Obstetric Fistula Is a “Neglected Tropical Disease”

The term ‘‘neglected tropical diseases’’ (NTDs) is commonly used to refer to a ‘‘baker’s dozen’’ of infectious conditions prevalent in resource-poor tropical countries. The 13 core diseases in the NTD group include ascariasis, dracunculiasis, hookworm, lymphatic filariasis, onchocerciasis, schistosomiasis, trichuriasis, Chagas disease, human African trypanosomiasis, Buruli ulcer, leprosy, and trachoma [1]. The World Health Organization has expanded the list to 17 conditions (http://www.who.int/neglected_diseases/ en/), and some authors add another 20 or so fungal, viral, and ectoparasitic infections to the list [1]. Here I argue that obstetric fistula should be classified as an NTD because it, like the infectious conditions listed above, is also a preventable, treatable malady responsible for much suffering, stigmatization, and lost productivity among the impoverished ‘‘bottom billion’’ of the world’s population. The entities traditionally classified as NTDs all have an infectious etiology. They are caused by exotic pathogens that flourish largely (but not exclusively) in tropical climates. Although this common biological underpinning is important, it should not cause us to overlook other, non-infectious pathologies that are prevalent in poor countries and which also produce enormous human suffering, because not all human pathology is infectious in origin and not all human suffering can be treated with antimicrobial agents. In clinical practice, diseases are manifested as specific illnesses, uniquely experienced by individual patients. Because much human illness is actually due to derangements in physiological functioning rather than the tissue changes traditionally studied by pathologists under the microscope or what a culture plate grows in a microbiology lab, medical textbooks are shifting their perspective towards discussion of ‘‘disorders’’ of various organ systems rather than limiting themselves to the more traditional discussion of ‘‘diseases.’’ We need to think of NTDs not as neglected tropical diseases but rather as neglected tropical disorders, recognizing that although they occur primarily in the tropics they are often linked more directly to poverty, economic insecurity, social instability, and institutional mismanagement than they are to climatic conditions. The classification of podoconiosis—a debilitating form of elephantiasis that mimics the classical infection produced by Wuchereria bancrofti (but which actually is an inflammatory geochemical disorder caused by silica particles absorbed through the feet of susceptible, barefooted farmers who are chronically exposed to volcanic red-clay soils)—as an NTD is evidence of this type of paradigm shift [2,3]. Obstetric fistula is a striking example of a neglected tropical disorder of this kind. Once prevalent in Western countries, obstetric fistula is today largely confined to the cultures of tropical poverty. Obstetric fistulas are caused by obstructed labor. Labor is obstructed when the fetus will not fit through the birth canal during the second stage of labor. This occurs either because the pelvis is too small, the baby is too large, or a malpresentation renders normal obstetrical mechanics impossible [4]. Because it is an involuntary process, once labor starts, the uterus contracts until its contents have been expelled, the uterus ruptures, or the laboring woman dies. When labor is obstructed, the presenting part of the fetus (usually the fetal head) is wedged progressively deeper into the pelvis until its further advance is prevented by the presence of the unyielding bones of the pelvic girdle. The uterine contractions relentlessly compress the entrapped soft tissues of the bladder, vagina, and pelvis between the two opposed boney surfaces, eventually shutting off their blood supply. The entrapped tissues die and slough away, creating a fistula between the urinary tract and the vagina (and sometimes between the rectum and the vagina as well) through which urine (or stool) leaks in a continuous and unremitting stream (Figure 1). Obstetric fistulas are completely preventable—if obstructed labor is diagnosed early and if appropriate intervention occurs in a timely fashion. This requires the presence of a skilled attendant at birth who can make the correct diagnosis and a system of management that functions efficiently to make sure needed interventions take place before the awful consequences of prolonged obstructed labor develop. Treating obstructed labor correctly often requires surgery: performance of a cesarean section that bypasses the obstruction in the pelvis and creates a new trans-abdominal passageway through which the fetus is extracted. Where skilled attendance at birth is lacking, however, a woman may linger in labor for up to a week. The suffering this entails is almost unimaginable to those living in resourcerich countries. When obstructed labor is protracted, fetal mortality almost always exceeds 90% [4]. After a day or two of unendurable stress, the entrapped fetus dies from asphyxiation. As the tissues decay, the fetus gradually macerates within the birth canal, eventually softening enough to allow delivery—unless the uterus ruptures from the unrelenting contractile activity or the woman dies from hemorrhage, infection, exhaustion, dehydration, or the combination thereof. To the agony of prolonged labor is added the grief of a stillborn child, yet the worst is often yet to come.