A Concept Paper on Eliminating Obstetric Fistula

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Obstetric fistula is caused by obstructed or prolonged labor which is when the process does not progress appropriately and the baby is not born in spite of strong uterine contractions lasting 24 hours. Of 135 million who give birth globally each year, it is estimated that 5% or almost 7 million women will experience prolonged or obstructed labor, according to WHO (World Health Organization).

In many countries without ready access to emergency obstetric care, women may labor for days. Under these conditions, as the baby’s skull gets pressed against the mother’s pelvis for long periods, the soft tissues squeezed against the inside of the pelvis get insufficient blood supply and are sloughed off after the birth if the mother survives. A permanent hole, or fistula, is created.

Obstetric fistula can form between either the bladder and the vagina (vesico-vaginal fistula) or the rectum and the vagina (recto-vaginal fistula). The consequences include incontinence of urine, feces, or both, with accompanying odour, bladder infections and much else, with profound effects on the lives of the women who have them. Women with fistula are often ostracized, shunned, abandoned by spouses and other family members, and worse. Constant seepage of urine and/or feces through the vagina is devastating in so many ways!

In addition to younger age and chronic poor nutrition in childhood which reduce the size of the birth canal, other risk factors include lack of skilled attendance at birth and emergency obstetric care (assisted vaginal delivery, symphysiotomi, and Caesarean sections), and in some countries harmful practices.

WHO estimates that of the 7 million women who experience obstructed labor each year, ~50,000 will die (~0.7% case fatality rate) and another 50,000–100,000 women will develop a fistula. Currently, more than 2 million women are thought to be living with obstetric fistula. These rates and percentages are higher in low resource countries where women have little or no access to proper emergency obstetric care.

But obstetric fistula can be prevented by interventions that are manageable even for today’s low resource countries. As Niger and HDI have shown through their community-based approach, interventions that prevent obstetric fistula will of necessity also reduce maternal mortality and the death of babies during birth.

UNFPA (United Nations Population Fund) has been leading an initiative whose goal is to prevent and treat fistula, with a particular emphasis on expanding the totally inadequate access to surgery for women who already have obstetric fistula. Surgical repair, which has an 75–93% success rate, requires a trained surgeon, a competent nursing staff and an anaesthetist and costs approximately US$350 per operation. Full treatment also includes post-operative care and provision of social reintegration services.” Great progress has been made.

HDI’s sharp focus on prevention is proposed as a SUPPLEMENTARY and collaborative method to rapidly reduce the number of women who die giving birth and the number who get an obstetric fistula.

HDI’s approach has been proving its efficacy for a decade as it also reduces poverty, addresses six of the UN’s eight Millennium Development Goals: number 1, 3, 4, 5, 6, and 8, and three of the subsequent Sustainable Development Goals (1-3).

Disease Elimination

Programs to eradicate and eliminate infectious diseases use organizational methods that have been honed by the need to succeed using often very limited resources. HDI’s now-proven community-based approach to save women’s lives and prevent obstetric fistula has been used very successfully in several disease eradication and elimination programs, even in the most challenging settings. In a 1998 conference in Atlanta, GA, participants and experts agreed that several micro-nutrient deficiencies, including folic acid-preventable spina bifida, Vitamin A, iodine and iron deficiencies could be essentially eliminated.

We propose that additional non-infectious conditions can also be brought under control and essentially eliminated, and that obstetric fistula is an appropriate condition to focus on, as is post partum hemorrhage mortality.

Traditional public health policy mandates the need for a multi-sectoral approach to address the many influences on maternal death risk, both within and outside the health system. These include health system financing, socio-cultural context, legislation, government policy, education, development and the economy. Addressing multiple influences on maternal health is inarguably necessary.

Even so, HDI’s founder says:
“There has unfortunately been a marked difference between the more modest success achieved by broader, longer-term “systems-building” approaches compared with disease eradication efforts in developing countries, for more than a century. Disease eradication efforts have been singularly successful in the face of corruption, political chaos even to the point of war, poverty, weak health infrastructures, etc. This is not because unlimited resources have been poured into these efforts!

While successful disease eradication efforts have the advantage of addressing a single infectious disease that is biologically eradicable, it is appropriate to learn from these programs and apply lessons to complex issues such as maternal morbidity and mortality that have multifactorial causes. Independent of the different technology that each uses, disease elimination and eradication efforts succeed because they have been forced to apply a small set of tools that are non-medical, under-recognized, and independent of the disease in question.”

Successful disease eradication efforts

Dracunculiasis (guinea worm) eradication has received less funding since its inception than the polio campaign uses each year. Yet, dracunculiasis too has been reduced by more than 99.99%, from an estimated 3.5 million cases in 1989 to 30 in 2017, of which there were 15 each in Chad and Ethiopia.

The Onchocerciasis Control Program (not an eradication program) enjoyed similar success through 28 years (1974-2002). For less than $1 (US) per person protected per year, 25 million hectares of land, abandoned due to river blindness, was reopened and feeds 17 million people. Similarly, efforts to combat lymphatic filiarisis are eliminating that awful disease from whole countries using annual mass administration of donated drugs to interrupt transmission among the billion persons at risk, combined with surgery for men with urogenital manifestations and treatment (mostly self-treatment) of lymphoedema and elephantiasis.

Village volunteers, many of them illiterate, provide monthly reports on guinea worm from even the most remote hamlets in Africa, including both sides of the conflict in South Sudan until the last case was reported in 2016. The intense search for cases will nevertheless continue for an additional three years. Probably no other health care initiative has come close to matching that accomplishment, year after year.

The guinea worm program receives, and uses the reports received monthly, and provides feedback on those same reports every month. Data that is not going to be used is not collected. Even disease eradication experts consider that eradication efforts cannot be applied in isolation from development of the health system. Yet, the focus on a single condition may be more achievable and considered a tool to chip away at the bigger problems that require multi-sectoral approaches. The Catalyst Approach to Public Health used by disease eradication efforts serves as a bridge between vertical and horizontal approaches and can in fact be used to strengthen health systems.

The Catalyst Approach to Public Health

The “Catalyst Approach to Public Health” is a term given to the organizational methods used in disease eradication programs. As endorsed by the 2005 reproductive health policy meeting, the report from which is available in the Resources section of this website, the aim is to apply organizational tools of successful disease eradication programs to carefully selected, important causes of ill health and impaired economic development that are not biologically eradicable. Ten years of implementation in Niger have shown conclusively that obstetric fistula and obstructed labor deaths can be addressed using a similar community-based catalyst approach. Volunteers are locally selected women and men (one of each in each village), who have been followed up monthly and re-trained annually.

The eleven essential tools applied together that successful disease eradication efforts tend to have in common are:

A Catalyst Approach to Public Health

  1. An organization (1-2 people) to handle monthly numbers
  2. A few people who really care (5-10)
  3. A data manager and program manager in each country
  4. Resident technical advisors in each country
  5. International meetings, e.g. 2 /yr (when 2 or more countries)
  6. Annual national program review meetings
  7. Annual training and re-training for village volunteers
  8. Supervisors
  9. Transportation resources
  10. Course correction mechanisms
  11. Mobilize political support (Not in WHO Bulletin article)

For more information about Obstetric Fistula check out Resources.

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