Women's Health and Education Center (WHEC)

Obstetrical Fistulae

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Obstetrical Fistulae & Efforts Of The United Nations

Dr. Rita Luthra
President, Women's Health & Education Center
Photographs from World Health, WHO Publication

The United Nations is an organization of sovereign States and not a world government. It is an international organization comprising 192 Member States. As the "town hall of global affairs", its work affects our life everyday. Founded in the aftermath of the Second World War, the United Nations came into being with the signing of its Charter in San Francisco in 1945. Whether working to maintain friendly relations among nations, encouraging human rights, protecting the environment or tackling illiteracy, disease and hunger, the United Nations is ready to be fully utilized for the betterment of humanity. The World Health Organization came into being on 7 April 1948. The priorities of 1948 are still priorities today. The WHO Constitution states that "the highest attainable standard of health" is a fundamental right of everyone and that governments are responsible for providing the means to achieve it. Health is an essential part of social and economic progress and even an individual's right.

Clearly no single organization can solve crisis of maternal mortality and morbidity worldwide. Its causes are incredibly complex, and its solution requires more than good obstetrical care alone. The United Nations is irreplaceable as a forum for international dialogue. Global issues require global action and global initiatives involving both from industrialized and developing countries. Building strategic and coordinated responses to this tragedy is the way forward. The need to take a fresh look at development aid is vital. There is also clear need to look at aid effectiveness from a different angle is essential. Investment in women's healthcare is best investment to build healthy communities. It will have far reaching implications for millions of people in the developing world who have every right to share in the opportunities provided by today's global prosperity.

The purpose of this document is to discuss principles for the development of a national or sub-national strategy for the prevention and treatment of obstetric fistula. This manual is intended to be a practical guide to be read and used at many different levels by many different people, especially health-care professionals and planners, policy-makers and community leaders. Its three main objectives illuminate its wide reach and potential utility. First of all, it strives to draw attention to the urgent issue of obstetric fistula and advocates for change. Secondly, it provides essential, factual background information along with principles for developing fistula prevention and treatment strategies and programs. Finally, it endeavors to contribute to the development of more effective services for women under treatment for fistula repair.

Millennium Development Goals (MDGs) and Women's Healthcare:

In December 2000, 149 heads of state and or government and 189 Member States jointly endorsed the Millennium Declaration, thereby committing themselves to achieving, by 2015, ambitious goals including reducing poverty, hunger and disease. These goals are known collectively as the Millennium Development Goals (MDGs) and they will serve as a basis for recording progress in development for the next 15 years.

Poverty, hunger and disease affect hundreds of millions of lives and kill a child every three seconds and a woman every minute. Every minute of everyday a woman dies in childbirth. Maternal death and obstetrical fistulae are only the tip of the iceberg. In developing countries large numbers of women are in a state of constant and debilitating ill health, which they often accept fatalistically as the normal and unavoidable price of childbirth. With the growing motivation and political will the need for better information has become more acute. The potential of information and communication technologies for advancement and empowerment of women is unlimited and should be tapped through training and capacity building.

About 1 Billion persons live in extreme poverty and hunger on less than a dollar a day in the world. Women constitute more than half of humankind. Women and children represent 70% of world's poor and two thirds of the world's illiterate population not to mention that 80% of the world's refugees and displaced persons are also women and children. If the number of victims of extreme poverty and hunger is to be halved by the year 2015, then women have to be empowered to achieve this goal.

Of the eight Millennium Development Goals, Goal 5 calls for Improve maternal health - Reduce by two thirds the mortality rate among children under five. Goal 3 calls for empowering women and promoting gender equality, specifically setting targets to eliminate gender disparity at all levels of education by 2015, with additional indicators on women's employment and the proportion of women in parliaments. The aim is to create conditions enabling all people to live in dignity and safety, free of hunger, fear or oppression. The United Nations has a vast array of functions to implement its mandates. How we work together towards more effective and mutually supportive relationships to enhance our role is more relevant than ever.

For more information on the Millennium Development Goals (MDGs), see Road Map towards the Implementation of the United Nations Millennium Declaration at: www.un.org/millenniumgoals

Plight of Obstetrical Fistulae Victims:

The horror of obstetric fistula is unimaginable to women born in countries where medical care is not available. A fistula results from prolonged labor when the child is unable to pass through the birth canal for long days of obstructed labor, eventually producing dead baby. The child's head bearing down on the vaginal passage results in the death of tender flesh and in a hole between the vagina and the rectum, causing feces, urine or both to leak for the rest of the life, unless surgical repair is done and it is successful. There are about 1 million women in Africa alone with obstetric fistulae and 80,000 more every year are reported. Poverty, lack of knowledge and cultural beliefs and values, poor roads, isolation and unreliable public transportation and no telephones or other direct methods of communication between villages, rural health centers and district hospital contribute to delay in cases of emergency.

Faces behind the tragedy

faces behind the tragedy

In many parts of the world, women can only achieve social status through getting pregnant. A woman who fails to conceive is less likely than others to be able to settle into a successful marriage. Women who deliver children who all subsequently die do not suffer a similar fate. Infertility and childlessness provoke the stigma, and is still disastrous for women in many parts of the world. The essential task is to proceed with open eyes, not blinded by bias, and to be prepared to take the long way around, should some cultural barrier demand a detour.

Maternity Centre in Benin
Maternity Centre in Benin

A Strategy for Development:

It is a grave mistake to expect medical expertise and technology alone can ensure the adequate health of a population. The other vital assistance aspects - food, water, sanitation and shelter are equally important in contributing to the success of health work. Public health will be a meaningless term unless it can truly be put across to the public. We need media today (in rich countries as well as poor) to serve as a channel to inform a growing public about healthy practices, sensible lifestyle, as well as the importance of education and equality for girls. The aim is to create conditions enabling all people to live in dignity and safety, free of hunger, fear or oppression. The United Nations has a vast array of functions to implement its mandates. The discussion on how we work together towards a more effective and mutually supportive relationship to enhance our role is more relevant than ever.

Education for Life

Getting the Message Across:

The African Region is caught in a downward spiral in which the poor health of the population is undermining economic performance, and resulting poverty means there is less and less being spent on health care. The health infrastructure in many countries is in a dire state: hospitals, clinics, health centers and dispensaries have become dilapidated and often lack basic equipment and drugs. Diseases like HIV/AIDS, malaria, tuberculosis and diarrhea are putting a greater burden on the health care system. Reversing this trend calls for imagination and careful use of scarce resources. Information, education and communication have a crucial role to play in this regard and are among the most cost-effective interventions for health. But at present only a small proportion of the population has access to such information. Major weakness of existing health information programs lacks the involvement of target audience. An effective information campaign should start with the assumption that people know best what their problems are and what they need in order to cope with them. They should be involved in setting the agenda, and in creating and delivering the information messages. Language, too, may be a barrier to effective communication. With the exception of a few countries, official languages in Africa differ from the languages most people use in their everyday lives. They need information in their mother tongue if they are to understand it and take heed.

Reaching rural audiences is a challenge. Moreover, rural people tend to have limited access to television, radio and internet. Systematic monitoring and evaluation of programs would enable countries to identify weakness such as these, and allow timely adjustments to be made. They are crucial elements in successful information programs and should always be an integral part of their design rather than an afterthought.

Safe Motherhood Initiatives:

Pregnancy is special; let us make it safe. Safe Motherhood means ensuring that all women receive the care they need to be safe and healthy throughout pregnancy and childbirth. What is needed is a system which starts at the community level, including at home and in the family, and links women to health care services. This implies a need to strengthen health systems so that they provide effective medical interventions and lots of coordination at all levels. The experience of the Safe Motherhood Initiative has demonstrated that there is no one simple technology or "magic bullet" to reduce maternal mortality and morbidity. Training of traditional birth attendant is a step in the right direction; however such training can only be effective way of reducing maternal mortality if there is a functioning referral system with back-up and support from professionally trained health workers. Risk assessment can not identify which women will eventually have poor pregnancy and delivery outcomes. The central role of the health services does not mean that the communities themselves do not have responsibilities for ensuring safer motherhood. Community members need to be aware of the importance of looking after the health of girls and women, particularly during pregnancy and childbirth. Influential family and community members have particular responsibilities for ensuring that when women need special care they are able to reach services in time. Community birth attendants need to know what practices to avoid during childbirth, to recognize complications, and to encourage women to go to a health facility without delay. Midwives have a crucial role to play in protecting and improving the health of vulnerable women and children.

For further information on the work of Safe Motherhood Initiatives; please visit www.safemotherhood.org

Forging the Links:

The interventions needed to prevent pregnancy-related deaths and disabilities have been known for a long time, and the skills and technology are attainable. So what is preventing the achievement of safe motherhood? Real progress will be made once the infrastructure of organizational framework is in place to link women and communities to the different levels of the health care system. The solution can be found by focusing on the critical missing links in the care chain. Training of midwives and healthcare professionals and providing them with necessary supplies, support and supervision is a good start.

WHO Graph

Global Campaigns to End Fistula:

Fistulae occur in areas where access to care at childbirth is limited, or of poor quality, mainly in sub-Saharan Africa and parts of southern Asia. In the areas where fistulae are most often seen, few hospitals offer the necessary corrective surgery, which is not profitable and for which surgeons and nurses are often poorly trained. Good-quality fist-level and back-up care at childbirth prevents fistula. Once the condition has occurred it is treatable. The plight of women living with fistula is a powerful reminder the pragmatic concerns should go beyond simply preventing maternal deaths. Decision-makers and professionals should be aware that the problem is not infrequent, that the girls and women who suffer from it need support to get access to treatment, that enough trained doctors and nurses need to be available to provide surgical repair, and that further support is necessary for women who return home after treatment. Collective action can eliminate fistula and ensure that girls and women who suffer this devastating condition are treated so that they can live in dignity. In 2003, the United Nations Population Fund (UNFPA) along with WHO and other partners launched a Global Campaign for the Elimination of Fistula. Many institutions and organizations have joined forces to address the problem of obstetric fistula. Key partners in the Campaign include: Addis Ababa Fistula Hospital; United Nations Foundation and Worldwide Fistula Fund are leading the mission. Without surgical repair, the physical consequences of fistula are severe, and include vaginal incontinence, a fetid odor, frequent pelvic and/or urinary tract infections, pain, infertility and often early mortality. The social consequences of fistula are immense: women with fistula are ostracized and frequently abandoned by their husbands, families and communities; they often become destitute and must struggle to survive. To make matters worse, many women are so embarrassed by this condition that they suffer in silence, rather than seek medical help, even if such help were available.

In just three years, the Campaign has brought fistula to the attention of a wide audience, including the general public, policymakers, health officials and affected communities. More than US $25 million has been mobilized from a variety of donors. The Campaign has made remarkable progress with relatively modest funding. But the needs are great. Ending fistula worldwide will demand political will, additional resources, and strengthened collaboration between governments, community groups, NGOs and health professionals. Fistula treatment goes far beyond repairing the hole in a woman's tissue. Many patients -- especially those who have lived with the condition for years -- will need emotional, economic and social support to fully recover from their ordeal. Through the Campaign, women receive counseling and skills training to help them get back on their feet after surgery. Working with communities is also key to help reduce stigma surrounding the condition and ensure women are welcomed back into society. Women's Health and Education Center (WHEC) is involved in number of activities at international, national and local communities. We welcome the thoughts and suggestions on the eradication of obstetrical fistulae. We hope our forums are helpful in suggesting solution to this devastation situation. Join us to make world without obstetrical fistula.

Editor's Note

The right to health is a fundamental human right. Achieving these goals is not a task for governments alone. It requires everyone to join forces. Finding the ways to team up for a world in which all people can achieve their full potential can make a winning team in fight against maternal mortality and morbidity. Providing universal primary education, food and shelter by the target date of 2015 (Millennium Development Goals) represent a set of simple but powerful objectives. Forming a blueprint for building a better world in the twenty-first century can only be achieved by building on people's strengths to create strong civil society and institutions. All levels of field operations and partnerships between the UN System and NGOs in developmental and healthcare missions are the key to success.

Suggested Reading:

  1. U. N. Chronicle
    Obstetric Fistula: Life Shattering But Preventable
    Imagine a world without obstetric fistula.

  2. World Health Organization
    Obstetric Fistula: Guiding principles for clinical management and programme development
    Maternal Mortality in 2005
    Accelerating progress towards the attainment of international reproductive health goals: A framework for implementing the WHO Global Reproductive Health Strategy

  3. The World Bank
    Poverty Reduction: Does Reproductive Health Matter?

Published: 16 January 2013

Women's Health & Education Center
Dedicated to Women's and Children's Well-being and Health Care Worldwide