The changing face of obstetric fistula surgery in Ethiopia

Author: Dr Felicity Gallimore – Obstetrician and Catherine Hamlin Fistula Foundation volunteer.

In late 2013, Hamlin Fistula Ethiopia commissioned renowned maternal health researcher Dr Karen Ballard of Trinity College Dublin to develop and coordinate research about obstetric fistula in Ethiopia.

Last year, Dr Ballard co-wrote an article ‘The changing face of obstetric fistula surgery in Ethiopia’ with specialist gynaecologist, Dr Jeremy Wright and Hamlin Fistula Ethiopia’s Medical Director, Dr Fekade Ayenachew. It was published in the International Journal of Woman’s Health.

She and her team, surveyed the number and types of obstetric fistula treated at three Hamlin Fistula Hospitals in Ethiopia over a 4-year period between 2011 and 2015.

The different types of fistulae

Obstetric urinary fistulae can be broadly divided into low or high urinary fistulae. Low fistulae are traditionally the result of prolonged compression of the lower vagina, urethra and bladder base between the baby’s head and the symphysis pubis of the pelvis. The outflow from the bladder, the urethra, can become disconnected from the bladder making surgical repair and return to full urinary continence much more difficult. Dr Ballard’s research showed 71% of all fistulae were of the low type.

High fistulae usually, but not always, follow operative intervention such as caesarean section. However, the bladder base and urethral sphincter are intact so the chance of cure following fistula surgery is very good. As a group, they comprised 29% of fistulas.

Fistula cases on the decline

Over the 4 years surveyed, Dr Ballard’s team showed that there were 2593 new cases of fistula. The overall incidence fell by approximately 20% per year.

Since Hamlin Fistula Ethiopia is the biggest provider of fistula care (80%) across Ethiopia this research points towards an overall national decline in fistula prevalence. Although only three of Hamlin’s Fistula Hospitals were surveyed, they account for 2/3 of the fistula workload within Hamlin and are likely to mirror the types of fistula experienced by women presenting to other centres. It obviously cannot report on types of fistula experienced by women who do not present for treatment.

Of those fistulae still occurring, there is a decreasing percentage of low fistulae suggesting that women are gaining access to help earlier when labour becomes obstructed prior to irreversible tissue damage occurring. These low fistulae are disproportionally represented in women less than 25 years old and particularly the under 20s.

High fistulae are still occurring, often as a result of the difficult surgery women require when they present late at health facilities. These caesareans can be technically very challenging and the high fistulae are more commonly seen in multiparous women (ie those who already have a child). Fortunately women with these high fistulae have a higher chance of having their continence completely restored.

A national focus on maternal health

Since 2005, the Ethiopian government has prioritised maternal health, and in the final two phases of the Health Sector Development Program it took steps to increase the number of health centres and maternal health professionals to provide a fleet of ambulances for transferring women in labour to higher level care facilities. Simultaneously they have also increased the number of medical student places and introduced an accelerated training program in emergency surgery and obstetrics. A key aim has been to produce a new generation of health professionals based in rural health facilities and capable of performing caesarean sections.

It is good to see these changes in the Ethiopian health sector are starting to bear fruit and with the support of the Hamlin Fistula Ethiopia, an Ethiopian woman’s journey in labour is becoming safer and safer.