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In the second of our Clinical Conversations series, Dr Melaku Abriha, Medical Director at Hamlin’s Mekele Fistula Hospital, explains the psychological impact of obstetric fistula.
How does obstetric fistula impact women emotionally?
Around 41% of our patients suffer psychologically because of their obstetric fistula injury. This ranges from minor anxiety, to post traumatic stress disorder, major depression and even attempted suicide.
In many cases women with obstetric fistula are experiencing psychological problems from the start of their pregnancy. A woman living in a rural area, without education or income, may be prevented from accessing family planning services and cannot decide on the number of children she wishes to have.
In 90% of cases, women who experience an obstructed labour have a stillbirth. Even where babies are delivered alive, the mother may not have access to antenatal care and she loses her baby in the first week of life.
Child loss causes its own mental anguish. Then, because of her obstetric fistula, more than 60% of women will be divorced by their husbands. Because she can’t bear children, the woman may experience neglect and be stigmatised and rejected from society.
When we find women living with obstetric fistula, we bring them to one of the six Hamlin fistula hospitals and put them on the road to recovery. With proper treatment, the outcomes are good. Surgery offers a successful treatment option for the physical injury, even some of the worst injuries. Once cured, many women will retain their marriages. Even the social mistreatment ends.
How does life change for a woman with an untreated obstetric fistula injury?
When the husband divorces her, the woman will have to go back to her family with maybe just a single room. Because of her smell, the family may not want to share that room with her as they have visitors coming for social and religious ceremonies.
Instead, she may be asked to live in another cottage where she will only have human interaction when food is delivered to her, like a dog. She may stop eating because of the urine and stool leakage and because she doesn’t like the odour and wants to prevent it.
Over time, she might develop adult malnutrition. We have seen women come to the hospital who are just 28-30 kg, dehydrated, malnourished and with their joints fixed in place because they have lain in just one position without moving.
The stigma of obstetric fistula results not only in psychological injuries, but additional physical injuries. Most of our patients come with a lot of orthopaedic complications.
What does the process of recovery involve?
For a simple fistula case, a woman can be discharged smiling in her new dress after just 29 days. A woman with a complex case may need 7 days of surgery alone.
Joint problems may require further surgery. You need to correct their anaemia and any infections. Being away from home for so long can result in further stigma and some women can never go back.
That’s why Dr. Hamlin designed a nurse aid arrangement. Former patients undertake the training and can then help in the hospital with new patients.
Only 25% of women will have a pregnancy and experience childbirth after fistula repair; 75% of our patients will end up with sort of reproductive failure. You can imagine the emotional impact on a young woman of just 18 years.
In addition to surgery, what else do women need to recover?
Hamlin looks at how to improve the quality of life of each patient. Surgery is very important, but the contact a surgeon has with the patient is not very long. As part of the pre-operative care, counselling is very important. You must tell the patient frankly the likely outcome of the surgery, the type of the surgery, and who’s going to do the surgery.
We have a 90% closure rate and 70% cure. But patients want 100%. They want to have another pregnancy. So, you have to counsel them on the likely results.
You also need to explain to women that their fistula is not because of God, but because of an obstructed labour. Sometimes I will say it’s obstructed justice. The woman had an obstruction somewhere in the health system. It’s a system failure, it’s not a punishment from God.
This is the second instalment of our Clinical Conversations series, where we interview our staff on a range of reproductive health topics. You can also find the interview recordings on our YouTube channel.
