Abstract

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Vesicovaginal fistula is a common complication of labor in some parts of the world, especially certain regions in Africa. Over the past few decades, several measures have been taken to reduce the global burden of this condition, and to treat patients already suffering from fistula. This article aims to describe the obstetric fistula situation in terms of prevalence, risk factors and available facilities in Sudan, where much work and effort has been put into fighting this condition.

Vesicovaginal fistula is a serious and debilitating condition, often aptly referred to as a ‘preventable tragedy’. The consequences of this condition are far-reaching, and it carries with it a lifelong social and economical burden, with lasting psychological and physical complications. Patients are often shunned from society and abandoned by their families.
It is estimated that 2 million women worldwid[i]e are living with vesicovaginal fistula, with the incidence being about 2 in every 1000 deliveries in Sub-Saharan Africa[ii]. In developed countries surgery and radiotherapy are the main risk factors for the condition[iii], while obstetric complications are the predominant risk factors in developing nations[iv].
In Sudan, the incidence of obstructed labor (followed by instrumental delivery) in 1997 to 1999 was 1.27%. Vesicovaginal fistula occurred as a complication in 1.5% of these cases[v], and 4.8% in another study[vi]. In one study in the city of Wad Madani[vii], the causes of fistula were obstructed labor (28%), forceps delivery (14%), Lower segment cesarean sections (16%), hysterectomy (24%), other gynecological operations (12%) and radiation (6%).
Poverty, early marriage, malnutrition and poor health services all seem to contribute to the obstetric fistula situation in Sudan. Low socioeconomic status contributed to over 80% of cases in one large study in 2008[viii], circumcision also played a significant role. Pharaonic (infibulation type) FGM is relatively common in Sudan, and in these cases healing with fibrosis may occur, leading to a delay in the second stage of labor causing obstruction. Most affected patients are young women in the age group 18-24 years old, and are primigravida. However, the majority of these cases married before the age of 18 years. More than half of patients with obstetric fistula in Khartoum did not attend regular antenatal care, and about 40% delivered at home. Most cases of obstetric fistula in Sudan come from the Western regions, including Darfur. In this region, sexual violence (including rape) is common[ix], and this has been shown to be a risk factor for fistula formation[x].
The authors of the 2008 study concluded that:
“Vesico-vaginal fistula in Sudan results from obstructed labor, mostly in a first pregnancy, a young woman who is poor and illiterate, not on regular antenatal care & being in labor for more than 24 hours"
It has been recommended that the emphasis on antenatal care, the training of midwives and the general improvement of socioeconomic status of women in Sudan should take priority to help prevent obstetric fistula. Doctors should also be advised to carefully consider the risks of instrumental (forceps) delivery, and opt for a Caesarian section in difficult cases.
In Sudan, there are 3 specialized fistula hospitals - Dr. Abbo National Fistula & Urogynecology Centre is by far the largest (two other centres in Kassala and Alfashir are also present). Dr. Abbo Hassan Abbo is one of the leading international experts in the field (awarded the life time achievement award by the International Urogynecological Association in 2009), and established this centre as an extension of Khartoum Hospital’s Fistula ward in 1989. Currently, the centre sees more than 700 patients per year[xi] and is tended to by 5 expert Fistula consultants. Also, all registrars training in obstetrics and gynecology in Sudan must work a shift at the centre. The hospital is a multidisciplinary effort including urologists, rectal surgeons and urogynecologists. The centre is the second largest in Africa and the Middle East, second only to the one in Addis Ababa, Ethiopia[xii].
In recognition of the essential role that social and economic factors play in fistula patients, the United Nations Population Fund, in collaboration with the Federal Ministry of Health, Sudan opened the National Centre for Rehabilitation and Social Integration of Fistula Patients in 2009 in Khartoum. It has a capacity of 40 beds, and complements the work of the Abbo National Fistula Centre.[xiii]

References

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http://countryoffice.unfpa.org/sudan/2010/05/20/2146/national_centre_for_rehabilitation_and_social _integration_of_fistula_patients_opened_in_khartoum/

Source(s) of Funding

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Competing Interests

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