November 24, 2008
Chad 2008 © Claude Mahoudeau/MSF
In 2007 a group of 11 women suffering from vesico-vaginal (VVF) fistulas approached MSF nurse Esther Moring and her medical team in eastern Chad, asking for treatment. At that time, Moring’s team was focused on performing war surgery, and the only MSF fistula project in Chad was in Bongor three days’ drive to the other side of the country. The sole Chadian surgeon treating fistula was located in the capital, N’Djamena, and limited funds meant he could perform no more than one repair per month, with a year-long waiting list.
In order to help those women and countless others with fistulas in eastern Chad, Moring and an MSF team initiated a pilot fistula surgery program based in the town of Abéché, near the border with Darfur, Sudan.
In January 2008, the program began admitting patients, including Sudanese refugees and Chadian women displaced by the ongoing Darfur conflict. These women are living in some of the most vulnerable conditions with little, if any, access to medical care.
Here, Moring describes what fistulas are and why starting this project was so important.
Survival is Only the Beginning
VVF is an abnormal opening between the vagina and bladder or the vagina and rectum, through which urine or feces leak continually. It’s usually a consequence of prolonged, obstructed labor where the baby cannot exit the womb, either because it’s in the wrong position or because the head of the baby is simply too big to pass through the mother’s pelvis. Usually, a woman develops a fistula trying for many hours, or days, to push the baby out, and the condition frequently occurs among young and adolescent girls because the girl’s body is too young and small to deliver the baby.
In the developed world, women experiencing these complications will have a C-section before it gets to the point where a fistula could occur. But in sub-Saharan Africa, usually, the baby will die during labor, before the birth, and the mother will often die from complications such as sepsis or hemorrhage relating to a ruptured uterus, a life-threatening tear in the womb, due to the obstructed and prolonged labor. If the mother survives the prolonged labor, she is very likely to have a fistula from the relentless pressure of the baby’s head during labor. It is thought that for every woman with such a fistula birth injury, up to eight others will have died during obstructed labor.
In addition to incontinence, there are other serious health issues that come with fistula, including neurological problems that make it difficult to walk, skin ulcerations caused by the continual leaking, renal infections, and major psycho-social problems stemming from the reactions of people around her to the smell caused by continual incontinence. Surviving means, in addition to the physical pain and burden of fistula, the woman will have an extremely hard life, as she will often be shunned by her own society and rejected by her husband. She may be completely isolated and have to beg for food. She will be unable to carry out normal activities such as going to the market, weddings or the mosque or church with other women.
Prevention of Fistula
Fistulas are preventable, but it requires skilled and trained birth attendants to follow pregnancies and detect problems early on and emergency obstetric care such as a C-section when necessary. Many women in sub-Saharan Africa have little or no access to such services. Births are traditionally at home with untrained people, and even when health care is available nearby, social mores can take precedence over the health of the mother.
Often the traditional birth attendant, or member of the family or community responsible for helping to deliver the baby, either doesn’t think of going to a hospital or doesn’t have the resources to pay for the ride there. In some parts of the region, custom requires a male elder to approve surgery, and medical professionals can meet with strong resistance, even when a woman is experiencing intense pain and suffering and even when her life is in danger.
A large number of those who die from obstructed labor or who survive with fistulas are between the ages of 10 and 18 and are of small stature. They might have been made to marry and become pregnant quite young, and because their bodies have not fully developed, they cannot deliver the baby. These are the women and girls who are at risk of such complications, and huge numbers of them die.
As the fistula program in Abéché grows, it will have a focus on prevention through training and outreach to traditional birth attendants and local community and religious leaders, as well as concentrate on training Chadian health care staff in fistula prevention and management.
Beyond the Operation
Treating women with fistulas involves much more than an operation. When women arrive for treatment, they can be in very bad shape anemic, malnourished, and psychologically traumatized. It may take weeks in a hospital for them to get healthy enough to undergo fistula repair.
Post-operative recovery takes about three weeks, and close, meticulous care is very important because if the first attempt at repair does not work, subsequent attempts are much harder.
Recovery presents new challenges for the patient, both physical and otherwise. She must relearn how to control her bladder; and she also must find a way to reintegrate into society, return to her community and explain what happened to her, as well as develop a way to be self-sufficient. This could mean learning how to read and write, or learning a handicraft some way to earn an income. The program plans to help patients recover in this way, as well.
After a woman leaves the facility, strict precautions must be taken in order for her to fully recover. She should not get pregnant for six months, and MSF provides contraception for that time period. But if she does become pregnant, she absolutely must have a C-section in a hospital. Otherwise, a new obstruction during labor could be fatal, or it could end in more serious tears. It is difficult for staff to monitor a woman’s progress after she leaves the facility, and the insecurity of eastern Chad makes it that much more difficult. So MSF is working with Chadian health care partners on finding new ways to do this.
Patient Story: Zeneba
Zeneba married very young, which is common in this part of the world, and became pregnant when she was barely 15 years old. Her delivery was overseen by a traditional midwife; it lasted five days and the child was stillborn. She came to MSF’s fistula repair hospital in Abéché to receive help.
“I had never been to a health center before giving birth,” she said. “The hospital was very far away, and it was certainly very expensive. My husband wouldn’t have wanted to go there.”
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)