July 14, 2015
5th Floor, Woodrow Wilson Center
Washington, DC

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Obstetric fistula and pelvic organ prolapse are two common maternal morbidities that impact thousands of women in developing countries each year but are often overshadowed by maternal mortalities. Obstetric fistula, a hole in the birth canal caused by obstructed labor, affects between 50,000 and 100,000 women each year, mostly in developing countries. Pelvic organ prolapse, which occurs when a woman’s pelvic organs slip out of place, is 10 times more common, according to Dr. Lauri Romanzi, who spoke at the Wilson Center on July 14.

Women who live through these complications may suffer incontinence, infection, kidney disease, and foot drop (reduced ability to walk caused by nerve damage). Additionally, 78 to 95 percent of women with obstetric fistula deliver a stillborn baby.

Many women in turn suffer from social isolation and depression. “If I cannot sleep with you, what is the use of keeping you?” one man told his wife after a prolapse, said Mary Ellen Stanton, maternal health adviser for the U.S. Agency for International Development (USAID). A woman’s inability to work in addition to the financial burden of paying for treatment has trickle-down effects for the entire family.

And yet obstetric fistula and pelvic organ prolapse are entirely preventable and have been eliminated in Western countries since the turn of the 20th century. “We could correct it, really, if we just had the political will to make that happen,” said U.S. Congresswoman Carolyn Maloney, who spoke at the event and has introduced several bills to provide U.S. resources and support for obstetric fistula treatment.

Inequity as a Root Cause

Obstructed labor is the most prominent cause of obstetric fistula and many other maternal morbidities. While women in high-income countries are able to access well-equipped facilities and other resources to prevent and respond to prolonged labor, such as emergency Caesarian section, women in low-income countries often cannot. Surgical facilities and expertise in particular are often far out of reach.

Unsurprisingly, rates of both conditions are highest in the poorest places. According to the UN Population Fund, more than 2 million women in sub-Saharan Africa, the Middle East, North Africa, Asia, Latin America, and the Caribbean are estimated to be living with fistula.

Erin Anastasi, the interim coordinator of the UN Population Fund’s Campaign to End Fistula, described how the socioeconomic status of poor women is compounded by structural issues and perpetuates cycles of vulnerability and marginalization. For many, the closest clinic or hospital may be several miles away and only accessible by foot – out of reach for someone who has to give birth on her own and runs into problems. If a woman does get to a health facility, it is often under-resourced and understaffed.

Medical students are often sent out to poor communities with little to no surgical training, said Romanzi, and midwives may not have the capacity to properly treat all their patients due to the number of patients they’re responsible for. Romanzi described one hospital in West Africa that increased the size of its maternity ward to accommodate 15,000 deliveries a year, up from 5,000 previously. But it still only had one operating theater. Those with obstructed labor are rarely the priority amidst so many deliveries and as a result, “it’s an obstetric fistula factory,” she said. Patients are “rolled down the hill” to a nearby fistula clinic to be treated instead.

Due to their heavy domestic workload and low status, poor women are generally conditioned to place others’ needs before their own, said Stanton. They are less likely to seek care and support for their medical problems. Furthermore, there is often a strong social incentive to remain silent, thanks to the shame and stigmatization that can follow. Communities may even sequester women with fistula and prevent them from carrying out religious rituals, for example.

New Approaches: Data Collection and Integrated Care

“If things keep going as they are with the status quo, most of [these] women will die without ever having treatment,” said Anastasi.

One of the roadblocks to ending preventable maternal mortalities and morbidities is data collection – or lack thereof. To that end, Johnson & Johnson, in collaboration with the UN Population Fund, Fistula Foundation, and Direct Relief, launched a global fistula map in 2012, said Conrad Person, director of corporate contributions for Johnson & Johnson. According to Person, 267 facilities currently use the map to report on the number of surgeries and other fistula care services they provide to increase awareness of where fistula treatment exists and how many women are getting care.

Person said Johnson & Johnson concentrates most of its efforts on treatment. The company is committed to contributing 80 percent of the global need for fistula sutures and is developing a training manual for fistula surgery, he said.

Stanton and Anastasi focused on integrated care and structural change. Launched in 2003, the UN Population Fund’s Campaign to End Fistula, supported by USAID and 91 other partners, has strengthened the role of midwives in managing and treating fistula, supported more than 57,000 fistula repair surgeries, and provided follow-up care, said Anastasi.

EngenderHealth’s Fistula Care Plus, a five-year project funded by USAID through 2018, builds on an earlier iteration of the project to strengthen public-private partnerships, educate communities on best practices and the reintegration of women, reduce infrastructural barriers to prevention and treatment, and improve the capacity of health facilities and systems, said Stanton. The vision is that girls born in the next five years “will no longer need to be concerned about obstetric fistula by the time they begin to start their own families.”

A Challenge

Congresswoman Maloney expressed frustration with the lack of U.S. political support for women’s issues and the politicization of women’s bodies. She came directly from a vote in the House of Representatives on a bill that would allow taxpayers to fund breast cancer research by purchasing special commemorative coins. Some lawmakers objected, she said, because it would provide support to the Susan G. Komen Foundation, which in turn provides some funds to Planned Parenthood.

Leadership and cooperation among women are key, said Maloney. “We are half the population… If we just stood up on these issues and voted together, we could win.”

But given the slow rate of institutional and cultural change, Romanzi challenged the audience to rethink their preconceptions about maternal health. Obstetric fistula was eradicated from the United States and Europe at the end of the 19th century, she reminded the room. This was long before many cultural norms that are today seen as linked to ending fistula in poor countries were up to modern progressive standards. Teen pregnancy and gender-based violence were widespread, women’s education was poor, and women couldn’t vote. Instead, she said, it was the advent of anesthesia and ability to perform Caesarian sections that seems to have made the difference.

With this in mind, Romanzi called for a narrower focus on obstructed labor screening programs and modern treatment. While social determinants are important in their own right, she said, perhaps the key to ending fistula and prolapse is to, “build it and they will come.”

“Let’s have competently trained people who are working under competent conditions, and people will come,” she said. “Communities will engage.”

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