The changing perception and knowledge of obstetric fistula

The World Health Organisation (WHO) estimates, each year between 50,000 and 100,000 women worldwide are affected by obstetric fistula, a hole in the birth canal. At least 33,000 of these women live in Sub-Saharan Africa where limitations in quality obstetric care and fistula corrective repairs are prevalent. Obstetric fistula is predominantly caused by a very long, or obstructed labour (process of child birth) which can last over 24 hours, or several days or even, sometimes, over a week before women receive obstetric care or dies. If labor remains obstructed, the unrelenting pressure of the baby’s head against the pelvis can greatly reduce the flow of blood to the soft tissues surrounding the bladder, vagina and rectum. If the mother survives, this kind of labor often ends when the baby dies. The injured pelvic tissue also rots away, leaving a hole, a fistula, between adjacent organs, and there is constant leakage of urine or stool. If the woman receives timely care, the baby would be delivered by a caesarean section, and both the mother and baby would most probably survive. Rarer causes of fistula are from sexual abuse and rape, the complications of unsafe abortions and surgical trauma (injury to the bladder at caesarean section). Gynecological cancers related radiotherapy treatment can also cause this condition, although this is rare in developing countries. In resource-poor countries, the reality is different. In these countries the vast majority of the women who die, or who develop fistula during childbirth, do so because they did not receive the health care that they needed. This may be due to a lack of basic health-care provision or through, for whatever reason, an inability to access the local health-care services, mainly due to poverty. Too early marriage and childbirth, inadequate family planning and birth spacing, harmful traditional practices, such as female genital cutting or mutilation (FGM), also contribute to the risk. Recently, a study was done to assess the current perception of Rwandan women towards obstetrical fistula and their knowledge of fistula etiology. One on one in-depth interviews were conducted on women with obstetrical fistula, women with urinary incontinence symptoms(loss of bladder control) but no fistula and Women without urinary incontinence or fistula symptoms who presented at Kibagabaga Hospital in Kigali during one of the International Organisation for Women Development (IOWD) missions where free surgical management of obstetric fistula is provided. It was believed that fistula was due to witchcraft or non-obstetrical reasons by some women. Jeanne (not real names) said, “…I thought that I was bewitched, that was the reason I was leaking”. Some women attributed fistula to be due to poor hygiene. One woman narrates about her encounter with a neighbor, “I thought it was a disease due to poor hygiene. We could say that they are just dirty and they can’t clean themselves…” However, many of the women believed fistula was due to obstetrical reasons. Justine (not real names) recalls, “…it was caused by delivering a dead baby… after a long time”, and Rose (not real names) deep in thoughts said, “I think it was due to a C-section and I started leaking with nausea and vomiting because of the big wound. I think he [doctor] might have used an instrument that injured my bladder…’’. Some women also believed that delivery at their homes with the help of inexperienced local ‘midwives’ might have been the cause of their continuous leakage. Overall, most women were aware of obstetric fistula as a medical condition. Women with incontinence or fistula were more knowledgeable than women that did not have these symptoms. Due to increased patient education, shifts in cultural beliefs, or increased and improved access to health care in Rwanda, women are becoming more aware of obstetric fistula as a medical condition comparing to the past. Additionally, women’s understanding of obstetric fistula seems to be changing from an ideology based in the occult to an understanding of fistula as a consequence of obstetrical trauma. However, there is need for continued community awareness about Fistula. Future public health strategies should include educational initiatives aimed at addressing the knowledge gaps in these women to ensure they receive the appropriate medical care and prevent the development of such debilitating conditions. Obstetric fistula is preventable. I couldn’t be more contented hearing about a fistula ‘awareness walk’ scheduled this 10th December where everyone should participate. The writer is a final year medical student.