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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. This is also a page for all those people who google the keywords “Lucy Bloom Fistula.

  • 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 which 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 labor. Mothers who have not been well nourished as children have a smaller pelvis but can produce full size babies.
  • 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.
  • The single most significant factor in preventing obstetric fistula is access to professional obstetric services.
  • Research shows that tragically, 90-95% of babies born to fistula patients during the birth that caused their injuries, are stillborn.
  • The side effects of these terrible injuries start with incontinence of the bladder and sometimes bowel. Sometimes both. Women living without sanitation in a village context find these symptoms utterly devistating and isolating.
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. 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.

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 long-held 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.
  • For more detail on this see the research here.

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 tens 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 pratices 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.

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

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 some physio.
  • The modern techniques for obstetric fistula surgery were perfected by Dr Catherine Hamlin AM and her late husband Dr Reginal Hamlin OBE.
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. 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 most under resourced countries when it comes to women’s health and therefore the highest rates of obstetric fistula are:

  1. Nepal
  2. Magagascar
  3. Congo
  4. Senigal
  5. Afganistan
  6. Pakistan
  7. Nigeria
  8. Liberia
  9. Zimbabwe
Lucy Bloom fistula
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