VESICO-VAGINAL FISTULAS

Fistulas are often one of the consequences of a protracted delivery, sometimes lasting several days or even a week, and leading to tissue necrosis which ends up forming a hole between the vagina and the bladder (vesico-vaginal fistula) and/or the vagina and the rectum (recto-vaginal fistula). These obstetric fistulas are most common when mothers have had no access to assisted deliveries (vacuum, forceps or caesarean).

Fistulas can  also be the consequence of violent sexual aggression or some traditional practices such as female genital mutilation <link back to the FGM section> although this is quite rare.

Women can be left with urinary and/or faecal incontinence, causing extreme suffering and often resulting in social isolation. The World Health Organisation estimates that more than two million women live with untreated obstetrical fistulas although this number is well below the true figure as it is only based on those women reported or seeking treatment.

Pramila with her 9-month-old son was transferred by MSF to Kathmandu for fistula repair surgery. Her crippled father (rear from left) also went with them to take care of her. © P.K. Lee / MSF

Fistulas are practically unknown in the developed world because the problems of obstructed delivery are detected early and treated before a lot of damage can occur. Interventions can include ensuring the bladder is being protected throughout labour, identifying malpresentations or obstructions early and correcting them with drugs or surgical interventions. But in developing countries, countless women deliver at home, running numerous risks of complications.

One of the major obstacles to fistula case management is the shortage of competent services for repairing them in the countries where they occur most frequently. "The surgical intervention for a fistula can range from being very simple to extremely complex, depending on the degree of damage," explains Dr Nathalie Civet, MSF doctor and head of its surgical team.

MSF’s APPROACH
The first step in dealing with obstetric fistulas for MSF is to prevent them occurring in the first place by offering access to quality emergency obstetric care for women and encouraging women to always deliver with a skilledattendant available.

Other than prevention, MSF’s work with fistulas also involves a curative approach, with surgical treatment. The success rate of fistula repair by experienced surgeons can reach 90%, but success also depends on the quality of post-operative care. With treatment and support for reintegration in families and communities, most women can go on to lead a normal life.

Given the gross lack of qualified staff, MSF is focusing on training. "We are trying to create a snow-ball effect," explains Dr Peter Bech Larsen, MSF gynaecologist. "We train a team of doctors in the prevention and surgical treatment of fistulas. Once they are trained, they can train other doctors on a local scale."

Dr Bilé, Ivorian, thus received four months’ training from his MSF counterparts in Ivory Coast, within the framework of a programme providing fistula treatment in the regional hospital of Man, and went on to train another gynaecologist in this technique. Around 130 women have received operations since the project started in August 2005. "Dr Bilé has taken over the continuity of fistula care, not just the operations, but also the medical organisation and the social and psychological follow up of patients," explains Dr Pierre Gielis, surgeon and MSF trainer.

MSF is currently spreading this type of programme to other countries through the creation of a 'mobile' team. They are also implementing comprehensive programs in countries like Nigeria and Chad where prevention and treatment are tackled together.

Women's Health index