Pregnancy complications in the developing world result in some 600,000 maternal deaths - and women who fail to get a Caesarean section may suffer from the shame of obstetric fistula, and be ostracised. But the situation is improving, writes Prof Eamon O'Dwyer
It is only when reading about the pioneering work of Australian couple, doctors Reg and Catherine Hamlin, in establishing a fistula hospital in Addis Ababa, and its successful operation over a period of more than 25 years, it becomes apparent how fortunate we are in the developed world to record minimal fistulas of obstetric origin (where obstructed labour has ruptured the internal passages of bladder and rectum).
Róisín Ingle's moving report in this newspaper (October 24th, 2002) of fistula in Africa was both inspiring and challenging. To have restored more than 20,000 young women to health and happiness after devastating trauma resulting from obstructed labour is an achievement in itself, but Lady Catherine Hamlin and her late husband have left a legacy, in the Hamlin foundation.They have trained scores of doctors and nurses to carry on their work. These in turn have helped to train others in the management of fistula in other areas of Africa.
In acknowledging the success of the Addis Ababa Fistula Hospital, we should recognise the contribution of a distinguished graduate of University College Dublin, gynaecologist Ann Ward, a Medical Missionary of Mary who has set up a fistula clinic attached to a mission hospital in Nigeria.
I wonder if many appreciate how fortunate we, in Ireland, are in relation to pregnancy and childbirth. Giving birth to a baby is very safe in Ireland. Here, the maternal mortality rate is about four per 100,000 births. Unfortunately, mothers in developing countries are not so fortunate, with upwards of 600,000 deaths each year from pregnancy and pregnancy-related conditions. In Ghana, for example there are 740 maternal deaths for every 100,000 births.
In a case of obstructed labour, where the baby's head is unable to pass through its mother's pelvis, there is prolonged pressure on pelvic tissues. The baby is usually born dead, while the mother, if she survives, suffers from a fistulous opening between the vagina and urinary bladder or the vagina and rectum, occasionally both bladder and rectum are involved. The end result is that the unfortunate young woman is permanently incontinent of urine or faeces, or both.
Outlining the consequences of obstetric fistulas, the United Nations Population Fund (UNFPA) states in its fact sheet Addressing Obstetric Fistulas: "affected women are often blamed for their condition, which may be confused with venereal disease. They are shamed, ostracised, divorced, abandoned, isolated and left without support. Many women are forced to become beggars".
Dr Ann Ward stresses the feeling of guilt which fistula patients experience: "My greatest job is to persuade them that they are not bad people and that what happened to them occurred because they are poor, they have no medical services, and they could not get to hospital in time for a Caesarean section".
It is estimated that for every maternal death in sub-Saharan Africa, upwards of 30 survivors suffer long-term damage to their health, including obstetric fistula. It is estimated that there are two million cases of fistula, with 50,000 to 100,000 new cases being added each year.
Is there any hope for those women with obstetric fistula who are not fortunate enough to benefit from direct care?
The 1987 Safe Motherhood Conference in Nairobi first drew attention to the tragedy of obstetric fistula and issued a call for action. Subsequent inaction, according to UNICEF, resulted from "a conspiracy of silence" and lack of initiative.
The Beijing Conference on Women, in turn, affirmed the right of women to the "highest attainable standard of physical and mental health".
And yet, in the words of the World Health Organisation, obstetric fistula remains "the forgotten disease". Women with fistulas remain outcasts, shamed and stigmatised and hidden from society because they are incontinent and foul-smelling and, because theirs is not a life-threatening condition, they rarely get to the top of hospital waiting lists.
In 1998, MaterCare International established a maternal health project at St Therese's Mission Hospital, a busy district hospital in Nkoranza, a small town in rural central Ghana. Plans to provide a birth trauma centre near the capital Accra, where Ghanaian doctors and nurses will be trained to carry out surgery and rehabilitation of women with obstetric fistula, are at an advanced stage.
MaterCare International is an organisation of health professionals dedicated to the care of mothers and babies, born and unborn, through new initiatives of service, training and research. It aims to provide all mothers in the developing world with care based on the highest medical and moral standards, and to promote the fullness of human life, including unborn life, through Christian principles.
MaterCare International has affiliates in Ireland, Australia, Canada, the UK and the US, all of which have charitable status. MaterCare chose Ghana for its initial activities because of the close co-operation which exists between the ministry of health and the conference of bishops in providing health care throughout the country. With an area eight times the size of Ireland and a population of 18 million, the country is poor by western standards. The per capita GNP is $400, compared with $25,000 in the US.
In Ghana, only 52 per cent of births are supervised, almost exclusively by traditional birth attendants. The maternal health project in Nkoranza has four programmes, now in their fourth year: a training programme to teach traditional birth attendants to recognise complications of pregnancy; a continuing-education programme for community nurse-midwives; provision of a radio-controlled, fully equipped emergency obstetric ambulances available on a 24-hour basis to the rural maternity centres to provide rapid transfer of mothers to St Therese's Hospital; and a blood transfusion service.
It is proposed to establish a 30-bed West African Regional Birth Trauma Centre to be located close to Accra, to provide treatment and rehabilitation for women with obstetric fistulas and training programmes in surgical repair and nursing for doctors and nurses.
The centre will be owned by MaterCare International and operated on its behalf by MaterCare (Ghana). Funding for the project will be provided, mainly, by MaterCare affiliates in various countries.
MaterCare (Ireland) Limited is a registered charity. To make a donation to MaterCare International's LifeSaver programme see:
www.matercare.org/lifesaver.html
Eamon O'Dwyer is Professor Emeritus, of Obstetrics and Gynaecology, National University of Ireland, Galway, and chairman of MaterCare International, and MaterCare (Ireland) Limited