"To meet only one of these mothers is to be profoundly moved. Mourning the stillbirth of their only baby, incontinent of urine, ashamed of their offensiveness, often spurned by their husbands, homeless, unemployable except in the fields, they endure, they exist, without hope......."

Dr. Katherine Hamlin, Second Fistulae Hospital, Addis Ababa, Ethiopia.

What is Fistula?

Fistulae are holes that are created between the vaginal wall and the bladder (vesicovaginal fistula VVF), and holes created between the vaginal wall and the rectum (rectovaginal fistula RVF). Fistula has severe physical and social consequences and is one of the most degrading morbidities resulting from pregnancy and childbirth. As these holes are formed as a result of pregancy and child birth the term Obstetric fistula is commonly used as an umbrella term. It can be caused by obstructed labour due to FGM type 3 or FGM type 4 , where cuts are made into the vagina, or by child marriage and early pregnancy. For this reason FORWARD at its strategic review in 2002 formally adopted the challenge of addressing child marriage, an issue contributing to and associated with Fistula and FGM.

In Northern Nigeria maternal morbidity as a result of fistula is particularly high, with an estimated 70% of the 150,00 cases, in Nigeria, occurring in the North. For this reason, FORWARD has been working on a Project in Nigeria in Kano State, working with girls and women who have suffer with this condition.

Causes of Fistula

Approximately 80% of fistula cases reported in Nigeria are due to unrelieved obstructed labour during childbirth. Obstructing labour is directly related to the custom of early marriage in Nigeria (frequently below the age of 18 and sometimes before the onset of menstruation, as early as 11 years old). Child marriage invariably leads to early sexual contact and subsequent pregnancy at a time when a young girl is not adequately physically developed to permit the passage of a baby with relative ease. This can lead to a prolonged and obstructed labour and damage leading to the misery of fistula. The same phenomenon also occurs in women whose growth has been stunted as a result of poor nutrition or malnourishment.

About 15% of fistula cases are caused by the harmful practice of female genital mutilation. The 'gishiri' cut, a form of female genital mutilation, is commonly practised in Nigeria amongst the Hausa people. This traditional practice, performed by untrained traditional birth attendants, is used in the treatment of a wide variety of gynaecological ills and is commonly employed during pregnancy and labour. A cut is made in the anterior wall of the vagina with an unsterilised sharp instrument, if the cut is made too deep, a hole is created between the bladder and the vagina resulting in VVF. The rationale for the 'gishiri' cut defies scientific explanation, but belief in its effectiveness persists.

Consequences of Fistula

The immediate physical consequences of VVF are urinary incontinence and / or faecal incontinence due to RVF and related conditions, such as dermatitis. If nerves to the lower limbs are damaged, women may suffer from paralysis of the lower half of the body.

As well as the physical consequences the social consequences for those who suffer from fistula are also severe. Many victims of obstructed labour, in which the fistulae subsequently occur, will also have given birth to a stillborn baby, thus leaving the woman childless. In some areas, a high percentage of fistulae occur during the first pregnancy. In a society where childbearing is so highly valued this gravely affects the woman's future. If the fistula is not repaired, and the woman remains incontinent and childless, she is likely to be abandoned by her husband, on whom she is economically dependent. In addition, she may be ostracised by society as being considered to have brought shame on her family. Victims, therefore, become social outcasts.

Fistula leaves such women physically, emotionally and socially traumatised. With no education, no vocational training, no gainful employment or visible means of livelihood, they travel a long road of rejection and pain.

Prevention and Treatment of Obstetric Fistula

Obstetric fistula was eradicated in western countries at the end of the 19th century when caesarean section became widely available. Obstetric fistula continues to plague women throughout the developing world and the key to ending fistula is to prevent it from happening in the first place. Ways to accomplish this are to ensure that there are skilled attendants at birth, and to guarantee a swift surgical intervention if obstructed labour occurs. Poverty, the empowerment of women, family planning and importantly FORWARD's key issues FGM and child marriage are critical areas to address for the eradication of fistula.

The success and recovery rate from an operation to correct simple fistula is very high - almost 90%. This essentially involves repairing a hole in the bladder or rectum and can usually take place through the vagina without the need for major incision. The operation is delicate and specially trained surgeons and support staff are required. Counselling is also required to heal non-physical wounds and is necessary for a complete recovery.

In some cases, woman who have also suffered severe nerve damage may require prolonged physical therapy. Unfortunately, for some women, the damage is beyond repair and continual care is required. New surgical techniques are being pioneered to improve results and address more severe tissue damage.

Approaches Towards Eliminating Fistula

Research and observations have shown that patients with fistulae are a particularly disadvantaged group in relation to both socio-economic status and education. The majority of patients are from rural areas, low in literacy levels and lacking in physical and economic access to medical care. Since many do not attend antenatal clinics, high risk conditions and medical and obstetric complications endangering the life or impairing the health of the expectant mother and baby will not be detected early enough to adopt precautionary measures. Many women in rural communities are taken to hospital only when the situation is hopeless and often too late.

In the short term, better use of existing obstetric services and increased provision of effective health services in rural areas will lower the incidence of fistula. However, in the longer term there is a need for an holistic approach to address both the direct and indirect causes of fistula and other maternal morbidities, including of course an end to female genital mutilation and child marriage. Ultimately, improving the education and economic empowerment of young women will remove the conditions that lead to the occurrence of fistula. Such improvements would lead women to seek safer obstetric practices, including the use of family planning, delay childbearing, and seek prenatal and antenatal care during pregnancy. It has been found that women with a formal education have a maternal mortality rate one fourth that of women with no formal education.

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