We regard it as an accident of birth: obstetric fistula results from prolonged obstructed labour. The sustained application of pressure onto the vagina and urinary bladder walls by the impacted fetal head during childbirth culminates into the destruction of septa between either the vagina and the bladder or vagina and the rectum, resulting into loss of urine or faecal control. Women who suffer from this catastrophe are often stigmatized and become social outcasts. Obstetric fistula remains a public health problem of resource-limited countries like those found in sub-Sahara Africa. It is a sign of poor obstetric care. We regard it as a shame to the nation.
Today, we shall gain insight into the understanding of obstetric fistula from the perspective of the Haddon matrix – we shall see how we can prevent this catastrophe. The Haddon matrix is a standard tool for injury analysis. Haddon, a former head of the National Highway Traffic Safety Administration and director of the Insurance Institute for Highway Safety in the United States, developed it. He contemplated that injuries and accidents were not unpredictable, unavoidable acts of fate about which we could do nothing. But they were discrete events that occurred in specific settings characterized by the circumstances in which the humans experienced excessive energy in harmful ways (Wall, 2012).
Focusing on automobile safety, Haddon was able to note that the factors that contributed to an accident could be analyzed and understood and that we could derive strategies to reduce or curb such events and their consequences. He grouped these factors into three sectors, that is, the host, the force vector, and the environment in which the injury occurred. Looking at these three parameters, Haddon was able to divide the timeline of an injury into preinjury, injury, and postinjury periods. He eventually came up with the famous Haddon Matrix, which various disciplines have utilized. Professor L. Lewis Wall attempted to discuss how to prevent obstetric fistulas in resource-limited settings through the use of the Haddon Matrix. We summarize his findings here.
Wall noted that in Haddon’s perspective, obstetric fistula is an injury during the birth process that inflicts a woman when her labour becomes obstructed but, the relevant measures to curtail this obstruction are either nonexistent or unnecessarily delayed.
The matrix that follows; lists factors that at every point on the timeline that increase or decrease the chances of obstructed labour occurring and which promote or hinder a favourable outcome. Let’s get into them. Each paragraph will entail the factors in a sector in terms of preinjury (before labour), injury (obstructed labour), and post-injury (after obstructed labour).
Many women in sub-Saharan Africa, because of poverty and disease, are poorly nourished, are likely to become pregnant at an early age, and thus stand a high risk of cephalo-pelvic disproportion. Many of them are not married: those who are married not only got there at a very tender age but also lacking paternal support. Their low socioeconomic status hinders them from utilizing health services like antenatal services. It is during this period that the midwives assess the current pregnancy for any eventualities. As if this isn’t enough, many of these women lack access to high-quality medical services, lack of transport, and communication. There are no maternity waiting homes, and even at the only health centre III in the village, the services provided aren’t effective enough. We can’t escape the catastrophic obstructed labour in such scenarios.
The woman starts labouring in a poor nutritional state – this implies that her pelvic tissues are less resilient should obstruction occur. Obstructed labour eventually occurs, she develops dehydration, fails to empty her bladder because the impacted fetal head has sealed off the bladder neck, develops anaemia and infection due to chorioamnionitis.
She becomes obstructed from a hut with no paternal support or in the hands of an unskilled birth attendant who can neither use tocolytic agents nor appropriately use oxytocin to prevent postpartum haemorrhage. When she decides to refer her, the development of further injury to the less resilient pelvic tissues will depend on the timing and nature of operative interventions. They include operative vaginal delivery, symphysiotomy, destructive procedures, and Cesarean delivery. All of them require a highly skilled workforce that Dr Herbert Kayiga noted that they are not only always unavailable, but also undermotivated. Many women have arrived at CEmONC sites with ruptured uteruses because of a lack of prompt transport means and poor communication. In a setting like this, obstructed labour will prevail, the poor woman will end up severe morbidities. With this, you find that the woman has been delayed along three lines; delay in deciding to seek care, delay in arriving at the medical facility, and delay in providing appropriate intervention.
Related article: Obstructed labour Injury Complex: As complex as it gets.
In the aftermath of obstructed labour, if the woman hasn’t died of postpartum haemorrhage, how she survives the complications depends on her medical status, nutritional status, appropriate bladder emptying, wound care, level of anaemia, and the presence of infection. The health care team should make every effort to provide the care there’s. She may undergo a hysterectomy or a repair in case of a sustainable uterine rupture. The presence of blood transfusion services, antibiotics, and supportive medical care is paramount. The use of oxytocics to prevent postpartum haemorrhage is part of standard care. Complete evacuation of the uterine contents after labour will certainly prevent both bleeding and infections. Effective communication, transport, access to competent care immediately after delivery, as well as access to fistula surgery in case one develops is vital to complete recovery from the aftermath of obstructed labour. There should be a dire need for the community to understand the nature of the injuries caused by obstructed labour. We should advocate against the stigma. Social and economic, as well as public support, must be encouraged. Social and economic rehabilitation of women with birth-related injuries should be a priority by the political systems: there should be a political will to promote safe motherhood, effective fistula care, and prevention programs.
All in all, it is everyone’s responsibility to understand the extent of obstetric fistula and its relation to obstructed labour. Everyone can help in mitigating this problem that still dwells in the confinements and corridors of the most impoverished societies in South Asia and sub-Saharan Africa. Together, we can put an end to obstetric fistula by advocating for safe motherhood through the adoption of high quality, readily available pregnancy and childbirth services with the availability of highly skilled and motivated birth attendants. Obstetric fistula leaves a stain on every nation. We regard it as a national dishonour and shame.
Thanks for reading. You can access professor L. Lewis Wall’s article about this topic here for a more detailed overview.