1. EXPLORING MARRIAGES AND FAMILY, 2 ND EDITION Karen Seccombe © 2015, 2012 by Pearson Education, Inc. All rights reserved. Chapter 8 Thinking about Parenthood Special Topic: Obstetric Fistula

2. Childbirth Most women experience no serious complications in childbirth, and mother and baby are healthy. –However, more than 500,000 women die each year from complications of pregnancy and childbirth, mostly in developing countries. Worldwide, obstructed labor occurs in 5% of births. Help is often unavailable in developing nations. © 2015, 2012 Pearson Education, Inc. All rights reserved.

3. Childbirth Begin with this video: http://www.engenderhealth.org/our- work/maternal/digital-stories-uganda- fistula.php © 2015, 2012 Pearson Education, Inc. All rights reserved.

4. What is a “fistula”? Obstetric fistula is a childbirth injury — a hole — –Usually occurring when a woman is in labor too long or when delivery is obstructed, and she has no access to a Cesarean section. © 2015, 2012 Pearson Education, Inc. All rights reserved.

5. What is a “fistula”? Prolonged labor presses the unborn child so tightly in the vagina that blood flow is cut off to the surrounding tissues… –Which rot away, leaving a hole between the vagina and bladder and/or rectum. © 2015, 2012 Pearson Education, Inc. All rights reserved.

6. What is a “fistula”? The woman endures internal injuries that leave her incontinent, continually leaking urine, and sometimes feces, through her vagina. She may have recurring infections, infertility, and damage to vaginal tissue, making sexual activity painful or impossible. © 2015, 2012 Pearson Education, Inc. All rights reserved.

7. Terefa Terefa is 14, poor, and lives in a small village in Africa. She never went to school and worked at home gathering firewood, drawing water, and working the fields. When she was 13, her father married her to one of his friends, and a few months later she became pregnant. © 2015, 2012 Pearson Education, Inc. All rights reserved.

8. Terefa She continued to work hard, and did not seek prenatal care because of the cost, distance, and lack of transportation. When Terefa went into labor the contractions were violent, painful, and lasted over three days. The village elders agreed that she must see a doctor and collected money for her. © 2015, 2012 Pearson Education, Inc. All rights reserved.

9. Terefa She rode in a cart to reach the road and find a driver to take her to town. At the health center she was examined by a midwife. The baby was dead, but she needed a Cesarean section to remove the dead baby. After the operation, Terefa realized that she couldn’t retain her urine. © 2015, 2012 Pearson Education, Inc. All rights reserved.

10. Terefa Back at the village she was ashamed because she had lost her child, was constantly wet, and continually gave off the smell of urine. Seeing that the situation would not improve, her husband rejected her and chose another wife, and, little by little, the entire village turned its back on Terefa. © 2015, 2012 Pearson Education, Inc. All rights reserved.

11. Terefa Since then, Terefa and her mother have lived in a tent at the edge of the village. The two women subsist on charity, but Terefa’s health becomes more precarious every day. No one knows how much longer she will survive. © 2015, 2012 Pearson Education, Inc. All rights reserved.

12. History Obstetric fistula was once very common around the world, but virtually disappeared in Europe and North America by the early 20th century due to the availability of obstetrical care. –Yet fistula is still very prevalent in the developing world, especially in parts of Africa and much of South Asia (e.g., Ethiopia, Bangladesh, Afghanistan, Pakistan, Nepal). © 2015, 2012 Pearson Education, Inc. All rights reserved.

13. How Common is Fistula? According to the World Health Organization: –About 2 million women have a fistula. –Between 50,000 and 100,000 women develop obstetric fistulas every year. © 2015, 2012 Pearson Education, Inc. All rights reserved.

14. Prognosis If left untreated…. –ulcerations and infections –kidney disease and kidney failure –urinal and fecal leaking –to avoid leaking, women may limit water intake, leading to dehydration –nerve damage to legs © 2015, 2012 Pearson Education, Inc. All rights reserved.

15. Prognosis –depression, feelings of shame, loneliness –abandonment by partners, families, and communities –living in isolation because of odor and stigma –increased poverty, decreased employment opportunities © 2015, 2012 Pearson Education, Inc. All rights reserved.

16. Physical Causes of Fistula Obstructed labor –Unrelenting pressure of the baby’s head against the pelvis reduces the flow of blood to the soft tissues surrounding the bladder, vagina, and rectum. –Labor often ends when the fetus dies and gradually decomposes enough to slide out of the vagina. –The injured pelvic tissue rots away, leaving a hole—a fistula—between adjacent organs. © 2015, 2012 Pearson Education, Inc. All rights reserved.

17. Physical Causes of Fistula Lack of access to maternity care –In the developing world many pregnant women do not receive needed medical care: –delay in deciding to seek care because of community or sociocultural factors –delay in reaching a health care facility because of cost, distance, or lack of transportation –delay in receiving adequate care once at a facility because of cost or lack of resources © 2015, 2012 Pearson Education, Inc. All rights reserved.

18. Underlying Social Causes Poverty –Women who suffer from fistula tend to be impoverished, malnourished (e.g., stunted growth), live in remote and rural areas, and lack basic education. © 2015, 2012 Pearson Education, Inc. All rights reserved.

19. Underlying Social Causes Early marriage and childbirth –The traditional practice of early marriage contributes to fistula because young women’s pelvises are not fully developed for childbearing. –In Ethiopia and Nigeria, for example, over 25% of fistula patients became pregnant before age 15, and 50% became pregnant before age 18. © 2015, 2012 Pearson Education, Inc. All rights reserved.

20. Underlying Social Causes Inadequate family planning –Little awareness of the need to delay the first pregnancy or space subsequent pregnancies apart, and little access to birth control. –It is estimated that 100,000 maternal deaths could be prevented each year if women who do not wish to become pregnant had access to contraception and used it. –The number of fistulas that could be prevented is considerably higher. © 2015, 2012 Pearson Education, Inc. All rights reserved.

21. Underlying Social Causes The low status of women –Young women and girls have few choices beyond marriage, and may have no say in who and when they marry. Women may be denied access to health care or directly harmed because of cultural beliefs. When women “fail” in their perceived duty to bear live children, and develop the stigmatizing condition of a fistula, they are often rejected by their husband and family, and have no means of subsistence. © 2015, 2012 Pearson Education, Inc. All rights reserved.

22. Underlying Social Causes Harmful traditional practices –Harmful practices such as female genital cutting or mutilation may contribute to fistula because large amounts of the vaginal or vulval tissue have been removed, causing thick scar tissue. –It has been suggested that these practices increase the likelihood of fistula by up to 7 times. © 2015, 2012 Pearson Education, Inc. All rights reserved.

23. Treatment Fistula treatment is relatively easy and inexpensive. –Reconstructive surgery has a 90% success rate. –The cost, including surgery and post- operative care, is about $300-$400. –Other options exist for those whose surgery was not successful, e.g., a bag for collecting urine. © 2015, 2012 Pearson Education, Inc. All rights reserved.

24. Treatment Many women can rejoin their families, communities, and societies without shame from their condition because the leaking and smell are gone. The largest challenge that stands between women and fistula treatment is information. –Most have no idea that treatment is available. They feel shame and suffer in silence. © 2015, 2012 Pearson Education, Inc. All rights reserved.

25. References Engender Health. 2011. Fistula. Online: http://www.engenderhealth.org/our- work/maternal/fistula.php http://www.engenderhealth.org/our- work/maternal/fistula.php The Fistula Foundation. 2011. What is Fistula. Online: http://www.fistulafoundation.org/whatisfistu la/faqs.html http://www.fistulafoundation.org/whatisfistu la/faqs.html United Nations Population Fund, Campaign to End Fistula. January 2011. © 2015, 2012 Pearson Education, Inc. All rights reserved.

26. References Frequently Asked Questions. Online: http://www.endfistula.org/q_a.htm http://www.endfistula.org/q_a.htm World Health Organization. 2006. Obstetric Fistula. Geneva, Switzerland. World Health Organization. March 2010. Ten Facts on Obstetric Fistula. Online: http://www.who.int/features/factfiles/obstet ric_fistula/en © 2015, 2012 Pearson Education, Inc. All rights reserved.