Poor reproductive health outcomes in developing nations, particularly in Africa, are the result of the culmination of many contributing factors. These include gender inequality, poor provision of education and inadequate infrastructure, causing suboptimal access and quality of health systems, thus leading to the unnecessary rates of maternal mortality and morbidity. Hundreds of women die in childbirth or from arising complications, each day.1 In addition, for every maternal death, 20–30 women fall victim to serious childbirth-related injuries.2 An example of such injury is an obstetric fistula (OF), which is the presence of a hole between a woman’s genital tract and urinary tract, or between the genital tract and the intestines.3 This injury occurs during obstructed labour, rendering a woman incontinent of urine and/ or faeces.4 It currently affects 2 million women and there are approximately 100,000 emerging cases annually.5 The additional physical effects secondary to OFs are often devastating, including atrophied limbs and foot drop secondary to perineal and sciatic nerve damage.6 Worsening the impact of physical trauma is the psychological trauma associated with OFs. Babies born to a mother with an OF are stillborn in 93 per cent of cases, as a result of obstructed labour.7 Mothers with an OF routinely experience social rejection from their communities, families and husbands.8 Often, they are completely socially isolated, spending most of their days alone, which leads to malnutrition and worsening poverty.9 OFs seldom occur in developed nations as they are entirely preventable; rigorous education on childbirth and comprehensive healthcare systems work to ensure adequate reproductive health outcomes.10 Thus, it is necessary to investigate the determinants of OFs and their genesis to lessen their overall burden in developing nations. Addressing this issue from a public health perspective highlights the scope of the problem, allowing for the betterment of preventative strategies and highlighting the increased need to mobilise resources.11
Women aged 10–19 constitute 50 per cent of OF cases, due to the reproductive immaturity that is attributable to low childbearing age. Evidence suggests that three years post-menarche the birth canal is narrower than at age 18.12 Malnutrition contributes to stunted bone growth, resulting in pelvic immaturity. Pelvic immaturity and poor reproductive development are positively correlated with obstructed labour, and, thus, the occurrence of an OF.13
Low parity between genders also contributes to the incidence of OFs. This includes social practices such as childhood marriage that are correlated to low education and rural settings.14 In Ethiopia, two-fifths of girls are married before they are 18 and nearly one-fifth before age 15.15 Childhood marriage facilitates early childbearing age, which is an aforementioned risk factor for OF.
Social stigma increases the risk of OF. Due to the marginalisation of its victims, important conversations pertaining to prevention and treatment are neglected. Surveys carried out on public perception of OFs conclude that societies think of them as an untreatable curse or punishment for sinning.16 Thus, a vicious cycle ensues: the issues are ignored and victims are ostracised, unable to share their stories and frequently unaware of treatment options.17
Young women are often prevented from making decisions regarding their own birth experience due to their disempowerment. Husbands and mature women in the community act as surrogates for decision-making, but their lack of education on childbirth risks and their minimal first-hand experience (particularly husbands, as OFs primarily affect primiparous women) means they are unable to make informed decisions.18 They often wait too long for the progression of labour before acting in emergency situations, while rural settings and distance from hospitals and emergency services make timely health interventions frequently unobtainable.19
Strategies changing social outcomes to prevent OF
To prevent OF, it is imperative to reduce social factors contributing to early childbearing. An important step is to abolish child marriage. Determinants of child marriage include poverty, lack of access to education and lack of economic autonomy. Studies into childhood marriage prevention indicate several effective methods. In communities where education for girls (12–14 years) was offered, they were 94 per cent less likely to be married. Furthermore, when they were offered a means to independence (chickens, providing food and economic security) girls (15–17 years) were 50 per cent less likely to get married.20Another measure that worked well was the initiation of conversations about the harmful and inappropriate nature of childhood marriage. In communities that participated in such conversations, two-thirds of girls were less likely to be married.21
Another initiative that aims to promote gender parity to prevent poor health outcomes is the United Nations Leave No Woman Behind (LNWB) program. It responds with a holistic approach of interventions, incorporating economic empowerment, access to health services, education and behavioural change at the local level.22 LNWB objectives focus on strengthening regional efforts to combat gender inequalities while increasing women’s power to achieve economic and education goals.
The program partnered with many keen stakeholders, predominantly NGOs, that work to implement initiatives into government systems to ensure program sustainability. The program developed at a community level by producing interactive discussions about social norms and values and providing a platform to advocate the dangers of child marriage. Furthermore, LNWB supported local schools through its provision of literacy programs and learning tools. It also provided adolescent girls with sanitary items to ensure school attendance, as poor attendance is a key risk factor of OF. The program supported local authorities to purchase obstetric equipment and key reproductive health materials to spread provision of services and improve their quality. From 2009–12 the LNWB achieved many tangible outcomes, including: reduced child marriage; an increase in births attended by health professionals; an increase of women using family planning, pre-and postnatal care; and increased attendance at supported schools.23
Timely access to appropriate healthcare services
Access to reproductive health services is a key strategy in preventing the occurrence of OF. This can be achieved in two ways: advocacy pertaining to accessing health services and strengthening presence of local healthcare providers. As OFs most often occur rurally, it is difficult to educate women about prospective treatment options. To overcome this barrier, several interventions have been put in place. Radio announcements, theatre, media and community education messages all play an important role to inform women about prevention methods and OF treatment options.24 Furthermore, a hotline service funded by the Freedom from Fistula Foundation (FFF) allows women to seek information about appropriate medical treatment. If a woman calling the hotline is symptomatic, she is referred to a hospital specialising in OF repairs.25
Dr Catherine Hamlin, a pioneer in OF treatment, highlights the importance of the provision of birth attendance by professionals in mitigating poor birth outcomes. Ethiopia alone has a population of more than 90 million, yet there are only 7000 trained midwives. Thus, she established the Hamlin College of Midwives. Since 2007, 105 midwives have graduated from this college, 34 of whom have gone on to work in rural midwife centres. To date, there have been no maternal deaths from births attended by graduates.26
A key resource in treatment and rehabilitation of OF
The Addis Ababa Fistula Hospital was the first of its kind exclusively dedicated to treating OFs. It has the capacity to treat 2000 patients per year and has thus far treated 50,000. Dr Muleta, former director of the hospital, is optimistic about the future directions of OF prevention. She states, ‘the government is taking the issue seriously now. At the policy level women’s issues are a priority for the government, and there is work to improve maternal health. Regional and federal government is talking about fistula, and they are giving us land so that we can build regional fistula centres’.27
Future directions of OF detection
Ultrasound technology has been promoted as a prospective detection and diagnostic tool. With a transvaginal approach, there is a reported 100 per cent successful retrieval rate of OF detection. It is portable, which is important in a rural setting and is battery operated, thus low cost. Ultrasounds can be set up in rural areas; however, there is currently little funding for this intervention.28
There are several effective strategies, programs and resources to lessen the prevalence and incidence of OF in developing nations. However, the barriers to the comprehensive delivery of preventative and surgical measures to treat OF remain challenging. These barriers include social factors, poor infrastructure and inadequate healthcare systems. Interventions show promising results with regards to barriers. Therefore, despite the complexity of the issue, it remains possible to eradicate OF.