Fistula Research Initiative

Obstetric fistulas are caused by prolonged obstructed labor, where the baby cannot pass through the birth canal. Due to limited access to emergency obstetric care, the baby often remains there for several days. This compresses the tissues of the vagina between the fetal head and the pelvic bones and causes significant tissue death (similar to a pressure sore). This leads to an obstetric fistula–a large hole between the vagina and bladder (and/or rectum), which results in unremitting urinary and often times fecal incontinence.

According to the UN Population Fund, there are approximately 2 million women around the world living with fistula, with 50,000 to 100,000 new cases every year. Although the hole, or fistula, can be closed surgically, only about 15,000 surgeries are performed worldwide each year, and the majority of women lack access to these surgeries. Nonetheless, in those who make the long journey to a surgery center, up to 50% of them remain incontinent even after the fistula has been closed, and therefore they continue to suffer the physical and social consequences of fistula.

Currently, obstetric fistulas are pandemic in areas where the majority of women deliver at home and do not have access to hospitals. These areas primarily include West Africa, Sub-Saharan Africa, and parts of Southeast.

Cultural Implications

The physical, social, and economic consequences experienced by a woman with fistula and incontinence are amplified by social and cultural factors. In many cultures where fistulas are common, prolonged labor is thought to be a punishment bestowed by God (or ancestral spirits) for adultery. The persistent incontinence and resulting urine crusted ulceration extending from the vulva to the feet make activities of daily living painful. The scarcity of water eliminates the potential for decent standards of personal hygiene.

The constant wetness is accompanied by an odor that makes sufferers unpleasant to be around. The incontinence leads to social isolation and abandonment by both immediate and extended family. Sufferers are often ostracized by society—forced from buses, unable to find employment, banished from social events, and compelled to live a life of shame and humiliation. In the words of one blind patient (treated by Dr. J. Kelly) who had been recommended to have her blindness treated first: “cure my fistula first…if I am blind people will come and sit with me and talk to me, but no one will come near me when I am wet and I smell”

Our Innovations

Evidence-based Fistula Care
Sites: Addis Ababa Hospital, Addis Ababa, Ethiopia; Panzi Hospital, Bukavu, eastern Democratic Republic of Congo

We have been working with the Addis Ababa Fistula Hospital (AAFH) in Addis Ababa, Ethiopia to improve the care of patients with obstetric fistula. Through collaboration with local care providers, we have designed and implemented novel medical equipment for patients at the hospital, and developed a series of innovative evaluation techniques for patients that continue to suffer from incontinence after fistula closure. These techniques, which aim to more comprehensively evaluate each patient, have since been adopted as standard of care at AAFH. We are currently working to disseminate our findings in the medical literature as well as begin implementing these techniques throughout the continent starting with the Panzi Hospital, Bukavu, eastern Democratic Republic of Congo.

A low-cost, durable medical device for patients with obstetric fistula
Site: Addis Ababa Hospital, Addis Ababa, Ethiopia

Through a partnership with Omni Medical Systems (OMS), a research and development firm that designs and manufactures in-flight bladder relief devices for NASA and the US military, we are working to develop a low-cost, culturally-acceptable urine management device. This device is not designed to replace surgical treatment, but instead designed to provide a means of managing the devastating consequences of obstetric fistula in the millions of women who lack access to surgery as well as those who continue to suffer incontinence after surgery, thereby helping patients circumvent the social and psychological implications of living with fistula.

Epidemiology of iatrogenic fistula in developing countries
Site: International collaboration with Dr. Thomas Raassen, Nairobi, Kenya

Recently, clinicians treating patients with obstetric fistula have noticed an alarming trend in increasing number of Cesarean sections (CS) performed in patients with stillbirths. Often times, these patients have been in labor for 3 or more days prior to CS. Although CS should be strictly reserved for cases where a viable birth is possible, more often than not, patients with prolonged obstructed labor undergo CS despite stillbirth. In addition to nearly 4 times increased likelihood for maternal death following CS compared to vaginal delivery, it has been shown that up to 13% of fistulas are iatrogenic in nature (i.e. fistula resulting from provider error during CS surgery). Through a data-set of fistula patients throughout Africa maintained by Dr. Thomas Raassen (a world-renowned fistula surgeon based in Nairobi, Kenya), we are working to collect and analyze the data necessary to better understand the epidemiology of iatrogenic fistula in developing countries. Together, we aim to educate local communities throughout the African continent and provide data-driven policy recommendation for reducing the rates of unwarranted CS.