Maternity and poverty

MANY mothers lose their lives while giving birth, others live with lifelong scars. One such scar is obstetric fistula, a disorder of female genitalia, mainly associated with the birth process. As studies reveal, it's a 'disease of the poor'. As medical technology advances, maternal mortality also reduces. But as poverty and social inequality still reign, many continue to suffer. 

Female genital fistula is a severe morbid condition of the genitalia. Fistula affected women experience uncontrolled, non-stop passage of urine or/and feces from the vagina. This happens when the birth canal gets connected with urinary system (urethra and bladder mainly) or/and rectum through abnormal hole(s). Historically, obstructed labour has been the main cause contributing to those holes finding ways for urine or faeces leaking through the vagina. 

Apart from obstructed labour, genital fistula is caused, among other things, by surgical trauma, clinical burns (radio therapy in cervix or other pelvic organs), forced intercourse, genital mutilations or even traffic accidents. In Bangladesh, three-fourth of all fistula cases at present are due to obstructed labour. Genital fistula, a major form of obstetric morbidity, is commonly associated with neglected, under-attended delivery. Only one-third of all deliveries here are attended by trained hands in hospitals or homes. 

Partograph, a simple tool used by midwives and nurses to plot the progress of normal deliveries in a graph is very helpful for prompt diagnosis of obstructed labour. It helps prevent fistula. Unfortunately, most hospitals here hardly use partograph. 

Fistula prevails in about 50 African and Asian countries. Presently, some one to two million women live with genital fistula globally. Annually 50,000- 100,000 new cases are added. A situation analysis report indicated that there were 71,000 fistula cases in Bangladesh in 2003. 2000 new cases are being added annually.

Poverty is an important determinant of obstetric fistula. Our findings reveal that many women with arrested fetal heads at birth canal for days did not receive any obstetric care. In Bangladesh, less than one third of the new mothers receive adequate ante-natal care.  

Early marriage is a predisposing factor of fistula. The average age of marriage of fistula patients is 15 years. Discouraging early marriage is likely to reduce fistula occurrence in women. Quality pregnancy care is of high import in early prevention. In case of obstructed labour, timely referral to a facility where caesarian section is available will help. Improved nutritional status of women is also a must to prevent fistula. It helps deal with the stress of pregnancy and labour. 

We observed fistula cases in almost all districts of the country. Some districts are apparently at greater risk. In haor areas of Netrokona and Kishoregonj, women suffering from obstructed labour failed to get adequate help in time. This is probably due to widespread poverty, early marriage, early pregnancy, malnutrition and low utilisation rate of ante-natal care.

Genital fistula, when caught in the early stages, could be treated by catheterisation. This treatment could be made available at district level facilities. It is good to know that the Ministry of Health and Family Welfare is currently working on a plan to set up a 'fistula corner' in all district hospitals to make early catheterisation services accessible. 

In most fistula cases, the only option open is surgical repair. Fistula surgery demands high skill levels of doctors but is a relatively low-tech surgery. Fistula surgery is available at the National Fistula Centre, Dhaka Medical College, BSMM University, and in a number of private hospitals in and out of Dhaka. In all concerned hospitals fistula repair operations are done absolutely free. 

Most of the time, obstetric fistula occurs at the first delivery of very young mothers. The average age of first delivery fistula cases is just eighteen. Women suffer from leaking decade after decade. The average age of the repair surgery is approximately thirty five.

Fistula is a disease of the poor. Poverty, status of women in society, access to family planning, quality maternity care and other factors feature in the spread of this disease. It needs a concerted and collective effort. A fistula-free Bangladesh is the call of the day

The writers are project manager at Engender Health Bangladesh, anthropologist at Centre for Asian Arts and Cultures, Dhaka; and the Country Representative of Engender Health Bangladesh, respectively.