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Kagando, Western region
Day after day, young women came to Kagando Mission Hos-pital after the radio announced a free fistula camp. Each woman has a sad story to tell. Lea, a 16-year-old girl tried to deliver her baby at home for days with-out a skilled birth attendant. By the time she reached the hospi-tal, her baby was dead and her vaginal wall showed a euro-sized hole towards the bladder. She could not afford an operation and left the hospital leaking. Christina, 27 years old, had two caesarean sections. Both children did not survive. Due to complica-tions during her second caesare-an, her uterus was removed. Not much later, she developed a hole between her bladder and vagina. 13-Year-old Stella walked for days to reach the hospital, her dress full of foul smelling yel-low stains. Her mother died, and her father looked for a job in the city leaving his daughter with ‘the workers at home’. She was sexually abused till her urine loss made her unattractive.

Introduction

It is called “a social injustice”, the “result of the egregious failure of health sys-tems” and even a “human rights trage-dy”. In describing the burden of (obstet-ric) fistulas, the use of superlatives is not feared. As a complication of obstructed labour, rape, or other trauma, fistulas are an abnormal connection between the vagina and rectum or bladder and leave a woman incontinent for faeces, urine or even both. Besides the physical consequences of the constant leakage of bodily fluids, the associated foul smell and stigmatization has enormous social and economic, not to mention emo-tional and psychological consequences.

The WHO estimates that worldwide between 50,000 and 100000 women develop obstetric fistu-las (OF) each year and 2 million women live with untreated fistula in Asia and sub-Sahara Africa (SSA). However the exact number remains difficult to measure. [1,2] Within SSA, Uganda has the highest preva-lence of OF with an estimated lifetime prevalence of 19.2 per 1000 women of reproductive age. [3] Only 62 percent of these women have sought treatment; others were too embarrassed, or among other reasons, did not know where to find treat-ment. [4] Even if all would seek treatment, at the current rate that fistulas are surgically managed, it would take at least 55 years to treat all existing patients, let alone to treat the new cases that develop every year. [5]

Figure 1. A few days after surgery. Women carry their indwelling catheter in a little bucket.
JANSZEN, KAGANDO, 2016

According to the WHO, most cases can be prevented, firstly by delaying the age of first pregnancy and secondly by improving access to obstetric care. Obstetric fistulas have been practically eliminated in many countries, yet in low- and middle-income countries “the most dispossessed, out-cast, powerless group of women in the world” [6] are still at risk of this condition. [7] The uneven global and national distri-bution of OF suggests a complex picture of determinants contributing to fistula development. Because Uganda has the highest prevalence of OF in all countries in Sub Sahara Africa and because of the author’s personal interest and experi-ence in fistula camps in Uganda, this study aims to create understanding of the determinants of OF in Uganda to provide a framework for improve-ment of health policy.

Methods

To understand the deter-minants that contribute to the development of OF, a review of litera-ture was done using the PubMed/MEDLINE database as well as data from Ugandan DHS and the Ministry of Health*.

The results were analysed using the model for the main determinants of health by Dahlgren and Whitehead.[8] This model unfolds the range of factors that threaten, promote or protect health. It depicts four levels for policy inter-vention, and one level that is ‘fixed’ or uncontrollable, namely age, sex and genetics (see Figure 2). The epidemiological pattern of OF suggests considerable inequity in the distribution of determinants of health, thus making this model highly rel-evant to approach the problem. For the purpose of this journal, only the most relevant results and references are cited.

Figure 2. Model for the main determinants of health according to Dahlgren and Whitehead.[8]

  • The key words for the PubMed search were synonyms for obstetric fistula in combination with Uganda. Using the snowballing technique (within Pubmed and Google Scholar) several papers and review articles were found. Search terms (Title / Abstract): vaginal fistula / genital (tract) fistula / vesicovaginal fistula / rectovaginal fistula / obstructed labour /prolonged labour; MeSH terms: vaginal fistula /vesicovaginal fistula / rectovaginal fistula.

Results

Constitutional and individual lifestyle factors

During obstructed labour the foetal head cannot pass the pelvis of the mother during the last stage of labour. Immaturity of the pelvis increases the likelihood of cephalopelvic dispropor-tion (CPD) which may result in OF. [9] Because the female pelvis continues to grow until late adolescence, an age below 18 years is associated with OF. [9,10] Constitutional factors like race and height (<150 cm) seem to be related to OF; African women are believed to have a narrower pelvis than Europe-ans which predisposes them to CPD. [10-13] Malnourished women are more susceptible to OF due to reduced height and poorer healing after (birth) trauma. [6,12] Yet malnourished women also give birth to smaller children (< 3500 grams), which is a protec-tive factor for developing OF. [11,12,14]

Social & community networks

Cultural norms and beliefs play an important role when it comes to the position of women and the choices they are able to make. The high unmet need for family planning, limited participation in decision-making, and acceptance of wife-beating are just a few indicators that female empower-ment in Uganda is limited. [4, 15) Although knowledge of family planning methods seems to be widespread in Uganda, limited empowerment is associated with limited use of these methods. [4,13], Furthermore, sexual violence by the intimate partner is common in Uganda and has been associated with OF. [4,10]

Living and working conditions

Although education is free in Uganda, 1 in 5 women have never had any form of education in Uganda and are con-sidered illiterate. [4] Being able to read is protective with regard to developing OF in SSA. Also, a woman who is the income-earner is less likely to be associ-ated with OF compared to a housewife. [11] The distance to a health-care unit is relevant; the mean distance to the nearest emergency obstetric care unit is sig-nificant higher among women with OF. [II] Birth by Caesarean is strongly associated with OF, which is most likely a reflection of the presence of obstructed labour. [1] Additionally, even though the sig-nificant delay in seeking care suggests damage might already be done before hospital arrival, a substantial part of the observed fistula is due to injuries created by the surgeon.[11]

General socioeconomic, cultural and environmental conditions

In certain regions of Uganda the risk of developing OF is significantly higher compared to other regions. [9,16] The explanation might be found in the accumulation of determinants: women living in remote rural areas are generally younger at marriage and first intercourse, have lower educa-tion, less wealth, are less empowered and live far from a healthcare unit with obstetric care facilities. [4,16]

Conclusion and recommendations

Early childbearing, malnutrition, low socio-economic status and low em-powerment of women, low community awareness and overall lack of access to emergency obstetric care paint the picture of OF. Poverty and low education link these determinants, creating a web that is dispropor-tionately hard to escape from for the poorest women. Consequently, aiming to improve the socioeconomic status or education of women in remote areas will theoretically influence both the prevention of obstructed labour as well as the access to care in case of obstructed labour, even without improv-ing health care services. The inequity that lies at the base of OF means that the Ministry of Health needs to improve healthcare services of family planning, emergency obstet-ric care and skilled birth attendance, as well as co-operation with other ministries to tackle the determinants that shape the environment for OF.
THIS PAPER IS A SHORT VERSION OF A REVIEW THAT IS UNDER CONSIDERATION FOR PUBLICATION ELSEWHERE

References

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  3. Maheu-Giroux M, Filippi V, Samadoulougou S, Castro MC, Maulet N, Meda N, et al. Prevalence of symptoms of vaginal fistula in 19 sub-saharan africa countries: A meta-analysis of national household survey data. Lancet Glob Health. 2015;3(5):2271-8.
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