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30 November, 2020 06:31:50 PM / LAST MODIFIED: 30 November, 2020 06:35:34 PM
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Obstetric fistula: When a normal birth goes wrong

Psychologically, this disease is unbearable. As a result of the smell and the suspicion that she is cursed, she is pushed away by friends, family, and community. She often shies away from social interactions. She is teased, shunned, and humiliated
Dr. Iftikher Mahmood
Obstetric fistula: When a normal birth goes wrong

Childbirth can often be complicated. Sometimes this natural process places the mother at risk of severe injuries and critical medical issues if not attended to properly. Of great concern is the occurrence of obstetric fistula. Obstetric fistula is a hole between the vagina and the bladder and/or the rectum. It is a painful, psychologically torturous, socially ostracizing disability that occurs because of obstructed labor where the mother does not have access to emergency obstetric care. The impact on the mother and child are devastating and unfortunately, often results in death of the baby. 

There are approximately 250 children born every minute throughout the world but not all births go well. Some unfortunate mothers develop fistula. Obstructed labor can happen for an array of reasons, and any lapse in seeking emergency obstetric care leads to prolonged obstructed labor for the mother and increases the chances of complications. Labor pain is responsible for pushing the baby down to the mother's birth canal; however, in some cases, the baby's size is too big, the mother’s birth canal too narrow or the baby is in an abnormal position. In such case, when the baby is pushed downward, the bladder can get trapped between the baby's head and the mother's pubic bone. Only treatment needed at this point is an emergency cesarean section. If such treatment is not available urgently, the prolonged pressure reduces blood flow to the tissues around birth canal, the tissues are injured and damaged, and she develops fistula.

An obstetric fistula happens to the women of poverty. This condition was prevalent in western countries until the 1800s, but it has mostly disappeared since then due to improved obstetric care. Obstetric fistula persists as a significant maternal morbidity in Bangladesh and in many developing countries where maternal health continues to lag. Most women who develop obstetric fistula report having endured labor for three days or more. These women primarily live in rural remote areas where they do not have access to health facilities and qualified medical professional are not available. They also do not have the means to travel to distant health facilities because of financial difficulties, social, cultural, and religious barriers. Frequently, their pregnancies and deliveries are cared for by traditional birth attendants known as ‘Dhai-ma’, or family members. These women do not receive antenatal care, are not aware of their risk from any underlying health conditions or size and position of the babies which might necessitate expert care in a facility or emergency cesarean section. As a result, their labor is managed in their homes, they end up having a deceased baby and devastating genital injury like obstetric fistula.

Obstetric fistula results in constant leaking of urine and sometimes feces also. It causes a foul smell. If left untreated, fistula can cause serious chronic medical issues, including ulcerations, kidney disease and nerve damage to the legs. She often experiences infection due to urine or feces and may even find it difficult to walk. Amongst villages where access to health knowledge is limited, they unfortunately do not understand the cause of obstetric fistula. Instead, they often believe in superstition or unproven ideologies, that the woman has been cursed, therefore she unfairly bears the blame for this horrific condition. 

Psychologically, this disease is unbearable. As a result of the smell and the suspicion that she is cursed, she is pushed away by friends, family, and community. She often shies away from social interactions. She is teased, shunned, and humiliated. She is unable to work due to the physical disability and further would find it difficult to find anyone that will hire her. The constant trickling of urine makes it hard to carry out normal household tasks. She is perceived as a financial burden on the family. She is most often incapable of having sexual relations, as a result her husband often leaves her and sends her back to her parental home. The depression, anxiety, and mental turmoil she experiences is horrific. In Bangladesh the exact number of women with fistulas is not known, but it is estimated that about 20,000 women are suffering from fistula, about 1000 added every year. Some of these women have been quietly suffering for decades. Worldwide, about 2 million women are suffering from this condition.

Treatment of obstetric fistula is usually by surgery. However, if care is provided by an experienced physician at the early stage, it can be treated with antibiotics and urethral catheterization for a period of time. Fistula repair is a specialized surgery, the surgeon must need special training with sustainable volume of surgeries regularly to maintain the necessary expert skills. In Bangladesh there are only a handful of surgeons who are expert in this surgery. The most rigorous training that is available is provided through the Federation of International Gynecologists and Obstetricians (FIGO). Only a few surgeons worldwide are FIGO trained, HOPE Hospital in Cox’s Bazar is the home of two such surgeons. HOPE Hospital has a robust fistula repair programme, and both of these surgeons perform an adequate number of surgeries every year to maintain their expertise. Fistula surgeons usually need a set of support staff such as experienced nurses, qualified field staff and a counseling team to provide care before and after surgeries. Rehabilitation is an important part of the care as most women need continued counseling so they eventually can return to their families to live normal lives.

Fistula surgeries are expensive, and patients are too poor to afford the cost, these are done through grant funding or individual contribution. HOPE Foundation is fortunate to have partnership with Fistula Foundation, UNFPA and Global Affairs Canada, to support the work done at HOPE Hospital. Other centres in Bangladesh that carry out these reparative surgeries are: Lamb Hospital, Kumudini Hospital, Ad-din Hospital, BSMMU, Dhaka Medical College Hospital, MAMM’s Institute, and some tertiary medical college hospitals.

Bangladesh government, with technical support from UNFPA, took a major initiative to eradicate fistula from the country by 2030, in line with Sustainable Development Goals. With their support, Hope Foundation began steps to eliminate fistula from Chattogram Division, the program was launched through a meeting in Chattogram on June 25, 2019 where all stakeholders were present  as part of the HOPE Foundation’s fistula elimination program, it is building the first stand-alone fistula repair center in Bangladesh which is slated to open in early 2021. HOPE Foundation is networking with government facilities in districts, upazillas and grassroots level of the Chattogram division for its outreach.

Alongside repair surgery, fistula prevention is very important for the future. It needs universal access to quality maternal care. All mothers, regardless of where they live should have access to a health facility with Skilled Birth Attendant (SBA) where women will receive antenatal care, safe delivery and referral to higher facilities if needed. This target requires a nationwide availability of quality maternal health. Prime Minister Sheikh Hasina, is a staunch supporter of quality maternal health, and has expressed her determination to train adequate number of midwives in Bangladesh and place them in remote areas.

Bangladesh is making impressive strides and gaining international recognition for its achievement in maternal health. With the combined effort from public, private and non-government groups, women will receive services when they are pregnant, and the country will be fistula free before the year 2030.

The writer is the President and Founder of HOPE Foundation for Women and Children of Bangladesh, Cox’s Bazar. He can be reached at [email protected]

 

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Editor : M. Shamsur Rahman

Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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