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International News: September 2012

The September 2012 issue of International News focuses on obstetric fistula.

This issue of International News is available online only. This page shows the editorial from Alison Fiander and David Nunns. Use the table below to access the other stories in this issue.

 

In their own words: 12 stories of vesicovaginal fistulae The problem of obstetric fistulae: a personal view
Provision of fistula services and programmes Update on the FIGO/RCOG and partners competency-based fistula training manual
The problem of continuing urinary incontinence after obstetric vesicovaginal surgery Creating a balanced narrative about women living with fistulae
Moving beyond incontinence Vesicovaginal fistulae in Nepal
Vesicovaginal fistula repairs at Aberdeen Women’s Centre in Sierra Leone Vesicovaginal fistulae in Bangladesh
Vesicovaginal fistula repairs in Tanzania transportMYpatient: overcoming the barrier of transport costs
Obstetric fistula surgery in Uganda Journal club

Editorial

Previously a neglected area of women’s health, the problem of obstetric fistulae has, in recent years, gained the attention of the international health community with resultant improvements in funding and resource allocation. Obstetric fistulae represent a failure of timely intervention in obstructed labour and a ‘near miss’ maternal death. Their occurrence represents a failure of maternal health services at a time when a woman is at her most vulnerable, leading to extreme suffering in the short term and resulting in long-term morbidity. There are few data on the size of the problem, but for every woman who dies in childbirth there are at least 20 more who suffer from injury, infection and disability. Interestingly, a British All Party Parliamentary Group on Population, Development and Reproductive Health reporting on global maternal morbidity in 2009 named their report Better off Dead, because of the often devastating morbidity suffered by women who survive complications of childbirth.

Patients recovering after fistula surgery

Recovering following surgery

It is estimated that 2 million women worldwide are living with obstetric fistulae, mostly in Africa and the Indian subcontinent, with between 50 000 and 100 000 new cases occurring each year. Despite the increasing awareness of the burden posed by obstetric fistulae on maternal health and developments in services for repair, there remain many women who live in constant discomfort. They are often unable to participate in tasks of daily living or income generation and may be isolated and unaware that there is help available. 

They frequently face insurmountable barriers because of the cost of treatment, transport, accommodation and food. It is for this reason we decided to dedicate a whole edition of RCOG International News to the subject of obstetric fistulae and are immensely grateful to our contributors for their willingness to share their insights and experience.

To set the scene, ‘In their own words’ has women with fistulae sharing their stories, followed by an insightful overview of the problem of obstetric fistulae by Michael Bishop, a retired consultant urologist who has worked in fistula care in several developing countries.

Sohier Elneil, a consultant urogynaecologist at University College, London, discusses the planning for provision of fistula programmes and gives a very useful update on the FIGO/RCOG and Partners Competency-based Fistula Training Manual. Andrew Browning,who worked for many years in fistula care in Ethiopia before moving to work in Northern Tanzania, discusses the problem of residual incontinence following surgery to ‘close the hole’, most notably stress incontinence as a consequence of damage to the closing mechanism at the bladder neck.

Maggie Bangser pleads for a balanced view of ‘the fistula sufferer’ and reminds us to celebrate the dignity, resilience and achievements of women with fistulae. Julia Irani undertook research investigating the experiences of women reintegrating into their local communities after fistula repair. Her work reminds us of the possibility and need for more research in the field of obstetric fistulae, in order that fistula services are evidence-based.

We are pleased to include news of fistula services in Nepal, Sierra Leone, Bangladesh, Tanzania and Uganda, but are aware that there are many other centres for which we do not have information. We would urge others working in the field to contact us. We would be interested to hear from students encountering fistulae during electives and about research in the field.

Last, but not least, we have included a journal club summarising two papers published in 2011 on the psychosocial experiences of women with fistulae and their birth histories. Classically, we are taught that there are three points of delay in accessing assisted delivery – first, the delay in a decision to access care by the woman, her family or carers; second, the delay in reaching a health facility because of a lack of transport; and third, the delay in intervention having reached a health facility. In the second powerful paper Mselle and colleagues note that once the health facility is reached there is a subcategory, namely receiving correct care, because of a lack of skilled decision-making capacity, lack of will or low numbers of appropriately skilled personnel able to deliver the required care.

Both papers illustrate that there is still a long way to go in treating and preventing obstetric fistulae. The mainstay of prevention is the provision of comprehensive maternity care with active management of labour, so that one day obstetric fistulae will be a condition seen infrequently, as is now the case in the developed world. The solutions are complex and include strengthening of national health systems and infrastructure; prioritisation and governance of resources for maternal health; governmental support; individual, community and health professional education on fistula prevention; training in provision of fistula services; research to underpin evidence-based care; and advocacy for women’s rights in accessing skilled and timely intervention where necessary during childbirth, along with a change in attitudes and expectations that fistulae can be prevented, treated and eradicated.

Women celebrating going home after fistula surgery, Tanzania

Women celebrating going home after fistula repair in Tanzania

Alison Fiander, Guest Editor, RCOG International News

David Nunns, Editor, RCOG International News