Summary

Obstetric fistula is an injury that results from obstructed childbirth, most commonly in girls and young women whose bodies are physically not mature enough for healthy birthing. As a result of this injury, which occurs almost exclusively in areas of poor countries in Africa and Asia where caesarian section is not available, these girls are left with a devastating condition that causes permanent leakage of urine and/or feces unless surgery corrects it.

An estimated 2 million women have fistula and must live with its consequences, while an additional 50,000 – 100,000 girls and women get obstetric fistula each year.

A number of UN-agencies, governments and non-governmental organizations (NGOs) have taken up the challenge.

Recent observations suggest that adopting catalyst approaches from successful disease eradication programs would make efforts to eliminate obstetric fistula much more effective, though fistula is not biologically eradicable.

Preventing fistula will of necessity also prevent deaths from one of the two biggest causes of death during childbirth.

Preventing and treating fistula is an effective way to deal with a guarantor of major poverty and addresses six of the eight UN Millennium Development Goals, numbers 1,3,4,5,6, and 8.

The cost of adding a catlyst approach onto existing fistula elimination efforts is well within reach if a few donor-countries and foundations join together, a pittance compared with the number of women to be protected, the poverty averted, and the amount of denigration prevented.

The Problem

• Obstetric fistula is a chronic opening between the vagina and bladder or the vagina and rectum, or both, resulting from a blocked birth (obstructed labor) that lasted several days.

• Women with the condition constantly leak urine and/or feces through their vagina.

• Women with obstetric fistula are often forcibly divorced, ostracized, or worse.

• The risk of getting fistula is highest in girls who get married in childhood and pregnant in their early teens, and for women who have given birth many times before.

• These are the survivors, those who did not die of their obstructed labor, though the babies often do.

• WHO estimates about 2 million women living with the condition today; 50,000-100,000 new women each year; and 500,000-750,000 women dying during child-birth every year, the equivalent of a fully-packed jumbo-jet crashing every 4 hours, with obstructed labor being one of the two main causes of death during child-birth.

• The number of affected women seems to be highest in central Asia and south Asia, while the rate of new cases seems to be highest in Africa, perhaps especially in areas near and in the Sahara desert. Nobody yet knows the exact extent of the problem.

• Agencies that address the issue have often focused on making surgical repair available. That’s very understandable, but prevention is also crucial.

• Obstetric fistula was previously a major problem in all countries of the world. The Waldorf Astoria, a luxurious hotel in New York, is on the site of the world’s first fistula hospital, which closed in the early 1900s when fistula was eliminated from New York.

The Cause

When the skull of the unborn child is forced against the woman’s pelvis for several days, in obstructed labor defined as labor lasting more than 24 hours, some of the soft, delicate tissue of the vagina can die for lack of oxygen and blood-supply. If labor lasts long enough, the woman too will die, as a birth in Afghanistan that lasted 10 days illustrates. Obstructed labor is the main cause of mothers dying while giving birth in many remote areas (while bleeding is often the main cause elsewhere).

If the woman survives the birthing process, and if some tissue between her vagina and the surrounding locations is no longer viable due to insufficient blood-flow during several days of obstructed labor, then that non-surviving tissue is sloughed off. The result is a hole.

A few days after the birth, depending on whether the hole is on the front wall or the back wall of the vagina or both, the woman leaks urine or feces or both, through her vagina. The hole and the leakage are permanent unless she has successful surgery.

Who’s Doing What About Fistula?

• UNDP started The Campaign to End Fistula in December 2003.

• Two young Australian doctors established The Addis Ababa Fistula Hospital in Ethiopia, where they dedicated their careers to operating on women with fistula. They also started training surgeons and even non-surgeons in these techniques. Though her husband has passed away, Dr. Catherine Hamlin is still deeply committed at more than 80 years of age.

· Several governments and non-governmental organizations (NGOs) have for years tried to alleviate the problem by training surgeons and even non-physician women to do corrective surgery for obstetric fistula. Ethiopia, Niger, Tanzania, and Uganda, are some countries where efforts are made to treat fistulous women.

• WHO is hoping to gather surgeons who do obstetric fistula repair, and seek consensus on what might be the best surgical technique to use in various fistula situations.

• In recent years there has been increased funding for research into causes of maternal death in developing countries, and into obstetric fistula. The Bill and Melinda Gates Foundation was a major source of funding through a 2001 - 2005 grant. Articles on maternal death and obstetric fistula were published in The Lancet, a prestigious journal, in its January 3, 2004 issue, and research is increasingly being publish elsewhere too.

• The CDC has had a medical epidemiologist working full-time on maternal mortality.

• Until recently, nobody has undertaken to deal with obstetric fistula by systematically using disease eradication approaches. Yet, HDI’s Rapid Fistula Prevention Project (HDI-RFP) is achieving promising results in a large pilot project covering a multiethnic mostly nomadic population of 100.000 who live across 4.560 square kilometers (3.059 square miles) of semiarid, almost roadless terrain in Niger. That’s a country where one in seven women sooner or later dies in childbirth, the worst such statistic in the world.

· It should be possible to eliminated obstetric fistula in Africa, Asia and elsewhere, as has been done in Europe and North America, although fistula is not biologically eradicable.

Is This a Good Time to Eliminate Obstetric Fistula?

YES!!!

Several UN-agencies, universities, governments and NGOs in various affected countries and donor-countries have taken up the cause.

The women who suffer obstetric fistula are no longer being ignored internationally.

Women and men in several affected countries are showing interest in alleviating and preventing this most devastating of all pregnancy-related complications.

Communications technologies and other needed infrastructure elements have recently become much more widespread, even in poor developing countries.

We now have a clearer understanding and several decades of experience with eradication approaches to disease. HDI alone has almost 20 years of such experience.

Initial results of a community based approach to prevent these tragedies (HDI-RFP; HDI’s Rapid Fistula Prevention) in remote areas that used to produce more fistula cases, uterine ruptures, deaths and other obstructed labor catastrophes than most, are very encouraging.

Therefore, it should now be possible to mobilize the scientific expertise and financial support needed to deal with obstetric fistula in new ways.

We are not battling windmills. This is a good time to take on the plight of women who would otherwise suffer obstetric fistula, and thus help save the lives of thousands of babies and thousands of women in the process, as well as helping those who already have the condition.

Eliminate obstetric fistula!

That should be the call!

Now is a perfect time for HDI to help raise the call, and help to get the job done.

What can HDI do about fistula?

Introducing an additional approach!

HDI is proving to be a catalyst at the global level, as it has been before, now to help get the ball rolling towards eliminating obstetric fistula.

HDI is introducing tools it has seen and used for 20 years, as a new way to approach this important women’s rights, dignity, and health issue, not to replace but as an addition to what else is going on, to spend relatively modest additional amounts and get faster results.

As an initial result, UNFPA, CDC, and HDI got international reproductive health policy agreement on using disease eradication approaches to prevent obstetric fistula. The policy meeting report is available by clicking it, on the front page of this website, as well as from several places on UNFPA websites.

Then Niger successfully demonstrate that maternal deaths can be rapidly prevented in a large population across a large, remote area, that process indicators including the number of births occurring in the health system can be improved, and that obstetric fistulas can be prevented using the HDI-RFP (Rapid Fistula Prevention) approach.

Next Steps

Having achieved two important successes, there are two next steps:

- Expand the pilot project to demonstrate success in an even larger area. Funding proposals are being considered (November 2009) which would allow testing this approach in even larger areas that are not contiguous, to serve a multiethnic population of over 262.000 people across more than 7.500 square kilometers.

- Introduce other agencies and countries to the idea of rapidly preventing maternal mortality and obstetric fistula. At The Carter Center in Atlanta, USA early in 2010, fifty representatives of UN agencies, important foundations, governmental development assistance agencies, NGOs (non-governmental organizations), and universities will consider the evidence on various approaches to rapidly prevent obstetric fistula.

Cost

It is estimated that all catalyst functions for a 12-country program eradicating guinea worm disease amount to around $2 million/year for the continent of Africa.

We estimate that catalyst aspects for a similar effort to rapidly reduce maternal mortality and prevent obstetric fistula would cost $5 million/year, well within reach for a consortium of bilateral donors and foundations.

(Updated November 2009)