A "Mark of Shame"

    What makes the difference is whether a woman received adequate obstetrical care. Because so many in poor countries do not, they suffer completely avoidable injuries that render them physically disabled and socially repulsive. The afflicted victims are the ones who must bear the burden of rejection and disgrace, but, in reality, “this situation is a mark of shame on the world medical community,” according to obstetrician and public health expert L. Lewis Wall of the Medical School of Washington University (St. Louis).¹

    These women have a condition called obstetric fistula. A fistula, the Latin word for “pipe,” is an “abnormal passage” between organs² —in this case, between the vagina and the bladder, the rectum, or both. The hole makes the woman uncontrollably incontinent of urine or feces or both and transforms a healthy person into someone viewed as a leaking, reeking, “moving latrine,” in the words of Veronica Yakobe, a Malawian woman who endured 23 years of indignity before an operation at Nkhoma Hospital in her country’s central region closed the fistula and restored control of her bodily functions.³  Soon after the obstetric disaster that created her fistula, “I was forced to flee my home,” she recalls. “I couldn’t stand the taunting of my own relatives and neighbors.”⁴

Despite the length of her ordeal and the fact that she tried three other hospitals before finding a physician able to perform the needed surgery, Yakobe is more fortunate than the estimated 2 million to 3.5 million women worldwide currently living with obstetric fistula. More than 100,000 more join them each year, the vast majority of whom have little chance of ever obtaining relief because the repair operations accomplished each year number only in the thousands.⁵  Given the condition’s great stigma, and the fact that it generally occurs in remote rural areas, experts believe that available statistics underestimate the true numbers. International assessments have found that the risk of fistula exists in African, Asian and Pacific countries, as well as isolated parts of Latin America.⁶  As many as a million women may live with fistula in northern Nigeria alone and more than 70,000 in Pakistan. About one delivery in every thousand in Kenya results in a fistula, according to reports.⁷   

    But if Yakobe’s outcome is more favorable than most, her years of destitution and social ostracism are distressingly typical. Statistics from Ethiopia, Nigeria, India, Pakistan, and elsewhere show that the majority of fistula sufferers are abandoned by their families, divorced by their husbands, and forced to fend for themselves, often by begging.⁸  Some, like a group of Somali women who leapt from a pier chained to one another, end their lives in despair.⁹  

    In developed countries, fistulas occasionally happen from surgical accidents or radiation therapy and are promptly repaired. Few in those countries have ever heard of the condition. But across much of the less developed world, fistula is an ordinary hazard of childbirth for many women and a permanent blight on countless lives. In those countries, obstetric fistula overwhelming results from obstructed labor, which occurs when the baby cannot pass through the mother’s birth canal because it either does not come head first or is too large for her pelvis. In the developed world, prompt medical intervention, often including Caesarean section, permits a delivery safe for both mother and child. But thousands of times each year in poor countries, birthing women receive no such aid and their labor is a futile agony lasting up to five days, with uterine contractions constantly forcing the baby, usually head first, against unyielding pelvic bone. 

    Long before the mother’s torment ends, however, the unremitting pressure kills the child.  It also cuts off the blood supply to the soft tissues of her vagina and other organs trapped between the baby’s skull and her pelvis. Eventually these tissues also die, forming one or more fistulas, and the baby’s head softens sufficiently for the stillborn child to pass from her body. Should she survive, the mother soon finds urine, feces or both leaking unstoppably from her vagina. In about a fifth of cases, the woman also suffers nerve injury that can cause a condition called footdrop, which prevents normal walking. Constant contact with urine or feces irritates and infects her skin and other tissues. Her kidneys, bladder, or other nearby organs may also be damaged.  Her menstrual periods may stop, rendering her infertile.

    The same shortages that Kabir and colleagues cite also underlie high maternal death ratios in much of the developing world, where “the problem of obstetric fistula is linked directly to that of maternal mortality,” according to Wall and co-authors. And that problem, they continue, is “embedded in a complex network of social issues [including] the social status of women, the distribution and availability of health care resources, perceptions about the nature and importance of maternal health problems, and the social, economic and political infrastructures of developing countries.” It can rightly be said, they note, that fistula “results from the combination of ‘obstructed labor and obstructed transport.’”¹⁴

    “Three stages of delay” keep women from the help they need.¹⁵  First, embarrassment, tradition, cost, or misplaced optimism delays the realization that labor has gone awry. Then, distance, bad roads, or lack of a vehicle delay the journey to a clinic or hospital able to salvage the situation. Finally, crowding, understaffing, or lack of resources may delay the needed services when the woman finally arrives. A Caesarean section performed within the first 48 hours of labor will generally prevent fistula, although it may not save the baby.¹⁶

 
    The stark difference between the experience of mothers in the developing and developed worlds explains one of the greatest discrepancies known in health statistics, that between the rates of maternal mortality in rich and poor countries—a gap that constitutes “one of the most neglected issues of social injustice in the world today,” according to Wall and co-authors.¹⁷  Only 1 percent of the more than half a million maternal deaths each year happen in developed nations. In Northern Europe and North America, 11 women die for every 100,000 live births and a woman’s lifetime chance of dying because of pregnancy is 1 in 4,000. In Africa, that risk has been estimated at 1 in 14,¹⁸  and in some of the poorest parts of the continent, where over a thousand women die for every 100,000 live births, at 1 in 7.¹⁹

    These differences starkly reflect the relative availability in each type of country of birth attendants trained to discern when labor is headed for trouble and of facilities that provide the needed care. Countries with low maternal death and fistula rates not only have hospitals or clinics staffed by competent health professionals, but also the will and the means to get women there in time. The frenzied race to the hospital is a staple of comedy in the developed world because it indicates the priority given to prompt maternal care.

    The emphasis on skilled attendance at every birth has done a great deal more than produce laughs, however. It has helped slash the rich countries’ maternal death rates, which in the 19th century matched those seen in poor countries today.²⁰  Obstetric fistula was also common in Western countries in those days—so common, in fact, that Dr. J. Marion Sims, the American surgeon who in the 1840’s developed the first fistula repair operation, established a hospital for fistula surgery in New York City in 1855. It stood on the site of today’s Waldorf-Astoria Hotel.

    The women of New York and the rest of the developed world no longer need fear obstructed labor and its disastrous consequences because, “with access to skilled maternal care, [it] can be predicted, identified and treated,” according to the World Health Organization.²¹  A birth attendant need not even have a high level of technical training to spot trouble early enough to prevent injury. Using a pencil-and-paper form called the partogram, an attendant with only limited training can record periodic observations that warn when the labor is not progressing properly and emergency help is needed. Even in areas like Northern Nigeria, where traditional attendants serve at least 75 percent of births, “the need for local governments to train more traditional birth attendants [in the] skills to enable early detection and referral of patients at risk of developing [fistula] cannot be over emphasized,” write Kabir and colleagues.²²  Even without the partogram, the message that a woman’s labor should not last 24 hours needs to be universally understood.²³