The final Millennium Development Goals report on maternal mortality for middle- and low-income countries was recently released. It says many countries around the world have reduced maternal mortality by nearly half, which is great progress.
However the global women’s health organization EngenderHealth Inc., says the world must not overlook the impact of maternal injuries, such as obstetric fistula, on the life of a mother. The group says fistula ruins a woman’s chances of having a livelihood, raising a healthy family and contributing to her community. And it argues that eliminating fistula means eradicating obstructed labor.
Obstetric Fistula results when obstructed labor causes a hole between the birth canal and the bladder or rectum. It leaves women leaking urine, feces or both, and over time, it leads to chronic medical problems.
According to the report, the still-high rate of obstetric fistula means much work still needs to be done in addressing maternal healthcare.
Dr. Lauri Romanzi, is the project director for Fistula Care Plus, a project of EngenderHealth, Inc. The project is funded by the U.S. Agency for International Development, (USAID). She says obstetric fistula is part of a long list of deadly problems caused by obstructed labor.
“The relationship between fistula and maternal mortality is simply that obstructed labor often kills women. But if it does not kill the woman, then she will have any number of morbidities, only one of which is obstetric fistula. She can also have severe internal scarring that make sexual relations impossible. She can have infertility, nerve damage that makes it impossible to walk properly," said Romanzi.
Obstructed labor also has a number have psychological effects.
“A lot of women,” she said, “have what is in essence post-traumatic stress disorder. They’re mourning very often the loss of a stillborn baby. They have anxiety, depression, difficulty concentrating and this can persist even after they have been treated for the fistula condition, and successfully so.”
Romanzi emphasized that fistula ruins a woman’s life because she is perpetually incontinent of either feces, urine or both.
“Here in the U.S. incontinence is either the number one or number two reason to admit someone to a nursing home," she said. "There’s no human community anywhere in the world that finds living with a constantly incontinent person to be something that is easily tolerated.”
In contrast, she said, “in poor countries women who have become constantly incontinent as a result of fistula don’t have the option of being warehoused into a community, so they’re often simply ostracized by their community. About 40 to 50 percent of them are divorced. What I find remarkable about that statistic is that we’ve got about half of the husbands not divorcing their wives. And I think those men deserve to be acknowledged and applauded for continuing to support the mother of their children.”
Another consequence of obstructed labor that receives little to no attention is that 70-80 percent of the babies are stillborn. Those who do survive the obstructed birth are born with a condition called hypoxia, or low-oxygen level.
Romanzi pointed out it can take a mother with obstructed labor up to nine days to deliver, which means the baby did not receive adequate oxygen during this period.
“These babies are often born paraplegic or quadriplegic, or with severe cerebral palsy, and or with severe intellectual developmental deficits,” she said.
Romanzi identified two groups of women who develop fistula in terms of obstetric indicators. The larger of the two groups are mature women who have given birth four or five times previously, and for whatever reason during the mother’s next labor, the baby does not come out easily. It is stuck.
“There are many reasons for this. She could have some untreated, undiagnosed gestational diabetes making the baby quite large. She might have a twin pregnancy this time. That’s more common as women get older," Romanzi said. "Also, newborn weight tends to be a little larger with each subsequent pregnancy. As women get past the mark of having had five babies, the babies are also more prone to be in a strange position, what’s called transverse lie where the baby is sideways. This could lead to obstructed labor.”
Another group of women develop fistula with their first baby, even though the young mother may have waited until her late teens or early twenties to have a baby.
“There is this what I call the poster child of fistula - the 12-year-old child bride who gets pregnant before she has her first menses and has an obstructed labor while she’s still a small child, possibly with stunted growth due to poor nutrition. And while that’s true, that group that gets all the attention in the lay press, is actually a very small component of the total group of women who actually survive obstructed labor and come in with a fistula,” said Romanzi.
The main message to learn from these mothers’ experiences emphasized Romanzi is that if we want to eradicate obstetric fistula, we must eradicate obstructed labor. Equally important she notes is there is no safe way to give birth without having a skilled birth attendant such as a mid-wife or doctor, or being at a proper medical center.
“This is something that is missing from a lot of literature. You read that people feel very sorry for these poor women and all the tragedy they face. They want to act like it is something that happens over there when in actuality obstructive labor happens every day everywhere,” said Romanzi.
She added, “in high-income countries it is a significant contributor to a cesarean section rate.”
EngenderHealth has been working for decades to improve health systems and reproductive health systems for both women and men. Romanzi said access to reliable contraception is the key to reducing the risk of fistula.
“EngenderHealth was originally founded some decades ago with the sole purpose of improving access to family planning and birth-control methods," she said. "As it expanded globally, this remained a core component and wherever we are working with women suffering fistula and fistula programs. We are also working to make sure that family planning services are available and the delivery mechanism is executed to a global standard.”
EngenderHealth also has offered gender equity improvement programs that include men as partners. The programs help men understand what women go through when they are in labor. They learn to recognize danger signs so they can mobilize the mother to get medical care as soon as possible, despite some traditional and cultural beliefs that only strong women have their babies at home.