In May 1855, Dr. James Marion Sims opened the first obstetric fistula hospital in New York City. Just 40 years later, it closed, reflecting a sharp decline in maternal morbidity rates in the United States and other Western countries. The Waldorf Astoria Hotel now stands on the site of the former hospital. “We know that we have eradicated obstetric fistula in high income countries; it happened at the turn of the 20th century,” says Dr. Lauri Romanzi, project director of Fistula Care Plus, in this week’s podcast.
That timing is crucial, says Romanzi, because there is a narrative that argues certain social determinants must be changed to eradicate fistula in developing countries today, such as forced marriage, teen pregnancy, women’s education and suffrage, antenatal care, and gender-based violence. Yet at the turn of the 20th century in the United States and Europe, many of these “mandatory” determinants were far from modern progressive standards (teen pregnancy remains substantially higher in the United States than other industrialized nations).
Speaking at a Wilson Center Maternal Health Initiative event, Romanzi says the turning point for fistula eradication in Western countries coincided with the advent of crude anesthetics, such as chloroform on cloth, which revolutionized surgical practices and made Caesarian sections more feasible for mothers. “Possibly that was a catalyst at that time, in those cultures,” she says. “We need to figure out what today’s catalyst is.”
Beyond the “Truffle Hunt”
Obstetric fistula is a childbirth injury caused by prolonged obstructed labor, often leading to incontinence, social stigmatization, infection, and even mental illness. Though fistula is almost entirely preventable and largely eradicated in high-income countries, it is stillwidespread in the developing world. Prevention and treatment is very simple says Romanzi, yet progress is moving slowly, leading some to question existing approaches.
Romanzi notes that in countries where fistula is more common, Cesarean section rates hover around 5 percent, whereas the ideal rate to prevent maternal morbidities is about 15 percent. But increasing the Cesarean section rate without regard to quality of care may cause further complications such as iatrogenic fistula, which is a form of genital fistula unintentionally caused by a health care provider. Iatrogenic fistula is often much more complicated than obstetric cases and is more likely to damage the kidneys, says Romanzi.
The “invisibility” of fistula and maternal morbidity care in general is often reflected in funding streams. A bigger budget for one West African hospital increased the number of deliveries the maternity ward could handle from 5,000 to 15,000 a year. Yet there was still only one operating theater, and poor quality of care caused many women to develop complications. “It’s an obstetric fistula factory,” says Romanzi. Patients are often funneled to a fistula clinic literally down the hill from the hospital to treat these maternal morbidities.
“Fistula has gotten a lot of attention, and deservedly so,” she says. “But there are many other morbidities as well.” Romanzi proposes implementing an obstructed labor screening program that would utilize many existing resources to address the multiple needs that obstructed labor patients have, rather than simply focusing on the “truffle hunt” of targeting fistula.
It’s important to look at the many factors that make eliminating maternal morbidities such a stubborn challenge in many places – patient to midwife ratios, midwifery education programs, waste management, water security, medical supply chains, and others, says Romanzi. She suggests focusing on localized, multi-sectoral, and self-sufficient systems that target disparities between the poor and wealthy to improve all areas of women’s health.
“The goal is that every woman, every time, has access to a facility that is outfitted and staffed to meet a minimum standard of care, within which both the health outcomes of the baby and the mother are optimized,” she says, “and that that care is rendered in a humane, kind, and caring fashion.”
Lauri Romanzi spoke at the Wilson Center on July 14.
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Sources: Academy of Surgical Research, Center for Disease Control and Prevention, Fistula Care Plus, Fistula Foundation, Medscape, RH Reality Check, The World Bank, World Health Organization