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Family Planning Strategies For Preventing Obstetric Fistula



Child spacing through the use of any family planning method can help most women to avoid developing obstetric fistulas- one of the worst childbearing diseases a woman can imagine. VICTOR OKEKE in this report writes on the options available to women.

It was the last birth that took the greatest toll on Josephine’s health. She had traveled 70 kilometers from home to the largest nearby town of Wamba, where she endured three days of labour and a Caesarian-section before giving birth to a stillborn baby.

Her difficult labour left her with a prolapsed uterus and a fistula, and Josephine began leaking urine. She underwent three surgeries to repair the damage, but none were successful. Heartbroken, she returned home to her two children and to her husband, who left her soon afterward.

Josephine, 34 years old, is the mother of two healthy boys, ages 11 and 9, the only surviving children from her four pregnancies.

The story of Josephine is shared by the over 200 000 Nigerian women suffering from fistula. Engender Health Nigeria Country Project Manager for the USAID-funded Fistula Care Plus (FC+) project, Chief Iyeme Efem says Nigeria currently has over 200,000 women living with fistula with 12,000 new cases occurring every year.

Fistula is one of the most devastating injuries of child birth.  It occurs mainly as a result of prolonged obstructed labour, without timely medical intervention – such as a caesarean section.

The sustained pressure of the baby’s head on the mother’s pelvic bone causes damage of soft tissues creating a hole – or fistula – between the vagina and the bladder and/or rectum. The result is continuous leaking of urine and feaces.  When this occurs, a woman has no control of this unnatural phenomenon and if not assisted may suffer isolation, social stigma, neglect and humiliation.

There are several different types of fistulas including: Traumatic fistula which is caused by sexual violence; Iatrogenic fistula- caused by unsafe surgery (often from cesarean section) and the obstetric fistula which is caused by obstructed or prolonged labor

According to United Nations Population Fund (UNFPA), in Sub-Saharan Africa alone between 3,000 and 130,000 of women giving birth develop fistula each year.

However, in up to 90 per cent of cases, the fistula can be surgically repaired. Through the Fistula Care Plus project, EngenderHealth works to restore dignity to women with fistula and to prevent other women from developing the condition.

The Fistula Care project covers the costs of treatment, equipment, and supplies. It also supports training for providers in fistula repair, nursing, counseling, and quality improvement.

And across the world, the United Nations has observed the International Day to End Obstetric Fistula since 2013. The day, 23 May, is meant to raise awareness of this issue and mobilize support around the globe. The theme of this year’s International Day is “Leaving no one behind: Let us commit to ending fistula now!”

Obstetric fistula (OF) is the most common type of fistula and—because of its relationship to obstructed or prolonged labour—is linked to maternal mortality. Women with OF face a number of physical, emotional and social challenges, including chronic leaking of urine or feces.

Obstetric fistula can be prevented with timely, high quality maternal health care. Women living in poverty and those living in rural areas are at greater risk of developing OF, primarily because they have less access to facility-based delivery with skilled birth attendants.

Related factors such as female genital mutilation, early marriage, poverty and lack of high quality sexual and reproductive health services can also increase a woman’s risk of developing fistula. Addressing these underlying causes is key to confronting the global burden of obstetric fistula.

According to public health expert and family planning advisor with EngenderHealth, Olajumoke Adekogba, “by ensuring safe pregnancy care, supportive input, access to well-staffed health facilities and postnatal care, many fistulas can be avoided.”

She added that “Access to voluntary family planning can help families choose when and how many children to have, which is one of the most effective ways to prevent obstetric fistula.”

Corroborating this, is the recent study by Audu Alayande of the United Nations Population Fund (UNFPA) and his colleagues on “Missed Opportunity for Family Planning among Obstetric Fistula Clients in North-Western Nigeria” which shows that, of the about 12,000 women who develop obstetric fistula annually in Nigeria, access to family planning services will prevent recurrence of fistula and increase the family planning utilization.

Sometimes, it is assumed that women with repaired fistula are not interested in family planning services because they might have lost a baby in the preceding complication. On the contrary, studies indicate that they are interested in using family planning if they know about it during their post-operative period.

More than 76 per cent fistula patients in four Kenya referral centers expressed their willingness to access FP services after the fistula repair. Enabling these women to access FP services can greatly reduce their chances of developing new fistula because it gives them more control over the “when and how” of their pregnancies.

Additionally, family planning counseling will also help women who want to achieve successful pregnancy to increase their chances through increased fertility awareness.

The study established the occurrence of missed opportunity for family planning at the obstetric fistula units as evidenced in the fistula register.

According to Adekogba, “Women especially of child bearing age should avoid following misconception against family planning. Women of reproductive age should visit clinics for family planning and see health provider that is proficient to enable them to get adequate information about child spacing so, that they can make their choice for themselves.”

“Child spacing would help women to rest between one pregnancy and another it would give the women opportunity to have exclusive breastfeeding with their child and it guarantees good health for the mother,” she said.

Many experts say that family planning is an effective strategy for preventing fistula because it enables couples to delay early childbearing and to avoid unplanned pregnancy.

According to EngenderHealth, it is estimated that up to one-third of all childbirth-related deaths and injuries could be prevented if women had greater access to contraception.

Family planning also has the potential to reducing infant mortality, prevent HIV and AIDS, empower people, enhance education, reduce adolescent pregnancies, and slow population growth.

Family planning is also important for preventing the recurrence of fistula following surgical repair. After treatment, women are generally advised to abstain from sexual relations for a period of 3–6 months to allow them to heal. However, it is often difficult for couples to comply with this recommendation.

In this situation, even if couples resume sexual relations early, family planning allows women to recover from their traumatic physical and psychological experience, without the additional worry of becoming pregnant again before they are ready. It also allows couples to decide the best time to try to get pregnant again, if this is what they want.

True, access to high-quality FP services and a wide range of methods supports a woman’s right to have the number of children she wants (if possible) and to space births to protect the health of the mother and her infant(s). FP is also uniquely important for women who have had a fistula.

Access to contraception helps to protect a repaired fistula and prevent breakdown and recurrence by delaying pregnancy. FP counseling can also help women who want to achieve a successful pregnancy to increase their fertility awareness and to delay a future pregnancy until they are fully healed.

FP counseling can be particularly empowering for fistula clients. By providing FP information to women who have undergone a fistula repair (and whose fecundity remains), post-repair support becomes a process that respects and protects women’s rights to reproductive self-determination, access to services, and nondiscrimination. Women are empowered to make their own reproductive decisions.

There are several safe and effective family planning methods open to a couple. For example, there is the pill (also known as the oral contraceptive) which is a small tablet that a woman can take every day to prevent pregnancy.  It is most effective when taken at about the same time each day.

Then, the injectable; which is a family planning injection given to a woman at regular intervals by a trained health provider. One commonly used injectable is Depo-Provera, which is given by injection every three months.  A woman can become pregnant after she stops taking the injection, but this may take several months.

Hormonal implants are also a set of small capsules—or just one capsule—placed under the skin of the upper arm by a trained provider. The capsule(s) can prevent pregnancy for an extended time period: seven years (Norplant®), five years (Jadelle®), four years (Sino-Implant (II))®, or three years (Implanon®). The capsule(s) must be removed or replaced after this time, when they no longer protect against pregnancy. The capsule(s) can be removed earlier if one wishes to become pregnant.

There is also the intrauterine device (IUD) – a small, flexible device that is placed inside a woman’s womb through her vagina to prevent pregnancy. It prevents pregnancy for up to 12 years, but it can be taken out sooner if the woman wishes to become pregnant. Normal fertility is not affected by the IUD.

Family planning can also be effected through condom use. The condom is a close-fitting rubber sheath that a man wears on his erect penis during sexual intercourse. Condoms prevent sexually transmitted infections (STIs), including HIV, as well as pregnancy.

There is also a female condom which is a sheath of thin, transparent, soft plastic (polyurethane) that you put inside your vagina before sex. For more effective use, use the female condom correctly every time you have sex.

The standard days method (SDM) is a family planning method that uses beads to help women and couples identify the fertile days in the woman’s menstrual cycle. If no pregnancy is wanted, the couple avoids sexual contact during the fertile days.  If a pregnancy is wanted, the couple has sexual contact during the fertile days.

Female sterilization (also called tubal ligation or tubectomy) is a permanent procedure that closes the tubes that carry eggs from the egg bags (ovaries) to the womb. A small cut is made in your abdomen (belly), and the tubes are blocked to prevent the sperm and egg from meeting. After the procedure is performed, you still have your periods, but you cannot become pregnant any more.

If you are sure that you do not want any more children in the future, female sterilization may be a good method.

Vasectomy is a permanent method for men who want to stop having children. It involves a short, simple procedure to cut or block the tubes that carry the sperm from a man’s testicles (balls) to the penis. After a vasectomy a man can have sex just as before, but he will not make his partner pregnant. However, he can still make a woman pregnant in the first three months after the procedure.

At times, a variety of situations may occur that will put you at risk of unplanned pregnancy. These situations may include: you forgot to take your pill, his condom broke or your condom got displaced, he did not pull out in time, you were not using any family planning method, he forced you to have unprotected sex.

For protection from pregnancy after unprotected sex, emergency contraception is a good option. It is designed to prevent pregnancy after unprotected vaginal intercourse but it does not interrupt an established pregnancy.

Evidence abound to prove that family planning is a sure bet way to protecting women against obstetric fistula. It is then very important that women of child-bearing age and couples make the wise choices and employ a child spacing method today. This is because even one woman living with obstetric fistula is one woman too many….it causes too much devastation in the quality of life for the woman, for her family and community.