Category — Fistula and Childbirth Injury

UNFPA campaign to end obstetric fistula invites you to change the world.

Fashion Internationale de la Mode Africaine

FIMA 2011

It was a pleasure to return to Niamey, Niger, this trip by far the most fashionable, sponsored by internationally renowned designer Alphadi and his innovative wife Kadidja, along with United States Ambassador Bisa Williams and the First Lady of Niger, colleague Dr Malika Issoufou Mahamadou. Promoting health and wellness along with creativity, fashion, beauty and the power of the African Diaspora, Fashion Internationale de la Mode Africaine 2011 made a clear statement – Health is Beautiful.

The Fashion Internationale de la Mode Africaine whirlwind of creative genius is the brainchild of haute couture designer Alphadi, whose dedication to the promotion of African fashion transcends the political landmines and traditional dogma of Nigerien culture, sparking debate in his country and awe in the world of international fashion.

Women’s Health

Committed to promoting health and wellness along with creativity and couture, FIMA 2011 invited 3 American physicians, Dr. Emily Nichols and her husband Dr. Jonel Daphnis – specialists in internal medicine and adult/pediatric emergency medicine, and myself – specialist in urogynecology and obstetric fistula repair. It was a pleasure to reconnect with colleague and expert fistula surgeon Dr. Abdoulaye Idrissa, connecting his work at the National Hospital in Niger with the newly minted Cure Hopital au Niger run by Dr. Gary Roark, and a tragedy to see the women suffering fistula waiting for surgical repair at the National Hospital no longer permitted to live on the hospital grounds, relocated instead to a garbage dump across the street from the hospital, camped out in a shared sisterhood of sorrow, resilience, patience and hope.

Dr. Gary Roark of CURE Hopital au Niger and Dr. Abdoulaye Idrissa of Hopital National, Niamey Niger

Obstetric Fistula

Obsetric fistula patients living in garbage dump next to hospital, Niamey Niger 2011

While these women gave permission to show their faces, the picture chosen is one that preserves anonymity, both for their privacy rights and to highlight the non-anonymous rag tents fenced with garbage in the background. In this place of filth and feral cats they have camaraderie, belonging and hope that was lost to them in their lives of exile as totally incontinent obstetric fistula sufferers living on the margins of their communities. As of my last mission to Niamey in 2005, these women were permitted to live on hospital grounds while waiting for surgery and after discharge from hospital while securing arrangements to return home. New hospital rules do not permit overnight stays unless you are in a hospital bed. With no half-way house option, these women now live across the street from the hospital, in sight of the side-entrance, in an open air garbage dump.

Maternal Mortality

The prevalence of obstetric fistula is difficult to know with certainty, typically extrapolated from the maternal mortality data to which it is closely related. Niger, for many years running, lays claim to the worst maternal mortality rate on the planet, at 1:7 risk. Compare this to maternal mortality in developed nations at 1:4000, and the difference between the two is simply obscene.

Obstructed Labor, Death and Disability

One great contributor to maternal mortality is obstructed labor. Without ready access to trained clinicians during labor, or EmOC (emergency obstetric care), women in obstructed labors lasting for 3, 4, 5 days and some up to a week, have 2 possible outcomes- maternal death, or maternal survival with severe damage to bodily function, including vaginal fistula causing constant incontinence of urine or stool, severe foot drop from pelvic nerve compression, uterine infection resulting in infertility, and vaginal fibrosis precluding sexual function, usually in some combination of miseries and almost always associated with a stillborn infant. Can you imagine the trauma, depression and anxiety these women suffer?

In developed nations we call this obstructed labor “failure to progress”, preventing the stillborns, fistulas, nerve damage and vaginal destruction with cesarean section performed according to accepted standards of care. For women living in remote rural areas of poor nations, access to such care does not exist. Women labor alone, or with a local lay-midwife with no formal training.

Access to emergency obstetric (EmOC) care allows any woman of any age and condition to be delivered safely, to be able to count on her own survival and that of her baby. Reduce maternal mortality through EmOC and watch obstetric fistula disappear, watch neonatal survival improve, just as occurred in the States and Europe with the advent of ready access to Cesarean delivery made possible by the then novel application of Ether anesthesia in the late 1800′s. Some 200 years later, the pregnant women of Niger are living as did women worldwide in 1850, in fear of their lives and the lives of their unborn babies with every single pregnancy every single time.

Taking care of the women takes care of the children, takes care of the men, takes care of the community and creates a new future full of hope and possibility for the country. Right now, as this post occurs, the pregnant women of Niger would be safer in DR Congo, in Somalia, Sudan, Bangladesh, Pakistan or Afghanistan. And all of these women in all of these developing and middle income countries can only dream of the safety and optimal mother-child outcomes enjoyed by their sisters lucky enough to live in wealthy nations where antenatal care and routine access to EmOC has nearly obliterated the constant threat of pregnancy-related death and disability.

With this initial collaboration of Nigerien and American doctors, the First Lady of Niger, the US Embassy and the creative genius of the House of Alphadi FIMA 2011, we look forward to the day when the women of Niger can rest assured that they, their daughters and grand daughters will bring forth future generations in comfort, in safety, in health as a birthright for mother and child.

FIMA 2011 Touareg Haute Couture – Niamey Niger

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org

Cesarean on Demand

More women than ever before are showing up at the hospital in labor and asking for a cesarean section.

According to the National Institutes of Health, the rate of c-section delivery has increased 40% since the mid-90s, a trend reflected in these NIH summary statements:

Between 1996 and 2007, the C-section rate rose by 53 percent, with similar rises seen among all age, racial and ethnic groups, according to the report released Tuesday from the U.S. Centers for Disease Control and Prevention’s National Center for Health Statistics, which used birth certificate data to arrive at this conclusion.

and:

After a slight dip in the late 1990s, C-section rates began marching relentlessly upward again. The pace of the increase has accelerated since 2000, with the overall rate surging from 23 percent to 32 percent in 2007

That translates to about one in four American babies being born via cesarean section.

So why has “cesarean on demand” become so popular?

One frequent reason is today’s mom-to-be believes avoiding a vaginal birth will reduce her risk of incontinence and pelvic organ prolapse down the road.

Pelvic organ prolapse is a condition that occurs when a woman’s bladder, rectum, or uterus shifts from its proper location, and moves into the vaginal canal.

But giving birth via cesarean section is NOT NECESSARILY the 100% protection from protection that some women think it is.

If only we came with zippers

Pelvic Organ Prolapse and Pregnancy

There’s new research on this topic, reflected in a new study published in the International Urogynecology Journal that examined the impact of a woman’s first pregnancy on pelvic support and found that less than one year after giving birth via c-section without labor, 21% of women experienced moderate organ prolapse and 5% of women who had cesarean deliveries experienced severe prolapse.

Since cesarean delivery did not necessarily prevent prolapse, the study’s authors suggest that simply BEING PREGNANT can increase a woman’s likelihood of prolapse, regardless of delivery mode!

This coincides with data showing that 50% of women who have borne children will experience prolapse at some point,  compared with 30% of ALL women, including women who’ve never been pregnant.

It IS important to note that women who gave birth vaginally DID experience higher rates of prolapse, according to the same Urogynecology Journal study.

But are these numbers significant enough to warrant cesarean on demand?

Maternal and neonatal mortality, uterine rupture, placenta previa & obstetric hemorrhage

Maternal mortality rates from cesarean are THREE TIMES higher than in vaginal delivery, according to Obstetrics and Gynecology.

Moreover, Birth magazine reported that babies are more than twice as likely to die when delivered via cesarean.

Knowing this, it makes sense NOT to opt for c-section delivery unless there is a legitimate medical reason for the best health of the mother or the baby.

Once the uterus heals from cesarean, future pregnancies are at risk for uterine scar separation, called uterine rupture, that can be deadly for the baby, and for problems with placenta previa, where the placenta is low and can hemorrhage at any time, further risking the life of the baby. Uterine rupture and obstetric hemorrhage are two good reasons to take cesarean section very seriously.

Thinking about elective cesarean section? Be a smart mother – make a wise choice with your obstetrician.

For a video on this topic, visit HealthGuru.com video on the truth about childbearing and cesarean on demand

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org

Pakistan National Women’s Health Forum Highlights Efforts to End Obstetric Fistula

I had the honor of speaking at The Pakistani National Forum on Women’s Health (PNFWH), held during the week of March 4^th, 2011 in Karachi.  The event featured renowned experts in reconstructive pelvic surgery, fistula treatment and women’s health from the Middle East, Africa, Europe, Asia and North America.

Based in Pakistan, PNFWH’s mission is to improve the quality of life for women regardless of race, creed or economic status.  Its holistic approach targets particularly those who would typically fall outside the reach of the benevolent hands of healthcare efforts – women who live along the rural areas and urban slum. The slogan of PNFWH is “Neglect No More, Dignity Restored.”

A fistula is an abnormal hole between the vagina and the urinary tract or the vagina and the rectum.  Fistula most often results from prolonged labor, where the woman cannot deliver the baby, often pushing for days and days before arriving for medical care. Once the baby is delivered, usually a dead baby, the delicate vaginal tissues that sustained all the pressure of days of pushing manifest the damage, resulting in fistula channels that allow the uncontrollable, constant passage of urine or feces through the vagina.

In many developing nations throughout Africa and Asia, where obstetric care is minimal or absent, obstetric fistulas are common and may be quite large.  Obstructed labors not only cause fistulas, it is not uncommon for a baby to be born dead under these circumstances, and for pelvic nerve damage to result in permanent foot-drop, making even the simple act of walking forever difficult for these women.

PNFWH joins with other civil service agencies, including United Nations Population Fund (UNFPA) to stand up for women’s rights and their health, empowering them to achieve their full potential in today’s society. In 2006, it’s Fistula Project aimed to do this by improving maternal health, decreasing maternal morbidity and disability, and rehabilitating women who suffer from the ‘aftershock’ effects of pregnancy and childbirth.

What does PNFWH look like in action?  The UNFPA-funded Fistula Project established seven regional and five referral Fistula Repair Centers that service women from all Pakistani provinces.  The free services include training of midwives, making quality surgery accessible to all patients by arranging reach-out camps and providing necessary transportation. Under these efforts, more than 2,111 fistulas were repaired with an impressive 93% success rate, restoring dignity to these patents  PNFWH promotes awareness and prevention of fistulas by advocating better childbirth practices across the globe.

To join the effort to end childbirth fistulas, or to learn more about PNFWH and UNFPA, visit

Pakistani National Womens Health Forum & United Nations Population Fund

Worldwide, “cesarean on demand” continues to increase. In the hopes of avoiding pelvic floor damage associated with birthing, some women have bought into the the trend for elective cesarean before onset of labor. Called “cesarean on demand” because patients demand it in the absence of a maternal or fetal indication, it’s the obstetric equivalent of Erica Jong’s “Zipless F**k”; the maternity version of having your cake and eating it too.

Well, guess what? Just BEING PREGNANT is a risk for all the unhappiness that pelvic floor mayhem can bring, including incontinence and its painfully un-sexy cousin, pelvic organ prolapse. One beautifully executed study evaluated vaginal anatomy before and after 1st pregnancy in three groups of mothers; one who had an easy vaginal birth, another who had a difficult vaginal birth with deep vaginal tearing that required lots of stitching, and third who, whatever the reason, had cesarean before going into labor. Understand that there are medically legitimate reasons for a woman to have cesarean without labor, such as toxemia (pregnancy induced high blood pressure), placenta previa (low-lying placenta blocking the cervix – natural labor with this condition results in the baby bleeding to death before it can be born), or breech presentation (at least in the States, due to out of control obstetric malpractice and the fact that breeches born vaginally have a small but real risk of birth injury that can be almost totally avoided with a cesarean, breech = cesarean until further notice), to name a few.

Looking at the pelvic floor support of these women after first birth, they found NO DIFFERENCE in moderate prolapse between the three groups. Severe prolapse was equivalent in the two vaginal birth groups and much higher than in the cesarean without labor group. But… the cesarean without labor group had a 5% incidence of severe prolapse – I’m talking cervix sticking out of the vagina prolapse, bladder bulging down pushing the labia apart when you walk prolapse.  Thinking a cesarean is the answer to your “I want to be a mother but I don’t want any physical changes in my body anywhere, especially in my vagina” dreams? Think again…

Here’s the study summary prepared for the Journal of Sexual Medicine:

Handa VL, Nygaard I, Kenton K, Cundiff GW, Ghetti C, Ye W, Richter HE. Pelvic organ support among women in the first year after childbirth. Int Urogynecol J (2009)1407-1411.

Increased public awareness of changes in pelvic floor anatomy related to pregnancy continues to foster the growing phenomenon of cesarean on demand, requested in the hopes of maintaining pre-pregnancy sexual function and reducing risk of prolapse and incontinence, two conditions known to negatively impact sexual quality of life in the majority of women so-affected. The true impact of pregnancy on pelvic support may be due to pregnancy itself, regardless of delivery mode, as stated by these authors; “cesarean delivery as a potential prevention strategy remains unproven.” This study prospectively evaluated the impact of first pregnancy on pelvic organ support of 256 women with three pregnancy outcomes – vaginal delivery without anal sphincter tear, vaginal delivery with anal sphincter tear, and cesarean delivery without labor. Pelvic support evaluation done at 6-12 month post-delivery showed stage 2 prolapse in 38% of women delivered vaginally with sphincter tear, 29% in those delivered vaginally without sphincter tear, and in 21% of women delivered by no-labor cesarean with no statistically significant differences between groups.  It is remarkable that 1/5 of the cesarean patients showed clinically significant stage 2 prolapse.  When looking further at stage 3 (true bulging past the hymen, clearly visible and palpable through the vaginal opening), there was a significant difference between vaginal birth and cesarean without labor, with 5% of cesarean women showing visible prolapse as opposed to 14-15% in both of the vaginal delivery groups.  Still, this 5% bulging prolapse despite non-labor cesarean raises the possibility that optimal patient counseling for women seeking elective cesarean for sexual function and pelvic organ protection may best include the realistic prediction of “a small but real risk bad prolapse even if you undergo cesarean before going into labor”. Letting women know that cesarean is NOT a 100% guarantee of avoiding pelvic floor consequences of pregnancy, along with the other risks of cesarean: peri-op morbidity, increased risk of placenta accreta, and increased risk of uterine rupture with subsequent pregnancies. This work adds to the data revealing that the impact of pregnancy on the pelvic floor may not be thoroughly negated by cesarean on demand.

Level of Evidence: IA

(c) 2010 Lauri Romanzi

In the Hausa/Fulani region of Northern Nigeria and Southern Niger, “Gishiri” is the term for salt, for “tasty” and slang for the genitalia of both sexes. “Yankan” is the word for cutting, and “Yankan Gishiri” (cutting with salt) has been used for generations as a local remedy for all sorts of ailments and conditions, including:
Pain with sex (dyspareunia)

Infertility

Pelvic Organ Prolapse (dropped bladder, rectocele, uterine prolapse…)

Boils

Itching

Urinary Retention (inability to urinate)

Prolonged Labor

Episiotomy

This remarkably harsh home remedy involved rock salt in it’s traditional form, but now, in the new millenium, Gishiri cuts are made either by a barber with a knife, or a local birth attendant with a razor. Seems a bit backwards- you might expect the barber to use the razor and the lay midwife to use a knife, but this is not the case, according to today’s presentation of “Yankan Gishiri” data at the 4^th annual meeting of the International Society of Obstetric Fistula Surgeons by Dr. Amir Yola from Kano, Nigeria.

As you can imagine, these cuts can do damage, including urinary or fecal incontinence from damage to the urethral or anal sphincters, or full thickness holes, or fistula, between bladder and vagina, urethra and vagina, or rectum and vagina.

Fistula after Gishiri cuts result from deep cuts that heal open, creating a fistula defect. Of 1372 fistula patients treated by Dr. Yola and his team in Kano, Nigeria, 78 (5.7%) of the fistula were the result of “Yankan Gishiri”.

How’s that for “pouring salt on the wound”?

A Yankan Gishiri-free view with which to recuperate from this blogpost

NOV 23, 2010

(c) L Romanzi 2010

The Step-Sisters of Fistula – Minimally Invasive Uterine Resuspension- Hysteropexy C’est Arrive au DR Congo.

The Stuff of Prolapse *image courtesy of "Women of the Shadows"

It is difficult to express how impressed I am during each and every Harvard Humanitarian Initiative mission (www.hhi.harvard.edu) by the  skilled, motivated, and wise  pelvic floor – fistula surgeons at Panzi Hospital in Bukavu, DRC.  On these many fistula-repair missions, I’ve come to understand that one of the most important ways to add value to colleagues upon whom we descend in our zealous compulsion to fix every woman with a fistula, is to realize that, in addition to the tragic, fashionable and international charity-funded fistula women found in every developing nation on the planet, there are women in these same villages suffering equal stigma, ostracism, divorce and abandonment as their fistulous sisters because they suffer incontinence of urine or stool, or waddle about in a state of severe pelvic organ prolapse. The prolapsing cervix can look a lot like the head of a penis, and many’s the woman accused of infidelity by the husband to whom she birthed all the children and for whom she’s carried all the loads of wood, water and supplies on her head that caused the prolapse in the first place. As if she had a single ounce of energy with which to seek out and fornicate with a man other than her husband – peeleeze.  Anyhow, this sort of tragi-comic mythology surrounds many medical and surgical conditions when the people suffering said conditions do so without the benefit of education and absolutely zero comprehension of internal anatomy. You have a fistula because you are possessed by evil spirits, you have prolapse because you cheated on your husband, you died from hemorrhage after your clitoris and labia were cut off ritualistically to transform you into a marriageable chattel because you were committing the ultimate sin of pleasuring yourself to the always dangerous female orgasm. Things like that.  Feel free to throw the conditions and myths into a hat to play the game of “mix and match”. It’s all the same, as are the personal ramifications – you’re divorced, thrown out of your house, often permanently separated from your children, and excommunicated from your village, this being the only home you’ve ever known and the only people that ever mattered to you since the day you were born.

The uterosacral/cardinal ligament complex holds the uterus in place

Unlike the condition of fistula, prolapse and incontinence don’t “go away” with modern medicine, new world economics or robust personal health and wealth. Even the well-healed at the Hampton Classic include wealthy ladies who are wetting their pants and wishing their parts would stay all up in there where they belong. While fistula vanished with the advent of ether anesthesia in the mid-1800’s, rendering vaginal fistula nearly obsolete in Europe and North America well in advance of the 1900 centennial, (the world’s first fistula hospital was in New York City, torn down when rendered obsolete by access to Cesarean section, replaced by the still present Waldorf Astoria Hotel on Park Avenue), prolapse and incontinence continue to plague even the wealthiest, best educated, most fashionable of women on the planet.  But fistula virtually disappeared as anesthesia made Cesarean section the cornerstone of optimal obstetrical practice and stellar reduction in Euro-American maternal mortality and morbidity statistics, because fistulas come from obstructed labors, and no one in a developed nation is allowed to suffer through a 2 week labor resulting in a dead baby and a destroyed, fistulous vagina. We just do a Cesarean if it’s taking too long. The luxury of quick, routine, easy access to Cesarean section remains unavailable to the majority of women in Sub-Saharan Africa and other impoverished nations.

So this time, rather than play the “American fistula heroine” game, I decided to back it up into the unglamorous territory of plain old US/European style pelvic floor disorders, these being pelvic organ prolapse and urinary incontinence. While these un-funded (they’re not on UNFPA’s radar at all) women have no international advocate, yet they are equally tortured and punished for these conditions that are beyond their control as is any fistula victim’s.

We started with prolapse patients today. Magically, (there’s a lot of magic in DRC), after being informed that there was only a single prolapse patient, 10 emerged from the ether, each with the most severe form of prolaase, called procidentia. Procidentia (remove the children from the room and erase this link from your laptop history, quickly!) is a total pelvic disaster easily diagnosed by visualizing the cervix dangling between the patient’s thighs, turning the bladder upside down and kinking the urethra and rectum in the process. It’s mortifying.

From Beverly Hills to Bukavu, uterine prolapse is all about the uterosacral ligaments

We started the day with a lecture-discussion where we engaged in robust, healthy debate about current theory and principle held true among international pelvic floor disorder specialists – with the exception of avoiding hysterectomy by utilizing uterine resuspension – in the States, with rare exception, uterine prolapse = hysterectomy unless the woman can find a pelvic floor specialist who understands that the uterus is the victim of prolapse, not the cause.

This notion of preserving the uterus even though it’s falling out my Congolese colleagues understood, given the large number of young women whose lives would be equally destroyed by hysterectomy as they are by the prolapse.  Here at Panzi they use a large abdominal incision to resuspend the uterus by shortening the round ligaments of the uterus, a somewhat dated technique used very rarely inEurope and North America currently because it tends to fail and distorts pelvic and vaginal anatomy. These round ligaments contribute little (or so we believe) to the vector support of the uterus, the starring role of which falls to the ligament pair known as the uterosacral (US) ligaments. These US ligaments are like 2 cables, holding up the uterus and cervix by suspension at the top of the vagina much like a chandelier is held up by cables in the ceiling of a room.

We talked about compartment analysis, evaluating the support of the uterus (Apex), followed by evaluation of the stuff of vaginal prolapse and vaginal laxity below the level of the uterus, bladder for cystocele (Anterior) and rectum for rectocele and perineocele (Posterior), and evaluation of the levator (a.k.a. Kegel) muscles separately. We reviewed the role and evaluation of the Kegel muscles and the support and potential childbirth damage to the all-important and under-appreciated perineal body (connective tissue separating vagina from rectum). We debated and evaluated each continent prolapse patient for occult stress incontinence by filling the bladder, holding the prolapsed parts in proper anatomic position as the might be after surgical reconstruction, and asking the patient to cough and strain to see if urine leaks with abdominal exertion – the finding consistent with stress incontinence. Shocker, just like we find in the States, 40% of these women with bad prolapse and no incontinence symptoms leaked like sieves with full bladders and the prolapse temporarily corrected with vaginal support, and these women will undergo incontinence sling for stress incontinence at the time of their prolapse reconstruction. Tomorrow, in the OR (operating room), the Congolese fistula surgeons of Panzi Hospital (www.panzihospitalbukavu.org) will be the first to perform vaginal uterosacral uterine resuspension (a.k.a. hysteropexy) in Central Africa.