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Obstetric Vesicovaginal Fistula – The World’s Neglected Continence Problem
implementing an effective programme of this kind requires the political emergency obstetric services, lack of access to skilled fistula repair
will to make obstetric care a pressing national health priority.
21
This, in remains a major problem in developing nations. If, as has been
turn, requires relentless advocacy and the shameless exploitation of suggested, there are as many as 130,000 new fistula cases each year,
13
‘focusing events’ to drive changes in policy.
22
this represents a huge burden of unmet surgical need.
Just because a medical infrastructure exists, however, does not mean that Surgical Prevention and Treatment
it will be utilised effectively. Fistulas develop when prompt intervention Among major public health problems, the obstetric fistula is unique in
does not occur in cases of obstructed labour, but labour is more likely to that both its prevention and its treatment are surgical: Caesarean delivery
become obstructed in parts of the world where girls receive inadequate on the one hand, fistula repair on the other. This unique characteristic
nutrition during childhood and enter their reproductive years anaemic
and malnourished,
23
where they are married as adolescents and become
pregnant before they have achieved their full pelvic growth
24
and where
Among major public health problems,
lack of education hinders their ability to make good medical choices.
25
The decision to seek care when labour becomes obstructed is often
the obstetric fistula is unique in that
hampered by a poor understanding of the nature of the problem, lack of
both its prevention and its treatment
transport and inadequate or incompetent care once the labouring
woman has finally reached a healthcare facility.
26,27
Preventing obstetric
are surgical: Caesarean delivery on the
fistulas requires changes both in the world economy and the world’s
one hand, fistula repair on the other.
valuation of women’s lives. Such changes are likely to be a long time in
coming, but the fact that the obstetric fistula has vanished from the
industrialised world proves that such changes are indeed possible. suggests that one way to tackle both aspects of the problem might be by
developing specialised maternal health units in tandem with fistula
What, then, is to become of the millions of women in impoverished centres dedicated exclusively to the repair of these devastating childbirth
countries who currently live with the abject misery of an obstetric injuries in parts of the world where obstructed labour is a common
vesicovaginal fistula? There is an urgent need to provide care for these problem. The failure of the safe motherhood movement to make much
women now, even as efforts are increased to prevent the occurrence of of an impact on the persistently high rates of maternal death and
future fistulas. The surgical repair of obstetric vesicovaginal fistulas disability in impoverished countries suggests that new thinking and new
usually does not require advanced technology; rather, it can almost approaches to both problems are required.
30,31
The medical community in
always be performed utilising a transvaginal approach under spinal the industrialised world should be squarely behind such efforts.
anaesthesia with rudimentary surgical equipment and supplies.
28
In skilled
hands, up to 95% of fistulas can be closed successfully, although That this entirely preventable scourge of womankind continues to exist
continence rates lag behind this high level of success due to urethral in the 21st century should be an embarrassment to medical
damage, fibrosis and reduced bladder capacities after repair.
29
As with practitioners everywhere.
32
■
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EUROPEAN GENITO-URINARY DISEASE 2007 87
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