Shereen Zulfiqar Bhutta ( Department of Obstetrics & Gynaecology, Jinnah Postgraduate Medical Center, Karachi. )
Obstetric vesicovaginal fistula due to obstructed labour has long been eradicated from the developed world1-3but it remains a major problem in developing countries like Pakistan4. Here underprivileged women still develop vesicovaginal fistula following obstructed labour. The poorest of poor women living in remote rural farming areas being more likely to do so5. Most reports on fistula, concentrate on surgical aspects. It is an issue that requires consideration of economic, social and cultural factors, a chain of events leading to its formation and the miserable status of the afflicted woman.
Obstetric vesicovaginal fistula has been termed an ailment of the young primigravida6-8, with the majority of patients from various developing countries7-9, including Pakistan three decades earlier 10 being primiparous. However, recently more multiparous women than before, in Paldstan develop urinaiy fistulae following labour 8. This is attributed to osteomalacia of the pelvis after repeated childbearing and lactation, another sad reflection on the nutritional status of these women. Also increasing parity is associated with increasing birthweight11,12, leading to foetopelvic disproportion not encountered previously.
With more multiparous women than before presenting with fistula, one would think that if women were to limit the size of their families, complications including fistula formation could be reduced. Health and Family Planning services in rural areas of Pakistan even if available, are seldom utilized. One discouraging reason being the high infant mortality rate. Despite high parity some of these women have no live issue. These women, after successful repair, go back to the same circumstances that resulted in fistula formation. This is reaffirmed by the fact that some return with recurrence following subsequent labours in the same setup. It is time the emphasis is shifted from curative to preventive strategies 9.
Only 11% of women in the subcontinent receive any antenatal care and 85% of deliveries are conducted at home by relative oruntrained traditional birth attendants13. Women are left in labour for long hours. This reflects poorly on the availability and utilization of medical services. Only a third of the rural population lives within 5 km or an hour’s walk from a fixed health facility13. Transport pmblems and difficult terrain make matters worse3,8. Even if a healthcare facility is available, it may not be availed. Labour is considered a physiological event7, the women themselves mistrust the unfamiliar hospital environment8. They do not wish to be attended to by males, who may be the only health personnel available there. If the husband happens to be away, the woman herself or the other family members cannot make the decision to take her to hospital14,15. The attitude of the family and society towards life and women are significant obstacles16. The impact of these factors is also evident in the long interval between development of fistula and presentation to hospital for treatment.
Fistula surgeey is undertaken in major hospitals in cities and patients often travel great distances to get there. Preparationfor surgery and postoperative care of a fistula patient takes time, a commodity which the accompanying relatives find difficult to sacrifice. Public hospitals, overwhelmed by emergency obstetrics and long waiting lists, give fistula patients a low priority1,8. At times the cost of subsistence in a big city is beyond their means and family members are unwilling to ‘leave the woman on her own inthe city’, even for treatment in hospital, forcing her to return untreated to her previous miserable existence. This is a sad reflection on the status of women in society, the root of the problem in the first place.
Of those who are cured, few return for follow-up. Infertility and dyspareunia due to vaginal fibrosis,are separate issues worthy of follow-up and rehabilitation17. It is not surprising that some women do not regain their self esteem despite a cure16.
Epidemiological studies in the community are required to determine factors responsible for obstructed labour and determine strategies for prevention of fistula. Hospital figures are not indicative of prevalence1. For every woman who manages to reach hospital for treatment, possibly many more suffer in silence, hidden away leading ostracized lives3,5,8,16. not even aware of a possibility of cure8,18.
Unlike other neighboring countries, the size of the problem in Pakistan remains unchanged8. There are no shortcuts to solutions. Eradication of illiteracy19,21and change of society’s attitude towards women for the better16 are fundamental for a favourable change.
1. Tahzib, F. An initiative for vesicovaginal fistula. Lancet, 1989,1:1316-7.
2. Kelly. J. Vesicovaginal and rectovaginal fistulae. J. Roy. Soc. Med., 1992;85:257-8.
3. Arrowsmith, S.D. Genitourinary reconstruction in obstetric fistulas. J. Urol., 199 1; 152:403-6.
4. Raut,V. and Bhattachaiya,M. Vesical fistulae- An experience from adeveloping country J.Postgrad. Med., 1993;39;20-1.
5. Murphy. M. Social consequences of vesico-vaginal fistula in northern Nigeria. J. Biosoc. Sci., 1981;13:139-50.
6. Harrison, K.A. Children crippled by childbirth. People, 1987;14:12-5.
7. Tahzib, F Epidemiological determinants ofvesicovaginal listulas. Br. J. Obstet, Gynaccol. 1983,90:387-91.
8. Lawson, J. Vaginal fistu!ae, 3. R. Soc. Med., 1992;85:254-6.
9. Mustafa, A.Z. Acquired genito..urinary fistulac in the Sudan. J. Obstet. Gynacc. Brit. Cwlth.. 1971;78:1039-43.
10. Aziz. S.A. Urinary fistulae from obstetrical trauma. 3. Obstet. Gynacc. Bril. Cwlth., 1965;72:765-8.
11. Cammileri, A.P. and Cremona, V. The effect of parity on birthweight. I. Obstet. Gynaec. Brit. Cwlth., 1970;77:145-7.
12. Brunskill, AS. Antecedents of macrosomia. Paed. Painat. Epid., 1991;5:392401.
13. Pakistan Demographic and Health Survey 1990/91, Islamabad, National Institute of Population Studies. Pakistan, 1992.
14, Han ison, K.A. Obstetric fistula: One social calamity too many. Br. J. Obstet. Gynaecol., 1983,90;385-6.
15. Jafarey, SN. and Korejo, R. Methers brought dead: An enquiry into causes of delay. Soc. Sci. Med., 1993;36:371-2.
16. Jays Rao,’K.S. Attitudes to women and nutrition programmes in India. Lancct, 1979;ii:1357-8.
17. Ojanuga, D. Social work practice with childbirth injured women in Nigeria.Health Soc. Work, 1994;19:120-4.
18. Coetzee T. and Lithgow, D.M. Obstetric fistulae of the urinary tract. J. Obstet. Gynaec. Brit. Cwlth., 1966;73:837-44.
19. Harrison, K.A. Traditional Birth attendants. Lancet, 1980;ii:43-4.
20. Ojanuga, D. Preventing birth injury among women in Africa: Case studies in northern Nigeria. Am. J. Orthopsychiatr., 1991;61:553-9.
21. Ojanuga, D.N. Education: The key to preventing vesicovaginal fistula in Nigeria. World Health Forum, 1992;13:54-6.