Overcoming phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries

Abstract

BackgroundAn obstetric fistula is a traumatic childbirth injury that occurs when labor is obstructed and delivery is delayed. Prolonged obstructed labor leads to the destruction of the tissues that normally separate the bladder from the vagina and creates a passageway (fistula) through which urine leaks continuously. Women with a fistula become social outcasts. Universal high-quality maternity care has eliminated the obstetric fistula in wealthy countries, but millions of women in resource-poor nations still experience prolonged labor and tens of thousands of new fistula sufferers are added to the millions of pre-existing cases each year. This article discusses fistula prevention in developing countries, focusing on the factors which delay treatment of prolonged labor.DiscussionObstetric fistulas can be prevented through contraception, avoiding obstructed labor, or improving outcomes for women who develop obstructed labor. Contraception is of little use to women who are already pregnant and there is no reliable screening test to predict obstruction in advance of labor. Improving the outcome of obstructed labor depends on prompt diagnosis and timely intervention (usually by cesarean section). Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. This time interval is often extended by delays in deciding to seek care, delays in arriving at a hospital, and delays in accessing treatment after arrival. Communities can reasonably demand that governments and healthcare institutions improve the second (transportation) and third (treatment) phases of delay. Initial delays in seeking hospital care are caused by failure to recognize that labor is prolonged, confusion concerning what should be done (often the result of competing therapeutic pathways), lack of women’s agency, unfamiliarity with and fear of hospitals and the treatments they offer (especially surgery), and economic constraints on access to care.SummaryWomen in resource-poor countries will use institutional obstetric care when the services provided are valued more than the competing choices offered by a pluralistic medical system. The key to obstetric fistula prevention is competent obstetrical care delivered respectfully, promptly, and at affordable cost. The utilization of these services is driven largely by trust.

Obstetric Fistula: A Narrative Review of the Literature on Preventive Interventions in sub-Saharan Africa

“…One article relied on the WHO's definition of prolonged labour as labour lasting over 24 hours, while noting that in rural settings there are misconceptions as to the ‗normal' length of labour 21 . Six articles detailed that standards set by the WHO are well understood by skilled birth attendants, however, most women in rural settings either deliver by themselves, in the company of family members, or with the aid of traditional birth assistants and are not aware that urgent obstetric care is needed past that point 1,3,11,14,19,21 . One study showed that in some settings, prolonged labour was not considered of enough importance to seek skilled medical care until two to five days had passed 21 .…”

“…Six articles associated the development of fistulas with prolonged labour 2,12,13,19,21,23 , which they defined as the prolonged presence and pressure of the fetus against the soft tissues that separate the vagina from the bladder and/or the rectum, leading to their degeneration 26 . Crucially, the articles noted common divergence in understandings of the length of labour.…”

“…All 33 articles detailed the role of obstructed labour, which occurs when the progression of the fetus through the pelvis is stopped despite ongoing uterine contractions, as a cause of obstetric fistula 19 . As referenced in two articles, obstructed labour was said to arise due to various factors including but not limited to abnormal fetal position, the size of the fetus, and a narrow birthing canal [20][21] .…”

“…In considering regional issues around obstructed labour, only one article detailed that obstructed labour is common in African women due to the narrow build of their pelvis 20 . It was noted in eighteen articles that many African girls get married at an early age, which increases their risk for obstructed labour, which if not managed leads to prolonged labour [1][2][3][4]11,12,[14][15][19][20][21][22][23][24][25][26][27][28] .…”

Cancer Presentation in a Developing Nation: The 3:1 Ratio

“…Phase I delays have been documented to be common in developing countries, including Sub -Saharan Africa (SSA [1][2][3]. A phase I delay is that caused by the patient's reluctance to seek medical attention [4].…”