Obstetric Fistula Guiding principles for clinical management and programme development World Health Department of Organization Making Pregnancy Safer ii WHO Library Cataloguing-in-Publication Data Obstetric Fistula: Guiding principles for clinical management and programme development Editors: Gwyneth Lewis and Luc de Bernis (Integrated Management of Pregnancy and Childbirth) 1.Rectovaginal fistula–therapy 2.National health programmes–organization and administration 3.Manuals 4.Practice guidelines I. Lewis, Gwyneth II. De Bernis, Luc ISBN 92 4 159367 9 (NLM classification: WP 180) © World Health Organization 2006 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 3264; fax: +41 22 791 4857; email: [email protected]). 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Printed in Geneva Table of Contents Acknowledgements Preface Section I: Understanding the problem and developing a national approach 1 1 Introduction 3 2 Principles for the development of a national or sub-national strategy for the prevention and treatment of obstetric fistula 11 Section II: Basic principles for caring for women undergoing obstetric fistula repair 31 3 Clinical and surgical principles for the management and repair of obstetric fistula 33 Annex A: The classification of obstetric fistula 44 4 Principles of nursing care 47 Annex B: Patient card (Addis Ababa Fistula Hospital) 55 Annex C: Recipes for tinctures and emulsions 58 5 Principles for pre- and postoperative physiotherapy 59 6 Principles for the social reintegration and rehabilitation of women who have had an obstetric fistula repair 69 Acknowledgements Managing Editors: Gwyneth Lewis and Luc de Bernis The members of the Fistula Manual Steering Committee, established by the International Fistula working group, include: Andre De Clercq, Charlotte Gardiner, Ogbaselassie Gebreamlak, Jonathan Kashima, John Kelly, Ruth Kennedy, Barbara E. Kwast, Peju Olukoya, Doyin Oluwole, Naren Patel, Joseph Ruminjo and Petra ten Hoope-Bender. We would like to express our sincere thanks to the Averting Maternal Death and Disability (AMDD) programme of Columbia University, USA, for their generous financial support to the development of the manual. We are also grateful to the following people for their advice and help with specific chapters of this manual: Chapter 1: Glen Mola and Charles Vangeenderhuysen Chapter 2: Maggie Bangser, Adrian Brown and Yvonne Wettstein Chapter 3: Fistula Surgeons: Ambaye Wolde Michael, Michael Breen, Andrew Browning, Baye Assane Diagne, Lucien Djangnikpo, Ludovic Falandry, Brian Hancock, John Kelly, Kallilou Ouattara, Tom Raassen, Charles-Henry Rochat, Shershah Syed, Ann Ward and Abdulrasheed Yusuf. Chapter 4: Ruth Kennedy Chapter 5: Lesley Cochrane Chapter 6: Maggie Bangser and Yvonne Wettstein Additional thanks are due to: Meena Cherian, France Donnay, Claude Dumurgier, Zafarullah Gill, Rita Kabra, Yahya Kane, Barbara E. Kwast and Kate Ramsey. Edited by Catherine Hamill and Tala Dowlatshahi, and designed by Duke Gyamerah. Preface Despite its devastating impact on the lives of girls and women, obstetric fistula is still largely neglected in the developing world. It has remained a ‘hidden’ condition, because it affects some of the most marginalized members of the population—poor, young, often illiterate girls and women in remote regions of the world. On a global scale, the continued incidence of obstetric fistula in low-resource settings is one of the most visible indicators of the enormous gaps in maternal health care between the developed and developing world. Obstetric fistula still exists because health care systems fail to provide accessible, quality maternal health care, including family planning, skilled birth attendance, basic and emergency obstetric care, and affordable treatment of fistula. In addition, social systems are failing to provide a safety net for girls and women. Thankfully, fistula has recently begun to gain international attention. Efforts to prevent and treat fistula have, until now, been primarily conducted by dedicated individuals who have worked with very limited political, financial or institutional support. Now, however, there is a growing global momentum to reduce drastically the incidence of obstetric fistula. Today, everyone working in reproductive and maternal health has the opportunity to make changes that will turn despair into hope, and restore dignity to the millions of girls and women living in shame and poverty. No woman should have to endure a condition which is both preventable and treatable. Our long-term goal should be to make fistula as rare a problem in the developing world as it is in the developed world. I hope this manual on fistula prevention and management will promote increased coverage of the recommended interventions, and become an integral part of the international Campaign to End Fistula. Joy Phumaphi Assistant Director-General Family and Community Health World Health Organization Section I Understanding the problem and developing a national approach Terefa’s story Terefa is fourteen years old. She lives in a small village in Africa, more than 200 km from the country’s capital. She is the sixth child in a family of eight children and has never been to school. Her father, a farmer, did not have enough money to send all of his children to the village school. The older children—two boys—thus benefited from schooling, while Terefa stayed at home to help her parents to survive. Her chores were to gather firewood, draw water and help work the fields. When she was thirteen, her father married her to one of his friends who was a little better off. Terefa could only accept this marriage and, a few months later, she became pregnant. Throughout her pregnancy she continued working, as if nothing had changed. The closest antenatal clinic was a few dozen kilometres from her house, but she didn’t go to it because she didn’t have money to pay for transport. Also, everyone in the village said that pregnancy was not an illness and that the other women had always given birth without any problems, so why shouldn’t she? Terefa’s husband and mother-in-law let the village traditional birth attendant know when labour started. The contractions became more and more violent, and more and more painful, but the baby did not seem to want to come out. Terefa saw the sun rise and set three times. She was exhausted by the long ordeal. The village birth attendant tried to speed up events, first with herbal potions, then by inserting various substances into the vagina and, finally, by making incisions with a rusty knife in her vagina, but nothing worked. The village elders then met to take a decision: Terefa had to be sent to the health centre. It took several hours to collect the necessary money, transport Terefa in a cart to reach the road and find a driver to take her to the town. Terefa was afraid, for she knew no one there and wondered how she, a simple peasant, would be received. At the health centre she was examined by a midwife. The midwife was not happy that Terefa had come so late and told her that the baby was dead, but that an operation was required. As the doctor who performed caesarean sections was away for several days for a training course, she had to go to another hospital. After the operation, Terefa realized that she couldn’t retain her urine. Back at the village she was ashamed because she had lost her child, was constantly wet and continually gave off the smell of urine. Seeing that the situation did not improve, her husband rejected her and chose another wife and, little by little, the entire village turned its back on her. Since then Terefa and her mother have lived in a tent at the edge of the village. The two women subsist on charity, but Terefa’s health is becoming a little more precarious every day. No one knows how much longer she will survive. 1 Introduction “In an unequal world, these women are the most unequal among unequals.”1 Living in shame Millions of girls and young women in resource-poor countries are living in shame and isolation, often abandoned by their husbands and excluded by their families and communities. They usually live in abject poverty, shunned or blamed by society and, unable to earn money, many fall deeper into poverty and further despair. The reason for this suffering is that these young girls or women are living with an obstetric fistula (OF) due to complications which arose during childbirth.