Fistula: Fixing the fate worse than death

Celine is a 50-year-old mother of six who has been living with fistula, a medical condition that causes incontinence, for a decade. She spends her days alone behind closed doors, ashamed by her condition, abandoned by her husband and shunned by her community.“It’s like a trauma and it’s disturbing to live like this,” Celine said. Incontinence is involuntary urination or defecation. This is a common scenario for millions of women in the developing world suffering from fistula, but recent advances in education and health infrastructure in Rwanda has brought new hope to women afflicted by this condition. Obstetric fistula is a severe medical condition in women when the wall between the bladder and vagina is damaged and a fistula or hole develops. This means the woman constantly leaks urine and sometimes, if the rectal wall is affected, the ability to control faecal excretion is also lost.One of the major causes of Obstetric Fistula is prolonged obstructed labour, meaning if a woman stays in labour pains for longer than 24 hours, then she risks suffering from the dreaded fistula.Celine is hoping to be approved for a fistula repair surgery that could change her life. In most cases, a fistula can be successfully closed by a skilled surgeon, giving the patient a chance to return to a normal life. However, the surgery is not always a cure for the problem of incontinence, but it can be managed through medication after the surgery.The latest on the calendar of health intervention in the fistula dilemma is the International Organisation for Women and Development (IOWD), an American non-profit organisation that partners with Rwanda’s health experts to help deliver quality care within the existing health system in the country. The team jetted into the country, last week, to carryout fistula repairs.IOWD organises for American doctors to travel to Rwanda three times a year, where they perform free fistula repair surgeries at the Kibagabaga Hospital. They also help educate Rwandan doctors, nurses and medical students about the condition. In Rwanda, most women with obstetric fistula generally acquire the condition through a delay in medical assistance during a birth or as a result of injury to the bladder during a caesarean surgery.Celine acquired fistula 10 years ago after giving birth at home. She lives in a rural area and was unable to travel to a health centre. A prolonged, obstructed labour lasting more than 24 hours and a delay in seeking medical attention left her with her terrible burden.Women who experience Obstetric Fistula suffer constant incontinence, shame, social segregation and health problems. It is estimated that more than 2 million young women live with untreated obstetric fistula in Asia and sub-Saharan Africa, according to the World Health Organisation.Prevention overrides treatmentFistula is a preventable condition. It mainly affects women in developing countries, particularly in Africa, where emergency obstetric care is not always available.Preventing fistula is even more important than repairing fistula, and the key is educating women and health professionals as well as improving health infrastructure, said Barbara Margolies, the IOWD director. “We can bring American doctors in to repair the fistula, which is great for the patient, but it’s not good for the country,” she said.IOWD focuses on more than just surgical repairs for fistula patients. They are actively involved in prevention efforts and provide education to Rwandan women on the importance of taking responsibility of their bodies. Margolies said Rwandan women do not have to risk acquiring fistula if they understand the importance of prenatal care, report any abnormalities during a pregnancy and deliver their baby in a health centre or hospital instead of at home. IOWD found 75 per cent of the fistula patients who were consulted at Kibagabaga Hospital acquired their condition following a normal delivery at home without professional medical attention.“It’s not going to happen overnight, but educating people about prenatal care and birthing will cause a significant drop in fistula cases,” Margolies said.Currently, Margolies said, between 40 and 50 per cent of the fistula patients seen at Kibagabaga Hospital had a caesarean delivery at the time their symptoms began, although some are due to a prolonged labor that preceded the caesarean. IOWD is working with Rwandan doctors and medical students to contribute to education efforts on performing a caesarean. During the surgery, the uterus and bladder must be properly separated so there is no risk of the bladder being punctured which could create fistula. “We have continuous training organised by the Ministry of Health for all doctors on how to do a better C-section and we are trying to reduce this problem of fistula,” said Dr Sebatunzi Osee, the director of Kibagabaga Hospital.IOWD works closely with the Ministry of Health in Rwanda and are leading a film project on how to perform a proper caesarean with the machines, tools and instruments available to Rwandan doctors. The film will be distributed by the Ministry of Health to doctors and medical students in the country.Dr Joan Blomquist, a urogynecologist–an obstetrician/gynecologist who specialises in the care of women with pelvic floor dysfunction–from Baltimore who is part of the team of American doctors, said he was impressed by the attitude of the Rwandan medical professionals toward the need to prevent fistula.“One of the things we notice, particularly in Rwanda, is that everyone is so eager to learn so they can do this when we’re not here,” Dr Blomquist said.Health infrastructureMargolies said educating women about the importance of giving birth under the supervision of a health professional would be doable because the Rwandan government has built the necessary health infrastructure to support women.“This issue has received phenomenal support from the Rwandan government,” she said. Much of the health system infrastructure was destroyed after the 1994 Genocide. Since then, government has been working to rebuild and train health workers. There are four national referral hospitals, 39 district hospitals and more than 400 health centres. The health centres provide maternity care for women and have helped improve key health indicators such as maternal and infant mortality. In addition, every village has a community health worker who is equipped with a cell phone. If a woman in a rural village goes into labour or has any complications, the community worker can contact a health centre for response such as transport. “The infrastructure has been set up over the past several years and it just gets better and better every year,” Margolies said.Women in Rwanda can access health insurance financed by the state and individual contributions, which helps cover the costs of prenatal visits and childbirth. In 2010, 91 per cent of the Rwandan population was covered by a community-based health insurance scheme, locally known as Mutuelle de Sante, government says.