Indian Journal of Public Health

REVIEW ARTICLE
Year
: 2019  |  Volume : 63  |  Issue : 1  |  Page : 73--78

Obstetric fistula: A challenge to public health


Dharitri Swain1, Swayam Pragyan Parida2, Saubhagya Kumar Jena3, Mahasweta Das4, Hrushikesh Das4,  
1 Assistant Professor, College of Nursing, AIIMS, Bhubaneswar, Odisha, India
2 Associate Professor, Department of Community Medicine and Family Medicine, AIIMS, Bhubaneswar, Odisha, India
3 Additional Professor, Department of Obstetric and Gynaecology, AIIMS, Bhubaneswar, Odisha, India
4 Research Fellow, ICMR Funded Project, AIIMS, Bhubaneswar, Odisha, India

Correspondence Address:
Mrs. Dharitri Swain
Department of Obstetric and Gynaecology, College of Nursing, AIIMS, Bhubaneswar, Odisha
India

Abstract

Obstetric fistula (OF) is one of the most important consequences of a prolonged obstructed labor, a big issue for low-income countries (LICs) like India. The objective is to identify and explore the knowledge regarding OF as a public health problem in LICs from peer review literature. The PubMed, Google Scholar, and Science Direct databases were searched to identify the prevalence, risk factors, and management of OF in LICs. Quantitative evidence-based paper reviewed. Twenty-seven articles met the inclusion criteria. The 15 provided population-based OF prevalence data of OF and 12 provided risk factors and social causes of OF rates associated with the birth that caused an OF. OF has one of the big public health problems. There is a lack of scientific research on the prevalence and risk factors of OF in LICs. This review helps to eradicate or alleviate the problem of OF in LICs like India.



How to cite this article:
Swain D, Parida SP, Jena SK, Das M, Das H. Obstetric fistula: A challenge to public health.Indian J Public Health 2019;63:73-78


How to cite this URL:
Swain D, Parida SP, Jena SK, Das M, Das H. Obstetric fistula: A challenge to public health. Indian J Public Health [serial online] 2019 [cited 2019 Oct 21 ];63:73-78
Available from: http://www.ijph.in/text.asp?2019/63/1/73/253885


Full Text



 Introduction



The obstetric fistula (OF) is a very serious complication of childbirth affecting millions of women in the developing world. The OF is a very common problem in most of the women in low-income countries (LICs) like India. An OF occurs when women experience obstructed labor.[1] It normally occurs due to prolonged or obstructed labor and spontaneous abortion or female genital mutilation and leads to physiological anomalies, including continuous loss of urine or feces through the vagina. A gynecologic fistula refers to an abnormal communication between the urinary tract and the gastrointestinal tract and the genital tract, produced by obstetric causes, usually prolonged and obstructed labor.[2]

The World Health Organization (WHO) defines that OF as an abnormal opening between female private parts such as vagina and bladder and rectum through which the urine and feces continually leak.[3] OFs is one of the most devastating medical disabilities afflicting women as a result of complications arising from lack of surgical intervention for prolonged labor. While the most common cause of OF is obstructed and/or prolonged labor, pertinent underlying factors such as poverty, lack of awareness, poor-health-seeking behaviors, poor health and referral systems, poor transportation networks, scarcity of skilled birth attendants, and inadequate obstetric care services (infrastructure) can contribute to the occurrence of OF.

 Methods



Literature sources

We conducted variety of searches the literature for the journal repositories such as, PubMed, Google Scholar, and Science Direct search were subsequently used to verify the previous outputs. Search strings and MESH word are used to identify the term “OF,” “vesicovaginal fistula,” “prevalence of OF,” “risk factors of OF,” and “management of OF” articles that were quantitative, evidence-based, and written in English languages and mainly focused on LICs. In addition, potentially relevant publications were identified from the reference lists of identified articles and from review articles.

Study selection

Descriptive or analytic studies presenting the characteristics or the outcome of women suffering from genital fistula were initially eligible for inclusion. After identification of potentially relevant studies, each of these studies was reviewed in detail and clinical case studies using as exclusion criteria. Studies providing complete or partial information on the sociodemographic characteristics of obstetric fistula patients, access to health care, or its consequences were included. Studies were excluded if they reported only the outcome without any presenting sociodemographic characteristics or information about access to emergency health care.[4]

Data extraction and analysis

From these articles, we extracted the following variables for the review: country of the study, study design, year of the publications, population characteristics, and prevalence/incidence rate and risk factors/treatments and a number of little defined additional factors.

 Results



The literature search produced 27 articles that met the inclusion criteria [Figure 1].[5] The 15 provided population-based OF prevalence data of OF and 12 provided risk factors and social causes of OF rates associated with the birth that caused an OF.{Figure 1}

 Prevalence of Obstetric Fistula



The prevalence of OFs varies from country to country and continent to continent, according to their causative factors vary. In the developing world, many fistula cases never come to medical attention, as these women were separated from their husbands [Table 1].[6],[7],[8],[9],[10],[11] Although the true prevalence in the developing world is unknown, high prevalence rates have been reported from Ethiopia, Sudan, and Nigeria [Table 1]. An incidence of 1 to 2 per 1000 deliveries has been estimated worldwide, with an annual incidence of 50,000–100,000 and a prevalence of untreated fistulas of 500,000–2,000,000.[12],[13] OFs in Ethiopia result mainly from obstructed labor, mostly in the first pregnancy in young women, and it is rare for the baby to survive. Prevention will involve awareness, education, communication, transport, and health-care measures, with good preoperative and postoperative care and attention to surgical detail can cure many women.{Table 1}

The prevalence of OF was 1 in 1000 women in a hospital-based study in Kenya.[14] Overall, the estimation that just over one million women may have a fistula in sub-Saharan Africa and South Asia and that there are over 6000 new cases per year in these two world regions and the consequences of OF for women and their families, this represents a very substantial burden. Prolonged labor, age, level of education, parity, occupation, severe female genital mutilation, lack of access to transport and primary health care in the rural community, and early marriage were characteristics of the fistula patients.

A 2007 systematic review identified 29 studies with population-based incidence and prevalence estimates and found incidence estimates ranging from 20,000 to 30,000 annual cases with a global prevalence estimate of 654,000 cases [Table 1].[15],[16]

 Fistula in Developing Countries



In developing countries, prolonged obstructed labor causes the overwhelming majority of OFs. It has been estimated that an OF occurs in 1–3 per 1000 deliveries in West Africa.[16] In developed countries, OF is mostly due to the complications of surgery or radiation therapy for cancer.[17]

Fistula in India

India is a LIC where many women lie in below poverty line, the women suffering from severe obstructed labor for more than a day. Those women are suffered from an OF being malnourished, lack of knowledge, and importantly, due to the poverty. Due to the above consequences, Indian women suffer from OF. From the literature, authors found that 717 women underwent genital fistula repair, but medical records could be retrieved for only 401 (56%) cases. States such as Bihar, Uttar Pradesh, and West Bengal had more than 100 cases, whereas Karnataka had no cases. Assam state has a higher percent of fistula (4.5%), followed by Madhya Pradesh (3.4%) and Uttarakhand (3.2%) [Table 1].[18],[19] Authors stated that obstructed labor caused nearly 97% of genital fistulae while pelvic surgery and accidental trauma contributed to 1.5% cases. A common type of fistula was genitourinary (86.6%), rectovaginal (12.1%), and both genitourinary and rectovaginal fistulae (1.2%). Fistula repair was attempted in 322 (83%) cases of whom 289 (89.71%) were successfully repaired [Table 1].[20]

Prevalence of obstetric fistula by district level household and facility survey (2007–2008)

According to the District Level Household and Facility Survey (DHLS) data (2007–2008), the prevalence rate of OF was given in [Figure 2]. Many women lived in tribal areas, and hospital facility is not available to that women [Table 1].[21]{Figure 2}

 Causes and Risk Factors of Obstetric Fistula



Physical causes

OF is predominantly generally caused by a very long or obstructed labor which can last several days or even, sometimes, over a week before, the women receive obstetric care or die. 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 fetus dies and gradually decomposes enough to slide out of the vagina [Table 2]. The injured pelvic tissue also rots away, leaving a hole, or a fistula, between adjacent organs. If the woman had received timely care, the baby would have been delivered by a cesarean section, and both the mother and baby would most probably have survived.{Table 2}

Lack of access to maternity care

In developed countries, obstructed labor and OF are medical problems which are largely in the past. This is because problems with labor may be anticipated during antenatal care and a difficult labor that may become obstructed. In resource-poor countries, the reality is different. In these countries, the vast majority of the women develop fistula during childbirth and many women are die. 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 [Table 2].

The need for skilled care

Skilled care before and after birth, and particularly during labor, can make the difference between life and death for women and their babies and can help to prevent OF. Yet only half of the women in developing countries receive assistance from a skilled attendant during delivery. The WHO publication, Global action for skilled attendants for pregnant women, sets out the evidence and responsibilities for increasing access to skilled professionals at delivery as well as identifying steps to maximize the effectiveness of current staff in countries where trained professionals are scarce.[22]

 Risk Factors



Several social, cultural, and health system factors contribute to the prevalence of OF in LICs.[23] These factors are context-bound and through observations by surgeons, some of the identified factors are lack of emergency obstetric care, child marriage associated with early pregnancy, severe forms of female genital cutting, gender discrimination, poverty, malnutrition, and poor health services.[4]

Maternal age seems to have a role in the development of fistula, and patients are reported to be <20 years of age when they get a fistula. This seems to vary from country to country with a mean age of 22 years in Ethiopia and 28 years in Nigeria [Table 2].[24]

Other factors include prime parity, prolonged labor, stillbirth delivery, and poor social economic status. In Ethiopia, more than 60% of the women are primiparas when they develop fistula with average labor duration of 3.9 days. The rate of stillbirth varies from country to country with up to 93% among women who sustain fistula in Ethiopia [Table 2].[25]

Among several causes, there are seven primary risk factors for obstetrical fistula commonly reported include the place of birth and presence of a skilled birth attendant, the duration of labor and the use of a young age at delivery, older age, lack of family planning, and a number of other poorly defined additional factors. About 92 of 201 fistula cases reported in northern Ethiopian women did not have any antenatal care. About 85 of the 52 fistula patients in a Niger series delivered at home [Table 2].

The data on risk factors for obstetrical fistula are controversial. Better knowledge of the risk factors for obstetrical fistula is needed to educate the community, health-care providers, policymakers, and program managers to improve prevention of OF at a regional and national level.[8],[26],[27]

The delays in seeking skilled care during prolonged and obstructed labor compounded by the delay to perform a cesarean section, a key intervention, eventually lead to the formation of a fistula developed a model that emphasizes the importance of mapping the factors that may cause delays in different phases of seeking maternal care.[28] In the model, originally developed for maternal mortality, Thaddeus and Maine divided the delay in seeking skilled care into three different phases as follows: delay in the community making the decision to seek care (phase one), identifying and reaching medical facility (phase two), and receipt of adequate and appropriate treatment (phase three) [Table 2].[29],[30],[31],[32],[33],[34]

To prevent morbidity and mortality due to fistula, a timely obstetric care is needed as apriority. The problems in accessing maternity care that can lead to maternal death or complications are commonly referred to as the “three-delays.” Fistula can develop because of any one of these as follows:

A delay in deciding to seek care caused by the community or sociocultural factors, by being unaware of the need for care, or of the warning signs of problemsA delay in reaching a health-care facility, perhaps because of transport problems, distance, or costA delay in receiving adequate care at the facility, because resources (human and equipment) and may not have been available, or the care provided was inadequate or harmful.

 Underlying Social Causes



Poverty

Poverty is one of the biggest problems for women for the underlying cause of OF. Although the immediate causes of OF are obstructed labor and lack of emergency care services. Women those who are suffering from OF tend to be impoverished and malnourished, lack of basic education, and to live in remote or rural areas without maternity care and without assistance from skilled birth attendants.[35]

Early marriage and childbirth

In rural areas, the practice of early marriage contributes to a risk of obstructed labor and fistula. In this world where OF is a very common, women often marry as adolescents, sometimes as young as 10 years of age, and many become pregnant immediately before their pelvis are fully developed for childbearing.[36] Fistula formation is more likely to follow the first labor. To compound the problem, often these girls may have been the victims of forced marriages, and many are undernourished.[37] Inadequate family planning and the role and status of women also are important social causes.

 Discussion



The review found that fewer than 1/1000 women of reproductive age in LIC and middle-income country suffer from OF, this value rises to 1.57/1000 when only data from sub-Saharan Africa and South Asia are used.[9] According to DHLS data, OF in India was 1.5% which is very less than African countries.[13] With clinically focused articles excluded, the public health research on OF is dominated by hospital-based study and cross-sectional studies. The abundance of this type of information demonstrates emerging awareness of OF as a public health problem, many women are young, poor, and they have lack of health-care facility. However, our review does highlight the reproductive women who suffer OF and they are abandoned by husbands and family. The prevalence rate is more in African countries as compare to the other countries. The prevention of fistula is important to reduce the burden of maternal morbidities and mortality and it could be attained by providing appropriate maternal health services and emergency obstetric care.[13] To overcome the burden of fistula, programmatic approaches integrated with other maternal health services are urgently needed. The few community-based or national-level studies demonstrate a tremendous gap in knowledge on the prevalence of fistula and the difficulty of using survey data to identify fistula patients. Population-level demographic data are increasingly being collected, but identifying fistula by survey is challenging.

Summary

In summary, OF is one of the important consequences for LIC like India. Improvising Obstetric care facilities can prevent obstetric fistula in most of the countries. Affecting women are suffering from untold misery and the great majority of these women are poor and lived in below poverty line.

Fistula patients are living indicators of maternal health care, and solution to the problem will ultimate the provision of essential obstetric care services. Finally, there must be many awareness programs to be conducted at the community level for proper knowledge and prevention of OF.

Key points

Prevention is key to ending OF as it is rightly said, “Prevention is better than cure.” Women in rural areas are always at greater risk to be affected by fistula, and the availability of emergency obstetric care in rural areas is very rare. Furthermore, illiteracy of women is likely to affect fistula than educated women. Public health should focus these affected women top preventing the OF and also by awareness. It is time to start giving them the attention and care they deserve.[1]

Acknowledgment

We are very thankful to All India Medical Sciences, Bhubaneswar, for their support and necessary help.

Financial support and sponsorship

We are thankful to the Indian Council of Medical Research for the budget approval for the smooth running of the projects.

Conflicts of interest

There are no conflicts of interest.

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