Obstetric Fistula

Welcome to the programmatic area on obstetric fistula within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. This is one of the subareas found in the women’s health part of the sexual and reproductive health (RH) section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications.

  • Obstetric fistula is a source of physical and psychological suffering, in addition to cultural and economic isolation, for large numbers of adolescent girls and women in low-income settings around the world.  A complication from prolonged or obstructed labor, the resulting lesion(s) between a woman’s vagina and bladder, and/or rectum, can leave a woman with a range of problems—from leakage of urine and feces to recurring infections, infertility, severe vaginal tissue damage, and paralysis of the lower legs (World Health Organization, 2006a). 
  • Needs assessments and monitoring and evaluation are essential components of programs to prevent and treat obstetric fistula.
  • Key indicators to monitor and evaluate obstetric fistula can be found in the links at left.

 

Full Text

Obstetric fistula (OF) is a source of physical and psychological suffering, in addition to cultural and economic isolation, for large numbers of adolescent girls and women in low-income settings of the world.  A complication from prolonged or obstructed labor, the resulting lesion(s) between a woman’s vagina and bladder and/or rectum can leave a woman with a range of problems from leakage of urine and feces to recurring infections, infertility, severe vaginal tissue damage, and paralysis of the lower legs (WHO, 2006a).  The pain and suffering can be so extreme that some women resort to suicide. The UNFPA Campaign to End Fistula estimates that at least two million women are living with OF worldwide and up to 100,000 new cases occur each year (UNFPA, 2010). 

In most cases, OF is preventable and treatable.  The immediate cause is generally very long or obstructed labor in which the constant pressure of the infant’s head against the pelvis reduces blood flow to the soft tissue around the bladder, vagina and, rectum resulting in a hole or fistula between the adjacent organs and in most cases, a stillbirth.  If the women had received timely obstetric care, the baby would have been delivered by caesarean section or assisted vaginal delivery, which probably would have saved the life of the infant and prevented the conditions leading to OF.  Less common causes of OF are sexual abuse and rape, complications from unsafe abortion, surgical trauma, and gynecological cancers and related radiotherapy treatment (WHO, 2006a). Underlying risk factors for OF include early marriage and childbearing, inadequate family planning and birth spacing, poor nutritional status, harmful practices such as female genital cutting, sexual violence, lack of education, poverty and low status of women.  In developed countries where antenatal care (ANC) and essential or emergency obstetric care (EmOC) are more readily available, the prevalence of OF is low, whereas the lack of these services in resource poor settings increases risk of labor complications, late or inadequate medical care, and resulting OF.     

The determinants of maternal morbidity and mortality, as well as infant deaths, are the same that cause OF and, therefore, strategies designed to prevent and treat OF should be an integral part of global and country-level maternal and newborn health strategies. Improving access to care and knowledge about OF are important first steps is reducing OF. It is also important that OF plans be integrated into broader reproductive health and poverty-reduction strategies (WHO, 2006). The UN Millennium Development Goals (MDG) most directly related to OF are #5 Improve maternal health and #4 Reduce child mortality. In 2003, UNFPA and its global partners united to launch the Campaign to End Fistula.  Currently working in 49 countries, the campaign focuses on three key areas: preventing fistula, treating affected women, and supporting women as they recover from surgery and rebuild their lives (UNFPA, 2010).  Beginning in 2004, the EngenderHealth ACQUIRE project, supported by USAID, focused on training surgeons and strengthening the capacity of sites to provide quality OF surgery.  The USAID Fistula Care Project expanded the scope of work to increase and strengthen the number of sites providing OF services, in addition to supporting prevention through advocacy, increased attention to provision of EmOC, family planning services, and identifying OF women post-surgery to assist them with rebuilding and reintegrating their lives (note: the Fistula Care Results Framework is available at EngenderHealth, 2009).  In 2006, WHO developed a comprehensive list of short-, medium- and long-term objectives, essential components for OF prevention and treatment strategies, and models for delivering OF repair services (WHO, 2006a).   

Needs assessments and monitoring and evaluation (M&E) are essential components of programs to prevent and treat OF.  Selected indicators from the WHO (2006b) list of 17 reproductive health indicators for global monitoring (e.g., percentage births attended by skilled health personnel, numbers of facilities with basic or comprehensive essential obstetric care), as well as, indicators for monitoring obstetric care (e.g., rates of treated obstetric complications, caesarean rates, and case-fatality rates) can be useful for identifying needs and monitoring OF programs (WHO, 2006a).  Core lists of indicators specific to OF have been recommended and are in the process of being tested and revised. The WHO (2006a) list of 19 OF indicators are grouped into four areas: epidemiological prevalence, service delivery, training, and quality of care. The 13 indicators selected for this database are a subset of the WHO (2006a) list that still cover the four areas and reflect the continuing work on refining core OF indicators by the CDC/DRH led Data, Indicators, & Research Committee of the International Obstetric Fistula Working Group.   

M&E plans and data collection for the OF indicators need to be integral to the strategy from the beginning, clearly planned for how they will be performed, and with robust data collection systems in place.  In addition to M&E, audits of clinical care can help ensure the highest quality of care.  Further research is needed on the optimal time for OF repair (i.e., as soon as necrotic vaginal tissue is cleared or two to three months after the OF occurred) and the effectiveness of the types of repair undertaken (WHO 2006a).  Ideally, such research can be built into the national strategies. 

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References:

EngenderHealth, 2009, Fistula Care: Annual Report October 2008 to September 2009, Washington, D.C.: USAID. http://www.engenderhealth.org/search2/search.php?query=obsteric+fistula&category=2&results=20&search=1&x=18&y=5 

UNFPA, Campaign to End Fistula, Dispatch; Nov. 2010. New York: UNFPA.  http://www.endfistula.org/sites/endfistula.org/files/pub-pdf/sep-chap_fistula-may24.pdf

UNFPA. 2004, Program Manger’s Planning Monitoring and Evaluation Kit, Part II: Indicators for Reducing Maternal Mortality, New York: UNFPA.http://www.unfpa.org/monitoring/toolkit/Tool6_2.pdf  

WHO, 2006a, Obstetric Fistula: Guiding principles for clinical management and programme development, Geneva: WHO.http://whqlibdoc.who.int/publications/2006/9241593679_eng.pdf

WHO, 2006b, Reproductive Health Indicators Reproductive Health and Research Guidelines for their generation, interpretation and analysis, Geneva: Who. http://whqlibdoc.who.int/publications/2006/924156315X_eng.pdf  

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