اقتباس:
المشاركة الأصلية كتبت بواسطة شوقي بدري
سلام زين . قبل 15 سنة كان عندنا في مدينتنا مؤتمرا متخصص في الختان . مثلت السودان كريمة العم فريد طوبيا . كانت هنالك افلام ونقاش . نعم الناسور البولي يصيب غير المختونات . والسرطان يصيب غير المدخنين . لكن التدخين يسبب سرطان الرئة .
عملية الخياطة المتكررة بعد الولادة او في البداية تفقد المهبل مطاطيته وتكون من اسباب الناسور البولي . لماذا يكثر الناسور البولي في الدول التي تمارس الختان الفرعوني ؟
الطب لم يعد طقوسا كهنوتية تسنعصي طلاسمهاعلي المساكين من امثالنا . واللغة الانجليزية يمكن ترجمنها بالكمبيوتر . ماهي المشكلة في ايراد المراجع الطبية بالانجليزية. لقد حضرت نقاشا وسمنارات في الختان وغير الختان . لقد شاركت في نقاش في اثيوبيا .والامهرا مثلا يتواجد الناسور البولي عندهم كثيرا . عند القوندر والشوا والولو . لكنه قليل عند القوجام . لان الامهرا القوجام لا يمارسون ختان الاناث .
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FGM and obstetric fistula: A common misconception that is barking up the wrong tree
Posted on
December 5, 2014 by
HamlinFistula
Author: Vibhushan Manchanda
There is a common misconception that female genital mutilation (FGM) is a highly prevalent cause of obstetric fistula. The publishing of inaccurate commentary with no evidence base fuels this misconception. The number one cause of obstetric fistula is a lack of access and underutilisation of proper obstetric care and caesareans where needed. Female genital mutilation (also referred to as ‘female circumcision’ or ‘female genital cutting’), though debilitating and condemnable in its own right, is not a cause of obstetric fistula. Those who perpetuate the misconception that FGM causes obstetric fistula are barking up the wrong tree.
In the vast majority of fistula cases, the vesicovaginal septum is trapped between the mother’s bony pelvis and the presenting fetus, leading to insufficient blood supply and subsequent death of the tissue (ischaemic necrosis). This sloughs away post-partum to reveal the fistula. It is illogical to try to make a causative correlation of FGM with fistula formation; the structures affected by FGM are the external genitalia (clitoris, labia majora and labia minora) that are 20-30cm away from the internal site where most vesicovaginal fistulas will occur.
Female genital mutilation (FGM) involves procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. These procedures have no health benefits for the girl or woman. FGM is mostly carried out on young girls between infancy and age 15, and is a result of a mix of cultural, religious and social factors within families and communities. There are four types of FGM:
• Type I: clitoridectomy – partial or total removal of the clitoris
• Type II: excision – partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora
• Type III: infibulation – narrowing of the vaginal opening through the creation of a covering seal by cutting and repositioning external female genitalia
• Type IV: other – all other harmful procedures to the female genitalia for non-medical purposes
In the journal article The Relationship between Female Genital Cutting and Obstetric Fistulas (Browning et al.), a comparison was made between 255 fistula patients who had undergone either Type I or Type II FGM and 237 fistula patients who had not undergone such cutting. The authors assessed the lack of correlation between fistula formation and FGM by evaluating the corresponding anatomical location of fistula within the female genital tract. It was logically derived that FGM types I-III involve the external genitalia, so if scarring from these procedures is to cause obstruction and subsequently cause fistulas, these should be found extremely low in the pelvis with a high proportion of fistulas involving the urethra. It was also suggested that there should also be a higher proportion of women with persistent urinary incontinence within the fistula patients who have undergone FGM compared to the fistula patients who have not, because of damage to the urethra. Statistical comparisons between the two groups of fistula patients revealed no discernable difference in the primary outcomes, being the site of genitourinary fistula and persistent incontinence. These remained consistent after adjustment for potential introduction of bias by age, previous childbirths, and number of days in labour. It was concluded that FGM is an independent variable to fistula formation.
However, it was clear that obstetric fistula is prevalent in areas where FGM is also common. Browning et al. suggested that FGM is a marker for risk factors that combine to promote obstetric fistula including low socioeconomic status, pregnancy before completion of pelvic growth, restriction of personal autonomy of women, limited or non-existent contraceptive choice, poor education level and political power of women, and difficult transportation and inadequate development of medical infrastructure. All of these variables lead to a lack of timely access to emergency obstetric services, sub-par quality of the delivery of these services or a reduced likelihood of awareness of the importance or availability of such services amongst individuals. This collectively produces a high level of maternal mortality and obstetric morbidity, including obstetric fistula. Thus it is apparent that eradication of FGM as a sociocultural practice will not equate with an elimination of obstetric fistula as a complication of childbirth. Instead, our efforts should focus on augmenting the presence of trained attendants during labour and timely access to emergency and competent obstetric services.
Several papers have independently reviewed risk factors and causes of obstetric fistula. In a case series study of the characteristics of 48 fistula patients in the Far North Province of Cameroon, only one case was associated with FGM type III, while 42 were a result of obstetric causes (primarily obstructed or prolonged labour). Similarly, in a thorough retrospective record review of 932 vesicovaginal fistula patients at Evangel Hospital in Jos, Nigeria, only 32 were due to non-obstetric causes, of which a mere 4 cases were associated with any genital trauma (usually “Gishiri cuts” – cuts in the vagina that are meant to treat gynaecological ailments but can inadvertently cause fistula). Noteworthy literature on obstetric fistula (such as Obstetric Fistula: A Preventable Tragedy by Miller et al., Obstetric Fistula: The Challenge to Human Rights by Cook et al. and Obstetric Vesicovaginal Fistula as an International Public Health Problem by L. Wall) provide overwhelming support that the condition occurs as a result of prolonged obstructed labour, and do not consider FGM or other trauma to the external genitalia as a significant cause.
We contacted Dr. Andrew Browning, experienced fistula surgeon and lead author of The Relationship Between Female Genital Cutting and Obstetric Fistulas for comment:
“It is a common assumption that FGM leads to obstetric fistula, but it is difficult to support this with any evidence. From the only study looking at this it was concluded that FGM is an independent variable in fistula formation; that is, it doesn’t cause the long obstructed labour that results in an obstetric fistula. It has been shown the FGM can lead to more tears to the perineum, but not obstetric fistula. From a personal series of caring for over 12,000 obstetric fistula patients I have not seen a single case caused by FGM, all the obstruction during labour has clearly been against the bone of the bony pelvis. This is an opinion shared by all senior fistula surgeons. Indirectly it can cause a fistula as during labour someone might cut an infundibulation open, also cutting into the bladder (we see this in about 1 per 1000 cases). A severe infundibulation does delay the delivery of the baby’s head, but the tissues eventually tear and the obstruction is not long enough to cause a fistula. It is also true in areas where they do not practice FGM you still see many obstetric fistula cases if there is no access to a caesarean if needed. There are many good arguments against FGM, but obstetric fistula formation is not one of them.”
However, we must consider why the belief exists in some quarters that there is an association between FGM and obstetric fistula. Perhaps it is easier for us to blame the sociocultural issues associated with FGM than to provide far-reaching and expensive obstetric care to millions of women worldwide. We support the fight against FGM on a global scale but this will not ameliorate the obstetric fistula situation. In order to move towards achieving Dr Catherine Hamlin’s goal of eradicating fistula in Ethiopia, we need to continue to fundraise for the hospitals and midwifery school to improve access to care and training within the communities in which we work. This is an issue that can be resolved.
Reference list:
1. Browning, Andrew, Jenifer E. Allsworth, and L. Lewis Wall. “The Relationship Between Female Genital Cutting and Obstetric Fistulas.” Obstetrics and gynecology 115.3 (2010): 578.
2. Tebeu, Pierre Marie, et al. “Risk factors for obstetric fistula in the Far North Province of Cameroon.” International Journal of Gynecology & Obstetrics 107.1 (2009): 12-15.
3. Wall, L. Lewis. “Obstetric vesicovaginal fistula as an international public-health problem.” The Lancet 368.9542 (2006): 1201-1209.
4. Cook, Rebecca J., Bernard M. Dickens, and S. Syed. “Obstetric fistula: the challenge to human rights.” International Journal of Gynecology & Obstetrics 87.1 (2004): 72-77.
5. Miller, Suellen, et al. “Obstetric fistula: a preventable tragedy.” Journal of Midwifery & Women’s Health 50.4 (2005): 286-294.
6. Lewis Wall, L., et al. “The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria.” American Journal of Obstetrics and Gynecology 190.4 (2004): 1011-1016.
