Expert Opinion: Fistula Care in the Underserved Parts of the World

A Tanzanian Surgeon’s Perspective

As the common type of urogenital fistula, vesicovaginal fistula is mainly caused by obstetric trauma and it is estimated that a million or more women in sub-Saharan Africa currently have an unrepaired fistula, with between 30,000 and 130,000 new cases occurring each year. The current total capacity for fistula repair in sub-Saharan Africa is estimated to be around 10,000 cases per year.

The burden is big for most of the underserved countries and several barriers are identified which include patient barriers and care providers barriers. Most patients who are unable to afford access to good obstetric care as part of fistula prevention will also not be able to access quality fistula repair surgery and hence, we see an increased backlog of unrepaired fistulas. The main patient barrier here is poverty. In some countries, including Tanzania, several donors have tried to overcome this barrier by helping cover transport and surgical costs for fistula patients.

Another identified barrier is on the care provider side: there are very few centers available which provide quality surgeries to fistula patients and most of these centers are in big cities where many patients cannot access the services easily. There is a big need to increase the number of centers in remote areas where care is more easily accessible to reduce the burden. Many of these treatment centers are in need of consumables like sutures, catheters (both urethral and ureteric), surgical sets, good theatre tables and lights. Another barrier is on the number of qualified fistula surgeons who can provide the best surgical care to fistula patients. More training centers are needed to train fistula surgeons.  We largely appreciate the presence of expert fistula surgeons from the developed word, who help a lot in reduction of the patient backlog, but this must go hand in hand with providing adequate skills to local surgeons who will continue treatment and care of these patients.

Holistic care is one of the treatment packages provided in only a few centers. This must be adopted in all centers where fistula treatment is provided. Apart from helping a woman heal psychologically, it also helps in reintegrating these women socially. As we know, most of these women are socially stigmatized in their communities. Social reintegration provides them with handcraft skills, literacy classes, entrepreneurship skills, etc., and helps to increase their confidence to go back to their communities with income generating skills.

Having various international organizations from developed countries collaborating with the government in underserved countries, working on both prevention and care provision has significantly reduced the burden to both the patient and the government itself.

A Volunteer Surgeon’s Perspective on Fistula Care in a Resource-constrained Area

Having worked as a self-funded medical volunteer mainly in the area of pelvic floor fistulas (Goh et al 2020) since 1995, many changes have occurred in the care of women with obstetric fistulas. In 1995, there was little or no interest or funding in fistula management. Yet I was able to spend two 6-month periods in Ethiopia, mainly working with Dr. Catherine Hamlin AC at the Addis Ababa Fistula Hospital. I also worked in rural Ethiopia and managed many women with obstructed labor. A Millennium Development Goal was to improve maternal health, and this highlighted the tragic maternal mortality/morbidity rates experienced by women living in limited resource areas. Obstetric fistula as a public health problem slowly became a topic of discussion and funding then became available.

In recent years, besides focusing on providing appropriate treatment for fistulas, coexisting issues affecting women with fistula have been highlighted including mental health, social isolation, and ongoing pelvic floor dysfunction (Goh et al 2020; Goh et al 2005; Krause et al 2017; Krause et al 2019). A more holistic approach to fistula treatment has now been adopted.

An advantage of having studied urogynecology is a deeper understanding in pelvic floor (dys)function. I recall in the 1990s, for women with post-fistula urinary incontinence, having surgery was the only option (and sadly, this still occurs today). Some of the surgeries that were not useful included ‘urethral lengthening’ – utilizing the labia minora as a tube to extend the ‘external urethral meatus’ to the clitoris; or ‘urethral plication’ for the overactive bladder. Up to 25% complain of urinary incontinence following genito-urinary fistula repair and diagnoses include voiding difficulty, overactive bladder, and stress urinary incontinence (Goh et al 2008; Goh et al 2013; Goh & Krause 2016). Again, a holistic approach is required rather than surgery alone, as surgery may worsen some urinary symptoms.

In the past 5-10 years, there has been an increasing trend of opting for cesarean sections (CS) in women with obstetric fistulas, even for a stillborn baby. In my experience, the increasing cesarean sections are associated with increased number higher fistulas involving the cervix and uterus, often with a tear extending from the anterior cervix to anterior uterus, opening into the bladder. These fistulas (including ureteric fistulas) may be more difficult to repair and also cause an incompetent cervix or risk of uterine rupture with subsequent pregnancies. With an obstructed and prolonged labor, the fetal presenting part is impacted deep in the maternal pelvis and maternal tissues are compromised (pressure necrosis). Even with an obstructed (not prolonged) labor in well-resourced areas, when the fetal presenting part is low in the maternal pelvis (and baby is still alive), there is difficulty in extracting the presenting part from deep in the maternal pelvis and significant tearing and injury can occur to maternal tissues. Hence, in a prolonged obstructed labor, with maternal tissues in a compromised state, there is often more significant maternal injuries. A brief review of my fistula data revealed the following: For my first 100 fistula repairs (1995-1997), the women’s CS rate was 13% with a live born rate of 5%. Review of 100 consecutive fistula repairs in 2015 demonstrated the CS rate had increased over 4-fold to 54% with no significant improvement in live born rate (6%) and in a review of another 100 fistulas in 2019 the CS rate rose again to 75% with no improvement in the liveborn rate. When I ask why there is an increase in caesarean sections, the answer is almost always “we are told not to use forceps to deliver babies as it injures the mother.” The blanket rule of ‘ban the forceps’ in well-resource areas is having a significant detrimental effect on women’s health in many areas around the world. Maternal health continues to be a significant public health issue.

REFERENCES

Goh JTW, Sloane KM, Krause HG, Browning A, Akhter S. Mental health screening in women with genital tract fistulae. BJOG. 2005; 112: 1328-30.

Goh JTW, Browning A, Berhan B, Chang A. Predicting the Risk of Failure of Closure of Obstetric fistula and Residual Urinary Incontinence Using a Classification System. Int Urogynecol J. 2008; 19: 1659-1662.

Goh JT, Krause H, Tesssema AB, Abraha G. Urinary symptoms and urodynamics following obstetric genito-urinary fistula repair. Int Urogynecol J. 2013: 24; 947-951.

Goh JTW, Krause H. Urinary incontinence following obstetric fistula repair. WJOG. 2016; 5(2): 182-186. DOI: 10.5317/ wjog.v5.i2.182.

Goh J, Romanzi L, Elneil S, Haylen B et al. An International Continence Society (ICS) report on the terminology for female pelvic floor fistulas. NAU. 2020; 39: 2040-2071. DOI: 10.1002/nau.24508

Krause HK, Hall BA, Ng SK, Natukunda H, Singasi I, Goh JTW. Mental health screening in women with severe pelvic organ prolapse, chronic 4th degree obstetric tear and genital tract fistula in Western Uganda. Int Urogynecol J. 2017; 28: 893-897. DOI: 10.1007/s00192-016-3177-3.