CHAPTER 22 Committee 20 The Obstetric Vesicovaginal Fistula in the Developing World Chairman L. L. WALL (USA) Members S.D. ARROWSMITH (USA), N. D. BRIGGS (NIGERIA), A. BROWNING (ETHIOPIA), A. LASSEY (GHANA) 1403 CONTENTS I. LEVELS OF EVIDENCE V. THE CLASSIFICATION OF CONCERNING OBSTETRIC OBSTETRIC FISTULAS FISTULAS VI. EARLY CARE OF THE FISTULA II. THE RELATIONSHIP OF PATIENT OBSTETRIC FISTULAS TO MATERNAL MORTALITY VII. SURGICAL TECHNIQUE FOR FISTULA CLOSURE III. EPIDEMIOLOGY OF THE OBSTETRIC FISTULA VIII. COMPLICATED CASES AND TECHNICAL SURGICAL IV. THE “OBSTRUCTED QUESTIONS LABOR INJURY COMPLEX” 1. THE FISTULA COMPLICATED BY URETHRAL 1. UROLOGIC INJURY DAMAGE 2. GYNECOLOGIC INJURY 2. URINARY DIVERSION FOR THE IRREPA- RABLE FISTULA 3. THE RECTO-VAGINAL FISTULA IX. PREVENTION OF OBSTETRIC 4. ORTHOPEDIC TRAUMA FISTULAS 5. NEUROLOGIC INJURY 6. DERMATOLOGIC INJURY X. DEALING WITH THE BACKLOG OF SURGICAL CASES 7. SOCIAL CONSEQUENCES OF PROLONGED OBSTRUCTED LABOR XI. CONCLUSIONS AND RECOMMENDATIONS 1404 The Obstetric Vesicovaginal Fistula in the Developing World L. L. WALL, S.D. ARROWSMITH, N. D. BRIGGS, A. BROWNING, ANYETEI LASSEY “In vast areas of the world, in South East Asia, in to and particularly prevalent in developing countries. Burma, in India, in parts of Central America, South Although the obstetric fistula was once common in America and Africa 50 million women will bring Western Europe and the United States, it is virtually forth their children this year in sorrow, as in ancient unknown in these regions today. The prevalence of Biblical times, and exposed to grave dangers. In obstetric fistulas has also fallen precipitously in the consequence, today as ever in the past, uncounted more industrialized nations of Asia and Latin Ameri- hundreds of thousands of young mothers annually ca; but fistulas remain both prevalent and problematic suffer childbirth injuries; injuries which reduce in Africa and in the less developed regions of Asia and them to the ultimate state of human wretchedness. Oceania. This disparity between the rich and poor nations of the world requires special attention, parti- Consider these young women. Belonging generally cularly because obstetric fistulas can be completely to the age group 15-23 years, and thus at the very and reliably prevented by the provision of proper heal- beginning of their reproductive lives, they are more th care. It is this lack of appropriate health care—-spe- to be pitied even than the blind, for the blind can cifically the lack of appropriate health care for pre- sometimes work and marry. Their desolation des- gnant women in impoverished Third World coun- cends below that of the lepers, who though scarred, tries—-that is responsible for the widespread preva- crippled and shunned, may still marry and find use- lence of this devastating cause of incontinence in cer- ful work to do. The blind, the crippled and the lepers, tain areas of the world today. The obstetric fistula has with lesions obvious to the eye and therefore appea- vanished from industrialized nations because those ling to the heart, are all remembered and cared for by countries created efficient and effective systems of great charitable bodies, national and international. maternity care that provide effective access to emergen- Constantly in pain, incontinent of urine or faeces, cy obstetric services for women who develop complica- bearing a heavy burden of sadness in discovering tions during labor. The fistula problem in Third World their child stillborn, ashamed of a rank personal countries will not be solved until those nations also offensiveness, abandoned therefore by their hus- develop effective systems of maternal health care. bands, outcasts of society, unemployable except in Unfortunately, “Safe Motherhood” has largely become the fields, they live, they exist, without friends and an “orphan” initiative (Rosenfield and Maine 1985);(Graham 1998; Weil and Fernandez 1999). In without hope. virtually no other area in which health statistics are Because their injuries are pudendal, affecting those commonly collected is the disparity between the indus- parts of the body which must be hidden from view trialized and the developing worlds as great as in the and which a woman may not in modesty easily speak, area of maternal health (AbouZahr and Royston 1991). they endure their injuries in silent shame. No chari- This remains one of the most glaring, and one of the table organization becomes aware of them. Their most neglected, issues of international social injustice in misery is utter, lonely, and complete.” the world today. It is no surprise that Graham has called this the “scandal of the century” (Graham 1998). —- RHJ Hamlin and E. Catherine Nicholson, (Hamlin and Nicholson 1966) This chapter provides an overview of the pathophysio- logy that leads to obstetric fistula formation and dis- cusses the relationship of obstetric fistulas to the broa- People in the developing and the industrialized worlds der issue of maternal mortality with which it is inex- share a common humanity and with this comes a com- tricably linked. This chapter also summarizes the most mon susceptibility to the pathophysiology that may important current issues in the treatment of obstetric lead to urinary incontinence; however, the obstetric fistulas and suggests directions for much-needed futu- fistula is the one continence issue that is both unique re research in this area. 1405 This report presents a general summary of the cur- I. LEVELS OF EVIDENCE rent state of our knowledge regarding obstetric fistu- CONCERNING OBSTETRIC las in the developing world and the challenges pre- FISTULAS sented by this condition. The committee regards this report as a point of departure for further work—-and Scientific data on the problem of obstetric fistulas, a clarion call for further action on this problem—- their prevalence and the ways in which they should acknowledging that many important issues remain be treated, are limited by unusual historical circum- unclear and urgently require more intensive scienti- stances. Prior to the middle of the 19th Century, an fic study. obstetric vesicovaginal fistula was generally regar- ded as an incurable and hopeless condition. It was only after the work of the American surgeon J. II. THE RELATIONSHIP OF Marion Sims and his colleague and successor Tho- OBSTETRIC FISTULAS TO mas Addis Emmett (Sims 1852);(Emmet 1868); MATERNAL MORTALITY (Harris 1950); (Wall 2002); (Zacharin 1988) that sur- gical cure of this condition could be undertaken with The commonly accepted definition of a maternal reasonable confidence. As obstetrics began to deve- death is “the death of a woman while pregnant or lop into a more scientific medical specialty in the within 42 days of termination of pregnancy, irres- first half of the 20th Century, maternal mortality pective of the duration and the site of the pregnancy, underwent a precipitous decline throughout Europe, from any cause related to or aggravated by the pre- the United States, and other developed nations (Lou- gnancy or its management but not from accidental or don 1992a; Loudon 1992b). This meant that the obs- incidental causes” (AbouZahr and Royston 1991). tetric fistula vanished from the clinical and social The most common measure of maternal mortality experience of the Western world just as Western used for international comparative purposes is the medicine was starting to become more rigorously maternal mortality ratio: the number of maternal scientific. As a result of these historical circum- deaths per 100,000 live births. The available statis- stances, the Western medical literature on obstetric tics show huge discrepancies between the developed fistulas is old and relatively uncritical by current and the developing worlds (WHO, UNICEF et al. scientific criteria. This literature consists mainly of 2000). The overall world maternal mortality ratio is anecdotes, case series (some quite large), and perso- estimated at 400 maternal deaths per 100,000 live nal experiences reported by dedicated surgeons who births. In developed regions of the world the ratio is have labored in remote corners of the world while 20 deaths per 100,000 live births, contrasted with facing enormous clinical challenges with scanty or 440 deaths per 100,000 live births in less developed absent resources at their disposal (Evidence Levels 4 regions. The worst statistics come from sub-Saharan and 5). The committee charged with producing this Africa, where nearly 1% of all pregnant women can report was able to locate only a handful of articles, expect to die in any given pregnancy. There are many all quite recent, that rise to a higher level of eviden- problems associated with the collection of maternal ce. For example, there appears to be only one pros- mortality statistics and the estimation of maternal pective, randomized clinical trial in the current medi- mortality ratios, especially in developing countries, cal literature on vesico-vaginal fistulas in the develo- and these statistics are generally acknowledged to be ping world (Tomlinson and Thornton 1998), and underestimates to some (usually to a substantial) only one comparative study of surgical techniques in degree. the repair of obstetric fistulas (Rangnekar, Imdad et al. 2000). This finding underlines how the problem For an individual woman, the most important statis- of obstetric fistulas in developing countries has been tic is not the maternal mortality ratio, but rather the neglected by the bioscientific medical community of estimation