Obstetric Fistula: complexities of health care shortage
Rachel Pope uses the story of a woman she interviewed in Tanzania to highlight the complex issues involved in the lack of appropriately trained health workers
Pili (her name has been changed to protect her privacy ) is a 27 year old woman from the Kara tribe. (1) She only made it to grade three in school, and was married at age 18. She was also 18 the first time she gave birth, but unfortunately for Pili, she does not have any children to this day due to complications in both of her labours that resulted in an obstetric fistula. (An obstetric fistula is the result of prolonged and obstructed labor. In cases where the fetus cannot pass through the birth canal safely, the constant pressure of the fetal skull in the birth canal reduces blood supply to the tissues, causing the tissues to disintegrate. Fistulas - or holes - develop, resulting in constant leaking of urine and/or feces through the vagina.)
She has had two fistulas in her lifetime, something especially in East Africa, many would consider a curse upon a curse. What is different about Pili’s story, is that she did not necessarily end up with a fistula because of pregnancy at an extremely young age, or because of physically small and malnourished stature, or even because of transportation problems in getting to a hospital with medical equipment for birth, like many of the women in sub-Saharan Africa and Southeast Asia who get fistulas. In both of Pili’s birth, it could be claimed that the problems that caused the fistulas were actually in the hospital itself. It could also be extrapolated that the poor conditions of the hospital are due to a complication of an urgent underlying problem: global poverty.
Pili was careful to head for the hospital as soon as her labour started. She knew that she would have to travel far in order to get there early enough to access medical help in case anything went wrong. It was a relief that she made the decision to go, because it was clear to the nurses on duty that she needed a caesarean section. It was 2 o’clock in the afternoon when they called the assistant medical officer (AMO) to perform the surgery. Pili and her family waited anxiously, but the AMO did not show up until six hours later-obviously intoxicated. He simply refused to perform the surgery. Pili’s family and the staff threatened that he had better do it because if she dies due to his irresponsibility, then he “would be in for it.” After extensive arguing, the AMO reluctantly agreed to perform the caesarean section. Although the infant had died, Pili fortunately survived. She escaped mortality, by a “near miss,” but did not escape morbidity. The prolonged pressure from the obstructed birth without an intervention left her with an obstetric fistula. She was sent to a larger hospital for surgical repair soon after it resolved.
Eventually she was healthy again and became pregnant again. As before, she began the long trek to the hospital when her labour started, knowing that she would need a caesarean because of her previous problems. This time a different AMO was there on time to perform it, but something went seriously wrong in the operating theatre. He became confused and frustrated during the surgery and simply left the room without explanation; leaving Pili lying on the operating table alone. He finally came back into the theatre and said that she would need to go to the major hospital again and that he would go with her and her family on the ferry. She lost another child and needed another operation. They all went together to the port, and just as they were boarding, he said that he had forgotten something and that he would be right back…. but he never returned.
Pili and her supportive family went to the hospital without him. Unfortunately, instead of quickly healing, this time she was continually sick. Besides physical ailments, she suffered emotional problems after the second repair. She describes this time in her life as one in which she was “always sad and crying, thinking about the two stillbirths.”
She says that she was not in a good condition; even economically she had problems because she was too weak to work in the farm in order to generate an income. She now thinks that it is better that she never try to have children. She asked the doctors at that hospital during her last repair to “just cut out [her] uterus so that this does not happen again,” but of course they refused.
The repercussions on Pili’s life because of the inability to access skilled medical care are not only unfortunate, but easily evoke anger. It is easy after reading this story to blame the health care professionals. How irresponsible, negligent, and blatantly cruel could someone who has decided to work in the medical field be? How could such a thing happen to a woman, who herself was defeating the odds by accessing healthcare that is supposed to be available to her when she simply puts forth the effort? As usual, these issues are much more complex.
In this particular setting in Tanzania, there is only one physician and three AMO’s for a population of 300,000. Each individual has worked for several years, studying hard to obtain the best marks and learning how to take care of people, with little return. Imagine trying to take care of the needs of all of the individuals in the community that need medical attention each day. Imagine the limited time with each one, the pressure to move quickly from emergency to emergency and to try to resist the bribe of a patient who hopes to buy your attention with a little extra money, when you are only being paid $300 a month to work in a situation where your patients are dying all around you. It would not be surprising if the health care workers suffer themselves from depression. This would explain turning to escape through alcohol, among other coping mechanisms. In impoverished communities around the world, we are facing an educational crisis. There are few resources for people to gain access to higher education, and even fewer ways to retain those locally once they hold a degree that can take them virtually anywhere. In an increasingly connected world, global changes are affecting more of us.
As usual, this cascade of poverty affects the most impoverished. Pili’s story is a clear illustration of just one of the many ways that an off-shoot of global poverty, the shortage of skilled health care providers, can do exponential harm. According to the Global Workforce Alliance, “fifty-seven countries, most of them in Africa and Asia, face a severe health workforce crisis.”
The World Health Organization estimates that a total of 4,250,000 health workers are needed to fill the gap and sub-Saharan Africa faces the greatest challenges; “while it has 11 percent of the world’s population and 24 percent of the global burden of disease, it has only 3 percent of the world’s health workers.” (2)
Causes of total shortage include the HIV pandemic, lack of access to education and training, and what we have all heard of referred to as the “brain drain;” the tendency of trained professionals to leave their home countries in order to find higher pay and higher standards of living. This “drainage” occurs within countries, too. Ministries of health try to respond to local needs by assigning professionals to communities that request more help, but these individuals simply do not report when the area is somewhere undesirable for living. According to one physician in an underserved rural community in Tanzania, “We requested 32 new staff this year. The ministry posted 12, but only 3 actually showed up.”(1)
Some countries have attempted both financial incentives as well as non-financial incentives in improving the staggering conditions of workforce shortage. South Africa, Ghana, and Zambia have used tactics such as granting allowances to health workers who work in underserved areas, and/or subsidizing salaries. Other countries have used housing facilities, automobiles, and intentional improvements in management practices to try to make postings more attractive. Some of these initiatives have been more successful than others, but predicting their long-term efficacy is impossible. Besides financial motivations, USAID’s Capacity Project explains that there are several other reasons for the lack of health worker retentions including: deteriorating living and working conditions, weak performance management, leadership and supervision structures, inadequate equipment and supplies, lack of recognition for good work, stress due to heavy workload, gender-related issues, including sexual harassment and gender-based discrimination, limited opportunities for career development and advancement and safety and security concerns, including those related to HIV/AIDS protection, care and risk. (3) The list is extensive and it all points to poverty.
Tackling deep-seeded and complex aspects of poverty in a community will take time. Therefore, temporary strategies will also have to be implemented in order to approach the immediate issue holistically, so that more women like Pili are not neglected. Therefore, a combination of strategies focusing on both alleviating the healthcare strain and local poverty is necessary.
Governments can use incentives to attract professionals to underserved areas, but will also need to focus on educational and training efforts like connecting women to higher education so that they might have the option to enter the health field. Richer countries that attract physician migration can discourage the trends of the brain drain through policy, while investing their donation dollars in projects that give people access to clean water. More people could spend more of their lives living instead of devoting hours of their day to collecting water and often becoming sick from water-borne diseases. The only way to ensure improvement of a problem that is itself an off-shoot of poverty is to recognize and address the base of the issue. There are many creative and practical ways to address the problem of workforce shortage as explained by the Workforce Alliance, Capacity Project, and other organizations and ministries of health. However, they must be combined with long-term strategies for addressing poverty on a local, national and international level so that there are not communities left behind other parts of the country, and not countries left behind other parts of the world.
Rachel J. Pope
Medical School for International Health BGU-CU
Be’er-Sheva
Israel
rachel.pope@gmail.com
(1) Pope R., Bangser M., Willy H., 2007. Restoring Dignity: Reintegration after Fistula Repair in Tanzania, Women’s Dignity Project. Dar es Salaam, Tanzania
(2) World Health Organizaion. Work Force Alliance. http://www.who.int/workforcealliance/en/
(3) Yumkella,Fatu. IntraHealth International. Retention of Health Care Workers in Low-Resource Settings: Challenges and Responses. Capacity Project. Knowledge Sharing. February 2006. Technical brief 1. (http://www.capacityproject.org/)
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