Specialist Fistula surgeon; Chairman and Founder Uganda Childbirth Injury Fund
Obstetric fistula is as old as the human race and it damages the bodies and lives of far too many women around the world. But fistula is treatable and preventable; alleviating the suffering and marginalization that comes with it is possible.
Better access to good obstetric care is fundamental in preventing this dreadful injury. Death or injury in labor is still all too common in countries where there is inadequate access to skilled obstetric care. In Uganda, 60% of women attempt to deliver at home. There, and in other resource-poor African countries, it is estimated that a woman has a 5% lifetime chance of dying in childbirth. Obstruction is a leading cause of death and disability. It requires an emergency Caesarean section and many women live far from the help they need or arrive too late for it.
Fistula patients are the survivors. They have usually labored for days and eventually delivered a still birth or may have been relieved too late by Caesarean. The prolonged pressure of the baby’s head in the pelvis wears a hole (fistula is Latin for “hole” or “hollow”) between the bladder and vagina. This vesico-vaginal fistula leads to life-long total incontinence of urine. In some cases, the rectum is damaged as well, leading to double incontinence.
The woman is left in a miserable state. Her chance of having more children is ruined - in 50% of obstetric fistula cases the injury occurs with the first delivery. Surgery is badly needed but it is rarely simple. The extent of damage varies enormously; in some, the hole is small and quite easy to close. But a few will have lost almost all their bladder tissue and sadly, are therefore incurable. The majority have intermediate damage that requires considerable surgical skill to repair.
Some women give up all hope of being cured; having been told that surgery was impossible in their government hospital and wary of the expense at a private hospital. Their marriages disintegrate. They end up in hiding, ashamed to go out. They become social outcasts, shunned and ridiculed because of the smell of leaking urine or faeces; they live a sad and isolated existence.
Dr. Hancock assists Dr. Matovu at Kamuli. (Photo courtesy of Dr. Brian Hancock)
I first encountered fistula in 1969 while working as a surgeon in Kamuli Mission Hospital. I was subsequently lucky enough to train at the world famous Addis Ababa fistula hospital. And since retiring from consultant practice in the UK in 2000, I spend three months a year devoted to fistula repairs in several African countries including Uganda where I am a regular visitor to my old hospital in Kamuli. Two or three times a year, I offer a fistula repair service and have been recently joined by Dr. Glyn Constantine, who will one day take over the work from me.
Obstetric fistula is as harmful to a woman’s health and well-being today as it was more than forty years ago. However, with appropriate skill about 80% of patients can be made completely continent again. Furthermore, many will have children again although they are strongly advised to have an elective Caesarean section. We can make great strides in healing these women but first we must find them.
For the last three years, Uganda Village Project has assisted us in finding women suffering from fistula by taking the initiative in searching for patients on a village-by-village basis and bringing them to Kamuli. We can operate in 20-25 cases per visits and have operated on over 500 in the last ten years. The treatment is free. This surgery encompasses the speciality of urology, gynaecology and colo-proctology and can only be learned by a long period of work in Africa with regular apprenticeship to another fistula surgeon. At Kamuli, we have a good theatre and usually two resident Ugandan doctors attending. We trained resident surgeon, Dr. Matovu, adding to his ceaseless workload where routine care and emergencies occupy most of his time. The fistula operations are done under spinal anaesthetic and require good post operative care for at least two weeks.
UVP drives our patients back to their homes diminishing the risk that they will re-open their fistula by walking long distances. Moreover, I am delighted that the UVP team follows-up with individual patients later and provides us with feedback on their progress, returning any who are not cured as some can be helped by a second operation.
Loy conducts a fistula education session for UVP. (Photo courtesy of Dr. Brian Hancock)
As with all care, it is critical to recognize complications early. The first step in prevention is to encourage ante natal care and deliveries in a healthcare facility. UVP is doing some wonderful work in education about the cause and prevention of fistula through, for example, teaching with flip charts in the villages. And UVP has trained a former patient named Loy to do this as well. She is in an ideal position to explain the problem to her community. She proves that not only is successful maternal healthcare possible but she also shows that re-integration can be realized and that the isolation from fistula can be overcome. Our efforts to cure and prevent this tragic injury will continue for the sake of all women in need of those goals.
Assessing new patients. (Photo courtesy of Dr. Brian Hancock)
Dr. Hancock is the author of the book “Practical Obstetric Fistula Surgery,” available at brian@yealand.demon.co.uk or http://www.talcuk.org/
Posts
No comments:
Post a Comment