Preventing Fistula :

Through Facility-Based Interventions

Obstetric fistula is preventable if obstructed labor is diagnosed early and if the woman receives appropriate, safe, and timely emergency obstetric care from a skilled provider.

In low-resource settings, delays in receiving this care at health facilities contribute to maternal death and disability, including fistula. Building on EngenderHealth’s long experience in improving the quality of clinical services, Fistula Care chose to focus its facility-level fistula prevention activities on strengthening three labor and delivery care practices:

Correct and consistent use of the partograph
Immediate urinary catheterization after prolonged or obstructed labor
Timely and appropriate cesarean section

This section includes a variety of materials focusing on facility-based interventions including evaluation and research studies, a journal article and technical briefs documenting service delivery models, reports from consultative meetings, and tools and job aides for providers.

Correct and Consistent Use of the Partograph
The partograph is an important decision-making tool for monitoring and managing prolonged and obstructed labor. It is a preprinted one-page form on which observations of labor progress and information about maternal and fetal condition are recorded. The partograph is designed to act as a low-tech early warning system, alerting doctors, midwives, and nurses to the need for action: referral to a higher level facility, labor augmentation, or cesarean section. Correct and consistent use of the partograph has the potential to reduce obstructed labor and its adverse consequences, including fistula.

Fistula Care routinely monitored partograph use at supported sites as an indicator of project effectiveness. A wide range of program activities aimed at promoting partograph use, and the resources contained in this section reflect the broad scope of these activities were undertaken.

A literature review on partograph use and effectiveness showed that in most low-resource settings, the partograph is underutilized, with many providers not understanding how to use it properly. As a result, labor monitoring may not translate into the emergency actions required to prevent maternal injury or death. The findings of this review led to an international consultative meeting on the partograph where participants were unanimously in favor of partograph use to improve quality of care in labor and delivery. Between 2013 and 2014 EngenderHealth and the University of Manchester, with funding from the Bill and Melinda Gates Foundation, will undertake research which will provide an original synthesis of existing evidence to help overcome barriers to effective partograph training and implementation.

Immediate Catheterization
Urinary catheterization is a procedure used for both prevention and early nonsurgical treatment of genital fistula. Evidence indicates that up to 25% of women with fistula may heal spontaneously with early catheterization treatment.¹ Based on current clinical guidelines, Fistula Care promotes immediate urinary catheterization to prevent fistula for all women who have suffered prolonged or obstructed labor at its supported sites.

Project experience from Nigeria (estimated to have the highest prevalence of fistula) demonstrated great variation in the ways in which immediate catheterization was implemented across sites. This indicates a need to develop clinical standards and guidelines to ensure quality of care and optimize outcomes.

Timely and Appropriate Cesarean Section
Safe and timely cesarean section saves the lives of women in obstructed labor and can also prevent fistula. It is vital that providers be clinically competent, because in the wrong hands, cesarean section can also cause fistula. For this reason, Fistula Care has focused on promoting access to and improving quality of cesarean delivery services. It has sought to achieve this through training surgeons, nurses, and midwives in emergency obstetric care by providing essential equipment and supplies.

Cesarean section is a major surgical intervention, so it must be performed appropriately and for valid medical reasons. The quality of clinical decision making depends on the availability of accurate information and standardized evidence-based guidelines. Strengthening the production and use of data for decision making to improve the quality and performance of fistula prevention and treatment services is one of Fistula Care’s main programmatic strategies.

View the Resources and Tools.

1. Waaldijk, K. (2004). The immediate management of fresh obstetric fistulas. American Journal of Obstetrics and Gynocology 191: 795-799.