagina. Both genital necrosis (genital cell damage) causes neural injury, and anatomical tissue loss occurs. The trauma of unrelieved obstructed labor is fatal, as it can take a mother's life. Only the lucky one survives. Vesicovaginal fistulas (abnormal opening between bladder and wall of the bladder), brought on by the trauma of obstructed childbirth, are a major issue in underdeveloped nations worldwide. This article evaluates the problem, and a suggestion for action is made.

What Is Obstetric Fistula?

Obstetric fistula is a condition in which there is a hole between the birth canal and bladder or rectum. It is one of the most serious childbirth injuries. It is caused by obstructed labor for a prolonged duration. The labor is obstructed and not relieved in time by a cesarean section. There is pressure necrosis of the bladder, and the anterior vagina wall develops. It is compressed in between the fetal skull and the maternal symphysis. Sometimes the fistula itself has been closed, but in those cases, some other serious problems remain, such as urinary stress (incontinence), vaginal stenosis or atresia, and infertility. That prolonged or unrelieved obstructed labor causes such a level of trauma that most of the women die. It is a fatal condition.

What Is an Unresolved Public Health Problem of the Obstetric Fistula?

The obstetric fistula is developed from the trauma of obstructed labor. It is an abnormal opening between a woman's genital tract and urinary tract or rectum. It has become a global problem in developing countries. Approximately 50000 to 100000 worldwide women are affected by obstetric fistula. One of the major reasons for mortality is directly linked to this obstetric fistula. The obstetric fistula is developed in these ways.

• It starts with prolonged obstructed labor.

• There is a frequent combination of intravaginal and extravaginal lesions.

• A rectovaginal (RVF) fistula develops (loss of pelvic floor muscles and vaginal stricture or stenosis).

• Due to necrosis, pelvic nerve damage, and anatomic tissue loss occurs.

• Perineal nerve paralysis (a condition in which damage of the perineal nerve occurs which causes numbness to hands and legs).

• Pressure ulcers (bedsores) develop over the sacrum and cachexia (these can occur during the rest phase of the pregnancy).

• There is continuous dribbling of urine down the legs, which causes an offensive smell due to wet clothes.

• Women are considered outcasts by most of the communities.

• Sometimes these women are not allowed to live in the village and have to stay outside.

• If not cured in a short period of time, their husbands divorce them.

• In such a situation, women become prostitutes at a young age and beggars later on.

• People think that this condition is contagious.

What Is the Treatment for an Obstetrics Fistula?

The obstetric fistula may heal spontaneously with or without inserting a bladder catheter. Most of the patients are treated by surgical intervention. Even though VVF is preventable, it will continue to pose a serious threat to global health since there are not enough resources to establish a reliable global network of obstetric and gynecologic care. The prevalence of this issue will likely rise as a result of the long time it will take to alter sociocultural norms and raise awareness of it in the industrialized world, as well as the rapid population growth in the developing world without a corresponding rise in health facilities.

It is vital to rely on secondary and tertiary healthcare professionals since VVF is one of the major public health issues whose prevention and treatment, i.e., surgery, require a high level of specialization. As such, it cannot be resolved within the primary health care system. The main healthcare provider's sole responsibility is to identify risk factors in pregnant patients, identify obstructed labor, and then take steps to arrange for a cesarean surgery as soon as possible.

How to Prevent and Control an Obstetrics Fistula?

There are some recommendations suggested from the public health viewpoint. These are as follows:

• Prevention- In developing countries, health education is provided to general populations through many sources. It is suggested that if any woman is in labor pain for longer, she should be taken to doctors. Doctors do perform a cesarean section as soon as possible. General education established a transporting network for functioning the obstetrics units.

• Research- Accumulating correct baseline data will raise more field research, including incidence, prevalence, and other regional factors.

• Rehabilitation- In developing countries, there should be multiple small and cheap obstetrics fistula units in the public health system. With the low cost and fewer instruments and materials, simple repairs should be performed in these units. For this process, teaching hospitals can be used. So, resocialization of the women into her society is possible as they are boycotted due to smelling bad.

• Training- Doctors should be trained in developing countries so that they know which type of fistula is handled by them. In serious conditions, the patient will be treated in teaching hospitals.

• Financing- The government, the voluntary aid organizations, and the government of industrialized countries must work together to provide the required resources, as developing countries have limited resources. They work in the form of two or multilateral agreements.

• Worldwide Attention- For the safety of motherhood, The World Health Organization (WHO) should take charge as it is an important task. The United Nations Fund for Population and other organizations are also involved in this program.

• Voluntary Aid- For the long term, it will be handed by the founding of an obstetrics fistula relief association.

• Backing of Patients- It becomes a major problem to manage obstetrics fistula under primitive conditions within a low budget. So a team member should handle the units for both service and training.

Conclusion:

The general public in developing countries should be educated about this condition through all means of information such as radio, television, newspaper, poster, school, and antenatal clinics. Women with more than one day of labor should be admitted as soon as possible to the nearest hospital. A cesarean section can be performed immediately as required. Doctors in developing countries should be trained to know the types of fistula.