1. OBSTETRIC FISTULA(OF) BY:- Turufat Tukura(PHO,MPH) REPRODUCTIVE HEALTH PROGRAM ADVISOR

2. PRESENTATION OUTLINE  Introduction  Definition of fistula  Epidemiology of fistula  Risk groups of fistula  Predisposing factors of fistula  Types of fistula  Complication of fistula  Development of Obstetric fistula  Prevention of fistula

3. Introduction Development of a nation expressed in terms of:-  Maternal mortality rate  Child mortality rate  Infant mortality rate  Neonatal mortality rate  Post-neonatal mortality rate (Population and demography, Reproductive Health)

4. Introduction What is maternal death?(ICD,WHO,FMOH)  Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes What are the causes of death?  Direct obstetric deaths:-Result from obstetric complications of the pregnancy state, from interventions, omissions, incorrect treatment or from chain of events. Examples:-unsafe Abortion, Ectopic pregnancy, pre-eclampsia, Eclampsia, Obstructed labor, infection, sepsis uterine rupture, hemorrhage, prolonged labor, others (embolism and anesthesia)

5. What are the causes death?  Indirect obstetric death:-Resulting from previous existing diseases or diseases that developed during pregnancy, which are aggravated by the physiologic effects of pregnancy Example:-Heart disease, diabetes mellitus, HIV/AIDS, TB, Malnutrition, anemia, malaria, Obstetric fistula, cardiovascular disease Prevention strategies (FMOH(HTP),NNPII,WHO,UNFPA,SDG)  FANC  Institutional delivery  PNC  Immunization  Comprehensive FP  Essential obstetric care

6. Prevention strategies  Micronutrient supplementation  MDSR  Maternal waiting area expansion  AYSRH  Provision of ambulances  HDF sensitization  Mix training and shift of skill

7. Definition of Fistula  Abnormal opening between a woman’s vagina and bladder and/or rectum through which her urine and/or faeces continually leak(WHO).  vesico-vaginal fistula (VVF) and recto- vaginal fistula (RVF)

8. Epidemiology Incidence  Each year 50,000 to 100,000 women affected globally (WHO,2018) Prevalence  More than 2-3.5 million young women live with untreated obstetric fistula in Asia and Sub-Saharan Africa (WHO,2018)  In Ethiopia the prevalence is 0.4%(EDHS,2016)

9. Epidemiology(UNFPA,2017)

10. Risk Groups of Obstetric fistula (UNFPA,USAID training guide)  Young poor girls and poorest of poor women(Illiterate)  Women and girls in rigid social, culture and gender norms  Women and girls in access to quality health care services

11. Predisposing factors  Home delivery  Prolonged labor  Obstructed labor  Three delays  Recognizing danger  Reaching care  Receiving care

12. Contributing factors  Poverty  Malnutrition  Inadequate health systems  Harmful traditional practices(FGM, Early marriage, teenage Pregnancy and violence against women)  Lack of skilled attendants  Limited access to emergency Caesareans  Unequal gender relations  Poor economic situation

13. Complications  Medical complications  Sepsis,Incontinence  Infertility  Foot drop  Area dermatitis  Vaginal stenosis  Malnutrition  Pelvic inflammatory diseases(PID) etc.

14. Social complications  Divorce  Isolation and humiliation =economic challenge  Dissolution of family  Street life (social pathology)  Abandonment  Stigma

15. Psychological complication  Shamefulness( smell of stool and urine)  Depression  Anxiety  Guilty

16. Types of Obstetric fistula  vesico-vaginal ( bladder and vagina)=VVF (most common)  Utero-vaginal (Uterus and vagina)  Vesico-uterine(bladder and uterus )  Uretero-vaginal (Ureter and vagina)  Recto-vaginal(Rectum and bladder)=RVF

17. Development of Obstetric Fistula

19. Anatomy of Obstetric Fistula

22. PREVENTION OF OBSTERIC FISTULA 1. Primary prevention  Cessation of harmful traditional practice(FGM)  Delay of early marriage and pregnancy (SRH)  Nutrition(AMIYCF )  Education and empowerment of women  Community awareness on three delays(Recognize, reach and receive)  SBCC  Infrastructure  Advocacy

23. Prevention of Obstetric Fistula (WHO,UNFPA,FMOH,RH of HSS) 2. Secondary prevention  Community awareness on Fistula care and treatment  Access to essential obstetric care ( Comprehensive and basic)  Labor monitoring (Partograph)  Family planning  Birth planning  Accessibility,Availability and Affordability of services  Quality and equity care  Gender empowerment

24. Prevention of Obstetric Fistula 3. Tertiary prevention(Rehabilitation)  Identification and treatment of Obstetric Fistula(skill, equipment  Reintegration in to family and community life  Economic opportunity ( through dialogue with leaders, husbands and family members)  Management standards for fistula survivors at Health Centers,Hospitals  Support

25. Active fistula centers in Ethiopia

26. WHAT IS REFLECTION ?  SBCC  Community involvement  Youth involvement  Community level platforms

27. Intervention progress in Ethiopia  Map from UNFPA

28. Obstruct labor accounts up to 6% of all maternal deaths

29. Obstetric fistula is a hole in the birth canal caused by obstructed labor

30. Obstetric fistula affects hundreds of thousands of women

31. Obstetric fistula leads physical and mental suffering

32. Obstetric fistula can be prevented

33. Obstetric fistula is observed in certain conditions ( poverty, esteem and status based on child bearing

34. A holistic approach can help address the condition

35. Training is critical

36. Surgical intervention can help in some cases

37. Remedying obstetric fistula works towards SDGS

38. SDGS  SDG 3:Ensure healthy lives and promote well-being for all at all ages  Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births  Indicator 3.1.1: Maternal mortality ratio  Indicator 3.1.2: Proportion of births attended by skilled health personnel  Target 3.2: By 2030, end preventable deaths of newborns, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births  Indicator 3.2.2: Neonatal mortality rate

39. Obstetric fistula is preventable and treatable MANY thanks For Attention!