Obstetric Fistula

A Concept Paper on Eliminating Obstetric Fistula

Background

Obstetric fistula is caused by obstructed or prolonged labor which occurs, when the birth process does not progress appropriately in spite of strong uterine contractions lasting 24 hours. Of 135 million women giving birth globally each year, it is estimated that 5% or almost 7 million will experience prolonged or obstructed labor.

In many countries without ready access to emergency obstetric care, women may labor for days. Under these conditions, as the baby’s skull gets pressed against the mother’s pelvis for long periods, the soft tissues squeezed against the inside of the pelvis get insufficient blood supply and are sloughed off after the birth (if the mother survives). A permanent opening, or fistula, is created.

Obstetric fistula can form between either the bladder and the vagina (vesico-vaginal fistula) or the rectum and the vagina (recto-vaginal fistula). The symptoms of fistula include incontinence of feces, urine or both, with accompanying odour, bladder infections and possibly infertility. These have a profound effect on the lives of the women who suffer from them: women with fistula often report feelings of shame and isolation, leading to less opportunity for community participation, or employment. Reports of abandonment by the husband or divorce are sadly frequent.  Constant seepage of urine and/or feces through the vagina is devastating in so many ways!

In addition to younger age and chronic under-nutrition which reduce the size of the birth canal, other risk factors include lack of access to family planning, skilled attendance at birth and emergency obstetric care (assisted vaginal delivery and Caesarean sections), and harmful practices in some countries.

The WHO (World Health Organization) estimates that of the 7 million women who experience obstructed labor each year, ~50,000 will die (~0.7% case fatality rate) and another 50,000–100,000 women will develop a fistula. Currently, more than 2 million women in the world live with the consequences of fistula. These numbers are all correspondingly higher in low resource countries, where women are more vulnerable.

But obstetric fistula can be prevented and treated by interventions that should be manageable even in today’s low resource countries. Obstetric fistula sufferers are the survivors of one of the two main causes of death that occur while giving birth. Therefore, interventions that prevent obstetric fistula will of necessity reduce maternal mortality and the death of babies during birth.

UNFPA (United Nations Population Fund) leads an initiative whose goal is to prevent and treat fistula. UNFPA’s initiative addresses the problem of fistula by preventing its onset through reduction of prolonged labor among women and by addressing primary risk factors of early age of marriage and at first birth, increasing access to Emergency Maternal Obstetric Care and providing surgical repair to women with fistula. To accomplish this goal, they outline the following necessary activities:

“To ensure sustainability of efforts, national policies must be created and enforced to: raise the legal age of marriage; provide free or subsidized family planning and high quality maternal health services including emergency obstetric care; and provide resources for fistula treatment. Surgical repair, which has an 88–93% success rate, requires a trained surgeon, a competent nursing staff and an anaesthetist and costs approximately US$350 per operation. Full treatment also includes post-operative care and provision of social reintegration services.”

Great progress has been made and our initiative is being proposed as a SUPPLEMENTARY and collaborative method to reduce fistula and the number of women experiencing obstructed labor.

This initiative is also designed to provide hard-data outcomes as evidence of its poverty-reducing effect, and it addresses six of the eight Millennium Development Goals: number 1, 3, 4, 5, 6, and 8.

Disease Elimination

Infectious disease eradication and elimination programs use organizational methods where existing and new cases of a specific condition in a population are actively identified, reported on and responded to. This community-based approach has been used very successfully in several infectious disease eradication and elimination programs, even in the most challenging settings. Examples include smallpox, polio, dracunculiasis (guinea worm) and onchcerciasis. Discussion of eliminating non-infectious diseases has begun and was addressed in an international conference on global disease elimination and eradication as public health strategies in Atlanta, 1998. In this conference, while participants and experts agreed that non-infectious diseases could not be eradicated (meaning 0% transmission or extinction of infectious agent), they could be controlled or eliminated. Several micro-nutrient deficiencies, including folic acid-preventable spina bifida, Vitamin A, iodine and iron deficiencies were all considered controllable. We propose that additional non-infectious conditions are controllable and that obstetric fistula may be an appropriate condition to consider focusing on.

Maternal mortality reduction policy identifies the need for a multi-sectoral approach to address the many influences on maternal death risk that occur both within and outside the health system. These include health system financing, socio-cultural context, development, legislation, government policy, education, and the economy. Addressing multiple influences on maternal health is inarguably necessary, however, Seim says:

“There has unfortunately been a marked difference between the success achieved by broader “systems-building” approaches and by disease eradication efforts in developing countries, for more than a century. Disease eradication efforts have been singularly successful in the face of corruption, political chaos even to the point of war, poverty, weak health infrastructures, etc. This is not because unlimited resources have been poured into these efforts! While successful disease eradication efforts have had the advantage of addressing a single infectious disease that is biologically eradicable, it is appropriate to take some lessons from these programs and apply them to complex issues, such as maternal morbidity and mortality that have multi-factorial causes. Disease eradication efforts succeeded because they have been forced to apply a small set of tools that are non-medical, under-recognized, and independent of the disease in question.

Successful disease eradication efforts

Dracunculiasis (guinea worm) eradication has received less funding since its inception than the poliomyelitis campaign uses each year. Yet, dracunculiasis too has been reduced by more than 99.5%, from an estimated 3.5 million cases in 1989 to less than 15,200 in 2004, of which all but 1,376 remaining cases were are in Ghana or Sudan in 2004.

The Onchocerciasis Control Program (not an eradication program) enjoyed similar success through 28 years (1974-2002). For less than $1 (US) per person protected per year, 25 million hectares of land, abandoned due to river blindness, was reopened and feeds 17 million people. And more than 9 million children were born to a future free of this scourge. Similarly, efforts to eliminate lymphatic filiarisis are making real progress using annual mass administration of donated drugs to interrupt transmission among the billion persons at risk, combined with treatment (mostly self-treatment) of lymphoedema and elephantiasis, and surgery for men with urogenital manifestations.

Village volunteers, many of them illiterate, provide monthly reports on guinea worm from even the most remote hamlets in Africa, including both sides of the conflict in Sudan. Probably no other health care initiative has come close to matching that accomplishment, year after year.

The guinea worm program receives, and uses the reports received monthly, and provides feed-back on those same reports every month. Data that is not going to be used, is not collected. While disease eradication experts consider that eradication efforts cannot be applied in isolation from development of the health system, the focus on a single condition may be more achievable and considered a tool to chip away at the bigger problems that require multi-sectoral approaches.

In this paper, and for discussion at the proposed meeting, we attempt to apply lessons learned in successful disease eradication programs that have succeeded under the most challenging of circumstances, to address the severe impediment to survival, health, and well-being that is fistula.

The Catalyst Approach to Public Health

The “Catalyst Approach to Public Health” is a term given to the organizational methods used in disease eradication programs. The aim would be to apply organizational tools of successful disease eradication programs to carefully selected, important causes of ill health and impaired economic development that are not biologically eradicable. We propose that obstetric fistula and the obstructed births that cause fistula and other maternal morbidity and mortality can be addressed using a similar community-based catalyst approach. Volunteers here would be locally selected women, followed up monthly and re-trained annually.

Seim suggests that ten key tools, that disease eradication programs have in common and that are specified below, can constitute a catalyst approach to public health, when all are applied together.  As concerns obstetric fistula, both prevention and treatment are required. The community workers should be women, and prevention means monitoring who is pregnant in the village, ensuring access to prenatal care, planning for birth including encouraging the youngest and the most high risk women to travel to a location where emergency obstetric care can be given if the need arises, and where possible, having a trained attendant at birth who can use a partograph to monitor labor to help prevent obstructed labor, registering a selected few hard-data outcomes of labor (live or dead mother, live or dead baby, fistula or not, etc). Also, these village volunteers should identify women with fistula and help them to access fistula repair.  Data collected from village volunteers and health care centres would be used in helping to secure an appropriate distribution of partographs in affected countries, working with countries to organize and monitor all aspects of their obstructed labor handling and fistula prevention activities on a monthly basis, etc, etc. It should be noted that, if community workers are trained to identify labor complications, a system of referral to a facility and providers who can provide specialized care, e.g. cesarean section, will also be developed in each participating country as part of the catalyst approach, from the outset.

The ten essential elements that Seim has identified, which he suggests successful disease eradication efforts tend to have in common are:

Ten essential elements of The Community-Based Catalyst Approach to Public Health

1. A few people who really care. Five-ten people in a handful of organisations, who are deeply committed to the issue at hand.

2. A data manager and program manager in each participating country. Data managers usually work full-time for the program. Program managers are usually Ministry of Health professionals, whether full- or part-time.

3. An organization that can provide technical assistance in epidemiology and statistics. One or two people with considerable expertise in epidemiology must, through friendly insistence, collect data from participating countries, analyze it promptly, and provide monthly feed-back to all partners. An organisation that can operate rapidly and with flexibility may perhaps best fill this critical role.

4. Resident technical advisors in each country. Usually ex-patriates, they are sometimes from the same continent. Resident advisors must work collaboratively yet be independent, funded from outside of the infrastructure with which they work. They must have some funds for meetings, travel, to stimulate activities, etc, and no formal authority. The balance between independence, lack of formal power, and focused, committed attention, in addition to their personal qualities, makes resident advisors effective.

5. International meetings, e.g. twice yearly. Key staff from countries and supporting agencies present data, plans, budgets, achievements and problems to each other. Broad annual meetings, and then smaller meetings (e.g. separately for Francophone and Anglophone African countries) six months later, may be best.

6. Annual program review meetings in each country. Representatives from all levels of the national program discuss successes, problems, and ways forward.

7. Annual training and re-training courses for village volunteers lasting 2-3 days. Old and new village volunteers receive updates on progress made in their localities, their country, and elsewhere and receive pertinent, new technical information.

8. A network of supervisors. Supervisors visit each village volunteer at least monthly, gather collected data, and relay messages up and down between villages and national level. They encourage the volunteers, visit homes with them, help volunteers refine the quality of their work, etc. Continual announced and unannounced visits by national staff to all levels of the program are also part of the supervisory system.

9. Transportation. From bicycles to 4-wheel-drive vehicles and the occasional camel or boat, transportation is needed for the network of supervisors, with adequate amounts for fuel and maintenance every year, and funds for replacement as vehicles wear out after 4-6 years of daily travel under rough conditions.

10. Course correction mechanisms. Operational research and other research are needed to improve technical tools and approaches specific to the health initiative.

Cost Estimate for A Catalyst Approach to Public Health

The cost of a Catalyst Approach to any major poverty-related health issue of course depends on the number of participating countries and their sizes.  It also depends on the number of people needing to be reached, the degree of geographic dispersion among these people, and a number of other factors. Some factors in the total program cost will be disease-specific, such as the cost of vaccine or medication.

By way of example, catalyst aspects of the guinea worm eradication program are estimated to cost approximately $2 million / year. That pertains to a 12-country initiative across sub-Saharan Africa north of the Equator, from Mauritania to Ethiopia. In the case of obstetric fistula / obstructed labor, it seems reasonable to start with Afghanistan and at least one of its neighbors, as well as a few countries in western Africa and a few in eastern Africa.

As soon as possible, i.e. when success is demonstrably being achieved concerning fistula (and thus obstructed labor mortality), one envisions using the network, monthly-data handling capacity, and strengthened infrastructure that the fistula elimination initiative develops, to also address other birth-related complications. Partly this means addressing other conditions requiring emergency obstetric care. And temptingly, this may also entail routine, immediate post-partum administration of oxytocin (medication to stimulate uterine contraction) via single-dose pre-loaded syringes at a peripheral, perhaps even a community level, and intensified vaccination to avert maternal and neonatal tetanus, for example. In addition, ethically, if community workers are trained to identify labor complications, a system of referral to a facility and providers who can provide specialized care, e.g. cesarean section, must also be developed.

As ever, all will fail if one attempts to solve every problem via community-based volunteers from the outset, which is why fistula has been selected as the starting-point, one that justifies the initiative on its own.

Next steps: As a next step, CDC (US Centers for Disease Control and Prevention) and HDI (Health & Development International) are seeking to organize a three-day developmental retreat on obstetric fistula, hopefully as soon as early autumn, 2005. See separate agenda.