Usually, we write about reproductive health issues that directly impact the Tarheel community on the Healthy Heels blog. Today, I want to explore a sexual health topic that’s generally not be part of life here, but might be something you address someday, like my friend Kathryn Stein (UNC School of Public Health, HBHE ’14). She’s spending 3 months at the Bwaila Maternity Hospital in Lilongwe, Malawi doing documentary work with women who have obstetric fistulas.
Summer’s here, and so many UNC students are doing inspiring work!
Plus, I figure all you New York Times nerds probably read Nicolas Kristof’s moving Mother’s Day article about the Addis Ababa Fistula Hospital in the capital of Ethiopia. It seemed like the perfect opportunity to talk about the sexual health issues at hand.
An obstetric fistula is a hole in the vaginal wall that often results from obstructed labor. These have been a problem across time and culture; evidence of obstetric fistulas dates back as far as 2050 BC, in a mummified Egyptian noblewoman from the Mentuhotep dynasty! In the 19th century, surgeons explored various strategies for repair; finally in the 1940’s Dr. Latzko developed a resection technique with 95% success rate. Conditions and care improved throughout the 20th century until obstetric fistulas ceased to be part of the typical Western female experience.
What happens when you can’t access that basic $350 surgery. What if you can’t afford it? What if you live too far away from trained providers? Untreated fistulas can lead to ulcerations, kidney disease, nerve damage in the legs, and death. The most common side effect is urinary and fecal incontinence. Some women avoid food and water to avoid leaking, resulting in malnutrition, dehydration, and kidney stones. Although incontinence may not seem that bad, the social and psychological consequences can be profound.
Incontinence can completely change your life. If you leak urine or feces, your husband might leave you and your family might kick you out. Maybe you live on the outskirts of town; maybe you live in a hospital. How do you support yourself? What happens to your children? What happens to your self-esteem, dignity, and hope? Freedom from Fistula Foundation is working to empower and help women, including those at the Bwaila Maternity Hospital, where Kathryn’s doing interviews, taking photos, and teaching media skills give them a voice with which to tell their stories to an international audience.
I’m going to discuss why fistulas happen, and I’ll warn you, this gets graphic and upsetting. Fistulas usually result when women don’t have access to emergency obstetrical care when complications arise in labor. Without medical intervention, obstructed labors can last up to 6-7 days. Obstructed labors are dangerous; UNFPA estimates they cause 8% of maternal deaths internationally. Many women survive them only to endure life-changing consequences. When the baby’s head is pressed against a woman’s pelvic bone, blood flow is constricted and the soft tissue in the pelvic region dies. Holes result between the vagina and the bladder or the rectum. Often the fetus dies in the second or third day of labor. I find it unfathomable to imagine a woman facing the grief over losing a child while enduring extraordinary physical pain and an injury that may completely change her life.
Poverty is a primary risk factor. Poverty is associated with low access to healthcare services, chronic malnutrition that leads to narrow pelvises, early age of marriage and early age of pregnancy. Early marriage and early pregnancy are concerns because young women may have pelvises that are small and still developing; however, age isn’t protective and older women get them too. In areas with low access to healthcare services, women may not be laboring with skilled attendants who can recognize obstruction and once the need for emergency attention is recognized, there aren’t accessible providers and facilities. Those circumstances and those delays all increase the risk of fistula.
In response to the many causes, the UNFPA launched the “Campaign to End Fistula” in 2003. The strategy to reduce the incidence and consequences of fistula is to increase access to prenatal care and emergency OB care; improve nutrition; increase access to education and family planning resources so women can postpone childbearing; and increase access to care for women who do get fistulas. This may not be a visible problem in the United States, but the UNFPA reports that over 2 million women are living with fistulas in sub-Saharan Africa, Asia and the Middle East. Props to everyone responding to this devastating but preventable, treatable condition. Check out the blog for more personal stories & photos from Bwaila Maternity Hospital.