Surgery: A Cure for Fistula, But Also a Cause

Four maternal health experts come together to examine how fistula, while known to be treatable by surgery, is also caused by unsafe surgical techniques, and what the global health community can do about it.

Written by Sarah Hodin, Kayla McGowan, Mary Nell Wegner, Vandana Tripathi Published on Read time Approx. 4 minutes
Patients wait in a ward prior to undergoing obstetric fistula repair surgery at the Mulago Hospital in Kampala.AFP/Isaac Kasamani via Getty Images

Giving birth in low-resource settings comes with substantial risks to mothers and newborns. Women who experience prolonged or obstructed labor – in which the baby is blocked descending through the birth canal – and do not have access to high quality emergency obstetric and newborn care are at increased risk of developing obstetric fistula.

The condition, an abnormal opening in the upper or lower female genital tract, leads to uncontrollable leakage of urine or feces. Many of these women have also had a stillbirth or developed other complications resulting from obstructed labor. Fortunately, obstetric fistula – a preventable condition that disproportionately affects the world’s poorest womencan be treated with skilled surgical care.

Margaret, a 50-year old mother of one, is among the women who received surgical fistula repair in Nigeria this year at a treatment center supported by the Fistula Care Plus project. In describing how she developed fistula, Margaret told staff, “After the doctor did a cesarean section and brought out my child, a few weeks later I could not control my bowel. I went back to the doctor … but he had no solution to the problem.”

Iatrogenic Fistula: A Quality of Care Issue

While surgery to treat obstetric fistula is often highly successful, surgical error that occurs during other operations – such as cesarean section (c-section), hysterectomy or ruptured uterus repaircan lead to a similar condition: iatrogenic fistula.

While the root causes of obstetric and iatrogenic fistula differ, both represent failures of the health system to provide women with timely, safe and appropriate care, and both have severe consequences.

Women living with fistula experience unpleasant odor and wetness, often accompanied by pain, stigma, lack of autonomy and isolation. Many women with the condition must also grapple with poor mental health, relationship disruptions and economic challenges. Some women have reported pain, weakness and persistent stigma one year after fistula repair surgery.

Fistula in any form has grave consequences for women as well as their children, families and communities. Evidence suggests that a growing number of genital fistula cases in low-income countries are being caused by surgical error, which means that more attention to iatrogenic fistula is urgently needed.

While the exact global burden of iatrogenic fistula is unknown, the number of women with the condition appears to be increasing with the rise of obstetric and gynecological surgery around the world. In a study assessing nearly 6,000 women who underwent fistula repair surgery across 11 countries – from South Sudan to Afghanistan – about 13 percent of injuries were caused by surgical error. Recent reviews of fistula case records from three countries indicated large variations in rates – from 8 percent in the Democratic Republic of the Congo to 27 percent in Bangladesh.

Why Is This Happening?

One of the main factors driving this trend is unsafe surgery. For surgery to be safe, it needs to involve a team of well-trained surgeons and other healthcare providers; a supportive health system; adherence to evidence-based policies and guidelines; access to anesthesia, essential drugs, supplies and equipment; hygienic conditions; electricity and a safe water source.

But many health facilities in low-resource settings do not have some of the most basic resources, such as electricity and safe water. As Lauri Romanzi, project director of Fistula Care Plus, has said, “Nobody can work well, no matter how well-trained they are or personally motivated, when they don’t have an environment that works.”

The Role of Rising Cesarean Section Rates

Another driver of the rising incidence of iatrogenic fistula is likely the growing pandemic of medically unnecessary c-sections.

Researchers have been trying to understand what has been causing cesarean rates to skyrocket in so many countries and why rates between and among nations vary so widely – from less than 2 percent of births to greater than 40 percent. As this trend continues, more clinicians – especially those working in low-resourced facilities – will be confronted with conducting surgery under challenging conditions, possibly increasing the problem of iatrogenic fistula.

Sustainable Solutions

There are three things we can do to reduce rates of iatrogenic fistula.

First, we must improve the quality of surgical care women receive. With the rapid expansion of surgical care in low- and middle-income countries must come improvements in quality. Advancing safe surgical practices for c-sections, hysterectomy and ruptured uterus repair is key to preventing more cases of iatrogenic fistula.

We must improve provider training, establish standardized surgical, anesthesia and obstetric criteria and routinely assess emergency obstetric and newborn care facilities for readiness and quality.

Second, we must reduce unnecessary surgeries – such as c-sections – in the first place. In childbirth, as in other health fields, averting unnecessary medical interventions is crucial. Strengthening the evidence base to support advocacy and empowering women to demand quality obstetric care are critical to prevent over-medicalization and, ultimately, reduce women’s chances of experiencing iatrogenic fistula. Providers themselves also need support, through evidence-based guidelines for labor monitoring and clinical decision-making for delivery methods.

Finally, we must expand access to basic maternal healthcare. All women have the right to family planning to space desired births, and quality midwifery services to reduce unnecessary c-sections and promote optimal birth outcomes.

Fortunately, Margaret accessed treatment and her iatrogenic fistula was repaired, but no woman should endure the pain and suffering of fistula – whether from childbirth or from unsafe clinical care.

Surgeons and maternal health specialists must come together to ensure women’s access to health care that prevents and treats – but never causes – fistula.

The views expressed in this article belong to its authors and do not necessarily reflect the editorial policy of Women & Girls.

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