Wall_EU_Genito.qxp 27/7/07 04:14 Page 87
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.
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,
‘focusing events’ to drive changes in policy.
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
where they are married as adolescents and become
pregnant before they have achieved their full pelvic growth
Among major public health problems,
lack of education hinders their ability to make good medical choices.
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.
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.
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.
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.
As with practitioners everywhere.
1. Olsen AL, Smith VJ, Bergstrom JO, et al., Epidemiology of 11. Goh JTW, Sloane KM, Krause HG, et al., Mental health Survival Series steering group, Maternal Survival 2, Strategies
surgically managed pelvic organ prolapse and urinary screening in women with genital tract fistulae, BJOG, for reducing maternal mortality: Getting on with what works,
incontinence, Obstet Gynecol, 1997;89:501–6. 2005;112:1328–30. Lancet, 2006;368:1284–99.
2. Adanu RMK, DeLancey JOL, Miller JM, Asante A, The physical 12. Wall LL, Karshima J, Kirschner C, Arrowsmith SD, The obstetric 22. Schiffman J, Stanton C, Salazar AP, The emergence of political
finding of stress urinary incontinence among African women in vesicovaginal fistula: Characteristics of 899 patients from Jos, priority for safe motherhood in Honduras, Health Policy Plan,
Ghana, Int Urogynecol J, 2006;17:581–5. Nigeria, Am J Obstet Gynecol, 2004;190:1011–19. 2004;19:380–90.
3. Manonai J, Poowapirom A, Kittipiboon S, et al., Female urinary 13. Wall LL, Obstetric vesicovaginal fistula as an international 23. Konje L, Ladipo OA, Nutrition and obstructed labor, Am J Clin
incontinence: a cross-sectional study from a Thai rural area, Int public health problem, Lancet, 2006;368:1201–9. Nutr, 2000;72;291s–27s.
Urogynecol J, 2006;17:321–5. 14. Wall LL, Dead mothers and injured wives: The social context of 24. Moerman ML, Growth of the birth canal in adolescent girls, Am
4. Thorp JM Jr, Norton PA, Wall LL, et al., Urinary Incontinence in maternal morbidity and mortality among the Hausa of northern J Obstet Gynecol, 1982;143:528–32.
pregnancy and the puerperium: a prospective study, Am J Nigeria, Stud Fam Plann, 1998;29(4):341–59. 25. Harrison KA, Rossiter CE, Chong H, et al., Antenatal care,
Obstet Gynecol, 1999;181:1107–14. 15. Cook RJ, Dickins BM, Syed S, Obstetric fistula: The challenge to formal education, and child-bearing, BJOG, 1985;92(Suppl. 5):
5. Thomason AD, Miller JM, DeLancey JOL, Urinary incontinence human rights, Int J Gynecol Obstet, 2004;87:72–7. 14–22.
symptoms during and after pregnancy in continent and 16. Ronsmans C, Graham W, on behalf of The Lancet Maternal 26. The Prevention of Maternal Mortality Network, Barriers to
incontinent primaras, Int Urogynecol J, 2007;18:147–51. Survival Series steering group, Maternal Survival 1, Maternal treatment of obstetric emergencies in rural communities of
6. Altman D, Ekstrom A, Gustafsson C, et al., Risk of urinary mortality: who, when, where, and why, Lancet, 2006;368: West Africa, Stud Fam Plann, 1992;23:279–91.
incontinence after childbirth: A 10-year prospective cohort 1189–1200. 27. Thaddeus S, Maine D, Too far to walk: Maternal mortality in
study, Obstet Gynecol, 2006;108:873–8. 17. Robinson JAJ, Wharrad H, The relationship between attendance context, Soc Sci Med, 1994;38:1091–1100.
7. World Health Organization, Maternal Mortality in 2000: at birth and maternal mortality rates: an exploration of United 28. Wall LL, Arrowsmith SD, Briggs ND, et al., The obstetric
Estimates Developed by WHO, UNICEF and UNFPA, Geneva: Nations’ data sets including the ratios of physicians and nurses vesicovaginal fistula in the developing world, Obstet Gynecol
Department of Reproductive Health and Research, WHO, 2004. to population, GNP per capita and female literacy, J Adv Nurs, Surv, 2005;60(Suppl. 1):S1–S51.
8. Fortney JA, Smith JB, The Base of the Iceberg: Prevalence and 2000;34:445–55. 29. Wall LL, Arrowsmith SD, The “Continence Gap:” A critical
Perceptions of Maternal Morbidity in Four Developing Countries, 18. Loudon I, Death in Childbirth: An International Study of Maternal concept in obstetric fistula repair, Int Urogynecol J, 2007; in
Research Triangle Park, North Carolina, Family Health Care and Maternal Mortality, 1800–1950, New York: Oxford press. Published online: DOI 10.1007/s00192-007-0367-z.
International, 1996. University Press, 1993. 30. Weil O, Fernandez H, Is safe motherhood an orphan initiative?,
9. Arrowsmith SD, Hamlin EC, Wall LL, ‘Obstructed Labor Injury 19. Goodburn E, Campbell O, Reducing maternal mortality in the Lancet, 1999;354:940–43.
Complex:’ Obstetric fistula formation and the multifaceted developing world: sector-wide approaches may be the key, BMJ, 31. Maine D, Rosenfeld A, The safe motherhood initiative: why has
morbidity of maternal birth trauma in the developing world, 2001;322:917–20. it stalled?, Am J Public Health, 1999;480–82.
Obstet Gynecol Surv,1996;51:568–74. 20. Anand S, Barninghausen T, Human resources and health 32. Graham W, The scandal of the century, Br J Obst Gynaecol,
10. Islam AI, Begum A, A psycho-social study on genito-urinary outcomes: cross-country econometric study, Lancet, 2004; 1998;105:375–6.
fistula, Bangladesh Medical Research Council Bulletin, 1992; 364:1603–9.
18(2):82–94. 21. Campbell OMR, Graham WJ, on behalf of The Lancet Maternal
EUROPEAN GENITO-URINARY DISEASE 2007 87
| Page 2
| Page 3
| Page 4
| Page 5
| Page 6
| Page 7
| Page 8
| Page 9
| Page 10
| Page 11
| Page 12
| Page 13
| Page 14
| Page 15
| Page 16
| Page 17
| Page 18
| Page 19
| Page 20
| Page 21
| Page 22
| Page 23
| Page 24
| Page 25
| Page 26
| Page 27
| Page 28
| Page 29
| Page 30
| Page 31
| Page 32
| Page 33
| Page 34
| Page 35
| Page 36
| Page 37
| Page 38
| Page 39
| Page 40
| Page 41
| Page 42
| Page 43
| Page 44
| Page 45
| Page 46
| Page 47
| Page 48
| Page 49
| Page 50
| Page 51
| Page 52
| Page 53
| Page 54
| Page 55
| Page 56
| Page 57
| Page 58
| Page 59
| Page 60
| Page 61
| Page 62
| Page 63
| Page 64
| Page 65
| Page 66
| Page 67
| Page 68
| Page 69
| Page 70
| Page 71
| Page 72
| Page 73
| Page 74
| Page 75
| Page 76
| Page 77
| Page 78
| Page 79
| Page 80
| Page 81
| Page 82
| Page 83
| Page 84
| Page 85
| Page 86
| Page 87
| Page 88
| Page 89
| Page 90
| Page 91
| Page 92
| Page 93
| Page 94
| Page 95
| Page 96
| Page 97
| Page 98
| Page 99
| Page 100