1. Obstetric Fistula An Overview Brad R. MacKinnon University of Vermont

2. 2 Contents  What is obstetric fistula?  Epidemiology  Vesicovaginal Fistula  Why do fistulas occur in young girls?  The obstructed labor injury complex  The obstetric fistula pathway  Treatment  Surgical management of urinary incontinence after obstetric fistula repair  Campaign to end fistula  References

3. 3 “ My name is Telanish Shabera. I am 14 years old. I was promised in marriage when I was 3, betrothed at 10, and pregnant at 12. After 3 days of labor, I was carried on a stretcher to a hospital, where my baby died 2 hours later. The obstructed labor left me incontinent. I smell, and I feel so ashamed.” Source: McKenna N. Fistula pilgrims. Federation International Gynecologists Obstetricians

4. Source: G. Lewis, WHO Press.4 “ Every minute, a woman dies in pregnancy or childbirth, and for every woman who dies, 20- 30 others will survive but with morbidity, one of which is obstetric fistula” 13

5. Source: Campaign to End Fistula Printed Materials5 What is obstetric fistula?  Injury of childbearing from prolonged obstructed labor w/o timely medical intervention – typically a caesarean section to relieve the pressure.  The baby usually dies.  The women is left with chronic incontinence.  Women often abandoned by husband and family, and ostracized by her community.  Prospects for work and family life greatly diminished.

6. Source: The Lancet 2006; 368: 1201-12096 Epidemeology 1  18 th Century obstetrical drawing of obstructed labor from absolute cephalopelvic disproportion.  From William Smellie’s Sett of Anatomical Tables, 1752.

7. Source: Aust N Z J Surg 2000; 70: 851–8547 How big a problem is this?  Estimates of 2-7 million women affected.  Estimates of >75,000 new cases each year.  Estimates of 3-5 cases per 1000 pregnancies.  Limited indigenous surgical repair capability.  Cultural and religious worldviews serve to perpetuate the status quo: “whatever will be, will be” “whatever will be, will be” “the will of God (Allah)” “the will of God (Allah)”  Women currently have neither the education, resources, nor rights to change the underlying causes of fistula.  Note: the occurrence in the western world approaches 0.

8. Source: Lancet 2006; 368: 1201- 1209.8 Socioeconomic factors in obstetric fistula formation.  African women predisposed to dystocia due to narrow pelvic architecture.  Marriage at early age, before pelvis growth is complete.  Malnourishment retards maturation.  Lack of access to emergency obstetric services.  Poverty, illiteracy and limited educational opportunities.  Note: Maternal mortality rates in Western Europe and the USA at the beginning of the 20 th century were similar to those in the developing world today…dramatically reduced between 1935 and 1950 due to access to emergency obstetric services.

9. Source: Source: The Lancet 2006; 368: 1201-12099 Vesicovaginal Fistula 1  Moderate-sized vesicovaginal fistula from obstructed labor.  Metal catheter passed through the urethra is clearly visible through the bladder base, which is missing.

10. 10 Why do fistulas occur in young girls?  Increased incidence of cephalopelvic disproportion.  Pelvic bone immaturity. Reduced birth canal size before age 18. Reduced birth canal size before age 18. Reduced inlet, midplane, outlet dimensions. Reduced inlet, midplane, outlet dimensions. Late onset of puberty. Late onset of puberty. Malnutrition. Malnutrition.  Net = “Low” gynecological age. Chronological age – age at menarche. Chronological age – age at menarche.  Younger age at marriage.

11. Source: Am J Obstet Gynecol 2004; 190: 1011-101911 The Typical Patient 14  Small (44Kg)  Short (<150 cm)  Married Early (mean age = 15.5 years)  Now Divorced 49%  Separated 22%  Uneducated 78%  Poor/Rural (>95%)  Developed fistula as primagavida 46%  824/899 fetal deaths  75/899 live births 14 died in first month  >50% of these women endured fistula for 1-9 years before seeking treatment.  Avg. fistula 3.5 cm  92% repair success  71% fetuses were ♂

12. Source: J Midwife Womans Health 2005; 50: 286-294.12 Articles on Association of Age, Gynecologic Age, Cephalopelvic Disproportion, and Obstructed Labor 15 AuthorsDescription Key Findings Chumlea et al., 2003 USA: Cross-sectional study of 2510 females age 8–20 Median age at menarche: 12.43 Moerman, 1982 USA: Longitudinal study of clinical, laboratory, and x-rays of 90 adolescent girls Pelvic inlet, midplane, and outlet clinically contracted during early adolescence (<17); growth of pelvis continues for 3 y after menarche Treffers, 2002 Global: Literature review Obstructed labor a major health problem for young adolescent girls, particularly in specific geographic regions Zlatnik and Burmeister, 1977 USA: Records review of 1005 girls <17 Gynecologic age is the chronologic age minus age at menarche; Patients with low gynecologic age ( 2 y; independent of chronologic age

13. Source: The Lancet 2006; 368: 1201-120913 The obstructed labor injury complex 10  Urological injury Vesicovaginal fistula Vesicovaginal fistula Urethrovaginal fistula Urethrovaginal fistula Ureterovaginal fistula Ureterovaginal fistula Uterovaginal fistula Uterovaginal fistula Complex combined fistulas Complex combined fistulas Urethral damage, including complete urethral destruction Urethral damage, including complete urethral destruction Bladder stones Bladder stones Stress incontinence Stress incontinence Marked loss of bladder tissue from extensive pressure necrosis Marked loss of bladder tissue from extensive pressure necrosis Secondary hydroureteronephrosis Secondary hydroureteronephrosis Chronic pyelonephritis Chronic pyelonephritis Renal failure Renal failure  Gynecological injury Amenorrhoea Amenorrhoea Vaginal stenosis Vaginal stenosis Cervical injury, including complete cervical destruction Cervical injury, including complete cervical destruction Secondary pelvic inflammatory disease Secondary pelvic inflammatory disease Secondary infertility Secondary infertility  Gastrointestinal injury Rectovaginal fistula formation Rectal stenosis or complete rectal atresia Anal sphincter incompetence  Musculoskeletal injury Osteitis pubis  Neurological injury Foot-drop from lumbosacral or common peroneal nerve injury Complex neuropathic bladder dysfunction  Dermatological injury Chronic excoriation of the skin from maceration by urine or faeces  Fetal injury Fetal case-fatality rate of about 95%  Social injury Social isolation Divorce Worsening poverty Malnutrition Depression (sometimes with suicide) Premature death

14. Source: The Lancet 2006;368: 121014 Complications of obstructed labor: pressure necrosis of neonatal scalp 2  >90% of neonates stillborn, another 3% died the first week postpartum.  Cause of death usually asphyxia or septicemia.  After intrauterine fetal death, the head collapses, which facilitates vaginal birth

15. Source: Source: The Lancet 2006; 368: 1201-120915 The obstetric fistula pathway 1  Factors include: Socio-economic Nutrition Education/literacy Early marriage Harmful traditional practices. Psychosocial damage  Result: Suffering,illness, and premature death.

16. Source: Campaign to End Fistula Printed Materials16 Common comorbitities associated with Fistula  Gynecologic Amenorrhea Amenorrhea PID PID  Musculo-Skeletal Lower limb contracture 2 0 to nerve damage. Lower limb contracture 2 0 to nerve damage.  Neurological Foot drop from sacral and perineal nerve compression Foot drop from sacral and perineal nerve compression Neurogenic bladder dysfunction Neurogenic bladder dysfunction  Dermatologic Ammmonical dermatitis Ammmonical dermatitis Vulvar excoriation Vulvar excoriation

17. Source: Lancet 2006; 368: 1201- 1209.17 Psychosocial damage resulting from obstetric with fistula  More devastating than the physical injury.  Divorce and abandonment.  Cast out by their families.  Social Pariahs.  Many treated as having received a punishment from God for sexual misbehavior.  Depression, anxiety and other forms of mental health dysfunction common.

18. 18 Early Detection and Treatment.  Catheterization Viable treatment during first 90 days +/-. Viable treatment during first 90 days +/-. Avoid urine flowing through fistula. Avoid urine flowing through fistula. Promotes spontaneous closure of fistula. Promotes spontaneous closure of fistula. Foley for 6-8 weeks. Foley for 6-8 weeks.  Prevention For women in prolonged labor. For women in prolonged labor. Continuous catheterization. Continuous catheterization. Administration of antibiotics postpartum. Administration of antibiotics postpartum.

19. Reprinted with permission from the WHO (H. Rochat)19 Fistula Examination.

20. Source: Am J Obstet Gynecol 2006; 195: 1748-1752.20 Simple vs. complicated vesicovaginal fistula. 5

21. 21 Treatment  Surgery to repair the fistula. At cost of $250+/- plus transport costs. At cost of $250+/- plus transport costs. Few hospitals with few trained surgeons. Few hospitals with few trained surgeons.  Rehabilitation Stretching and mobilizing limbs. Stretching and mobilizing limbs. Physiotherapy of lower limbs, foot. Physiotherapy of lower limbs, foot. Psychological and emotional counseling. Psychological and emotional counseling. Employment skill building. Employment skill building.  Outreach Crucial to recruiting women for treatment. Crucial to recruiting women for treatment. Locate, educate, and transport. Locate, educate, and transport. Treated women as role models. Treated women as role models.

22. 22 Preoperative Care  Early detection/treatment of fistula is rare. Fistulas in patients exist for months to years. Fistulas in patients exist for months to years.  Malnutrition and Anemia  Physical Therapy Lower limb weakness. Lower limb weakness. Muscular contractures. Muscular contractures.  Complete physical examination Fistula location with Foley and Dye. Fistula location with Foley and Dye. Rectovaginal fistula rule out. Rectovaginal fistula rule out. CBC and STD Labs. CBC and STD Labs.

23. Source: European Urology 2006; 50: 1000-1005.23 Urethrovaginal fistula before (A) and after (B) surgical repair. 4  Surgery performed in the in dorsal lithtomy position.  Careful vaginal examination essential to ensure no other fistulas present.  16-18F Foley placed in bladder.  Success Rate >90% reported in multiple studies.

24. 24 Postoperative Care  Catheters left in place. Urethral 1 week. Urethral 1 week. Urinary 2 weeks. Urinary 2 weeks. Clamped for short periods to accustom the bladder to distention. Clamped for short periods to accustom the bladder to distention.  Confined to bed rest for 2 weeks. Bedsore preventative steps. Bedsore preventative steps.  Abstain from intercourse for >3 month. Family planning education. Family planning education. Advise future deliveries be cesarean. Advise future deliveries be cesarean.

25. Source: BJOG 2006; 113: 475- 47825 Surgical management of urinary incontinence after obstetric fistula repair 12  >25% of women still incontinent after fistula repair.  Most common in women who had a urethral- vaginal fistula.  Second operation can be done to repair using a combination of uretheralisation (urethral lengthening), plus fibromuscular sling of rectus fascia.

26. Reprinted with permission from the WHO. (P. Virot)26 Addis Ababa Fistula Hospital Fistula Ward.

27. Source:Int J Gynecol Obstet 2006; 94: 254-261.27 The forgotten fistula patients.  Helping women to reintegrate into society  Education and training in work skills.  Health education sessions and family counseling services  Raising awareness of obstetric fistula locally and globally.  Gaining agreement and resources for change.

28. Source: The Lancet 2006; 367: 535-53628 Obstetric fistula and stigma 9  Women’s Dignity Project (WDP) work on obstetric fistula in eastern Africa has two main themes: Poverty, which precludes access to care, and Poverty, which precludes access to care, and Power of society to reject, banish and isolate Power of society to reject, banish and isolate  Three types of engagement by WDP: Action-oriented research Action-oriented research Partnerships of people and institutions committed to equitable treatment of women Partnerships of people and institutions committed to equitable treatment of women Challenging underlying policies that create and perpetuate stigmatizing conditions and poverty Challenging underlying policies that create and perpetuate stigmatizing conditions and poverty

29. Source: Campaign to End Fistula Printed Materials29 Campaign to end fistula  A part of the United Nations Population Fund (UNFPA), goals include: Universal access to reproductive health services by 2015 Universal access to reproductive health services by 2015 Universal primary education and closing the gender gap in education by 2015 Universal primary education and closing the gender gap in education by 2015 Reducing maternal mortality by 75 per cent by 2015 Reducing maternal mortality by 75 per cent by 2015 Reducing infant mortality Reducing infant mortality Increasing life expectancy Increasing life expectancy Reducing HIV infection rates Reducing HIV infection rates Universal access to reproductive health services by 2015 Universal access to reproductive health services by 2015 Universal primary education and closing the gender gap in education by 2015 Universal primary education and closing the gender gap in education by 2015 Reducing maternal mortality by 75 per cent by 2015 Reducing maternal mortality by 75 per cent by 2015 Reducing infant mortality Reducing infant mortality Increasing life expectancy Increasing life expectancy Reducing HIV infection rates Reducing HIV infection rates  Campaign launched in 2003, and performing detailed needs assessment.

30. 30 Campaign to end fistula Click on flash player link below or go to web address listed Click on flash player link below or go to web address listed to start video to start video http://www.endfistula.org/movie/wm_english.htm

31. 31 Summary  A very real problem with an annual rate of new cases > indigenous repair capability. The pool of affected women is growing faster then the ability to effect surgical repair, even if it was freely available to all who needed it. The pool of affected women is growing faster then the ability to effect surgical repair, even if it was freely available to all who needed it.  The surgery repair is uncomplicated and inexpensive, but the real need is to avoid the occurrence of obstetric fistula in the first place.  Under WHO leadership, an organized needs assessment and awareness campaign has started…to soon to evaluate results.  Success will require fundamental changes: in the availability of emergency obstetric treatment in the availability of emergency obstetric treatment in tradition and cultural mores regarding early marriage, in tradition and cultural mores regarding early marriage, and an elevation in the respect for the human rights of women in general, and young girls in particular, in the developing world. and an elevation in the respect for the human rights of women in general, and young girls in particular, in the developing world.  My take is that this is a monumental effort, and will only occur if piggybacked with other, broader programs related to human reproductive rights.

32. 32 References 1. Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 2006; 368: 1201-1209. 2. Van Beekhuizen HJ, Unkels R, Mmuni NS, Kaiser M. Complications of obstructed labour: pressure necrosis on neonatal scalp and vesicovaginal fistula. Lancet 2006; 368: 1210. 3. Norman AM, Breen M, Richter HE. Prevention of obstetric urogenital fistulae: some thoughts on a daunting task. Int Urogynecol J 2006; (Epub ahead of print). 4. Pushkar DY, Dyakov VV, Kosko JW, Kasyan GR. Management of urethrovaginal fisyulas. European Urology 2006; 50: 1000-1005. 5. Roenneburg ML, Genadry R, Wheeless CR. Repair of obstetric vesicovaginal fistulas in Africa. Am J Obstet Gynecol 2006; 195: 1748-1752. 6. Mishra SK, Morris N, Uprety DK. Uterine rupture: preventable obstetric tragedies? Aus and NZ J of Obstet and Gynecol 2006; 46: 541-545. 7. Jokhio AH, Kelly J. Obstetric fistulas in rural Pakistan. Int J Gynecol Obstet 2006; 95: 288-289. 8. Serour GI, (FIGO Committee Report). Ethical guidelines on obstetric fistula. Int J Gynecol Obstet 2006; 94: 174-175. 9. Bangser M. Obstetric fistula and stigma. Lancet 2006; 367: 535-536. 10. Donnay F, Ramsey K. Eliminating obstetric fistula: Progress in partnerships. Int J Gynecol Obstet 2006; 94: 254-261. 11. Ramphal S, Moodley J. Vesicovaginal fistula: obstetric causes. Curr Opin Obstet Gynecol 2006; 18: 147-151. 12. Browning A. A new technique for the surgical management of urinary incontinence after obstetric fistula repair. BJOG 2006; 113: 475-478 13. WHO. In: Lewis G, de Bernis L, editors. Obstetric fistula: guiding principles for clinical management and program development. Geneva: WHO Press; 2005. 14. Wall LL, Karshima JA, Kirshner C, Arrowsmith SD. The Obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004; 190: 1011-1019. 15. Miller S, Lester F, Webster M, and Cowan B. Obstetric fistula: A preventative tradegy. J Midwife Womans Health 2005; 50: 286-294. 16. R.F. Zacharin, A history of obstetric vesicovaginal fistula, Aust N Z J Surg 2000; 70: 851–854