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Healing the Pain of Obstetric Fistula

Women rest following surgery to repair fistulas at the Doctors Without Borders' clinic in Boguila, Central African Republic

A medical aid group says many pregnant African women suffer needlessly from complicated or prolonged labor. As a result, they’re forced to live with obstetric fistula – a condition that scars them physically, emotionally and socially. Doctors Without Borders is highlighting the problem as the world marks the 100th anniversary of International Women’s Day on March 8.

Obstetric fistula is a problem rarely seen in western countries, but it can be all too common in developing nations. It’s a hole between the vagina and bladder. It’s caused when the baby’s head places too much pressure on soft tissue in the pelvis. The blood supply to the tissue is cut off, causing it to die and leave a hole. It happens in labor lasting days, not hours.

Surgeon Michiel Lekkerkerker, the group’s medical advisor for reproductive health, says, “It is of course certainly a medical problem, but maybe even [a] bigger social problem because many of these women are just ostracized by their families or their social fabric, so to say, because they are wet all the time. But they smell, too. And since they don’t want to be wet all the time, these women also tend to limit their water uptake. And therefore the urine gets more concentrated and they may be less wet, but they start to smell even more.”

It gets worse.

“They lose their husbands. They’re kicked out of their house. They often have to fully take care of themselves because they have dropped out of their [social] system and they even have to resort to becoming whatever, sex workers or something,” he says.

Doctors Without Borders, also known as MSF, has fistula repair and treatment projects in Burundi, Chad, Nigeria, DRC, and Central African Republic. It estimates that two million women worldwide have fistulas, most of them in Africa.

Esther Feibouko of CAR developed a fistula in 2008. She says, "When I walked, I would leak urine, and it made me feel bad."
Esther Feibouko of CAR developed a fistula in 2008. She says, "When I walked, I would leak urine, and it made me feel bad."

Surgery to repair the damage during childbirth is complicated and requires great skill. It can take anywhere from a half hour to several hours, depending on the damage.

“The majority is quite difficult,” he says, “It is of course delicate surgery in a very confined environment because 95 percent is operating within the vagina.”

Dr. Lekkerkerker says obstetric fistula usually occurs among young women. But there are cases of women who have been living with the condition for 20 years.

Fistula is just a symptom of a much bigger problem. And that is lack of access to obstetric care. There may be many more women that die as a consequence of a lack of access than you have women that survive with the price of a fistula,” he says.”

He says we may never know just how many poor women die from a lack of obstetric care.

What’s being done

The good news is that with proper medical care fistula can be prevented. And with surgery, repaired.

Prior to surgery, while women are at MSF clinics, they are told to drink a lot of clean water. Usually something they avoid because of their incontinence.

Fistula patients wait outside the operating room for a consultation.
Fistula patients wait outside the operating room for a consultation.

Lekkerkerker says, “You want to kind of clean the system. And the less the whole environment is, let’s say, infested or contaminated with bacteria the better. So, ideally, you only operate [on] these women when they produce colorless and odorless urine. And indeed in a good fistula repair environment you have many women that are waiting to be operated [on], but there is no stench of urine. There may be puddles of basically water everywhere that those women lose, but it is so unconcentrated that there is no urine stench.”

Once the fistula is repaired, recovery may take several weeks. Patients will probably need to use a catheter to urinate, so there isn’t much pressure on the surgical area.

However, women still may be incontinent after the surgery. Dr. Lekkerkerker says that may disappear with rest or pelvic floor exercises. Sometimes the catheter will be left in for a few more weeks and in some cases more surgery may be needed.

An African proverb says, “The sun should not rise or set twice on a woman in labor.” Doctors Without Borders says the best way to ensure that holds true is to improve medical care for African women.