FEMALE GENITAL FISTULA: A changing landscape in Bangladesh

by Nazmul Huda and Desdemona Khan

FEMALE genital fistula is a medical condition in which urine and faeces, either or both, keep leaking through a woman’s vagina. The malady occurs when the birth canal gets entangled with the urinary system and rectum by way of one or more abnormal holes, which results from trauma of obstructed labour or surgical injuries inflicted in the lower abdomen, uterus or vagina on the operating table. Sufferers do often get smelly and isolated from family, friends and society. They are not allowed to handle food, take part in child care and many other daily activities. Many are divorced and displaced from their living facilities. Life becomes more painful than death to fistula victims.
Fistula has virtually disappeared from the northern part of the globe long ago. Unfortunately, it still prevails in more than 50 countries of Africa and Asia. The World Health Organisation estimates that more than one million women globally are living with fistula. In Bangladesh, as a 2003 survey indicated, the figure of women living with fistula was 71,000. Approximately 2,000 new cases are also added every year.
Considering the significance of fistula as a women’s key health hazard, May 23 is observed as International Fistula Day. In 2016, the day’s theme chosen is ‘eliminating female genital fistula in this generation’. The day is observed in a befitting manner also in Bangladesh. The government is committed to the prevention and amelioration of fistula. In 2015, a national fistula strategy is launched, a national fistula task force with representatives of concerned ministries, development partners, academic institutions and the UN has been formed and a fistula action plan is also in place.
Prolonged labour, historically speaking, has been the main cause of fistula in many countries, not excepting Bangladesh. If obstructed, labour remains untreated for over 12 hours, the foetal head in the birth canal exerts pressure on the thin vagina wall against bony pelvis. It tears that wall in places and, by creating holes, connects it with the urinary system or the rectum.
Poverty, inequity, early marriage and pregnancy, status of women in society, living in hard to reach areas, low utilisation of pregnancy care and lack of access to quality emergency obstetric care are some potential determinants of obstetric fistula in Bangladesh. Fistula is preventable. Prevention option should be the first option for any programme addressing fistula. Family planning helps in preventing early pregnancy and in some cases avoiding obstructed labour. In Bangladesh, approximately 60 per cent of all women deliver at home. Home delivery certainly increases the risk of obstetric morbidities including fistula. If birth attendants, including midwives, nurses and doctors, use partograph for monitoring every delivery, it helps in identifying and treating obstructed labour and other labour complications as soon as it occurs. Unfortunately, many hospitals are missing this opportunity of using partograph for labour monitoring in Bangladesh. If women receive antenatal care at least four times during pregnancy, it will benefit in many ways.
Surgical trauma is gradually becoming apparent as the leading cause of genital fistula in Bangladesh. Fistula resulting from surgical trauma are called iatrogenic fistula. At present, at least one-fourth of all fistula cases are caused by surgical trauma. In 84 per cent of all iatrogenic fistula, hysterectomy (removal of uterus) operation is the source of the trauma. Rest of the iatrogenic fistula are caused by the caesarean section. It seems hysterectomy operation is being done throughout the country by surgeons with various levels of training and experience. In a poorly regulated environment, this has become a real challenge to tackle now. Hysterectomies are done with questionable indications and in many different types of health facilities.
Caesarean section often is the solution to avoid fistula in cases of obstructed labour. As such, we promote increasing access to Caesarean section for the cases of prolonged labour. Again, in Bangladesh, Caesarean section is now the second leading cause of iatrogenic fistula. Though Caesarean section is not accessible or available to many women in obstructed labour at present, there are indications that in many places Caesarean sections are being done in excess. In fact, the rate of Caesarean section is the highest of all countries in Bangladesh among the women who deliver in hospitals and clinics.
Fistula is repairable. Most of the fistula cases could be repaired successfully. It is a high skill but low-tech surgery. In fact, fistula surgery does not require any sophisticated instrumentation beyond a skilled surgeon. Fistula repair surgery is available at the University Fistula Centre at Bangabandhu Sheikh Mujib Medical University, at Ad-Deen Hospitals (Dhaka, Jessore and Khulna), at LAMB Hospital (Parbatipur, Dinajpur), at Kumudini Hospitals (Mirzapur, Tangail), at the Mamms Institute of Fistula and Women Health (Eskaton, Dhaka) and at Dr Muttalib Community Hospital (Bijoynagar, Dhaka). USAID with Engender Health Bangladesh ensure fistula treatment, surgery and rehabilitation free in these hospitals. Patients are also provided with travel expenses and rehabilitation support as and when required. Hope Foundation Hospital, Cox’s Bazar also provides surgery free. The National Fistula Centre, Dhaka Medical College Hospital, and some other medical college hospitals also provide repair surgery free.
Etiology, perspectives and consequences of iatrogenic fistula are significantly different from obstetric fistula. Addressing the obstetric fistula calls for prevention of early marriage, ensuring pregnancy at right age through the use of family planning. Accessibility and availability of emergency obstetric care including Caesarean section also matter. Compared with this, to address iatrogenic fistula cases, we need to ensure right skill of obstetricians, gynaecologists and surgeons. Regulatory environment to ensure that the right person is doing the right operation at the right place is a must. The Obstetrical and Gynaecological Society of Bangladesh, the Bangladesh Medical Association, the Bangladesh Association of Urologists and the Nursing and Midwifery Association has a vital role to play in the prevention and amelioration of female genital fistula.

Sheikh Nazmul Huda is country manager at Fistula Care Plus Project and Desdemona Khan is an anthropologist specialising in public health.

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