Putting Fistula on the Health Agenda – Guest Post by Leigh Bernstein Reardon

By Leigh Bernstein Reardon

Last month, I wrote about the importance of midwives in reducing the incidence of maternal mortality in sub-Saharan Africa. This month, I’ll discuss one of the specific conditions that midwives can be particularly vital in addressing.

Obstetric fistula very rarely occurs in the developed world, and might be one of the most devastating conditions you’ve never heard of. Caused by prolonged obstructed labor, often due to lack of access to Caesarian section, 50,000 -100,000 women are newly afflicted with fistula each year and more than 2 million women suffer from the ongoing chronic health conditions created by it. An obstetric fistula is a hole between the vagina and rectum or bladder. It typically results in incontinence, and sometimes death. Tragically, fistula almost always results in the death of the baby. In addition to the grueling physical conditions it creates, the leaking of urine and feces caused by the fistula often leads women to be rejected by their families and ostracized from their communities. In many sub-Saharan African cultures a woman’s self-worth and value to her family is often closely tied to her ability to have children, exacerbating the already compromised social standing of facing women with fistula.

UNFPA estimates the average cost of fistula treatment, including surgery, post-operative care and rehabilitation support, to be $300 per patient—an insurmountable sum for most women burdened by fistula. Coupled with limited access to health facilities and no knowledge that treatment exists, women with fistula are often unable to access treatment. Though approximately 90 percent of all obstetric fistula cases can be repaired when treatment is sought, these barriers to care make prevention the best option for eliminating this entirely preventable condition.

However, preventing fistula amongst the most vulnerable women necessitates more than access and funding. As the Guttmacher Institute articulately stated in a 2010 Policy Brief: “Equally important to preventing fistula are interventions to combat the other, often interlocking, social and economic inequities that contribute to this particular maternal morbidity: low status of women, lack of education for girls, early marriage and pregnancy, malnutrition, poverty, inadequate health and transportation infrastructure and harmful traditional practices such as female genital mutilation. Failure to aggressively take on these persistent, root causes of fistula—and indeed of most other poor maternal health outcomes—will only ensure that the problem endures.”

An example of a program that took a multisectoral approach on this issue was Fistula Care. Administered by EngenderHealth and funded by USAID, the program, which ran from 2007-2013, worked on the immediate structural needs of women by training surgical teams and strengthening the capacity of hospitals to provide care, as well as developing, implementing and monitoring standards for care in the context of maternal health programs. Furthermore, the project worked to engage communities to change social norms and enable women to have timely access to maternal health care, improved access to family planning, and encouraged a supportive policy environment for fistula repair services and prevention. The combination of the efforts led to the support of over 23,000 fistula repair surgeries; the training of more than 33,000 people in areas related to fistula prevention, fistula repair and advocacy for fistula care; and the development of numerous advocacy and training tools. Based on the achievements of the Fistula Care project, EngenderHealth and its partners will continue their vital work under the newly awarded Fistula Care Plus project. Building on successes achieved during the Fistula Care project, Fistula Care Plus seeks to “remove the barriers that prevent women from accessing prevention and treatment, including alleviating obstacles to transportation and eliminating financial impediments that block access to care.”

Fistula impacts millions of women and their families worldwide. Increased access to treatment and care, together with desperately needed parallel maternal health services, will help stop this preventable condition and put countries one step closer to meeting Millennium Development Goal 5. Until that time, more women, and their communities, will suffer.