What is a fistula? Unless you are a nurse or a midwife, you may not know what a fistula is because they are virtually unheard of in the developed world due to improved obstetric care and early intervention.
A fistula is a tract that develops between one part of the body and another. Occasionally fistulas result from trauma caused by rape but approximately 97% of fistulas are obstetric fistulas – a preventable childbirth injury caused by prolonged obstructed labor.
Continued contractions push the baby’s head against the mother’s pelvic bones exerting pressure which squishes the soft tissues between the baby’s head and the bones of the pelvis. Prolonged pressure reduces the blood flow and therefore the delivery of oxygen to these vital parts of the body causing tissue death. The dead tissue disintegrates and a tract or passage develops between the woman’s birth canal and bladder and/or rectum resulting in urinary and faecal incontinence.
Surely modern medicine can fix this? Once a fistula has developed there is only one cure – surgery – but there are many other challenges. Fistula surgery is difficult and requires a correct diagnosis, highly qualified staff, access to specialized facilities, money (because medical care is not free in Nepal) and individualized patient care.
Unfortunately, not all fistulas can be cured and the surgical success rate is around 70 – 80%. For the remaining 20 – 30% life is desperate.
Why do fistulas develop? There are many reasons why women in developing countries experience fistulas, however the major culprits are:
- malnutrition caused by poverty and early marriage. Malnutrition prevents a woman’s pelvis from growing to the size that can easily deliver a baby
- women who are married young and bear children at an early age are also at risk because the pelvis is not fully developed. Obstructed labor is more likely to occur simply because the pelvis is not big enough, and with obstructed labor comes the risk of fistula formation. It is not uncommon for women to experience obstructed labor that can continue for several days before help is sought.
- lack of access to adequate antenatal assessment
- lack of access to medical facilities – Only 33% of births throughout Nepal occur in health care facilities with access to medical supervision. Early intervention, forceps deliveries and Caesarian sections are often simply not an option and many hospitals in Nepal do not even have operating theatres. 81% of Nepalese live in these rural or remote poorly resourced regions. This photo is of the maternity ward in a hospital in a remote region of Nepal…
- lack of access to appropriate facilities with suitably educated and skilled staff. It is difficult for fistula affected women to secure a correct diagnosis because public and professional knowledge of fistula is poor and even if these women are referred on, medical staff often simply do not have the specialized skills to treat them
- poverty – medical care is not free in Nepal so surgical intervention is often simply not affordable without external funding
What about early intervention and Caesarian sections? Early intervention is not commonplace in Nepal because access to adequate antenatal assessment is limited. Home for the majority of Nepalese is a village in a rural or remote region where there is a lack of accessible appropriate hospital facilities with suitably skilled staff, a lack of transport and poor communications, so access to medical treatment is also challenging.
Why are fistulas a problem & what happens to women in Nepal who cannot access medical care for their fistula? Fistulas are a huge problem because the majority of women who go on and develop an obstetric fistula have not only given birth to a stillborn baby, but have to contend with urinary and/or faecal incontinence for the rest of their lives unless they can access surgery which then has to be successful.
What are the consequences of fistula? Fistulas have enormous physical, psychological, social and financial consequences for women who experience them. Left untreated, obstetric fistula results in a range of physical problems including frequent infections, kidney disease, painful sores and infertility. Physical consequences of fistulas result in psychological harm, distress and depression and physical and psychological consequences result in social and financial ones.
Many women in Nepal with fistulas become marginalised and experience social isolation like this woman who lived in a cave. They are unable to work resulting in deepening poverty. They are shamed and abandoned by their husbands and families, and ostracized by their communities, driving them even further into poverty. It is estimated that approximately 30% of fistula affected women are abandoned so many women lose their husbands, loved ones, marriages, relationships, are sometimes forced to sleep away from family areas and have been found in shocking conditions.
WHAT DOES ROADS TO REHAB NEPAL DO FOR WOMEN WITH FISTULA IN NEPAL?
In Nepal there is an estimated 5000 women living with fistula. Our philosophy is to forget about the 5000 and focus on one woman at a time.
Nepal is lucky enough to have this wonderful man working at BPKIHS. Dr Mohan heads Fistula Free Nepal and as well as his work at BP Koirala Institute of Health Sciences (BPKIHS) as Head of the Department of Obstetrics and Gynaecology, he is also Professor of Obstetrics and Gynaecology, Vice President of the South Asian Federation of Urogynecology, a National Trainer of Obstetric Fistula in Nepal.
Our fistula project partners with Fistula Free Nepal (FFN) to support women whose fistulas have been unable to be cured by conventional surgery. FFN has funding from a large US charity called the Fistula Foundation to cover the surgical repair of fistula and education at both the community and professional level but does not help the women for whom fistula surgery has been unsuccessful.
This is where we come in…..Fistula Free Nepal sources patients for us and with the help of Saguna, our Fistula Project Manager, we all work together to change the lives of women living with inoperable obstetric or traumatic fistula.
We rely on donations and the number of women we can help is determined by the generosity of our donors. We recognise that every woman is different; every woman’s circumstances are different and every surgical outcome is different and we work together to create an individualized patient care plan for each fistula affected woman referred to us depending on:
- Their age – the patients we help range in age from 33 to 69
- Their personal circumstances – whether they live alone; are on the street; live in a hut or a shack; are cared for by a neighbor or are still supported by family
- Their fistula – whether they have a vesico-vaginal (bladder to vagina) fistula, a vesico-rectal (rectum to vagina) fistula or both; whether it remains inoperable; whether multiple surgeries have failed; or whether they have undergone alternative radical surgery called a Mainz procedure where a new bladder is created out of a loop of bowel. This is last resort surgery and patients require life-long medical follow up
- Many need incontinence products and even patients who have had their fistulas fixed may still experience some incontinence
- Some like 69 year-old Hasta Maya who has lived with a fistula for 50 years and lives alone simply need funds
- Most need skills training
HOW YOU CAN HELP: Your generosity will enable us to change the life of a woman in Nepal with an inoperable fistula. It will support and help them with health and medical care, ongoing medical expenses, incontinence products, skills training, income generation and sometimes simply cash donations. These women have no one else to turn to and nowhere else to go.
Thank you for your generosity.
To visit our Fistula Project Facebook page click on the following link: