I have borrowed a book 'Practial Obstetric Fistula Surgery', and while I don't plan on ever doing any it has helped me learn more about caring for women with fistulas, especially before history taking today. The authors say that nobody knows how many women are affected by this condition, but estimates are up to two million in Africa alone. We have had 14 new potential patients arrive mostly from Togo who are waiting for screening prior to surgery. They are a fantastic bunch of women who are are having their histories taken this week, will be assessed by the Surgeon on Monday (once they have arrived) and then surgery will start Tuesday.
VVF is caused by unrelieved obstructed labour. Prolonged pressure of the baby's head on the pubic bone results in tissue necrosis of the surrounding soft tissues. The authors of the book do emphasise that a fistula patient is so much more than someone with a hole in their bladder - the whole person is affected following development of this condition. At one of their places of work 100% of women test positive for psychological disorders such as depression on admission. Despite leaving dry, 30% will still test positive - when you think that they have lost so much else - often their baby, job, husband... maybe it is not so suprising.
It is tough reading for a midwife, the average labour endured by affected women is 3 days. Most of the labours result in stillbirth and most of the women infertile due to a number of causes - only 20% of post-repair patients will achieve a term pregnancy in the future. There is a high risk of miscarriage or prematurity due to the cervix not being able to support pregnancy. This problem would not need to affect so many women if there was greater access to care in labour, with the availablility of caesarean sections. We might moan about the health care systems at home, but obstructed labour can be diagnosed and interventions used leaving the mother and baby healthy. I might be a midwife who can't praise normal birth enough and who would rather work in a birthing centre than an Obstetric led unit, but I am glad they are there! So a caesarean section might not be part of your birth plan, but given some of the alternative consequences that we see here they are truly not the end of the world.