Obstetric Fistula
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.
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.
Further Information
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
