Obstetric Fistula
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What is a fistula?
Fistula is a Latin word that literally translates as 'tube', 'pipe' or even 'flute'. The bland innocuousness of its origin belies the terrible implications of the term in the context of obstetrics (the branch of medicine concerned with childbirth and midwifery). It describes an abnormal passage between one hollow organ of the body and either another hollow organ or the surface of the body. Common examples include direct communications between the bladder and vagina (vesico-vaginal fistula) and bowel and vagina (recto-vaginal fistula).
In childbirth these abnormal passageways result from complications of the birthing process, such as prolonged or obstructed labour, where prolonged pressure of the presenting part of the baby on the wall of the mother's genital tract results in necrosis (literally death) of the tissues and eventually a hole in the structure concerned. Sometimes fistulae result from tearing of the birth canal from the sheer force of the emerging head or breech, or as a result of problems with instrumental deliveries, such as forceps. In any case, the end result is terrible suffering for the mother, both during the birth itself, and in the aftermath, when the mother is left unable to control the leakage of urine or faeces through the fistula. This makes personal hygiene very difficult, and the woman is condemned to a perpetually soiled and malodorous state.
Apart from the health problems the social consequences of a fistula for the woman may be grave. The mother may be severely stigmatised and completely rejected by her husband, family and friends, and an already intolerable situation is made worse by homelessness, poverty and social isolation.
Such conditions are almost unheard of in industrialised societies, and where they do occur surgical treatment is almost invariably successful. However, in many developing countries even basic health facilities are lacking - one of the reasons why so many of these fistulae occur in the first place - and specialist gynaecological treatment is almost non-existent.
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Female Genital Mutilation (FGM)
FGM describes a cultural practice, mainly confined to certain African countries, where parts of the female external genitalia are cut or removed, sometimes in their entirety. The more extreme versions may be followed by closure of the opening by suturing, leaving only a small aperture for the passage of urine and menstrual fluid. The 'circumcision' (as it is sometimes misleadingly called) is invariably prescribed by religious doctrine and, in its mildest forms, may be little more than symbolic. However, the more severe forms of mutilation are designed to prevent penetration before marriage, thereby assuring virginity and justification of the bride price. Such women may need to be surgically opened to allow penetration, and may be closed up again following childbirth.
Although research into the association of milder forms of FGM with complications around delivery is currently inconclusive, there is little doubt that severe forms of FGM are associated with an increased risk of birth complications, in some cases leading to fistula.
Maternal morbidity and mortality associated with FGM is a good example of where safe motherhood initiatives must look beyond MDG 6, in this instance MDG 3 'promote gender equality and empower women', in those societies where FGM is a manifestation of patriarchal control over women's sexuality.
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Further information on FGM may be found in the WHO web site at http://www.who.int/topics/female_genital_mutilation/en/
Guidance on management of obstetric fistula
WHO: Obstetric Fistula. Guiding principles for clinical management and programme development
http://www.who.int/making_pregnancy_safer/publications/obstetric_fistula.pdf
¹ WHO study group on female genital mutilation and obstetric outcome; Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006 Jun 3;367(9525):1835-41.
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