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Sivajohan B. Ending Obstetric Fistulas by 2030: The Role of Global Surgery in Rural Communities. HPHR. 2021;32
DOI:10.54111/0001/FF2
An obstetric fistula is an injury sustained during prolonged, obstructed labour that has devastating consequences on a women’s physical, psychological, and social wellness (Nardos et al., 2020). During protracted, obstructed labour, continuous fetal compression on structures in the birth canal and against the bony pelvis causes tissue ischemia and necrosis (Boene et al., 2020). This results in the formation of a pathological connection between the bladder and genital tract (vesicovaginal fistula) or rectum and genital tract (rectovaginal fistula) which leads to symptoms of urinary or fecal incontinence amongst other complications (Kulkarni et al., 2013). Fistula formation during obstructed labour can be partly prevented through timely access to high-quality, emergency obstetric services (ie. Caesarean sections) and routine maternity care. Despite being declared an international public health problem (Wall, 2006), obstetric fistulas are virtually nonexistent in high-income countries (HICs) but are a prevalent maternal morbidity in low- and middle-income countries (LMICs), especially in rural regions of Sub-Saharan Africa and South Asia (Boene et al., 2020). In 2016, the United Nations declared their commitment to ending obstetric fistulas as an integral part of achieving the Sustainable Development Goals by 2030 and it has been since used as a marker to assess maternal health in many countries (UN, 2016). Many of the underlying sociocultural & systemic factors that contribute to fistulas also contribute to maternal mortality and morbidity (UN, 2016). Despite this call to action, there is a pressing need to enhance global surgical care and strengthen capacity-building systems to prevent and treat the burden of obstetric fistulas.
The prevalence of this problem is difficult to determine and current estimates likely undershoot the true global burden due to the stigmatisation and consequent underreporting of obstetric fistulas in many countries (Nardos et al., 2020). However, it is estimated that approximately 2 to 4 million patients suffer from obstetric fistulas in low- and middle-income countries with an annual incidence between 50 000 to 100 000 new cases (Wall, 2006; Thompson, 2012). A meta-analysis has shown that the prevalence in Sub-Saharan Africa could be as high as 1.57 for every 1000 women (Adler et al., 2013).
Obstetric fistulas overwhelmingly impact young, primiparous women in these countries (Miller et al., 2005). Obstructed labour often occurs in cases of cephalopelvic disproportion and malpresentation and this tends to complicate the pregnancies of women and girls who are of low gynaecologic age with pelvic immaturity (Miller et al., 2005). Approximately 50% of all obstetric fistula cases occur in women and girls aged 10 to 19 and sociocultural influences such as child marriages, early malnutrition, and lack of pelvic maturation can give rise to cephalopelvic disproportion and consequent obstructed labour (Miller et al., 2005). Additionally, research has shown that this problem is endemic to rural and remote communities with low-socioeconomic status and health illiteracy (Degge et al., 2020; El Ayadi et al., 2020), thus disproportionately detrimental to marginalised groups. It should be noted that obstetric fistulas are an entirely preventable public health problem that are reflective of and exacerbated by current healthcare inequities and accessibility barriers. Holistic campaigns to end obstetric fistulas should work with communities and governments to change the narrative for many of these sociocultural contributing factors.
Global surgery presents an opportunity to supplement current gaps for inadequate emergency obstetric services and to assist in capacity-building to strengthen current systems of care for women with obstetric fistulas. Through prevention, treatment, and long-term follow-up the lives of these patients can be significantly improved and community reintegration can be promoted for many women who have been ostracised due to their conditions. Global surgery can be used to meet all three of these needs, in conjunction with targeted advocacy and significant political and community engagement to increase awareness around this maternal morbidity.
Preventing obstetric fistulas from a healthcare access perspective with global surgical efforts requires a thorough understanding of the gaps and delays in care that contribute to fistula formation in rural geographies. There are three major delays identified in the literature that complicate obstructed labour and prevent timely access to safe obstetric care. These include a delay in seeking care, a delay in arriving at a healthcare facility, and a delay in acquiring appropriate interventions (Degge et al., 2020; Wall, 2009). The delay in seeking care can be attributed to many factors (ie. Lack of financial means and autonomy, cultural practices, etc.) but most prominently, a lack of skilled birth attendants and physicians in these communities leads to inadequate early identification of patients at risk for obstructed labour (Miller et al., 2005; Nannyonga et al., 2020).
This delay can be significantly hastened through early detection of high risk obstetrical cases by skilled providers and early referrals to innovative centers and community programs such as Fistula Prevention Centers or maternity waiting homes (Mantey et al., 2020). A qualitative study conducted in Ghana demonstrated that having dedicated fistula centres would better address prevention, surgical repair and social reintegration for patients who were at risk of or experiencing obstetric fistulas (Mantey et al., 2020). Global surgical care programs should establish partnerships with communities where women and girls are at high risk for obstructed labour and create training programs to teach community midwives and other birth attendants how to identify and refer high risk cases to specialised centers. This can include training on detecting cephalopelvic disproportion and malpresentation, red flags that can indicate prolonged, obstructed labour, and early identification of pregnant patients with pelvic immaturity (a proxy for obstructed labour) (Miller et al., 2005; Nannyonga et al., 2020)).
Structural intervention may also be required to reduce the second delay in arriving to the healthcare facility and to ensure rapid accessibility for life-saving interventions. Training of birth attendants and community midwives can include assisting the community with developing a standardized protocol for referral and emergency transport plans for patients in obstructed labour (Miller et al., 2005; Nannyonga et al., 2020). The Government of Uganda has shown prioritisation of maternal health in recent years through their “Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda” action plan. Part of this plan invests significantly in skilled birth attendants that have been shown to play a vital role in the detection and management of obstetric complications as well as supporting delivery, arranging referrals to specialised centers and providing timely postnatal care (Nannyonga et al., 2020). In addition to improving the antenatal screening mentioned above, communication channels between community providers and referral facilities should be strengthened and established to ensure timely referrals are made. Through global surgical efforts and community-led interventions, standardised guidelines for prevention and early detection of obstructed labour can be developed and disseminated to reduce delays in seeking and accessing emergency care. Moreover, capacity building by global surgical teams plays a significant role in this scenario. Partnerships should be facilitated between local health departments and rural communities to support the ongoing community education, improve health literacy surrounding obstetric fistula formation, increase accurate recognition of obstructed labour, and to arrange emergency transport to specialised centers when needed.
Early management and detection of obstetric fistulas is an important step towards surgical repair. Due to low health literacy in these areas, many patients are unaware of their condition or do not realize that it can be surgically repaired (Miller et al., 2005). Despite many advocacy campaigns over the years, the lack of awareness continues to persist. Swain et al. (2020) have shown that only 0.3% of patients in a rural Indian community recognised obstetric fistula as a disease and almost none of the patients (0.1%) realised that this problem could be prevented or surgically repaired free of charge at district hospitals.
Deficient postpartum care in many rural communities complicates the early diagnosis and management of even simple fistulas which can be resolved through catheter insertion (Boene et al., 2020; Bangser et al., 2011). Community midwifery and birth attendant training programs should be complemented with education on postpartum management so that simple fistulas can be managed in the community. Also, referral channels can be established by global surgical teams between specialist centres and local health practitioners to ensure that complex patients can be referred and treated before long-term complications develop. This should be done simultaneously with community education to improve health literacy, reduce stigma and increase patient autonomy in recognising their own symptoms to seek care.
Capacity building in female pelvic medicine and reconstructive surgery requires significant community buy-in, resource allocation and a thorough understanding of the problem’s scope. Many of these patients are treated by general gynaecologists or surgeons who have not been properly trained in specialist skills to provide optimal surgical care and followup for obstetric fistulas (Gjerde et al., 2018). This leaves many women at risk for iatrogenic injuries, further surgical complications or recurrence. Moreover, a lack of available training and inadequate resources to evaluate and surgically repair fistulas makes it harder for this condition to be managed (Kulkarni et al., 2019). Global surgery can make a profound difference here through the provision of trained surgeons, development of training programs, and capacity-building to increase resource allocation for surgical repair. By working alongside local care providers in these communities, global teams can provide training and education for the evaluation and management of fistulas and share best practices while being cognisant of cultural differences.
Increasing training and ensuring standardised surgical repair has been a priority for many global healthcare organisations over the past decade. This is evident through the many initiatives launched to increase training to repair obstetric fistulas. Nardos et al. (2020) reference building a sustainable global partnership to increase the practice of female pelvic medicine and reconstructive surgery through a specialised fellowship in Ethiopia. While this fellowship provides surgical teaching for all pelvic floor disorders, it is an excellent model to expand and help train more surgeons in other countries where access to adequately trained specialists is poor. This program is unique in that it allowed for quality care to be developed in a local, resource-constrained context and the fellows were further supported in training other general obstetrics and gynaecology residents to ensure appropriate diagnosis, management and widespread sharing of best practices for many pelvic floor disorders. This model can be taken one step further to help train and expand the scope of current rural community midwives and physicians to ensure that they can adequately manage and monitor simple fistulas.
With regards to global surgical teams and fistula repair, it’s important to note that global surgery requires in-depth ethical analyses that are contextual in nature. This means ensuring that the visiting team’s intentions do not disrupt the local healthcare goals and objectives but rather operate as a complement. For instance, Rane et al. (2020) mention the location of surgical camps and caution global teams to set-up these temporary camps in facilities that can continue to sustainably provide care past the visitation from the foreign team. When camps are located in communities and facilities that are not able to accommodate this type of care or sustain it, the preoperative, intraoperative and post-operative care is not optimal for the patient (Rane et al., 2020) and may cause more harm than good. Global teams should instead focus on capacity building, establishing lines of communication between community providers and urban specialists, setting up consultation lines, and assisting with standardising care when facilities are not accustomed to sustain and care for fistula patients.
A large gap in global obstetric fistula care is the lack of research around surgical repair procedures and techniques to prevent recurrence and the lack of a standardised classification system to capture the heterogeneity of fistula presentation (Rane et al., 2020). This further compounds the problem of inadequately trained surgeons. A very successful global initiative implemented in the past decade is the FIGO and Partners competency-based training manual, developed to provide standardised training on fistula repair (Elneil, 2015). The creation of this manual along with cumulative global efforts to improve surgical repair of obstetric fistulas has led to increasing numbers of physicians being trained, the development of specialised units and programs, and more awareness around the condition leading to earlier diagnosis and management. Despite this progress, we are still far from reaching the 2030 goal to end obstetric fistulas and need to further support global surgery initiatives in partnership with governments and communities to invest in training, streamlining and standardising medical and surgical management for obstetric fistulas.
The sustainability of global surgery models rely on ensuring adequate post-operative care and long-term followup for these patients. Approximately 19 to 40% of women with obstetric fistulas continue to experience urinary incontinence after fistula closure (Browning, 2006; Kopp et al., 2018; Siddle et al., 2014). Many global surgery missions provide short-term care for patients but are unable to engage in long-term follow-up (Nardos et al., 2020), thus it is important to establish local capacity prior to providing surgical repair to ensure that patients can continue to receive follow-up care. Engaging community providers and training them on adequate post-operative follow-up is one way to monitor complications or recurrence of symptoms. One study has explored reaching patients directly through mobile health innovations for follow-up and shown some success in an initial pilot project (El Ayadi et al., 2020)—a particularly useful way to bypass geographic barriers to continuity of care.
Post-operative patient education that is led by and developed in collaboration with local healthcare providers and surgeons is crucial to ensuring that patients are able to understand how to care for themselves after surgery. Kulkarni et al. (2019) outline a global surgical mission in which the surgical team developed a post-operative education curriculum using illustrative visual aids and translated teaching guides (to accommodate low levels of health literacy). This project was done in collaboration with their local colleagues and demonstrates a successful method by which post-operative care was optimised and done so in a manner that allowed for capacity building within the local area.
Global surgical efforts to reduce disease burden are often met with many limitations and systemic challenges and the case of obstetric fistulas is no different. A significant lack of infrastructure, funding, geographic disparities, low health literacy, and skilled surgical centers can often complicate rural health problems especially in the case of emergency obstetrical care, reconstructive pelvic medicine, and post-operative follow-ups. Inadequate prenatal care, difficulty accessing emergency obstetric care, and the low socioeconomic status of many of these patients are significant barriers in universally reducing the burden of obstetric fistulas but through capacity-building efforts by global surgical teams and sustainable partnerships with health departments it is possible to garner some administrative and political will to reduce these healthcare inequities. Only through concerted national efforts and international partnerships can we establish sustainable global surgery initiatives to reduce the public health burden of obstetric fistulas.
In addition to these challenges, one must understand that obstetric fistulas are not only a pathological condition but reflective of a societal problem caused by economic, systemic, structural, social and gender inequities. To tackle this problem as a whole, it requires a multidisciplinary and multifaceted approach. Global surgical efforts that are rooted in capacity-building can help with streamlining care and moving countries closer to the goal of ending obstetric fistulas by 2030.
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Brintha Sivajohan is an MD Candidate at Western University. Previously, she graduated from Western University with a Bachelor of Science in Medical Sciences & Psychology. She is interested in the intersections between maternal health and global surgery.
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