Skilled Obstetric Care for All
The key to ending fistula is to prevent it from happening in the first place. Skilled attendance at birth, including swift surgical intervention if obstructed labour occurs, can prevent a fistula.
Prolonged obstructed labour puts a woman at risk for fistula and other serious injuries, including death. Unless she receives prompt medical treatment - usually a Caesarean section - the lack of blood flow can cause soft tissues to die, leaving a fistula, or hole, in her bladder or bowel [see diagram]. Fistula has all but disappeared in countries where women experiencing complicated deliveries have access to timely emergency obstetric care.
The longer obstructed labour continues, the more likely it is to cause fistula or death. Delays - in the decision to seek medical attention, in reaching a health care facility, or in receiving emergency obstetric care at the facility - jeopardize both mothers and infants. A skilled attendant with obstetric training can help to recognize danger signs and treat certain complications. But women with obstructed labour need to get to an operating theatre quickly - so back up referral and transport to an appropriate facility also need to be organized ahead of time.
The sun should not rise or set twice on a woman in labour.
—An African proverb
Longstanding customs may also limit a woman's access to obstetric care. In some cultures, women are expected to give birth at home, sometimes with no help, or with the help of traditional midwives. Husbands, male relatives or mothers-in-law may be the ones to decide what care a woman receives, and cost may play a large part in the decision.
The complexities of getting timely and appropriate medical care are reflected in this story by an Eritrean girl: "I had laboured in the home of a traditional midwife for four whole days. They kept me in a separate room, and the women smoked incense for me. They also killed chickens and spread the blood on the floor around me. The midwife pushed very hard on my stomach. After a long, long time my mother went to the health station and brought a health worker back to where I was kept. When he saw me he said, 'You will kill this lady if you don't take her to the hospital right away.' "
It is better to prevent than to treat. The real hope in ending fistula lies with prevention, not surgery.
—Dr. Kalilou Ouattara, fistula surgeon, Mali
About 15 per cent of all pregnancies result in complications and require emergency medical intervention. Caesarean sections to relieve obstructed labour are needed for between 5 and 15 per cent of all births. However, a recent assessment of health care in West Africa found that Caesarean sections represented fewer than 1 per cent of births in Cameroon, Côte d'Ivoire, Mauritania and Niger.
Women in remote rural areas face greater risks
In rural areas where fistula is most common, hospitals are spread out over vast distances and transportation systems are often rudimentary. Women often rely on traditional midwives, who may fail to recognize danger signs in time and in any case do not have the medical skills or equipment to provide life-saving interventions in emergencies.
Some women in the throes of labour travel for many hours - or even days - by bus, donkey cart or on foot to reach a hospital or medical centre that can help them. Often by the time they get there, it is too late. Health care providers in Ethiopia estimate that it takes women 2.5 days on average to reach an operating room. By that time, the foetus will most likely have died and the woman will have undergone significant physical trauma.
The medical officer at the health centre told Habiba to go to the hospital, since they did not have the capacity to treat her. But there was no transport available. She would have to walk 11 kilometres to the main road to catch the pickup truck that could take her there. Even then, she might not be able to board because the truck was often too full to fit any more passengers. So Habiba stayed at the health centre, unable to deliver for three days. Doctors may be able to repair the fistulas she developed, but her uterus also ruptured, so she will never have children.
—Adapted from Faces of Dignity, Women's Dignity Project, Tanzania
What UNFPA is doing
UNFPA and its partners in the Campaign to End Fistula are committed to the internationally agreed-upon goal of improving maternal health by increasing access to skilled attendance at birth and emergency obstetric care.
UNFPA and its partners also work with community and religious leaders, traditional birth attendants, radio stations, influential public figures and policy makers to increase awareness of the needs of pregnant women and to mobilize support for them. UNFPA supports training of doctors, nurses and other health workers in life-saving obstetric care in 76 countries.
Chances of an African woman dying in pregnancy: 1 in 16
Chances of a woman in high-income countries dying as a result of a pregnancy: 1 in 2,800.