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1. Les fistules obstétricales UNFPA Nouakchott 15-16 décembre 2009 J.Milliez, Équilibres et Populations

3. Maternal mortality UNFPA 2008 vital statistic Maternal mortality: / 100.000 live birth Sweeden : 2 Danemark: 5 Slovaquia : 3 Ireland: 5 Spain: 4 Finland: 6 Austria: 4 Switzland: 7 Portugal : 5 Germany 8 Italy: 5 Croatia: 8

4. Maternal mortality UNFPA 2008 vital statistics Maternal mortality: /100.000 live births Sierra Leone: 2000 ( 2% ) Afghanistan: 1900 ( 1.9% ) Malawi: 1800 ( 1.8% ) Angola : 1700 ( 1.7% ) Niger : 1600 ( 1.6% )

5. Maternal mortality The reason for maternal mortality Why are 600.000 women dying each year at delivery, 99% in developing countries? They dye because they deliver alone, unattended ONE EVERY MINUTE

6. Birth professionals at delivery Inequality in access to reproductive care Birth professionals at delivery ( % ) World population: 62% Developed countries: 99% Developing countries: 57% Poor resource countries: 34% Nearly all maternal deaths occur at delivery ( INSERM U149 MOMA study 2002 )

7. Birth professionals at delivery Inequality in access to reproductive care Birth professionals at delivery ( % ) Africa: 47% East Africa: 35% Ehiopia: 6% Chad: 14% Western Africa: 41% Niger: 16%

8. Caesarean section rates Inequality in access to reproductive care Caesarean section rates: ( % ) USA: 30% UK: 18% France : 20% The Netherlands: 17%-25% Brazil: 30-72% Urban China: 40% WHO: the optimum rate is 15%

9. Caesarean section rates Inequality in access to reproductive care Caesarean section rates in developing countries: ( MOMA West Africa ) : 1.7% Abidjan ( Ivory Coast ) : 1.5% Bamako ( Mali ): 1.6% Niamey ( Niger ): 2.1% Nouakchott ( Mauritania ): 0.7% Ouagadougou ( C. A. ): 2.7% Kaolack ( Sénégal ): 0.8%

10. Caesarean section rates= rates of obstetric fistula Inequality in access to reproductive care Caesarean section rates: WHO: life saving rate of caesarean section is 3%. Who will do caesareans when there is no doctor? ( BJOG 2005; 112: 1168-9 ) Midwives? Trained non medical health professionals?

11. Obstetric fistula Unattended obstructed labour: Education of TBAs has never been proven to be of any medical benefit. A.H.Jokhio et al.An intervention involving Traditional Birth Attendants and perinatal and maternal mortality in Pakistan N Engl J Med 2005; 352: 2091-9.

12. Obstetric fistula The cause of obstetric fistula: Prolonged obstructed, unattended labour Teenagers, small patients, narrow pelvis. Labour during 2-3 days Intra uterine fetal death Impaction of fetal head and attrition of pelvic tissues, vagina, bladder, rectum, Vesico vaginal recto vaginal fistula. P.M.Tebeu et al. Risk factors for obstetric fistula in the Far North Province of Cameroon Int J Gynecol Obstet 2009; 107: 12-5.

13. Obstetric fistula The « 3 D »: Delay in the recognition of obstructed labour: TBAs Delay in transport to emergency obstetrical center: no money, no vehicle… Delay in access into the specuialized birthing center: no money for CS

14. Obstetric fistula

15. Obstetric fistula

16. Obstetric fistula

17. Obstetric fistula

18. Obstetric fistula

19. Obstetric fistula Obstetric fistula: a social disease After delivery patient leaks urine thru the vagina Two weeks later they still leak Same 40 days later, husband refuses to resume sexual intercourse Husband accepts for a while Then repudiates his wife

20. Obstetric fistula A social disease: The young mother returns to her family, who cant afford to feed her. Unable to find any work, even prostitution Ostracized, stigmatized: lives as an outcast outside famlily home because she stinks Goes to wash at the river when humans are gone, at night, with the animals.

21. Obstetric fistula Treatment technically possible: Surgical classification of fistula: Simple* Moderate** Complex*** Most of * and ** curable in a single surgical procedure (FIGO manual) Success rate: 70-90% A.T.Lassey Simple fistula:diagnosis and management in low resource settings Int J Gynecol Obstet 2007; 99: suppl.n°1.

22. Obstetric fistula Management far more complex than surgery: Identify: ashamed, hidden, secrecy: role of midwifes, social workers,TBAs. Convince: safe demonstrable results Re socialize: before surgery community life, sense of sisterhood : after surgery: teach a job Rehabilitate

23. Obstetric fistula The best treatment: prevention: Safe motherhood programmes Easy access to emergency obstetrical care: Obstetrics Risk Insurance (Nouakchott, Mauritania) Free emergency obstetrical care Selection of patients who should deliver in a hospital (Ruth Kennedy, Addis Abeba)

24. Obstetric fistula The pioneer model: The Fistula Clinic in Addis Abeba (Reginald and Catherine Hamelin). Many other projects implemented by UN Agencies: UNFPA Professionnal bodies: FIGO NGO’s

25. Obstetric fistula Équilibres et Populations Advocacy and lobbying to direct governmental aid for development towards women’s health. Field actions: HIV prevention, education… fistula repair Nouakchott Mauritania Bamako, Mali

26. Obstetric fistula Mauritania: Funded by private foundations Partnerships with UNFPA and FIGO As of 2005 Nouakchott, Kiffa, Nema, Kaedi > 100 patients treated (C.Dumurgier, L.Falandry) + social rehabilitation Trained: the 3 urologists of the country 3 hospital teams ( Sebkha, Nema, Kiffa)

27. Obstetric fistula Mali: Hôpital Point G Bamako Funded by the Ministry of Foreign Affairs (MDG 4 and 5) As of 2006 Urologists, Gynecologists, Mauritanians, Malians 240 women treated

28. Obstetric fistula 2008: Merger of francophone surgeons Under the auspices of J.M.Dubernard, M.P. President of the Committee of Social Affairs. Urologists and Gynecologists France, Belgian and Swiss 50 fistula specialists Acting in 13 spots in Western Africa

29. Obstetric fistula E&P 2008 merger: 5 NGOs: Fondation Genevoise pour l’éducation et la recherche médicale Association de lutte contre les fistules en Afrique Médecins du Monde, MDM Gynécologues sans Frontières E&P + 2 academic societies CNGOF , AFU

30. Obstetric fistula A code of ethics for the fistula surgeon L.Wall et al. Int J Gynecol Obstet 2008;99: 532-9 Fistula patients vulnerable Fistula surgeons not always able Nonmaleficience: primum non nocere Beneficience: properly trained skilled surgeons, not only public health opr social workers Autonomy: respect of vulnerability Justice: fistula patients should be treated as any other patient within the regular health care system

31. Obstetric fistula The code of ethics: the fistula surgeon must: 1. Provide the best possible care permitted by the resources available, including psychological support. 2. Treat all fistula patients with respect, dignity, compassion, and honesty, sageguarding their confidentiality and vulnerability. 3. Accept direct personal responsability for the care of patients on whom he or she has operated, with an appropriate preoperative evaluation, competent intraoperative treatment, and adequate postoperative care. Restric his or her practice to that which he or she is competent to deliver by education, training experience and avalaible resources.

32. Obstetric fistula The code of ethics: Practice a method of healing founded on science and engage in regular and critical self evaluation. Never take advantage of a patient in anyway that might subject her to physical, emotional, economic or sexual abuse. Never pay nor receive a commission for the referral of patients. Obey the laws of the country in which they practice. Acknowledge the fundamental social inequalities that promote the developement of obstetric fistulas and help eradicate these injustices.

33. Obstetric fistula Conclusion: The higher obligation for OBGYN, professional bodies, and health authorities, is to prevent obstetric fistula by implementation of safe motherhood practices and to help achieving the 4 and 5 WHO 2015 MDG. IAMANEH a natural leader.