The article by Madeline King that appeared in O&G Magazine Vol 19;No 3:p 60, Obstetric fistula: a public health issue, reminds us of the tragedy affecting about two million women in developing countries. The majority of fistula sufferers live in isolation in the rural areas of Sub-Saharan Africa. Commonly, they have co-morbidities such as renal disease, anaemia and lower limb palsies.
Unrelieved obstructed labour is the cause of obstetric fistula formation. About 5 per cent of all labours become obstructed and the problem is solved in the developed world by assisted delivery. But where there are no obstetric services, obstructed labour usually resolves with fetal death and delivery of a stillborn with reduced diameters.
Although a narrow pelvis undoubtedly contributes to obstructed labour, the basic cause is malposition of the baby’s head, inadequate flexion, occipito-posterior position and deep transverse arrest. More than 90 per cent of women deliver at home in the rural areas of huge swathes of Sub-Saharan Africa, so assistance for obstructed labour is lacking.
Madeline King points to early marriage and childbearing with a narrower pelvis as the prime cause of obstetric fistula. However, experienced fistula surgeons dispute this. For example, Dr Andrew Browning, who has operated on 6500 fistula sufferers and seen 10,000, states ‘It is a commonly held assumption that early marriage is a risk factor for obstetric fistula formation. The link seems to follow common sense as it is known that pelvic maturity is reached some two years after menarche.’ Hence, the thought is that pregnancy at an early age leads to a higher chance of obstructed labour and fistula formation. However, this has not been proven in the field and it is hard to find an established fistula surgeon who would agree. For example, of an unpublished series of 2500 consecutive fistula patients in the Amhara region of Ethiopia, where marriage before menarche is the norm, only 45 per cent of fistula patients got their injury during their first labour, that is, when their pelvis was immature. A recently published paper by Browning1 showed that of those fistula sufferers who become pregnant ‘early’ or ‘late’, the obstructed labour occurs in their first labour in equal proportions, hinting that regardless of pelvic maturity, obstructed labour occurs in the first pregnancy in equal rates.
Northern Nigeria has one of the busiest fistula services in the world, in an area where early marriage is not the cultural norm. There are many arguments against early marriage, but obstetric fistula is not one of them. Eradicating early marriage will have a minor, if any, impact on the rates of obstetric fistula formation. The only way that obstetric fistula will be eradicated is the same way that it was in the West, by ensuring that all women have access to safe and timely obstetric services such as is provided by Maternity Africa.
The author also proposes that ultrasound would be valuable in the diagnosis of an obstetric fistula. This is not the case. A fistula is simple to diagnose, as the average size of an obstetric fistula is 3×2.8cm. All you need is a gloved hand. If that is not available, inserting a gauze or tissue in the vagina and removing after an hour or so will see that it is soaked with urine, indicating a fistula. Or there is the traditional dye test – a low-technology and widely available investigation rendering an ultrasound superfluous. Neither FIGO nor WHO guidelines nor any obstetric fistula text lists ultrasound as a diagnostic test.