Keywords

1 Introduction

Every day, about 830 women die worldwide from complications of pregnancy or childbirth with about 99% of deaths occurring in developing countries (Alkema et al., 2016; WHO, 2018). Current estimates indicate that for every woman who dies from pregnancy-related complications, 15–30 suffer from serious co-morbidities (Schwartz, 2015)—these include urogenital fistula, and all of these conditions are preventable and treatable (UNFPA, 2009). Urogenital fistulas are defined as abnormal communication, congenital or acquired, between the urinary tract and the female genital tract. This communication may appear between the bladder and the uterus or urethra and vagina. There are various varieties of urogenital fistulas: urethro-vaginal fistulas, vesico-uterine fistulas, and vesico-vaginal fistulas (Langkilde et al., 1999; Tafesse, 2008).

Urogenital fistulas can occur congenitally, but are most often acquired from obstetrical, surgical, radiological, malignant, and various causes. In developing countries, including most of those in Africa, more than 90% of fistulas are of obstetric etiology, while in resource-rich countries such as the United Kingdom and the United States more than 70% occur after pelvic surgery (Hilton, 2003, 2016). In this chapter, we will discuss obstetric fistulas (OF) occurring as a complication of pregnancy.

Obstetric fistula is a condition that results from prolonged obstructed labor, most commonly affecting women living in resource-poor countries where access to Emergency Obstetric and Newborn Care (EmONC) including obtaining an operative delivery is difficult for a variety of reasons. Those women living in rural areas and those in households with low socioeconomic status have fewer opportunities to benefit from such EmONC, and especially cesarean delivery, and therefore are more likely to be at risk of having an obstetric fistula. The prevention and management of obstetric fistula is included in the Sustainable Development Goal 3 (SDG3) of improving maternal health by the United Nations (United Nations, 2018).

Obstetric fistula is rarely seen in developed countries, but it continues to cause pervasive physical, emotional, and social suffering for many women in developing countries (Donnay & Weil, 2004). Despite its devastating impact, it is one of the most neglected diseases of maternal health in low-income countries (Wall, 2012). Among its serious repercussions on the patient’s life are urogenital discomfort, psychosocial morbidity, and disruption of conjugal life.

Obstetric fistula is a major global health challenge, although it is difficult to determine its global, national, or even regional prevalence for a number of reasons: (1) it is not a reportable condition; (2) there is no routine surveillance for this condition in countries where it is prevalent; (3) women with OF may not be forthcoming about having the condition; (4) it mainly affects women living in the most remote areas; and (5) women with OF are often stigmatized.

The World Health Organization (WHO) estimates that between 2 and 3.5 million women worldwide live with untreated fistula and that between 50,000 and 100,000 women are newly affected with it each year (WHO, 2006). The vast majority of cases are in sub-Saharan Africa and South-East Asia (Creanga et al., 2007; UNFPA & EngenderHealth, 2003). The exact prevalence in the Democratic Republic of the Congo (DRC) is not well-known, but the United Nations Population Fund (UNFPA) estimates that about 40,000 women suffer from obstetric fistula in this country (UNFPA, 2009; UNFPA & EngenderHealth, 2003). The 2007 DRC Demographic and Health Survey reports indicated that 0.3% of women report having already experienced fistula symptoms (Ministère du Plan et Macro International, 2008). Due to the hidden nature and the complex veil of misperceptions that surround this condition, many researchers consider these figures largely underestimated, mainly because many fistula women do not seek care or are unaware of the possibilities of surgical repair (Creanga et al., 2007; Nsambi et al., 2018).

The Democratic Republic of the Congo is a developing country where a large part of the population lives in rural areas. The urbanization rate, the urban population in relation to the total population of the Democratic Republic of the Congo, was estimated at 32% in 2007 (Flouriot, 2008).

This chapter focuses on obstetric fistulas as they are observed in the Democratic Republic of the Congo and more specifically in the province of Haut-Katanga which is located in the south-east of the country.

2 Haut-Katanga and Its People

2.1 Geography

Since 2015, Haut-Katanga has been a province in the Democratic Republic of the Congo following the break-up of the province of Katanga. This new province’s territory corresponds to that of the historic Katanga-Oriental that existed during the early period of post-colonial Democratic Republic of the Congo between 1963 and 1966. It is located in the south-east of the country, on the border with Zambia (INS, 2016). Haut-Katanga has an area of 128,264 km2 and shares its borders:

  • in the North with the provinces of Haut-Lomami and Tanganyika,

  • in the West with the province of Lualaba,

  • in the East and South with the Republic of Zambia.

Haut-Katanga comprises six territories (Kipushi, Mitwaba, Pweto, Sakania, Kasenga, and Kambove) and two major cities (the capital city of Lubumbashi and Likasi). Its climate is temperate in the South, and warm in the North. The average temperature varies between 10 °C and 40 °C. It is marked by two seasons: dry season from April to September and rainy which goes from October to April (INS, 2016). The soil is sandy in the north and sandy clay in the south with the dominant vegetation being the “savanna”. There are mountain ranges and two main lakes (Moëro and Tshangalele) as well as large rivers (Luapula, Lufira, Luvua). The Luvua River connects Lake Moëro with the Congo River (INS, 2016).

2.2 Population and Activities

In 2015, its population was 4,391,146 (50.4% male and 49.6% female), which represents approximately 4.4% of the population of the country as a whole. Its density is 34 inhabitants/km2. The dominant ethnicities and tribes are: Lamba, Sanga, Bemba, Bakunda, Balomotwa, and Kaonde (INS, 2016).

The main activities are fishing, trade, mining, and agriculture. Lubumbashi, the second largest city in DRC, is the mining capital of the country and is a base for many of the country’s biggest mining companies. The various resources of this province constitute a major asset for its economic development. All the territories of this province are rich in wealth. Its subsoil is rich in copper, zinc, manganese, cobalt, gold, etc., and attracts large mining companies to set up on its territory. These create jobs and generate considerable resources for the State (INS, 2016).

The province of Haut-Katanga is becoming more and more a crossroads of large mining companies as a consequence of the considerable increase of the population. The soil of Haut-Katanga is rich and thus constitutes an important source of income for its inhabitants. Food crops are cultivated in a traditional manner and without the use of chemical fertilizers (INS, 2016). Livestock, including cattle, is practiced in the Kundelungu plateaus and in many other areas. Fishing occurs in the Luapula and Moëro lakes, as well as in rivers such as the Lufira and Luvua. The territory is also rich in tourist reserves. These tourist sites constitute one of the main sources of income for the State. Among these are the waterfalls such as those of Lofoï (the highest waterfall in Africa, sheltered by the Haut-Katanga, which falls from a slope of 384 m in height) and those of the Luapula River called the “Falls of Johnson”, close to Kasenga on the Luapula, which forms a natural border between Katanga and Zambia, between the Moëro and Bangwelo lakes. Another natural resource is the Kundelungu National Park that was created in 1970, which covers 7600 km2 and contains many animal species including monkeys, lions, leopards, antelopes, and zebras (INS, 2016).

Although French is the official language, the main spoken lingua franca in the province is Kiswahili.Footnote 1 In addition, the influx of many people from rural areas for employment has resulted in a variety of imported languages including Kiluba,Footnote 2 Chokwe,Footnote 3 Bemba,Footnote 4 and Kisanga,Footnote 5 among others.

3 Environmental and Cultural Context of Childbirth

Obstetric fistula is associated with certain socio-economic and cultural factors (Holme et al., 2007; Kasamba et al., 2013; Muleta, 2004). Obstetric fistula (called “kasusu” or “kinswi” in the Bemba language) is more the preserve of rural than urban women because of the qualitative disparity of the health structures concerning in particular the qualification of its personnel. The rural setting is characterized by under-qualification of antenatal clinic staff and lack of access to surgical interventions, while most qualified physicians live in urban areas and most rural hospitals have inadequate facilities for surgical emergency care (Cavallaro et al., 2013; Hsia et al., 2012; Kinenkinda et al., 2017). In addition, the reference health structures in which a cesarean section can be performed are too remote from environments where most rural populations live (sometimes beyond 100 km). Added to this are the geographical inaccessibility and the lack of roads to access hospitals. The rural population resides for the most part in remote and isolated areas with a mediocre road network making emergency evacuation for dystocia difficult or late. It often takes hundreds of kilometers to reach a health center with a hypothetical functional surgical unit (Meyer et al., 2007; Nsambi et al., 2018), and the bicycle is most of the time used as an ambulance (called “kitebo” in the Bemba language) (Fig. 21.1).

Fig. 21.1
A photo of a man with his bicycle. 2 women help a pregnant woman seated at the back to get down, while 2 other women in aprons look at each other.

Bicycle being used as an ambulance. (Photo Credit: Olivier Mukuku)

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In addition, there are ethnocultural beliefs that regard as sacred early marriages, home deliveries, and delivery by vaginal birth, the latter praised as the method of delivery whatever the cost. This pronatalist ethnocultural attitude characterizing sub-Saharan Africa makes cesarean births highly unpopular, and operative deliveries can be stigmatizing to a mother. In some villages where we have recruited patients with obstetric fistula, cesarean section is seen as a curse and in addition, a woman who undergoes a cesarean section is considered unfit for marriage and can even be divorced.

The combination of these environmental and socio-cultural factors explains the fact that most women (70.7%) deliver their infants at home (Table 21.1) (Nsambi et al., 2018), mainly under the supervision of a traditional birth attendant (called “nakimbela” in the Bemba language). Other authors have also reported high rates of home-based delivery ranging from 91.1% to 97.1% (Hilton & Ward, 1998; Ijaiya & Aboyeji, 2004; Meyer et al., 2007). The duration of labor leading to the development of obstetric fistula was, on average, 2.25 days with 99.6% of mothers having a labor duration of 24 h or more (Nsambi et al., 2018). In the literature, this average duration varied from 2.5 to 4 days (Harouna et al., 2001; Hilton & Ward, 1998; Melah et al., 2007; Meyer et al., 2007; Nafiou et al., 2007), while 72.5% to 95.7% of obstetric fistula patients had labored for 24 h or more (Ahmad et al., 2005; Holme et al., 2007; Melah et al., 2007; Nafiou et al., 2007; Wall et al., 2004).

Table 21.1 Distribution of patients by location of delivery. [Source: Adapted from Joseph Bulanda Nsambi, Olivier Mukuku, Jean-de-Dieu Foma Yunga, et al. (2018) Obstetric fistulas in Haut-Katanga province, Democratic Republic of Congo: report of 242 cases. Pan African Medical Journal. 29(34). Some modifications were made. https://doi.org/10.11604/pamj.2018.29.34.14576, licensed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/)]
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The major risk factors associated with the development of obstetric fistula include neglected obstructed labor, accidental injury during cesarean section, forceps delivery, craniotomy, symphysiotomy, and traditional obstetric practices. In rural areas, deliveries are conducted at home in the huts (Fig. 21.2) used as delivery rooms (called “Musakuta” in Bemba) by traditional birth attendants, who are in most cases untrained. They have no knowledge of dystocia and are unaware of the normal duration of parturition. For them, all pregnant women must give birth vaginally at all costs; this helps to explain the long duration of labor until childbirth (average: more than 2 days). Sometimes, the nakimbela make use of prohibited maneuvers (e.g., use of mortar and pestle pressure on the belly of the parturient) to force the expulsion of the fetus, thus leading to obstetric morbidities such as uterine rupture or obstetric fistula.

Fig. 21.2
A photo of few huts on a sandy ground with trees in the background.

Hut used as a delivery room—musakuta. (Photo Credit: Olivier Mukuku)

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Obstetric fistula leads to serious social and economic impacts on the lives of these affected women (Mselle & Kohi, 2015). The majority of women are abandoned by their spouses or partners who cannot bear the stain originating from the permanent flow of urine and stool with foul-smelling odors. In the series of 242 women with obstetric fistula recruited in rural areas of the province of Haut-Katanga (Nsambi et al., 2018), we reported that 71.5% of them were abandoned by their spouses. The divorce rate due to fistula is about 50% in Nigeria (Wall, 2006) and 87% in Niger (Harouna et al., 2001). Socially, these patients (called “bakinswi” in Bemba) fear stigma and discrimination end up evading the community to avoid the gaze of others and live in a state of ostracism without sharing their state. This is a factor aggravating the social experience of the patient who is subjected to physical and moral suffering (total loss of status and dignity) (Mselle & Kohi, 2015; Ndiaye et al., 2009).

4 Characteristics of Women with Obstetric Fistula

4.1 Sociodemographic Characteristics

Obstetric fistula occurs preferentially in young parturients: the very young age of the woman with obstetric fistula has been noted by several authors (Falandry, 1992; Harouna et al., 2001; Holme et al., 2007). Among 242 women with obstetric fistula (Table 21.2), we noted that the mean age at onset was 23.20 ± 7.72 years (range: 13–51 years); 65.3% of them (158/242) were under 25 years of age and 40.1% (97/242) were teenagers (age under 20) (Nsambi et al., 2018). The increased obstetrical risk in adolescent girls may be partially explained by anatomical immaturity. In adolescents, the pelvis grows more slowly and gradually until old age. In addition, the acquisition of the adult size does not imply an equivalent growth of the pelvis because “the pelvis does not definitively finish its configuration until the 25th year, although the adult forms are reached around the age of 16” (Maryam & Ali, 2008). This immaturity of the pelvis is responsible for the anomalies of the basin (limited basin, basin usually shrunk) in the teenager, who is prone to more frequent obstetric complications (Faucher et al., 2002).

Table 21.2 Distribution of patients by age and parity at the onset of obstetric fistula. [Source: Adapted from Joseph Bulanda Nsambi, Olivier Mukuku, Jean-de-Dieu Foma Yunga, et al. (2018) Obstetric fistulas in Haut-Katanga province, Democratic Republic of Congo: report of 242 cases. Pan African Medical Journal. 29(34). Some modifications were made. https://doi.org/10.11604/pamj.2018.29.34.14576, licensed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/)]
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In our study, the majority of women (90.9%) were primiparous at the time of fistula onset (Table 21.2) (Nsambi et al., 2018). Studies in Uganda and Zambia reported that one in two women with obstetric fistula was primiparous at the time of fistula development (Hancock & Collie, 2004; Holme et al., 2007). This shows that obstetric fistula usually affects primiparous adolescents probably because of pelvic insufficiency leading to obstructed labor (for cephalopelvic disproportion and prolonged labor) (Jokhio & Kelly, 2006; Munan et al., 2017; Nafiou et al., 2007; Rosenfield et al., 2007).

In the villages where we conducted our study (Nsambi et al., 2018), marriage takes place traditionally at an early age. The girl, as soon as she has her menarche, is directly considered ready for marriage (early marriage), and this results in school abandonment. The vast majority of our patients (94.7%) were out of school, and this is in line with the findings of most African authors who have observed that girls and women with obstetric fistula have rates of out-of-school attendance ranging from 90.5% to 94.7% (Jokhio & Kelly, 2006; Kaboré et al., 2014; Kambou et al., 2006; Nielsen et al., 2009). Studies by Holme et al. (2007) in Zambia and Roka et al. (2013) in Kenya reported that the level of education in girls and women was statistically very low compared to those without fistula. Uneducated or poorly educated women are often deprived of the necessary information on the importance of antenatal care and hospital delivery; they also do not often have access to quality care, as the low level of education is an indirect reflection of the low socioeconomic level.

4.2 Anthropometric Characteristics

Women with obstetric fistula are usually small. In our study (Nsambi et al., 2018), 68.2% of the patients had a weight of less than 50 kg and 73.2% of the patients were less than 150 cm in size (average: height of 145.1 ± 7.1 cm). In a study by Wall et al. (2004), 55% of fistula patients weighed less than 50 kg and 79.4% of them were less than 150 cm in height. Holme et al. (2007) and Ahmad et al. (2005) reported average heights of 148 and 145 cm respectively. The small size and weight deficit in obstetric fistula patients have been confirmed in most published series (Ahmad et al., 2005; Holme et al., 2007; Melah et al., 2007; Wall et al., 2004). This deficit of stature and weight reported by various studies is due to several factors: anemia, malnutrition, early pregnancies occurring before the end of puberty, and early cessation of growth. Previous studies found that girls and women with obstetric fistula were thin and short, two independent risk factors for obstructed labor (Malonga et al., 2018; Sokal et al., 1991). According to Lansac et al. (2006), small stature is a classically known risk factor for dystocia. Since growth in height typically stops shortly after menarche, as pelvic growth continues (Moerman, 1982), women who are married at a young age (as are most cases in our series) may become pregnant before they reach full adult pelvic status. The combination of early marriage with short stature, incomplete pelvic growth, and generally contracted pelvis predisposes this female population to cephalopelvic disproportion during labor.

5 Characteristics of Obstetric Fistula

In our environment, the delay between the development of obstetric fistula and its repair (age or duration of obstetric fistula) is often very long. The average duration of obstetric fistula was 4.76 years with extremes of 6 months and 34 years; more than one in three patients had fistula for 5 years or more (Nsambi et al., 2018). In Pakistan, Jokhio and Kelly (2006) reported that 40% of patients had fistula for more than 5 years. In Tanzania, Cichowitz et al. (2018) reported that 48.3% of patients had lived more than 10 years with obstetric fistula. This advanced age of fistula in our patients was multifactorial, encompassing social, technical, financial, and environmental issues:

  • The stigmatizing nature of the pathology that leads patients to isolation.

  • The long clinical tolerance of the disease which is not immediately life-threatening, with many women who do not seek medical attention preferring to live alone with their illness.

  • Lack of information about the possibilities of surgical management of the condition that results in women resorting to traditional treatment.

  • Lack of financial resources to cope with healthcare expenses, which is also a contributing factor to the delay in medical consultation.

  • Lack of integrated prevention and management policy of obstetric fistulas in our health system.

The duration of obstetric fistulas is an important factor in preventing socioeconomic and psychological consequences. The long delay in the development of the disease is a source of stigma, discrimination, and abandonment, and is among potential factors influencing the separation of married couples (Ndiaye et al., 2009).

Regarding the anatomical variety of obstetric fistulas, vesico-vaginal fistulas are the most frequent with proportions ranging from 70.6% to 96.3% (Fig. 21.3) (Harouna et al., 2001; Holme et al., 2007; Kaboré et al., 2014; Kayondo et al., 2011; Washington et al., 2015). In some of our patients in Haut-Katanga, we found vesico-vaginal fistulas associated with a rectovaginal fistula. This high frequency of vesico-vaginal fistula compared with other types of fistulas is probably due to the greater likelihood of compression of the anterior vaginal wall by the fetal head against the pelvis causing more frequent ischemia of the bladder than that of the rectum.

Fig. 21.3
A photo of the vagina depicts obstetric fistula. 2 gloved hands with forceps.

An obstetric fistula. (Photo Credit: Olivier Mukuku)

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6 Management of Obstetric Fistula

6.1 Status of Organized Surveillance and Planning

At the national level, no strengthened plan for the eradication of obstetric fistula has been developed (i.e., subsidizing deliveries, making delivery kits available in rural maternity hospitals, giving priority to doctors working in rural areas, etc.). Up to the present time, obstetric fistula is not listed as a notifiable disease in the DRC’s health information system.

Obstetric fistula appears to be a silent morbidity among Congolese women that has attracted the interest of donors, non-governmental organizations, local partners, and United Nations’ reproductive health organizations who have joined forces for the elimination of obstetric fistula. Technically, there is a lack of infrastructure, staff, and healthcare workers specialized in the repair of obstetric fistulas. As in other African countries where fistula is prevalent, patients who are poor are not able to afford the cost of medical care and transportation to consult in a specialized medical center.

Not long ago, there were no public facilities specialized in the management of fistulas throughout the province of Haut-Katanga. Nevertheless, in our country, there were only two public centers that were created with the support of international organizations. These centers are located in the capital city of Kinshasa (Saint Joseph Medical Center) and in the province of South Kivu (Reference General Hospital of Panzi). In the province of Haut-Katanga, there was no specialized center, and obstetric fistula care was performed in the form of campaigns in rural areas by Médecins sans Frontières (Doctors without Borders) and Médecins du Désert.

Beginning in 2013, a private structure has emerged in the city of Lubumbashi. This structure works in collaboration with a non-governmental organization of Congolese rights called “Hope Mama Africa”. It provides specialized care in the field of repair of urogenital fistula permanently and thus covers the entire province of Haut-Katanga. It is composed of four doctors trained in vaginal surgery (specifically in the repair of fistulas) including a gynecologist-obstetrician, eight nurses, and two anesthesiologists (Figs. 21.4 and 21.5). This structure, although private, is in close collaboration with the rural health zones for the search for and selection of patients with obstetric fistula.

Fig. 21.4
A photo of 3 medical staff in scrubs perform surgery in an operation theatre.

Dr. Nsambi (middle) and his assistants in the operative theatre repairing an obstetric fistula. (Photo Credit: Olivier Mukuku)

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Fig. 21.5
A photo of 4 medical staff in scrubs.

Dr. Nsambi (second from left) and his fistula repair team in the operating room in Lubumbashi. (Photo Credit: Olivier Mukuku)

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6.2 Recruitment of Patients

Recruitment of affected women is implemented through awareness messages distributed via community relays and non-governmental organizations working in rural areas. These non-governmental organizations are reaching out to more remote areas of the province for patients with obstetric fistula. Some patients are referred by public health facilities such as health centers and general referral hospitals.

Given the technical plateau and the short period for campaigns, women in care were those carrying a simple urogenital fistula (or type 1) or a type 2 or 3 complex urogenital fistula according to the Goh classification (Goh, 2004). No woman with a complex type 4 urogenital fistula or severe urogenital fistula (transection) was treated.

7 Results

Surgical repair is the mainstay of treatment for fistula management (Figs. 21.6 and 21.7). Recall that abnormal communication between the viscera tends to close spontaneously before the end of epithelialization, provided that the natural flow pathways are not obstructed.

Fig. 21.6
A photo of the vagina. 5 gloved hands perform surgery.

An obstetric fistula undergoing surgical repair. (Photo Credit: Olivier Mukuku)

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Fig. 21.7
A photo of the vagina with obstetric fistula during surgery.

An obstetric fistula before undergoing surgical repair. (Photo Credit: Olivier Mukuku)

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To promote an early closure, especially in cases where the fistula is small, it is necessary to circumvent the mechanisms of the urethral sphincter by catheterization. Continuous drainage of the bladder, combined with antibiotics to limit tissue damage caused by infection, is an initial treatment for obstetric fistulas that develop after a dystocic delivery. Indeed, spontaneous closure of obstetric fistula has been reported in up to 28% of cases when catheterization was used (Waaldijk, 1997).

The success rate after surgical repair of obstetric fistula—defined by complete closure of the fistula—varies from one center to another and is determined by many factors such as fistula site, degree of healing, previous attempts at repair, repair technique, surgeon’s expertise, equipment, and post-operative nursing. The success rate in our study was 86% (Nsambi et al., 2018). Such high rates of success after repair are reported by other authors ranging from 71.7% to 93.4% (Gessessew & Mesfin, 2003; Holme et al., 2007; Kambou et al., 2006; Kayondo et al., 2011; Loposso et al., 2016; Moudouni et al., 2001; Muleta, 1997; Paluku & Carter, 2015; Sori et al., 2016). However, even after successful closure, 15–20% of cases may continue to suffer from urinary incontinence. Predictors of failure include vaginal scarring, circumferential fistula, and previous attempts at repair (Browning, 2006; Goh et al., 2008; Nardos et al., 2009; Roenneburg et al., 2006). The most important factor in successful fistula repair is adherence to basic surgical principles, including careful preoperative evaluation, exposure of the fistula and surrounding tissue scale, tension-free closure, excision of all fibrotic tissue, and maintenance of a suture line that is kept uninfected and dry (Kayondo et al., 2011). Closing the bladder is much more important in achieving a successful repair than vaginal closure. As long as these principles are followed, the surgical approach often concludes successfully. In most cases, the choice is essentially dictated by the procedure which the surgeon is more comfortable and familiar with.

The same is true about the method of approach when repairing the fistula. The arguments differ as to whether the abdominal or vaginal approach is the most appropriate for fistula repair. But we must recognize the need for individualized care based on anatomical relationships, extent of injury, and co-morbidities. In our series from Lubumbashi, 69.4% of fistulas were repaired vaginally (Nsambi et al., 2018). The vaginal way represents for us the best path, because it is the most anatomically simple and offers an optimal surgical exposure, thanks to the traction on the balloon of a Foley probe. We have favored the vaginal approach when vesico-vaginal fistula was near the neck of the bladder. The benefits include a low rate of complications, less bleeding, rapid postoperative recovery, and short hospital stay (Kayondo et al., 2011). Almost all types of vesico-vaginal fistula can be repaired vaginally. There are technical devices to widen the vaginal way (Dupont & Raz, 1996). These include:

  • Schuckhar lateral episiotomy (used to repair a rectovaginal fistula associated with a vesico-vaginal fistula).

  • Posterior episiotomy of Picot-Couvelaire (considered dilapidated, but which lowers the vaginal dome and makes it possible to externalize a high-situated fistula).

  • Disinsertion of the anterior face of the bladder to the pubis.

We reserve the abdominal surgical approach for those cases that had a fistula that could not be properly visualized and exposed vaginally behind the orifices of the ureter, either because of vaginal stenosis, or in rare cases where an intra-abdominal pathological condition required simultaneous care, or in cases of vesico-uterine fistulas.

8 Conclusion and Perspectives

In summary, obstetric fistula remains an important obstetric problem in low-resource countries. It is strongly associated with stillbirth because both are related to obstructed labor in the absence of EmONC. Reliable epidemiological and demographic data on obstetric fistula in low-resource countries are lacking.

Safe delivery is a basic human right; the real challenge is to make it a practical reality for everyone. National strategies for prevention are much more important for the ultimate eradication of this devastating disease. These strategies include government’s recognition of fistula as a major public health concern, improving the status of women in society, expanding primary education especially for girls; development of supportive infrastructure and trained specialists; and affordable, accessible, and acceptable services for all pregnant women.

Emphasis should also be placed on the involvement of religious and traditional leaders in circumventing certain socio-cultural barriers.

The government, as the ultimate guarantor of the country’s health policy, should:

  • Implement a coherent health coverage plan and ensure equilibrium in terms of equipment and human resources between urban and rural areas (in particular, motivation of the nursing staff).

  • Give women access to a health center, skilled medical care, and cesarean section in those cases of obstructed delivery.

  • Train nurses in these facilities to perform antenatal referral consultations and EmONC.

  • Implement legal instruments that condemn early marriage and increase the number of doctors repairing fistulas (training and encouragement of sustainable care projects).

The community should help and support the government’s efforts in this area by relaying information through community health workers who would be in charge of sensitizing the community on the use of health services.