By Mary Nell Wegner, Executive Director, MHTF
On July 8-11, the MHTF had the privilege of co-hosting two meetings with the Fistula Care Plus project, led by EngenderHealth. It was a terrific opportunity to learn about the current state of fistula research, discuss gaps in surveillance and measurement, as well as consider our shared goal of how best to support providers in high burden countries to tackle this persistent problem.
These providers of obstetric care and women with fistula offer important insight into the existence of fistula, but the reality is that we have no idea how many women in the world are currently living with fistula or are at risk for getting a fistula. Because obstetric fistula is a relatively rare event and women with fistula are often stigmatized, appropriate measurement mechanisms are elusive. Although household and mixed method surveys, key informant interviews, health management information systems, and modeling all offer insight, none of these alone adequately captures the scope of the problem. Consequently, measuring incidence and prevalence of this maternal morbidity is difficult. Additionally, fistula often affects the poorest, most vulnerable, and powerless women and, because they are frequently so marginalized, they can be hard for a “system” to find.
Still, that is no reason to give up.
As the global community comes together to work towards ending preventable maternal mortality and morbidity and address the needs of newborns, fistula is a critical issue. Obstetric fistula, often a sequela of unskilled or absent emergency obstetric care, provides an important lens on how health systems are failing women and newborns when they are at their most vulnerable.
While arguably the vast majority of obstetric fistula is caused by lack of emergency obstetric care during obstructed labor, it is becoming increasingly apparent that there is also some proportion caused within facilities by providers with inadequate skills. In the process of providing cesarean sections, some providers may actually cause a fistula. A forthcoming retrospective review by Dr. Thomas Raassen and others will provide data on this topic covering 18 years and 11 countries.[i]
While the maternal health community is to be commended for all of the work conducted in the last decades to increase access to emergency obstetric care, in our haste we may have made a critical error in failing to ensure the provider has the skills and resources needed to operate effectively. It’s time to take a closer look at the training providers receive and what can improve their competence.
Not all women who arrive at a facility with obstructed labor are guaranteed to receive the care they need for the prevention of fistula. Some women arrive too late after a fistula has begun to form. For those who arrive promptly, a skilled provider can make a critical difference in a woman’s life when the provision of a c-section to relieve obstructed labor will safeguard the health of the mother and newborn. Let’s pause to recognize this need for prompt, skilled emergency obstetric care and plan accordingly.
Let’s also pause to congratulate the Fistula Care project and the incredible surgical teams and facilities staff in the Global South who have provided more than 29,000 fistula repairs to women in more than ten countries, as well as published 22 journal articles, in the last five years. With this kind of track record, further substantial progress in preventing both obstetric and iatrogenic fistula certainly seems within reach.
[i] Raassen TJIP, Ngongo CJ, Mahendeka MM, Iatrogenic genitourinary fistulas: An 18-year old retrospective review of 801 iatrogenic injuries. International Journal of Urogynecology, in press