Anatomy in the news: Obstetric Fistula

Okay, let me just start this one off with a disclaimer. This is probably a subject many people would find unpleasant, so if you’re eating lunch, maybe come back after you’ve finished. Nonetheless, it’s a significant health issue worth talking about and it’s all about anatomy, so I feel like I have something to say about it.

You may have recently seen or heard something in the news about a condition called Obstetric Fistula. It’s a complication usually seen in cases of prolonged or obstructed labor. What happens is the walls of the vagina (or birth canal if the “v word” is too much for you to handle) tear during delivery. The rectum and bladder, situated behind and in front of the vagina, respectively, can then also tear. Then when they heal, they heal together creating an artificial opening from the bladder to the vagina or from the rectum to the vagina. Check out the illustration of a midline cut pelvis for clarification, courtesy ADAM.

This is not a significant medical problem in the developed world where perinatal and obstetric medicine is sophisticated and freely available. However, in undeveloped countries, such as many in Africa, obstetric medical aid is often not available and when it is, there is usually a lack of basic tools that would allow the physician to do their job to the best of their ability. A recently released documentary called A Walk to Beautiful does a great job of telling the story of four women from Ethiopia who deal with this debilitating condition. I caught it on PBS, but it comes out on DVD soon. After their traumatic deliveries, which almost always result in stillborn infants, the women do not have the option to get surgical repair, so they are forced back into their communities with no bladder or fecal control at all. I’m not just talking leaking during coughing, like stress incontinence (which affects millions of women after childbirth, here and everywhere else in the world), I’m talking constant flow of urine with no regulation whatsoever, or even worse, the same scenario with feces. It’s not hard to imagine that these women are completely cast out of their societies. They are perceived as filthy and broken, often useless to even their husbands.

As I mentioned before, this is not a significant problem here in America and in other similar countries, because when this happens here, the physician immediately repairs the tears and the mother can heal in the hospital before returning to her normal life. In Africa, the supplies and staff it would take to perform the fistula repair are cost-prohibitive for many of the obstetric clinics, so the surgery is not even an option. And when I say cost-prohibitive, let me be totally clear, the total cost of the surgery is $300.00. Crazy world! Thankfully there are a growing number of “doctors without borders” who are bringing this surgery to the women of Ethiopia and other countries in Africa for no cost. Hopefully their compassion can relegate fistula to the fringes of medical concern in these places.

I could probably go on for days about the anatomy of the pelvis and how delivering a baby is a unique anatomical challenge for humans. Did you know that we are one of only two species of mammals that has difficulty delivering babies? This is because of two things. First, we walk on two legs. Walking on two legs requires a narrow pelvis, so the center of gravity can easily shift as we step from one leg to the other. If we had larger pelvises to make deliveries easier, we would tip over when we walked. Second, we have larger brains for our body size than any other mammal, which is probably not a surprise when you think about all of our abilities to process complicated thoughts and emotions into decision-making. Interestingly, we’ve already evolved to reduce brain development as much as possible until after birth to accommodate for our mothers’ smaller pelvic dimensions. Consider the relative brain development of a newborn baby and a newborn horse. The newborn horse is running around in a matter of hours, walking alongside its mother. The newborn baby can’t see colors or discriminate complicated sounds, has little motor control and most certainly can’t walk alongside mommy for many months. It’s funny that even that adaptation isn’t enough to counteract the narrow pelvis-large brain dilemma.

Incidentally, the other mammalian species that has difficult deliveries is the squirrel monkey. They are a dwarf species that gradually evolved smaller bodies but neonatal head sizes did not diminish similarly over time. Squirrel monkeys lose something like 30% of their babies in delivery, so obviously it’s a big problem for them. How significant is this problem for women? According the World Health Organization, over 500,000 women die each year in childbirth. And in Africa alone, as many as 3 million women a year are permanently handicapped by obstetric complications.

Some people have said that women have been having babies without obstetric help for thousands of years before doctors came along and ruined it with drugs and hectic deliveries. First of all, people have been helping women have babies for all of those years, only they weren’t called doctors, they were called midwives. And unfortunately due to rampant sexism in the middle ages, we have a rather spotty historical record of the science behind their amazing work until the physicians in the 17th century “medicalized” it. Second, those drugs and hectic deliveries have no doubt saved countless lives of mothers and their babies.

The home birth issue has been hotly debated in recent years. Do I think having a baby at home is irresponsible? Not if the attending midwife is aware of the facts and able to deal with a dangerous situation. If I had a uterus and it was my choice? I’d probably be at the hospital, although I tend to favor medical solutions over natural, homeopathic or faith-based ones in general, and I’m not a woman anyway, so I’m not sure what my opinion really means.

It’s an interesting thing, having babies. Me Mom and Santa ClausIt’s one of my favorite things to teach about in class. We’ve all been born and many of us will have babies of our own, so it’s immediately relevant and captivating to an audience. Everyone can imagine what their own mothers went through, and we should all thank them for taking on the challenge. There’s mine at right trying to make me not fear Santa Claus. I think we also owe a debt of thanks to the medical professionals who helped out our moms, and to the many others who continue to take on this uniquely human issue.

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8 Responses to “Anatomy in the news: Obstetric Fistula”


  1. 1 Laura May 21, 2008 at 9:37 pm

    That is a hilarious and wonderful photo, your look of surprise and comical fear are truly hilarious and the whole situation is fantastic! You should put that on your next Christmas card. I think I just might have to save that as my computer background.

    Also, the entry was very informative and very interesting. Of course I have baby fever so anything at all related to child baring captivates me. Do you have thoughts about biological clocks?

  2. 2 Laura May 22, 2008 at 2:59 am

    I tried to comment earlier, I love the picture of you with your mom. It should go on your next Christmas card. 🙂 Thank you for the other information, I shared it with a few of my friends whose biological clocks are in chime with my own.

  3. 3 dshoffmann May 22, 2008 at 2:53 pm

    Biological clocks are totally real. The circadian clock has been well defined biochemically and linked to lower brain regions. The “I want a baby” clock has not been as well defined, but it seems just as significant from a survival of the species point-of-view, so I’m sure it’s real too. It’s probably just more complicated and involves more higher brain functions like awareness of the lives of others and sensing the passage of time. Interestingly, men also appear to have a sort of biological clock. As they get older, their sperm become less genetically “perfect.” In fact, Down syndrome appears to have as much to do with the father’s old genes as the mother’s. Crazy world!

  4. 4 Laura again! May 22, 2008 at 4:34 pm

    Interesting, but when do men’s biological clocks kick in?

  5. 5 dshoffmann May 22, 2008 at 6:00 pm

    Hmm, well I think the paper I was looking at focused mostly on the 40’s. But it’s different than the ladies’ biological clock in the sense that it just happens and there is not necessarily any awareness of it on the man’s behalf. I think the popular press really clung to the concept of a male “biological clock” to describe the gradual genetic degeneration of sperm progenitors because it catches your attention. Pretty much all of our cells get crappier with time, hence saggy skin and cancer, so by that definition, everything is on a biological clock. A clock of DOOM. 🙂

  6. 6 Laura again! May 22, 2008 at 7:09 pm

    Nice. 🙂

  7. 7 Carole LaRochelle April 7, 2009 at 3:59 pm

    Darren,

    Thank you for this post. I watched A Walk to Beautiful on PBS last night. These poor women are suffering so much!!! It brought me to tears and I thought of my own grandmother who gave birth to 12 children and died with the 13th one. Reproductive control should be every woman’s right!!

    On a lighter note, how cool that you love anatomy. As a Rolfing practitioner I am an anatomy buff myself. I’m adding you to my blogroll. http://explorethejourney.wordpress.com

    Thank you so much,

    Carole LaRochelle, CSI
    Certified Advanced Rolfer

  8. 8 Leah July 6, 2009 at 7:46 pm

    Hi there,
    I work for Engel Entertainment, the company which created the film “A Walk to Beautiful.” It is indeed finally available on DVD! This is the feature-length cut, rather than the abridged PBS version, and comes replete with deleted scenes, filmmaker commentary, two new short films (one of which follows up on main characters three years later, and one about obstetric fistula around the world), and more. Anyone interested in purchasing a copy may do so at http://www.walktobeautiful.com. And Anatomist, if you’re interested in posting this news and link and you’re blog, we’d be grateful! Thanks!
    Leah


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