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Obstetric fistula--the untreated tragedy.

ONE OF the most distressing health conditions I have come across in South Sudan is young girls suffering from an obstetric fistula. An obstetric fistula is a childbirth complication due to obstructed labour. The tissues between a woman's vagina and her bladder or rectum are damaged from the continuous pressure from the baby's head stuck in the birth canal. (2) The tragic combination of a young girl having sex, getting pregnant and going through childbirth, when her body is not developed enough accounts for at least 25 per cent of known fistula cases. (2)

One of the surgeons at Wau Hospital, who tries to help these girls--he refers to them as the "fistula girls"--described to me how this situation arises. The story begins when a young girl is married off as soon as she has reached puberty. The average age for puberty for girls in South Sudan is 15, in contrast to New Zealand where, I understand, girls reach puberty as young as eight or nine these days.

Female circumcision still occurs in South Sudan, so the consummation of her marriage would be very painful. The husband has to penetrate the scar tissue at the entrance of the vagina--the direct result of the circumcision. Whether the young girl understands what is happening or not, this must be terrifying.

These girls very soon become pregnant. When labour begins, the baby's head is jammed against her pelvic bones, the inlet already narrowed by rickets. In New Zealand, she would have a Caesarean as soon as the contractions began but, in a remote village without the help of anyone but her mother-in-law, the girl suffers for days, her uterus trying to do the impossible. What actually happens is the baby's head is rammed against the bladder and cervix, crushing those tissues against the unyielding bony pelvis. The baby soon dies.

If the mother doesn't die due to a ruptured uterus or infection, septicaemia or shock, the dead baby has to be removed bit by bit, first by crushing the skull, then pulling the rest out. If the girl survives that ordeal, then the dead and gangrenous tissues inside her birth passage eventually slough off, leaving her with a jagged hole between the bladder and the vagina. Instead of urine passing from bladder to urethra to emerge only when the girl chooses to pass urine, the bladder now constantly leaks its contents into the vagina and down her legs.

Girls with this problem are never dry--their clothes are permanently soaked. Some girls are faecally incontinent as well. The bladder and urine quickly become infected and foul-smelling, resulting in wet and macerated labia and thighs, which ooze pus. If the husband and/ or his other wives haven't done so already, the girl is then cast out to fend for herself. Some girls are banished to live in a separate hut on the edge of the village and, if someone takes pity on them and brings them food, they survive an isolated, lonely existence as outcasts. If, by some miracle, they get to a clinic and from the clinic to a hospital that does fistula surgery, then these girls are well and truly survivors and deserve every chance.

I have heard stories of girls walking to clinics on foot, riding donkeys or travelling as far as they could by bus, before being thrown off by the other passengers because of the smell.

Before having surgery, the girls need to be admitted to hospital and fed meat, eggs, milk and vitamins, and given antibiotics to clear up any infections for at least one week but preferably two. Physiotherapists, who are part of the fistula team, teach the girls gentle pelvic floor and leg strengthening exercises to help them with the arduous recovery ahead.

The current team in Wau are from Spain and Switzerland. They come to South Sudan for a month once a year. There are 81 patients in the fistula wards, some reguiring repeat surgery. There can be only three attempts to repair the fistula before the patchwork of tissue left has no hope of healing.

Part of the surgeon's goal is to train surgeons here. It is up to the nurses to counsel the girls, who are badly traumatised by all the experiences that have seen them end up here. What they really need is long-term therapy with fully gualified psychiatrists.

Among the resources developed by the World Health Organization for its fistula prevention campaign is a poster called "The five failings that lead to fistula". It shows a hand with the fingers splayed out. In the palm is a dejected looking woman. The first failing, on the thumb, is being married off too young--child brides. The second finger represents non-existent prenatal care; the third is waiting too long to get help to the labouring young woman; the fourth, too few and too distant health centres where Caesareans can be done. Presuming the mother lives (the baby never does), the final failing represented by the little finger is that of the husband and in-laws, who cast the girl out because of the constant dribbling and smell.

What happens to these girls if they are lucky enough to get surgery and it is successful? I have no idea what the success rate is. I guess there are many variables, depending on the girl's condition before she seeks treatment. These girls cannot have children so they are no use back in their village. Going home to their parents can be problematic because then the father has to return the dowry of cattle he gets when each of his daughters is married off. No-one seems to know what happens here in South Sudan but, in neighbouring Ethiopia, I am told one of the fistula hospitals there helps the women learn a trade as part of their recovery. Some learn to sew and are helped to set themselves up in small businesses. Others make baskets or grow vegetables to sell in the local markets--at least some regain a livelihood and some sense of dignity.

Colette Blockley, RN, MA, works in Dunedin Hospital's neonatal intensive care unit. She is currently on leave, spending a year teaching student nurses and midwives at a Catholic Health Training Institute in South Sudan.


(1) Blockley, C. & Moore, Y. (2006) Working among the poorest of the poor. Kai Tiaki Nursing New Zealand; 12.11, pp23-25.

(2) Fookes, F. (2013) Fistula, a silent tragedy for child brides, Retrieved 23/11/15.

(3) Wikipedia. (2015) Obstetric fistula. https://en.wikipedia.Org/wiki/0bstetric_fistula#/media/File:Addis-ababa- fistula-hospital.jpg. Retrieved 24/11/15.
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Title Annotation:nursing overseas
Author:Blockley, Colette
Publication:Kai Tiaki: Nursing New Zealand
Article Type:Report
Date:Dec 1, 2015
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