Obstetric Fistula, The Enemy Of Women In Ghana

According to the World Health Organization (WHO), an estimated 50,000 to 100,000 women develop obstetric fistulas each year and over two million women currently live with fistula injuries.

The WHO claims that fistula was largely eradicated in developed countries in the late 19th century but it still affects two to three million women in developing countries.

Obstetric fistula is a devastating injury in which abnormal opening forms between a woman's bladder and private part resulting in urinary incontinence

It could also be described as a severe medical condition in which a fistula (hole) develops between either the rectum and vagina (recto-vaginal fistula) or between the bladder and vagina (vesico-vaginal fistula) after severe or failed childbirth, due to the unavailability of adequate medical care. It is also a common complication of child-birth resulting from prolonged obstructed labour.

Obstetric fistula was very common throughout the entire world but virtually disappeared within Europe and North America due to improvements in obstetrical care.

To date, the prevalence of obstetrical fistula is much lower in places that discourage early marriage, encourage and provide education of women, and grant women access to family planning and skilled medical teams to assist during childbirth.

This condition is still very prevalent in the developing world, especially in parts of Africa and much of South Asia (India, Bangladesh, Afghanistan, Pakistan, and Nepal).

In 1857, the widespread prevalence of fistula prompted the building of the world's first fistula hospital, known as the Women's Hospital of New York. Eventually, economic development and improvements in healthcare drastically reduced the incidence of obstetric injuries in the United States. However, even though it has long been known in the West that fistula is both preventable and often treatable, this condition still affects large numbers of young women in the developing world, a situation that speaks to problems with both economic resources and healthcare infrastructure and specifically in maternal health care.

But improved access to adequate antenatal and emergency obstetric care would allow many women to avoid days of obstructed labour, which can often result in fistula.

Women living with fistula are typically between 15 and 30 years old, illiterate, poor and unaware that treatment is available. If they are aware of treatment options, they often cannot afford them. Direct causes of fistula include bearing a child before reaching full physical maturity, limited access to obstetric care, and malnutrition. Some of the indirect causes, such as poverty, women's status in society, and lack of education, keep women from accessing services, such as C-sections, that could keep them safe even in a difficult labour and delivery. Prevalence is highest in impoverished communities in Africa and Asia.

In Africa and other developing countries, there are many remote villages where there is little or no obstetric care. Pregnant women may be in labour for days without relief. The infant's head becomes tightly wedged into its mother's pelvis, cutting off the blood supply to the soft tissues of her pelvic organs. After a few days, the infant dies. Postmortem degeneration of the infant's head allows the mother to give birth to her dead infant. Damaged pelvic tissues have created the fistulae. Women with fistulae have absolutely no control over their urine or bowels. They are always wet, their clothing soiled, their stench offensive. They are divorced by their husbands, cast out by their families and ostracized by society.

Fistula is a relatively hidden problem, largely because it affects the most marginalized members of society: young, poor, illiterate women in remote areas. Many never present themselves for treatment. Because they often suffer alone, their terrible injuries may be ignored or misunderstood. The Campaign to End Fistula is working to break the silence around this condition and the stigma attached to it.

In response to the high incidence of teenage pregnancy, maternal and child morbidity in the Central Region of Ghana, the Archdiocese of Cape Coast, in January 2000, began working to establish Mercy Reproductive and Child Health Centre (MRCHC) and FISTULA Hospital in Mankessim for poor pregnant women and their offspring.

The number of Fistula Patients in the Central Region of Ghana (CRG) is estimated to be 3,000 to 5,000 with an incidence of 200 cases per year. In the CRG 10,000 give birth annually; 50% are teen-agers and 65% of the births do not occur in a clinical facility. The incidence of obstetric fistula correlates with the level of poverty. The CRG is the 4th poorest of the 10 regions in Ghana, surpassed in poverty only by the Northern, Upper East and Upper West regions.

The Catholic Church in Ghana, with the aim of responding adequately to the needs of the disadvantaged and marginalized women built the Obstetric Fistula Complex christened MERCY WOMEN'S CENTRE at Mankessim in the Cape Coast Archdiocese which was commissioned in 2010 .

There is only one Fistula Hospital (fully dedicated to treatment of obstetric fistulae) in Africa, in Addis Ababa, Ethiopia, where about 200,000 cases exist. In the West African Sub-region, its incidence is greater than 1200 per year; estimates indicate that Nigeria alone has a total of about 800,000 obstetric fistulae cases. One hospital in Southern Nigeria (Jos) and the Korle Bu Teaching Hospital in Ghana handle some cases of obstetric fistulae, as part of the medical services they provide, but not with dedicated facilities or departments.

The opening of the Fistula Centre was an indication of the Catholic Church's continuous interest in both the spiritual and health needs of the people. This facility by the Church is an encouragement and urge for Ghanaians to make good use of since the Church continues Christ's healing Ministry in bringing healing to them through the provision of quality health care.

It is very disturbing of the increasing maternal mortality in the country and it was time all Ghanaians in collaboration with other stakeholders to work hard to protect the lives of women.

The prevailing social and economic conditions which underlie the persistence of Fistula problem in Ghana and Africa include social and cultural practices that leave young, inadequately nourished women to pregnancy complications especially if they marry early.

It is estimated that annually about 3,000 to 3,500 poor women who have no funds for transportation or hospital fees will benefit from services to be provided by MRCHC and the FH after their programs are implemented. Further, it is predicted that 700 to 800 Cesarean sections (CS) will be needed annually to save lives of mothers and infants. Clients diagnosed for CS will be admitted by the 37th week of pregnancy to be built up for surgery in case an emergency CS if necessary. Although MRCHC programs are designed specifically for the desperately poor, no client will be refused care.

Causes
The fistula usually develops when a prolonged labour presses the unborn child so tightly in the birth canal that blood flows is cut off to the surrounding tissues, which necrotise and eventually rot away. More rarely, the injury can be caused by female genital cutting, poorly performed abortions, or pelvic fractures.

According to medical experts, other potential direct causes for the development of obstetric fistula are sexual abuse and rape, especially within conflict/post-conflict areas, other surgical trauma, gynecological cancers or other related radiotherapy treatment and, perhaps the most important, limited or no access to obstetrical care or emergency services.

Distal causes that can lead to the development of obstetric fistula concern issues of poverty, lack of education, early marriage and childbirth, the role and status of women in developing countries, and harmful traditional practices and sexual violence. Poverty, early marriage, and lack of education place women in positions of severe disadvantage and do not enable them to be advocates for their own health and wellbeing.

Access to obstetric emergency care is one of the major challenges in preventing the development of obstetric fistula. The availability and access to medical facilities that have a trained staff and specialized surgical equipment needed for cesarean births is very limited in certain parts of the world.

Factors that may heavily influence an individual's ability or decision to access this emergency care can involve everything from general fear and mistrust of hospitals and healthcare workers, a lack of equipped facilities and trained staff, economic constraints, religious beliefs and practices, cultural norms, and previous birth experiences.

In terms of cultural factors surrounding the birthing process, opinions and practices vary all over the world. In many developing countries, giving birth at home with the assistance of an elder woman or traditional birth attendant is considered the preferred and respected way to give birth. Some consider this point to be controversial and see it more as an economic access issue instead of a cultural issue.

Seeking out the option of surgery versus a vaginal birth, in certain places, is also thought to be less womanly and unnatural. This negative perception of surgery can greatly influence a woman's decision to not seek out emergency obstetrical treatment.
Other factors surrounding a woman's ability and choice to access obstetrical care can be rooted in the nature of her relationship with her male partner or male decision makers within her family.

This can affect the kind of care and assistance women receive during child labor. In many instances, receiving treatment from a male physician is not pursued or considered a real option due to the religious or cultural violations connected with a male treating a woman who is not his wife or intimate partner. This is an opinion held by both men and women in various parts of the world.
Yet another causal factor is that of logistical access to health care clinics. Many women who suffer from this condition are living in very rural areas and, therefore, access to emergency services often requires some form of travel. The availability of transportation cost of transportation and road construction can all play a crucial role in the ability of pregnant women to access emergency obstetrical services.
The availability and access to medical facilities that have a trained staff and specialized surgical equipment needed for cesarean births is also very limited in certain parts of the world. In many instances, women do not consider their local hospitals and clinics to be places where they could ever seek such care and therefore do not go when there is an obstetrical emergency.
The resulting disorders typically include incontinence, severe infections and ulcerations of the vaginal tract, and often paralysis caused by nerve damage. Sufferers from this disorder are usually also subject to severe social stigma due to odor, perceptions of uncleanliness, a mistaken assumption of venereal disease and, in some cases, the inability to have children.
Risk factors
Primary risk factors are early and/or closely-spaced pregnancies and lack of access to emergency obstetric care; a 1993 study in Nigeria found that 55 percent of the victims were under 19 years of age, and 94 percent gave birth at home or in poorly equipped local clinics. When available at all, cesarean sections and other medical interventions are usually not performed until after tissue damage has already been done.
Early marriage, domestic violence, female genital mutilation, malnutrition which is linked to under-development of the female body, and lack of education/illiteracy also put women at great risk for developing obstetric fistula. Personal knowledge, tradition and experience with childbirth may also put a woman at risk to developing obstetric fistula, especially for women who have previously experienced limited complications with past vaginal births. Women giving birth for the first time and with no real knowledge regarding childbirth may not recognize an emergency situation/complication and therefore not seek out help.
Countries that suffer from poverty, civil and political unrest or conflict, and other dangerous public health issues such as malaria, HIV/AIDS, and tuberculosis often suffer from a severe burden and breakdown within the healthcare system. This breakdown puts many people at risk, specifically women. Many hospitals within these conditions suffer from shortages of staff, supplies, and other forms of necessary medical technology that would be necessary to perform reconstructive obstetric fistula repair.
Medical consequences
If left untreated, ulcerations and infections can persist as well as kidney disease and kidney failure leading to death. Urinal and fecal leaking are the major physical side effects and because many women suffering from obstetric fistula do not want to leak, they will limit their intake of water and other liquids. This can lead to a very dangerous case of dehydration. Nerve damage to the legs is also noted as a medical side effect. In some cases, many women struggle to walk from this nerve damage and need physical therapy following the treatment of the fistula.
Mental consequences
Most women living with obstetric fistula also struggle with depression, abandonment by their partners, families and communities, and live in isolation because of the constant leaking and odor. Many women report feelings of humiliation, pain, loneliness, shame and mourning for the loss of their lives and the child they lost during delivery.
Because of the constant leaking and smell, many women are isolated from food preparation and prayer ceremonies because they are thought to be constantly unclean. Suicide and attempted suicide are also common amongst women with this condition. Social isolation, increased poverty and decreased employment opportunities due to this condition force many women to turn to commercial sex work and begging.
Treatment
Treatment is available through reconstructive surgery. This surgery for uncomplicated cases has a 90% success rate, and success rates for more complicated cases are estimated to be 60% successful. Successful surgery enables women to live normal lives and have more children, but it is recommended to have a cesarean section to prevent the fistula from recurring. Post operative care is vitally important to prevent infection.
Some women are not candidates for this surgery, but can seek out alternative treatment called a urostomy and a bag for the collection of urine is worn on a daily basis.
Challenges with regards to treatment include the very high number of women needing reconstructive surgery, access to facilities and trained surgeons, and the cost of treatment. For many women, even $300 US dollars is simply an impossible price and they cannot afford the surgery.
The largest challenge that stands between women and fistula treatment is information. Most women have no idea that treatment is available. Because this is a condition of shame and embarrassment, most women hide themselves and their condition and suffer in silence with no relief.
The largest benefit of surgical treatment is that many women can re-join their families, communities, and societies without shame from their condition because the leaking and smell are no longer present.
Prevention
Prevention comes in the form of access to obstetrical care, support from trained health care professionals throughout pregnancy, providing access to family planning, promoting the practice of spacing between births, and supporting women in education and postponing early marriage. Fistula prevention also involves many strategies to educate local communities about the cultural, social, and physiological factors that condition and contribute to the risk for fistula.
One of these strategies involves organizing community-level awareness campaigns to educate women about prevention methods such as proper hygiene and care during pregnancy and labour. Prevention of prolonged obstructed labour and fistula should preferably begin as early as possible in each female's life. For example, improved nutrition and outreach programs to raise awareness about the nutritional needs of female children to prevent malnutrition as well as improve the physical maturity of young mothers, are important fistula prevention strategies.
It is also important to ensure access to timely and safe delivery during childbirth; measures include availability and provision of emergency obstetric care as well as quick and safe caesarean sections for women in obstructed labour. Midwives located in the local communities where fistula is prevalent can also contribute to promoting health practices that help prevent future development of obstetric fistulas. Promoting education for girls is also a key factor to preventing fistula in the long term.
There are currently several organizations that have developed effective fistula prevention strategies. One of them is the Tanzanian Midwives Association, which works to prevent fistula by improving clinical health care for women and delaying early marriages and childbearing years, as well as help the local communities advocate the rights of females.
An Obstetric Fistula Consultant, Dr Barnabas Gandow, called for a joint concerted effort in fighting fistula and maternal mortality in a bid to reduce their negative impact in the country.

He said actors including the family, opinion leaders, chiefs, religious bodies, the media, government groups as well as health practitioners had a major role to play in maternal health which if not handled with care often led to fistula cases.
Dr Gandow who is also a Gynaecologist at the Tamale Teaching Hospital, was speaking at a seminar in Tamale as part of activities to mark International Women's Day. The International Women's Day, which falls on 8th March every year, is a global day designated to celebrate the economic, political and social achievements of women.

Awareness
In 2003, the United Nations Population Fund (UNFPA) and its partners launched the first-ever global Campaign to end Fistula. Its overall goal is to make the condition as rare in the South as it is in the North. This includes interventions to prevent fistula from occurring, Treat women who are affected, Renew the hopes and dreams of those who suffer from the condition. This includes bringing it to the attention of policy-makers and communities, thereby reducing the stigma associated with it, and helping women who have undergone treatment return to full and productive lives.
The Campaign by UNFPA currently covers more than 40 countries in sub-Saharan Africa, Asia and the Arab region.
In each country, the Campaign proceeds in three phases:
• First, needs assessments are undertaken to determine the extent of the problem and the resources to treat fistula.
• Second, each country that completes a needs assessment receives financial support for planning, including raising awareness of the issue, developing appropriate national strategies and building capacity.
• Finally, a multi-year implementation phase begins, which includes interventions to prevent and treat fistula, such as improving obstetric care; training health providers; creating or expanding and equipping fistula treatment centres; and helping women reintegrate into their communities.
The Campaign, launched in 2003, has already brought fistula to the attention of a wide audience, including the general public, policy-makers, health officials and women with fistula. More than $25 million in funding has been mobilized from a variety of donors. Activities are underway or being planned in more than 40 countries.
UNFPA's long involvement in programmes to reduce maternal mortality and morbidity make it uniquely qualified to tackle the challenge of fistula. Moreover, fistula touches on nearly every aspect of UNFPA's mandate, including reproductive health and rights, gender equality and empowerment.
During most of the 20th century obstetric fistula was largely missing from the international global health agenda. This is reflected by the fact that obstetric fistula was not included as a topic at the landmark United Nations 1994 International Conference on Population and Development (ICPD).
The 194 page report from the ICPD does not include any reference to obstetric fistula. However, since 2003 obstetric fistula has been gaining awareness amongst the general public and has received critical attention from UNFPA, who have organized a global campaign to "End Fistula".