Re: Delivery mode for prolonged obstructed labour resulting in
obstetric fistula: a retrospective review of 4396 women in Central and
East Africa
In their paper ‘Delivery mode for prolonged obstructed labour resulting
in obstetric fistula: a retrospective review of 4396 women in Central
and East Africa’1 Ngongo et al make the point that
84% were delivered of a stillbirth and that there was a rising trend in
caesarean delivery rising from 45% to 64% in the 14 year study period.
This is mirrored in a recent study by Tasnin2 et al
who in a cohort of 634 women reported that 58% of the fistulae they
were seeing were iatrogenic, rising from 43% in 2007-7 to 71% 2017-18,
a significant number resulting from hysterectomy. A study from Hamlin
Fistula Ethiopia3 looking at all new fistula
presenting to 3 of their facilities between 2011-2015 showed that the
number of new cases fell year on year by 20% but the percentage of
iatrogenic fistulae rose from 26-32%.
It is worth examining the possible reasons for this apparent rise in
iatrogenic fistulae. Millennium development goal number 5 was to reduce
maternal mortality and improve maternal health. Countries with a high
maternal mortality ratio tried to increase the number of women
delivering in an institution with a skilled birth attendant who could
identify the onset of obstruction by the use of partograms and detect a
deterioration in the maternal and fetal condition, hopefully ensuring
proper management in the most suitable setting. . To this end hospital
practitioners, in Ethiopia health officers with surgical training, were
taught caesarean section, and newly qualified doctors had to spend time
in rural health facilities. They were required to undertake caesarean
section with little training other than limited practice in carrying out
elective caesarean section under supervision in a regional facility.
Importantly they have little training in how to place incisions
appropriately when the fetal head is deeply engaged and in safe
techniques to dis-impact the head. Even basic care such as ensuring the
bladder is empty, and continuous drainage post-delivery may be ignored.
This pattern is repeated in most Sub-Saharan countries and those that
have limited access to medical care. Practitioners would have had little
if any training in operative vaginal delivery and would be very unlikely
to have carried out a destructive delivery. Those of us working in
fistula surgery have also noticed an increasing number of women
presenting with severe perineal and urethral (leading to loss of the
distal urethra) trauma which has not been treated or poorly treated at
the time as the necessary expertise or equipment has not been available.
Health professionals are reluctant to take responsibility, blaming a
failing service and mothers who do not seek help early.
Dealing with these problems in rural areas with poor transport is
difficult. Medical professionals in rural areas with their lack of
facilities, long hours if not weeks of duty, and associated poor pay are
not attractive for either the professionals or their families, many of
whom will stay in urban centres isolating the doctor further. These
problems are difficult to resolve but need to be tackled if one is going
to improve maternal outcomes in a low- income setting. There are no easy
solutions but better audit, possibly performance related pay and a
greater personal responsibility for the care provided may be a start to
improve the care for the many thousands of poorly provided for mothers.
Jeremy Wright
Semi-retired Obstetrician & Gynaecologist
Previously gynaecological specialist and fistula surgeon
Hamlin Fistula Ethiopia
Fekade Ayenachew Aklilu
Consultant fistula surgeon International Fistula Alliance
Previously Medical Director Hamlin fistula Ethiopia
- Ngongo CJ, Raassen TJIP, Lombard L, van Roosmalen J, Weyers S,
Temmerman M. Delivery mode for prolonged, obstructed labour resulting
in obstetric fistula: a retrospective review of 4396 women in East and
Central Africa. BJOG 2020;
https://doi.org/10.1111/1471-0528.16047.
- Tasnin N, Bangash K, Amin O, Luqmen S, Hina H Rising trends in
iatrogenic urogenital fistula: A new challenge.
https://doi:10.1002/igjo.13037
Wright J, Ayenachew F, Ballard KD. The changing face of obstetric
fistula surgery in Ethiopia. https://doi.org/10.2147/ijwh.s106645