When we talk about obstetric fistula, there is a tendency to emphasize the treatment side, probably because of the well recognized backlog of cases. Indeed, the needs are vast, almost impalpable. In my missions and during my exchanges with colleagues however, it has become evident to me that, as well as treatment, we should focus much more on prevention of fistula. While fistula treatment certainly addresses the problem, fistula prevention on the other hand, although often very challenging, actually deals with the causes.
Obviously, prevention (including access to voluntary family planning services), should go beyond strengthening health systems and reinforcing competencies, but this is usually the first step we consider when tackling the problem in affected countries. The reason behind this is simple: stronger health systems increase the chances for all women to access timely, skilled health care, therefore reducing the risks associated with pregnancy and childbirth.
However, in some contexts, even if we strengthen the health systems and improve access to skilled health care, problems may persist simply because, when it comes to childbirth, women may not be able to seek appropriate care for many reasons. For example, they might not have decision-making power about their own reproductive health, or perhaps culture and traditions dictate that they should deliver in their home, or maybe their well-being is simply not a priority in their community at that time.
When addressing these problems, we need to examine issues such as increasing public awareness on the value of girls, as well as self-esteem and the social status of women. These are important factors which determine and shape their health condition.
However to empower women socially and economically is not only very challenging, but it also takes time and investment. Besides, it encompasses dealing with deeply rooted cultural norms, as well as beliefs. Changes in these structures can take generations to occur. As we know, most development programmes have much shorter time spans for such interventions, and must also produce quicker, measurable results.
To magnify this challenge, many countries with high numbers of maternal deaths and disabilities like obstetric fistula, are often affected by natural and man-made disasters, such as conflict, as well as severely entrenched poverty and inequality, crumbling (or non-existent) infra-structures and other complex developmental issues.
Dealing with fistula is like dealing with a bath tub which is filling with water because the taps are both on. We are trying, with great determination to empty the bathtub with a cup. But the cup is small and cannot make much of an impression, as the tap water is greater in volume than what can be removed with the cup. The obvious solution to emptying the bath tub is to continue removing the water with the cup, while turning off the taps.
Our approach to obstetric fistula has to be a holistic one. Of course, we have to treat the existing cases as best we can with the limited resources we have, hoping to mobilize national commitment and funds to reduce the huge backlog of cases.
It is vital that governments are fully engaged in the fight against the problem. The inclusion of fistula as a public health priority in national programmes and policies is an important indicator of the level of commitment at country level. In addition, if we are able to foster financial support, we will certainly have a more robust system that can help to promote a more integrated approach in countries with high numbers of fistula cases.
It is of course important to strengthen national health systems, since they create the infrastructure to both enhance prevention mechanisms and perform quality fistula repairs. And when we talk about national health systems we also mean national health professionals, since forever bringing surgeons and other health personnel from abroad is not a sustainable way of addressing the issue.
If we maintain only a salvation approach with the occasional seasonal fistula camp managed by travelling professionals, we are but renewing a process that does little to empower nations and to promote sustainable public health strategies.
In addition to all this, we need to address the causes leading to fistula. Not only the ones related to the delays that might put a woman at greater risk of developing a fistula, but the ones associated with social factors, embedded cultural norms, gender relations and women’s education and empowerment.
As the evidence repeatedly shows us, educated and respected women have a better chance of having good health. And healthier women inevitably means healthier families and communities.
Fistula is a complex issue, but like our bathtub the solution lies in reducing the volume of cases, while preventing the development of new ones. I can’t help but feel that, although it might sometimes look like an endless dilemma, we should try to think outside the box to identify ways to change the perspective, and prevention is certainly the way forward.