This article appears in the May 2011 Edition of the Catholic Medical Quarterly
Obstetric Fistulae and the Developing World
John Kelly OBE F.R.C.S.
This presentation deals mainly with obstetrics and gynaecology, with emphasis on obstetric fistulae.
Some stark facts are:-
- One billion people lack access to safe drinking water.
- Eight hundred and fifty million people will go to bed hungry tonight — as they did last night and the night before ... and the same for future nights.
- Ten million children will die this year before their fifth birthday — 99% from preventable causes.
- 0.5 million women (one per minute) will die in childbirth this year (less than half of 1% in the Developed World), while many suffer morbidity — all because appropriate emergency obstetric care is not available (nor accessible) to those who require it.
Poverty is a major cause of these tragedies in the Developing World. Why should this happen when we in the developed world have so much? It is true that some things are beginning to improve, but with a long way to go. I was reminded of this when I read the latest statistics and someone informed me that the number of children dying before reaching the age of five, was now only nine million or slightly less. I ask you, only nine million!
Sometimes, when engaged in a specialised field, we might forget basic needs. I complained when one of our rural hospitals lost a valuable midwife. She went to another area, learned a new local language to discover what the priority needs were of that local community. An important finding was that the women of the area spent six hours per day fetching water. Clearly, the people saw their first need as water — not a surgeon (fistula or other) nor a hospital, but water. The husband of one of my patients in Darfur related how he spent his time fetching water. He was fortunate in that he possessed a donkey and cart and containers for water. He would leave home at 6 a.m., reach the source of the water just before dark, sleep there, then fill his containers the next morning and set off with his donkey, cart and precious water, reaching home as darkness fell. The following morning he would set off to repeat the process, while his wife would sell some of the water and use the remainder, as well as doing her many other tasks. No relaxing or sitting back together watching T.V. .... Survival was the aim!
A fistula is an abnormal connection between two surfaces — a hole where there shouldn't be one! A vesico-vaginal fistula, between the bladder and vagina, results in continuous leakage of urine; a recto-vaginal fistula is between the rectum and the vagina and results in faecal incontinence — some women have both.
The cause of such obstetric fistulae (now rarely seen in the developed world but sadly still affecting many women in the Developing World) is lack of access to appropriate emergency obstetric care, 24 hours per day, 7 days per week, for those women requiring such care. Unrelieved obstructed labour is the main culprit. The late Reg Hamlin, co-founder with his wife Catherine, of Fistula Hospital in Addis Ababa, used to teach that obstetric fistula was due to the two obstructions — obstructed labour and obstructed transport ! Access to appropriate care, when required, may be difficult and costly for those living in rural and remote areas, some with lack of roads. In many parts of the Developing World, travel at night is unsafe and if the patient manages to persuade someone to drive her, the cost may be prohibitive. Problems associated with darkness can occupy 50% of the 24 hours.
A Maternity Waiting Area (MWA) is a building, not a ward, in the grounds of a hospital where a woman and her attendant can reside during the latter weeks of pregnancy. The hospital provides emergency obstetric care so that the woman can receive prompt treatment when required and not have to be travelling for hours, or even days, to reach such care. Women identified as at risk, either by previous history or during the current pregnancy, are advised of the facility. As in the provision of total care (hospital and district), the local people or community should be involved at the planning stage. Such local village committees should include women's groups. Attat Hospital, in a rural area of Ethiopia, provides hospital, community and primary health care — sanitation, clean water, construction of wells and MWA as well as appropriate acute services. The local people
decide what and where they wish a facility and contribute labour for the construction. 95% of clean water wells are still functioning after 5 years in that area because the locals were involved initially and they continue to care for the facility, e.g., by appropriate fencing and prevention of fouling by cattle ...
Sadly, obstetric fistulae are still common in the Developing World. Treatment has become more available for the poor women who suffer such a condition. Sadly, in many parts, such care does not reach all and some carers are forced to charge something for treatment. There have been numerous (guesswork) studies regarding the true incidence. It is common experience that where an appropriate service is made available to treat such afflicted women, the numbers seeking treatment increase. The care provided should include the correct medical/surgical approach, while respecting the dignity of each woman. The staff (treatment is not by an individual but by a team) should show compassion, which is not the same as pity. Compassion indicates one has total respect for the patient, on the same level, while pity may suggest the carer is on a higher level. Many of these women have experienced terrible ordeals in labour, either at home or sadly in hospital. Rehabilitation, an important aspect of treatment, should commence at the patient's first visit, where she is treated with respect. I was working with such poor women for 13 years before one of them taught me a lesson. She had attended on a day when the hospital was absolutely full, and she had presented early (the ideal time to repair her fistula would be about 2 months later). I knew where she lived and told her about our advised plans, she would be given a definite appointment and other assistance, including bus fare to her home. She replied, "They will not let me on the bus when I am leaking!" Some of our staff have the task (which they carry out in expert fashion) of making sure the patient is appropriately "padded" before the journey. Other patients, we have discovered, when travelling long distances have been put off the bus once it is discovered they are leaking. Some use old tin cans to collect the leakage or bind themselves up with plastic bags, which results in further excoriation of the skin around the leakage. Whenever I see these women and excoriation of the vulva and perineum, I think, "why are they denied access to "barrier" creams or creams to prevent "nappy rash", which are so readily available in our society". Sometimes I ask, "if there were as many male scrotal areas similarly affected, more action might be taken" !!
Our nursing colleagues, while obtaining the initial information from a patient, sensitively enquire about the woman's obstetric history. When obtaining details of previous history and finding out how many live-born children the woman had, the next question posed is, "How many are alive now?". The relevance of such an enquiry was brought home to me when two successive patienfs described having seven live children each. The first had one child still alive, while the other had none alive — one out of 14 had achieved a fifth birthday ! Most women (and men) in the Developing World love children. In such a society, women who think they may be approaching the end of fertility with no children and little or no chance of having a child, become very anxious. To have no "live issue" in such a society is considered a terrible situation.
I must give credit to some pioneers in the care of such women — the late Reg Hamlin and his wife, Catherine (still working) in Ethiopia, Anne Ward in Nigeria, Maura Lynch in Uganda and Michael Breen in Zambia. There are others. There are also those who donate to such a worthy cause.
Maternal mortality and morbidity (including fistulae), and infant and child mortality are all
preventable. We do not see such problems in the developed world, we know the cause of the problems in the Developing World, so our aim must be prevention.
Various procedures in fistula surgery have been described as achieving the best continence rates. However, there is no continence procedure that comes anywhere near the continence achieved by prevention !
The Millennium Development Goals (MDG) were designed to see improvements in the terrible statistics particularly associated with maternal and infant mortality and morbidity. The aim of MDG5, to reduce maternal mortality by 75% by 2015, is by far the least likely to be achieved and is correctly regarded as the "The scandal of our Time". There are many causes of this, including the lack of incentive for locally trained health care providers to work in rural areas, or even anywhere in some of the developing countries. The human resource issue is one cause of failure.
There are some rays of hope in the work — Some "cured" patients are now trained as valuable providers of health care — trained assistants and nurses, trained village midwives, upgraded clinical officers (non doctor), and even one fistula surgeon. Some medical and certificated staff elect, despite disadvantages financially, to work with their own people. When all grades work as a team, and receive initial and in-service training, they become accountable, invaluable members of the health provider group.
We clinicians can learn so much from collaboration with, and guidance from, colleague(s) in public health and epidemiology. We owe it to the poor women who suffer, to obtain robust scientific evidence so that we may inform correct, appropriate health care policies at regional, national and international levels.
Those from the developed world who give their life "permanently" to the Developing World are truly committed. For those who do part-time, the rewards, although not financial, are great indeed. We go out to heal and to be healed.
This is an edited version of a talk given by John Kelly to the Conference organised by the Kent Branch Faith and Hope at the Heart of Healthcare, Saturday 19th March 2011.
John visits Uganda, Ethiopia, Zambia, Darfur in the Sudan, Pakistan and Ghana on a regular basis. The hospitals involved are aware of his dates and the patients are assembled by radio and Bush Telegraph