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Everything I know about obstetric fistula, by Lucy Bloom

Once upon a time, I was the founding CEO of a multi-million dollar Australian charity which funded a network of hospitals and a midwifery school in Ethiopia. I cover a lot of this in my memoir, Get the Girls Out, but there is so much more that I have learned about this horrid childbirth injury, it seems a shame to waste that knowledge. So here it is…

  • Fistula is a medical term used to describe a hole that shouldn’t be there between two organs. Obstetric fistula is a hole between the vagina and bladder, or the vagina and rectum.
  • This injury is caused by a prolonged, obstructed labour. About 5% of women worldwide will go into an obstructed labour. The stats on this vary from 2% to 6% but there are a number of influencing factors on these figures but the obstetric establishment tends to quote the 5% rate as a global average.
  • The main causes of obstructed labour are a large or badly positioned baby, a small pelvis and other problems with the birth canal.
  • Both the size and the position of the baby can lead to obstructed labour. Mothers who have not been well nourished as children have a smaller pelvis but can produce full size babies.
  • The single most significant factor in preventing obstetric fistula is access to professional obstetric services.
  • For women who have access to proper medical care, obstructed labour is treated with a swift caesarean section. For women who do not have access to a good hospital and an obstetrician, labour will last for days and days. Eventually, the pressure of the baby’s head for such a long time will kill off the internal tissue causing holes or defects in the vaginal wall, bladder and sometimes the rectum.
  • Research shows that 90-95% of babies born during the birth that caused obstetric fistula injuries, are stillborn.
  • For every woman who is injured by an obstructed labour and presents with obstetric fistula injuries, it’s estimated there is a woman who dies before she can be treated.
  • The side effects of these injuries start with incontinence of the bladder, sometimes bowel. Sometimes both. Women living without sanitation in a village context find these symptoms utterly devastating and isolating. It usually ends their marriage.
Lucy Bloom fistula
Image copyright Lucy Bloom. All rights reserved.

Pictured here is Dr Catherine Hamlin at the age of 85, operating at her hospital in Addis Ababa, Ethiopia. I shot this image in 2009. Catherine appointed me to my first CEO role in 2012 and it changed the direction of my career and taught me much of what I know about these injuries and how they are treated. Catherine’s surgical team was almost entirely local Ethiopians, many of whom were women, some of whom were fistula survivors themselves.

FGM AND OBSTETRIC FISTULA

  • The WHO defines female genital mutilation as all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons.
  • FGM is a cultural or tribal practice, not a religious one and is on the decline globally. See this study, though note the focus group only applied to girls aged 0-14.
  • For a long time, it was assumed that FGM was a direct causal factor in obstetric fistula. In fact, the WHO still bangs that drum. It seems a fair assumption to make, especially in cases where women suffer Type 2 FGM which involes the removal of the clitorus and labia then the sewing up of the the whole gential area with only a small hole through which to urinate.
  • But the research shows that obstetric fistula is not caused by female genital mutilation (FGM). To learn more, see the research here. The closure of the vaginal opening does not slow down the second stage of labour for very long at all.

CHILD MARRIAGE AND OBSTETRIC FISTULA

  • Research shows that obstetric fistula is not caused by child marriage. In the past, it was a fair assumption to make that smaller girls would suffer a higher rate of obstructed labour but the research conflicts with this assumption.
  • If a girl can conceive, she is built deliver. She might not be mentally ready for it, or legally the right age but the research shows that small girls as young as 12 and 13 who are properly nourished, can deliver babies without a higher rate of obstetric fistula.
  • In Catherine’s book, Hospital by the River, originally published in 1999, Catherine wrote that child brides were a major factor in this terrible childbirth injury. By 2015, we knew from the research quoted above, that this was not the case so it was edited out of the second edition.
  • However, it is always important to look at the full picture. A girl who is pregnant by age 13 is no longer in school and is likely to be pregnant every year for the next ten years. This increases her chance of risk for all pregnancy and birth related complications.

OBSTETRIC FISTULA IS MORE COMPLEX THAN CULTURAL PRACTICES IN ISOLATION

  • What we do know about the social factors behind obstetric fistula is that this injury tends to hold hands with poverty. Women living in poor countries, who live in remote communities, relying on agriculture to survive are the most likely to be unable to access proper maternity care when they are in labour.
  • Hand in hand with poverty is a lack of education, especially for women. And when women are uneducated they marry younger, have more babies and are more likely to practice FGM.
  • While clinically, these things don’t cause the injury, they are cultural practices and social expectations which are more commonly adhered to by the poor. And the poor are least likely to afford the hospital care they need to prevent childbirth injuries.
  • A woman living in poverty is about 100 times more likely to die from avoidable pregnancy and birth complications than a woman with access to professional, affordable medical care.

It wouldn’t be correct to say that obstetric fistula only happens in countries where women don’t have access to good healthcare. It happens in wealthy countries, too – usually when an obstetrician has done the damage. A violent mechanical delivery or just good old-fashioned negligence can cause a fistula and leave a woman needing very specialist surgery. But because these cases are relatively rare in countries such as Australia and the United States, surgeons don’t have the experience to repair them properly. The best surgeons for smashed-up vaginas are almost all in Africa. In Australia, the only surgeon I could recommend was a doctor in Queensland who spent three months every year operating in African hospitals. Once, Catherine operated on a Canadian woman who had travelled to Ethiopia because she couldn’t find a surgeon to fix the damage to her bladder; she was cured in one simple op.

Lucy Bloom, Get the Girls Out, HarperCollins Publishers 2019

Dr Catherine Hamlin
Image copyright Lucy Bloom. All rights reserved.

This is one of my favourite pictures of Catherine which I shot as she prepared for theatre one morning in Addis Ababa. Zero fuss. The hospital was pretty simple and theatres were very Ethiopian in style with stone floors and big windows for natural light. Catherine operated until she was 90 years old but only gave up when there was pressure on her to stop. She would still visit the wards and chat with patients but after she stopped operating, she was never the same and stopped having an active role in the hospital for a number of years before she died aged 96 on 18 March 2020.

OBSTETRIC FISTULA TREATMENT

  • Surgery is the only effective treatment for these injuries. For a skilled surgeon, a straightforward procedure for a fistula repair takes only an hour or so in theatre. A common hospital stay is about three weeks for recovery and physio. Some are complex injuries which require several operations.
  • About 7% of cases can’t be cured and the patient will need to learn to live with a stoma and a colostomy bag.
  • The modern techniques for obstetric fistula surgery were perfected by the late Dr Catherine Hamlin AC and her late husband Dr Reginald Hamlin OBE. They based their early work in the 1960s on another doctor’s findings from the 1920s, most of which were perfected on patients before modern anaesthetics were developed.
Lucy Bloom fistula
Image copyright Lucy Bloom. All rights reserved.

HOW CAN YOU HELP CONQUER OBSTETRIC FISTULA?

I am often asked for my recommendations on the best charitable organisations to support when it comes to the erradication of obstetric fistula and maternity services to the poorest women in the world. My recommendation is to look at the countries who have the highest rates of this terrible injury, then look for reputable organisations who are working in those countries in a sustainable way. The best way to prevent obstetric fistula is to give women access to good maternity care. This means training midwives and equipping remote clinics AND equipping hospitals for life-saving caesarean sections.

The most under resourced countries when it comes to women’s health and therefore the highest rates of maternal death and obstetric fistula are listed here. I will add links to charities funding maternity care as I vet them.

  1. Nepal
  2. Magagascar
  3. Congo
  4. Senegal
  5. Afganistan
  6. Pakistan – Koohi Goth Hospital, Karachi
  7. Nigeria
  8. Siera Leone – Aberdeen Women’s Centre
  9. Zimbabwe
  10. Uganda – Love Mercy Foundation
  11. Tanzania – Dr Andrew Browning

Unfortunately, much of the work of Medecins Sans Frontierers (Doctors without Borders) in obstetric fistula has been in temporary fly-in-fly-out demountable 6 week camps, which is not a good model of care, so I cannot recommend their work.

Dr Hamlin’s projects in Ethiopia are well funded and Australian fundraising is capped so I do not recommend donations there if you are looking for impact. Catherine’s legacy will be her model of care, not the charities who swarmed around her.

Lucy Bloom fistula
Obstetric fistula patient by Lucy Bloom
Image copyright Lucy Bloom. All rights reserved.

One of the biggest problems all over Africa is the brain drain. There are world-class training hospitals throughout Africa but talented doctors are often attracted to salaries in America and the UK which are 300 times the doctor’s salaries in their home country. Look for organisations which focus on training a local workforce of midwives and surgeons and pay them well to keep them in their home country. Shipping in short-term volunteers is almost always not the answer.

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