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Forgotten Disease: fistulas | part 4/13

In this post I will present the phenomenon known colloquially as fistula.

Obstetric fistulas

This is not a disease, but a physical problem that occurs during childbirth. It is heavily stigmatised not only in the majority world, but as late as last week I watched a Swedish documentary on this problem where medical staff has failed to report obstetric fistulas because these would reflect badly on their resumés.

Occurrence

As I said, obstetric fistulas occur during childbirth and is the rupture of the vaginal birth canal into either the bladder or the anal tract, see the body map below. Between 50 000 and 100 000 women are affected every year, around the globe, and the WHO estimates the total number of women living with this condition to be around 2 million (!). Many of them stigmatised, alienated, and left to provide for themselves with a condition that is looked upon as a shame.

This leads to severe hygiene problems, where faeces and urine will leak out of the vagina. Women suffering from this may be rejected by their husbands and families, leaving them to do for themselves in very harsh conditions. Men are often the breadwinners and providers in majority world nations, leaving these injured women very vulnerable because their main pride in some societies is to provide children and care for the family. The urinary incontinence can also lead to further medical problems, e.g. skin infection, kidney disorder, or even death if untreated.

Detection

The condition can and should be recognised at the delivery of the child, as was the case in the Swedish documentary where the staff responsible for the safety of the mother did not register the injuries because of unknown reasons (negligence or incompetence?). Symptoms are pain and tenderness, itching, and fever. In a number of the cases badly smelling discharge (urine and faeces) will leak from the vagina. To confirm the condition, endoscopies can be used, or even x-rays if that is available.

Prevention

Education of nurses and midwives involved in delivering children is necessary, and information about reproductive health can inform people about appropriate ages for carrying children (age is a factor, the younger the greater the risks). Also, of course, access to obstetric health care would lessen the risks that complications during delivery go that far.

Treatment

Fistulas are treated surgically, a short process of about 45 minutes for the simpler ones. However, in more complex cases specialised surgeons are required – but these are few, even in the minority world. Are a surgery, women can be taught to ‘exercise’ their pelvises so their muscles regain their elasticity and strength. MSF recommends additional psychosocial and psychological treatment, due to the immense taboo and stigma. MSF has three permanent fistula treatment centres, in Burundi, Chad, and Nigeria. In 2010 they performed 1000 repairs, increasing from 100 in 2006.

Why dangerous?

  • Women in poorer countries hold weak social statuses by birth, unfortunately, and a fistula would more or less eradicate her personal value due to the heavy stigma surrounding it
  • It is only realistically treatable if the affected woman has a simpler type of the condition and there is a competent surgeon available, but in many cases the ruptures are complex and complications many, calling for specialised but scarce surgeons
  • Affects around 2 million women today, whereof many suffer socially in addition to the physiological, and hence it contributes to hinder social progress and development

http://ibdcrohns.about.com/cs/relatedconditions/a/fistula.htm

http://www.who.int/features/factfiles/obstetric_fistula/en/

http://www.who.int/features/factfiles/obstetric_fistula/facts/en/index1.html

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