What is a fistula?
A fistula is a hole between the vagina and the bladder or rectum, through which urine or stools leak continuously.
What causes a fistula?
Almost all fistula are caused by obstructed labour. In remote regions, where there are few hospitals or midwives, complicated childbirth can result in a woman being in labour for days. Without access to emergency Caesarean section operations, complications in childbirth can be fatal. If the woman survives the labour, permanent injuries to the birth canal may result.
Mr Geert Morren, MSF's flying fistula surgeon, operates on a patient in Mali.
Photo by Lindsey Mackenzie/MSF
As the baby's head presses on the soft tissues within the mother's body, the blood supply may be cut off. If the labour continues for a long time, a hole may develop in these tissues, which will never heal naturally. Most often, the baby will be stillborn, adding yet more suffering for the woman.
A small number of fistula cases seen by MSF surgeons are due to extreme sexual violence.
What are the effects of a fistula for a woman?
Leaking urine will cause an unpleasant smell and may also 'burn' the woman's legs. Women may reduce their fluid intake drastically to try to reduce the urine flow, which can result in kidney diseases and bladder stones.
Women who suffer from fistula will often be ostracised by their communities because of the symptoms. In many cases, they will be abandoned by their husbands, who will take another "healthy" wife.
In some cases, the pressure of the baby's head on the nerves may cause paralysis of one or both of the woman's legs, or leave her with difficulties in flexing her feet – a condition called drop foot. The walking difficulties that result will further isolate the woman.
What can be done to help?
Fistula can be repaired by skilled surgeons. A simple repair may take only 45 minutes to complete, but many cases are more complex and require several operations.
After the operation, the woman will need a bladder catheter for a couple of weeks and will be taught pelvic floor exercises to strengthen her muscles.
Women who have had a fistula repaired are able to have a healthy child in the future, if they receive appropriate antenatal care.
Training local midwives to help mothers give birth safely is vital. They can spot when a mother is in difficulty with the labour and arrange help before it is too late.
MSF's work in treating and preventing fistula
Today, MSF treats obstetric fistula in three permanent centres in Burundi, Chad and Nigeria.
In January 2008, MSF set up a flagship fistula project in Abéché, Chad. It is the first MSF fistula project to be a permanent fixture within the national health system in Chad; it works on prevention and surgical treatment of fistula with experts from around the world.
The number of patients treated by MSF teams has been steadily rising: from approximately 100 repairs in 2006, to between 400 and 500 repairs in 2009, and then about 1,000 in 2010.
These numbers will continue to increase in the future as MSF refers more patients to partner organisations, as well as increasing the number of projects treating patients directly.
In 2006, MSF teams were treating fistula in Sierra Leone and Democratic Republic of Congo (DRC). In 2007, work expanded into Somalia and in 2008 included Darfur, Nigeria and Chad.
During 2009, MSF teams were treating fistula patients in DRC, the Central African Republic, Nigeria, Chad, Mali and Burundi.
The latest location to open its doors, in July 2010, was the Urumuri centre, backed by the regional hospital in Gitega in the heart of Burundi. This is the first centre specialising in fistula treatment in Burundi and is able to treat women seven days a week.
MSF has also built four houses to accommodate the patients before surgery and then during rehabilitation.