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Why obstetric fistula will still exist in 2018

Photo by Smiley Pool Photography 

Elon Musk is building a rocket to transport people to Mars and a supersonic rail to make traveling long distances on this planet less time-consuming and more environmentally friendly. Biomedical engineers are using 3-D printers to create intricate parts needed in a moment’s notice in surgery. Anyone with a smart phone can order items from books to clothing to gourmet food and have it delivered in less than an hour. We are living in incredible times of innovations all to make life simply better. Yet with all of these incredible advances, we still have not universally achieved quality in the most basic and fundamental part of advancing humankind: childbirth.

While we debate about the over-medicalization of childbirth in the United States, in much of sub-Saharan Africa and south Asia, women are delivering in facilities often lacking fundamental tools such as electricity. Basic surgical instruments, materials and personnel needed to perform a cesarean delivery in the case of obstructed labor are missing. The result is often death of the child and at times, the mother. The women who survive the difficult childbirth frequently develop a fistula, or hole, as the baby’s head applies constant pressure on the pelvic tissues, interrupting the normal blood supply and killing the underlying tissues. The result is an unnatural connection, usually between the bladder and the vagina, which allows urine to pour directly and uncontrollably out of the vagina. In the worst cases, this connection continues into the rectum, and therefore not only urine flows freely through the vagina, but stool as well. It is a lifetime of disability and social isolation.

Operation Fistula founder Seth Cochran calls fistula “the worst problem you have never heard of.” Colloquially known as “fistula,” it is a problem overlooked as it leads to deep social embarrassment. The women affected either limit their interactions in their communities or spend most of their lives hiding the incontinence. In some contexts where fistula exists, communities blame the woman for her child dying, and then for the subsequent incontinence. 

The number of women who develop an obstetric fistula every year is a symptom of a much larger systemic problem: a failed reproductive and maternal health system. The United Nations Population Fund (UNFPA) estimates that 2 million women are currently living with an obstetric-related fistula and that every year, up to an additional 100,000 women develop fistulas. Therefore, obstetric fistula is a sign of a broken health system that is failing women, their babies and their communities.

Obstetric fistulas largely disappeared from the U.S. in the early 1900s, and yet millions of women in sub-Saharan Africa and Asia are still affected by them today. The national and local governments responsible for making the necessary improvements are already encumbered by high rates of HIV, tuberculosis, malaria and many other health concerns. The will power to address safe childbirth may exist for these political authorities, however resources are stretched beyond limits. Funding and initiatives from outside organizations and governments often help, but organizations must work closely with the local government to be sustainable.

Baylor College of Medicine and Texas Children’s Hospital provides a replicable example of a successful partnership. In conjunction with the Freedom from Fistula Foundation, it is providing obstetric fistula surgery to restore continence and restore dignity for the millions of women impacted by this basic problem. Doctors are performing surgeries in Kenya, Madagascar, Malawi, and Sierra Leone. New initiatives are also beginning in Cameroon with Mercy Ships. While surgeries are performed, experienced surgeons are training local surgeons to empower them to continue this work.

While technology and women’s progress advance in leaps and bounds at home, it is often the most low-tech problems and typically forgotten women who would greatly benefit from a modest investment. For approximately $1,000, a woman can undergo surgical repair of obstetric fistula and go on to lead a productive life, realizing her full potential.

When you consider history and our current zest for innovation, ask yourself, why does obstetric fistula still exist? It simply should not.

Post by:

Rachel Pope, MD, MPH