Obstetric Fistula: Living With Incontinence and Shame

Over 2 million women worldwide have an obstetric fistula, with the majority of cases occurring in resource-poor countries. Afflicted women tend to be young, primiparous, impoverished, and have little or no access to medical care. Incontinent of urine and/or stool, these women become ostracized and shunned by their community. Most obstetric fistulas are surgically correctible, although surgical outcomes have been poorly studied. Programs that improve nutrition, delay the age of marriage, improve family planning, and increase access to maternal and obstetric care are necessary to prevent obstetric fistula.Key words: Obstetric fistula, Obstructed labor, Vesicovaginal fistulaObstetric fistula (OF) has virtually been eliminated in industrialized nations, yet continues to plague women in resource-poor countries. The condition is entirely preventable; prolonged obstructed labor is estimated to account for 76% to 97% of OF (and is also a major cause of maternal mortality). The condition results when the descending fetus is unable to pass through the mother’s pelvis. The fetal head enters the vagina, but the shoulders cannot pass through the bony pelvis (Figure 1). Without access to medical care to relieve the obstruction, the woman may remain in labor for days. The fetal head compresses the vaginal tissue and widespread ischemic damage of the soft tissue occurs. Once fetal death from asphyxiation occurs, the dead fetus is expelled. The necrotic tissue sloughs off, leaving a hole between the vagina and bladder (vesicovaginal) or vagina and rectum (rectovaginal) (Figure 2). The woman develops incontinence of urine and/or stool, and is affected by multiple devastating medical and psychosocial sequalae.Open in a separate windowFigure 1Obstructed labor. Illustration from A Sett of Anatomical Tables, With Explanations, and An Abridgment, of the Practice of Midwifery, by William Smellie, printed in 1754.Open in a separate windowFigure 2Simple vesicovaginal fistula. A metal catheter through urethra is visible through destructed bladder. Copyright? Worldwide Fistula Fund, used by permission.