Obstetric fistulas in resource-limited settings
- L Lewis Wall, MD, DPhil
L Lewis Wall, MD, DPhil
- Selina Okin Kim Conner Professor in Arts and Sciences
- Professor of Anthropology (Medical Anthropology)
- Washington University in St. Louis
Obstetric fistulas are abnormal communications between the genital tract and the urinary tract (urogenital fistula) or the gastrointestinal tract (most commonly, rectovaginal fistula). These fistulas result in urinary or fecal incontinence. Obstetric fistula is uncommon in countries in which the healthcare infrastructure is well developed. When a fistula occurs in the industrialized world, it is usually the result of a complication of pelvic surgery [1,2]. Less frequently, it arises as a complication of surgical treatment of cancer or radiation therapy.
In resource-limited countries, particularly in sub-Saharan Africa, vesicovaginal fistulas are much more common than in industrialized countries [3,4]. Obstetric trauma from prolonged, obstructed labor is the cause of the majority of vesicovaginal fistulas in these settings. Other causes of vesicovaginal fistula are complications of surgery or of traditional practices (eg, genital cutting or vaginal “salt packing”).
Developing countries lack the resources to treat all patients with obstetric fistulas. It is estimated that between two and four million women in sub-Saharan Africa currently have an unrepaired vesicovaginal fistula, with between 30,000 and 130,000 new cases occurring each year [3,4]. The current total capacity for fistula repair in sub-Saharan Africa is estimated to be around 10,000 cases per year .
Vesicovaginal fistulas, particularly obstetric fistulas, in resource-limited settings are reviewed here. General information regarding genitourinary fistulas is discussed separately. (See "Urogenital tract fistulas in women".)
The incidence of vesicovaginal fistulas in resource-limited countries is difficult to ascertain and studies report rates of fistulas arising from obstetric causes and not from other etiologies. The World Health Organization (WHO) estimates that there are 130,000 new cases of obstetric fistula each year, calculated from an assumption that fistula is likely to occur in 2 percent of the 6.5 million cases of obstructed labor that occur in developing countries . A prospective study of maternal morbidity in sub-Saharan Africa reported an annual incidence of 33,000 obstetric fistulas . The prevalence of obstetric vesicovaginal fistula is directly related to the prevalence of obstructed labor and the accessibility of emergency obstetric care, including facilities capable of performing cesarean delivery. Obstetric fistula closely parallels maternal mortality because both conditions are directly linked to the accessibility of emergency obstetric care. The fistula problem is most severe in sub-Saharan Africa because maternal mortality is highest there, but fistulas are also found in other parts of the world where fertility is high, the status of women is low, and obstetric services are poor, such as Afghanistan, Pakistan, Bangladesh and parts of India. Obstetric fistula is a disease of poverty.
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- ETIOLOGY AND PATHOGENESIS
- Obstructed labor
- Surgical complications
- Traditional practices
- Economic and societal issues
- EVALUATION AND DIAGNOSIS
- Physical examination
- Obstetric fistula repair
- - Operative conditions
- - Preoperative preparation
- - Procedure
- - Postoperative care
- - Outcome and complications
- Persistent incontinence after surgical repair
- Long-term outcomes
- Urinary diversion
- SUMMARY AND RECOMMENDATIONS