Lessons From the Developing World: Obstructed Labor and the Vesico-Vaginal Fistula

Julia Cron, MD

Conclusion

In their work characterizing the obstructed labor complex, Arrowsmith, Hamlin, and Wall^[9] emphasize that "obstructed labor is one of the greatest unaddressed healthcare needs for the women of this planet. It should not be allowed to remain so." This is a most important women's healthcare issue. One must understand the historical context of obstructed labor and the obstetric fistula, the societal complexities, and biological factors surrounding the current epidemic, and the surgical principles that govern fistula repair. With a better understanding of these issues, we can begin to address the problem and work to improve the healthcare status of women around the world.

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Cite this: Lessons From the Developing World: Obstructed Labor and the Vesico-Vaginal Fistula - Medscape - Aug 15, 2003.

Table 1. WHO Regional Estimates of Maternal Mortality, 1995
Region	Deaths per 100,000 Live Births	Lifetime Risk of Maternal Mortality
Developed countries	21	1:2500
Least developed countries	1000	1:16
United States	12	1:3500

Adapted from Maternal mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA. World Health Organization; 2001.^[4]

Table 2. Etiology of Vesico-Vaginal Fistulas at UCLA and Affiliated Hospitals, 1958-1978
Primary Cause	Number of Cases
Surgery	39
Obstetric	2
Radiation therapy	2
Total cases	43

Adapted from Goodwin and Scardino, 1980.^[13]

Table 3. Etiology of Vesico-vaginal Fistulas in Nigeria and the United Kingdom
	Nigeria 1953-1969	United Kingdom 1970-1988
Obstetric	369	21
Surgical	7	116
Radiotherapy	0	19
Other	1	10
Total	377	166

Adapted from Lawson, 1989.^[14]

Table 2. Etiology of Vesico-Vaginal Fistulas at UCLA and Affiliated Hospitals, 1958-1978
Primary Cause	Number of Cases
Surgery	39
Obstetric	2
Radiation therapy	2
Total cases	43

Adapted from Goodwin and Scardino, 1980.^[13]

Table 3. Etiology of Vesico-vaginal Fistulas in Nigeria and the United Kingdom
	Nigeria 1953-1969	United Kingdom 1970-1988
Obstetric	369	21
Surgical	7	116
Radiotherapy	0	19
Other	1	10
Total	377	166

Adapted from Lawson, 1989.^[14]

Table 4. Primary Closure Rates by Fistula Type
Region	Deaths per 100,000 Live Births	Lifetime Risk of Maternal Mortality
Developed countries	21	1:2500
Least developed countries	1000	1:16
United States	12	1:3500

Adapted from Maternal mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA. World Health Organization; 2001.^[4]

Table 5. Decreasing Success Rates of Fistula Closure With Multiple Attempts
Successful Repair	Number of Patients
First attempt	70/82 (85%)
Second attempt	6/12 (50%)
Third attempt	2/6 (33%)

Adapted from Elkins TE. Surgery for the obstetric vesicovaginal fistula: a review of 100 operations in 82 patients. Am J Obstet Gynecol. 1994;170:1108-1120, with permission from Elsevier.^[11]

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Lessons From the Developing World: Obstructed Labor and the Vesico-Vaginal Fistula

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