Aira Hospital

About Child Birth Injuries

VVF / RVF

A fistula is caused by unrelieved obstructed labor, either due to Cephalo Pelvic Disproportion CPD (“the baby is too big and/or the pelvis too narrow”) or Malposition (“the baby comes the wrong way” – ex. transverse or oblique). The presenting part of the fetus causes continuous strong pressure on the bladder and/or rectum, and if not relieved in time necrosis (tissue death) of the bladder and/or rectal wall will occur. An abnormal opening between the vagina and the bladder (Vesico Vaginal Fistula = VVF) or the rectum and vagina (Recto Vaginal Fistula =RVF) is the end result. The women with a fistula cannot control the urine and/or the stool, and despite every effort she can never keep herself clean and dry, or free from bad smell. Often she will be abandoned by her husband, and will eventually end up as a social outcast. Only surgical repair of the injuries can restore her health and social integration.

VVF / RVF repair at Aira Hospital

Aira Hospital has offered surgical repair of vesicovaginal (VVF) as well as rectovaginal fistulas (RVF) since more than 40 years. The present surgeon at the hospital was trained in Addis Abeba Fistula Hospital in 1979, and has since then been practicing the skills learned there.

Previously a German mission hospital, it has since many years been under the administration of the Ethiopian Evangelical Church Mekane Yesus (EECMY).

Approximately 75% of the hospital budget is covered by income, mainly from patients’ fees, the remaining 25% used to be covered by a Christian NGO in Germany, but not anymore since 2007. The organization has decided not to support curative health care anymore, stating that the hospital ought to be self-sufficient. At the moment the hospital only receives regular financial support from Evangelisches Luteranisches Missionswerk in Niedersachsen (ELM), which allocates a yearly grant of 100 000 ETB to the hospital’s poor fund, but that is far from covering the actual needs. The majority of patients who gets support from the poor fund are women with complicated deliveries and childbirth injuries (like VVF and RVF). In principle all fistula patients are treated for free. But as the hospital now is without the previous financial support, it is questionable if the free service can continue.

The number of deliveries in the hospital is approximately 1 300 a year, the majority of which are complicated, so we perform around 400 cesarean sections a year. This is due to the fact that no medical trained person is present in 97% of all deliveries in our area. That is also the cause for the very high number of complications and childbirth injuries like VVF and RVF. We perform around 70 surgical procedures for ruptured uterus a year with a maternal mortality of only 3%. Approximately 50 fistula operations are performed a year at the moment. The number used to be higher, but since the Norwegian Mission started a “women’s project” in Begi the number has decreased substantially. One agenda in this “women’s project” is to collect and transport fistula patients to the Addis Abeba Fistula Hospital for surgical treatment. A somewhat embarrassing situation for Aira Hospital when the EECMY, in which the Norwegian Mission is said to be integrated, does not show confidence in their own institution.

The hospital is in dire need of external grants to the poor fund so that free treatment of the most poor and vulnerable, mostly women with complicated deliveries and childbirth injuries (VVF /RVF) can continue..

Prevention is better than cure

It is commonly misunderstood that fistulas are caused by early marriage, by selective malnutrition of girls, by female circumcision, or even by rape and sexual abuse.

Even if all marriages and first time pregnancies could be delayed until whatever age, even if malnutrition could be prevented and female circumcision eradicated, there would still be a lot of new fistula patients.

One has to focus on the fact that the one and only cause for a fistula is lack of competent nearby obstetrical service. Everything else is of no or minor importance. If only every woman in labor had access to obstetrical service, so that a caesarean section could be performed within four hours after the delivery gets complicated, there would be no fistulas occurring.

Remember that some hundred years ago fistulas were as common in the west world as it is in Ethiopia today. Only when trained midwifes and hospitals with surgical service became generally available in the west world, the incidence of fistulas decreased, and is now unheard of.

Teen-age pregnancies are not very uncommon in the developed world, certainly not in the USA (where you even have religious sects practicing polygamy, child marriage and child pregnancies) but VVF/RVF are extremely rare due to the fact that good obstetrical service is at hand, and no obstructed labor goes unattended for a longer period.

Another important fact to keep in mind is that more than 50% of the fistula patients in Ethiopia are multipara (have already delivered one or more children), so it is certainly not exclusively young first time pregnants who are victims of VVF/RVF.

Any midwife who has seen a large third degree tear (a tear involving the rectum) in an otherwise normal delivery will understand that the soft tissues can never cause any major obstruction to delivery. The expelling forces are simply too powerful. That is why female circumcision, even in its most extreme form, is not related to fistula. Some years ago a Swedish gynecologist published her result of comparing the second stage (the time from start of pushing to the delivery of the child) in circumcised and uncircumcised women. Very surprisingly she found that the second stage was shorter in circumcised women!

Only when good obstetrical service is general available, are fistulas prevented. The Ethiopian government is planning to build 400 health centers all over the country, and has already started to train a great number of health officers, who will have legal right to perform cesarean section. Bringing obstetrical service to the far countryside, near to the patients, will certainly have a great impact, and will hopefully bring down the present high frequency of childbirth injuries.

How to support the fistula service in Aira Hospital

1) Financial support to the hospital’s poor fund. That will help to continue our free treatment of fistula patients.

2) Funds for upgrading nurses to health officers, who can staff remote health centers and bring obstetrical service near to the needed. The cost of a three year training program is approximately 100 000 ETB for one nurse.

3) Funds for employing a permanent (Ethiopian) gynecologist at the hospital to improve the obstetrical service. The cost would be at least15 000 ETB a month.

It is difficult to imagine how miserable a life with a fistula could be. The fistula patient is often young and will have to suffer the rest of her long life, if not cured by surgery.

Two out of these five women, who were operated for fistula in the hospital, have suffered for more than 20 years.

Now and then we have the great joy to perform caesarean section on women who previously got a successful fistula repaired in our hospital. This young woman got a lovely baby by caesarean, and promised to come back again for another caesarean when she is due to delivers her next baby:

Even the most experienced fistula surgeons have an overall success rate of approximately 75%. In spite of the fact that more than 90% of the fistulas will close after one or more surgical procedures some women have suffered such a severe injury that the sphincter mechanism is permanently damaged, and because of that cannot control the urine. To repair this injury is far more difficult than the fistula repair as such..

Whenever I have a failure after fistula surgery I remember the father of modern fistula surgery Dr J Marion Sims. He tried several years and did 30 surgical procedures on the same woman before he succeeded to cure the fistula!

This also demonstrates what a miserable life you have when suffering from a fistula. Imagine to voluntary undergo surgery - which at that time 160 years ago- was crude and cruel without anaesthesia - thirty times in the desperate hope of a cure. The womans name was Anarcha, and although the surgeon was was the most stubborn of the two, she was the bravest.