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How Prenatal Events Influence the Development of a Vesicovaginal Fistula

Chioma is a Medical Doctor and Public Health practitioner based in Gombe state Nigeria, with years of experience working in rural settings.

The Life Course Perspective of the Vesicovaginal Fistula (VVF)

Ever wondered if the sum total of a person's actual experiences were the result of a sequence of socially defined roles, events and decisions that an individual makes over time? Well, it is possible to examine an individual's life history and from it deduce how events before birth and in early life influence future choices, events and even the development of disease. This is known as the life course perspective, also referred to as the life course approach or life course theory (I'll be using these terms interchangeably). In this article, we'll lay the groundwork for the analysis of the life course perspective of the VVF that we will study in detail in a separate article.

Ever wondered if the sum total of a person's actual experiences were the result of a sequence of socially defined roles, events and decisions that an individual makes over time? Well, it is possible to examine an individual's life history and from it deduce how events before birth and in early life influence future choices, events and even the development of disease.

Getting Started

To get a head start on this topic, we need to be clear on some terminologies and understand why the VVF is fit to be looked at from a life course perspective. When reading various literature on VVFs, you may notice a number of terminologies being used interchangeably; these include: “vesicovaginal fistula”, “obstetric fistula” , “genitourinary fistula” or simply just “fistula”. Given that our focus is on VVFs that result specifically from obstetric events; it is imperative that we make a clear distinction between each of these terms.

how-events-and-decisions-made-early-in-life-ultimately-influence-the-development-of-the-vesico-vaginal-fistula-vvf

Definition of Terms

Fistula: This is an abnormal connection between two hollow organs.

Obstetric Fistula: An abnormal opening between a woman’s genital tract and her urinary tract or rectum.

Genitourinary Fistula: Sometimes referred to as a urinary fistula, is an abnormal connection or passageway between the urinary and genital structures.

Vesicovaginal fistula: An abnormal opening between the bladder and the vagina that results in uncontrollable leaking of urine through the vagina.

High occurrences of VVFs have been shown to occur where maternal mortality rates are high.

High occurrences of VVFs have been shown to occur where maternal mortality rates are high.

Prevalence and Etiology

VVFs although once common in Western Europe and the United States, are generally more prevalent in developing countries where most cases are as a result of injuries sustained during childbirth. VVFs chiefly result from obstetric and operative injury, malignancy, radiation, trauma, and infections.They are rare in developed countries were they arise as complications of either radiation therapy and/or surgery. However, in developing countries, it is the commonest type of genitourinary fistula, with eighty to ninety percent of VVFs resulting from obstetric injury.

Brief Historical Background and Early Analysis of VVFs Within Structural, Social and Cultural Contexts

The oldest evidence of a VVF is found in the remains of Queen Henhenit, the wife of Egypt’s ruler around 2050 BC. As it has been noted: “to Queen Henhenit belongs the dubious honor of having suffered the most antique vesicovaginal fistula documented.” In the 11th century, the Arabo-Persian Physician named Avicenna was the first individual to make a connection between obstructed labor and vesicovaginal fistulas. It is interesting to note that though he is a physician, Avicenna actually looked beyond the scope of his field to discover a determinant which he believed to be critical to the development of the vesicovaginal fistula—women who marry at an early age—that he mentions it first before what was clinically obvious (the weak bladder) in women he examined. This, in my opinion, is remarkable and probably the first attempt at a life course perspective of the vesicovaginal fistula.

Portrait of Ibn Sina or Avicenna (980–1037 CE). 

Portrait of Ibn Sina or Avicenna (980–1037 CE). 

In this article, we are focused on the life course approach of VVFs that are a sequel to prolonged obstructed labor; or in other words the “obstetric fistula” (given its obstetric cause) which has a rich history of events that culminate in its occurrence and hence can be addressed from a life course perspective.

Conceptual Framework for the Vesicovaginal Fistula (Vvf)

how-events-and-decisions-made-early-in-life-ultimately-influence-the-development-of-the-vesico-vaginal-fistula-vvf

Are You Ready? Let's go...

I guess by now you would have noticed the diagram above and you're probably trying to make sense of it. It is a conceptual framework, and simply put, a conceptual framework is a tool that can be used to organize ideas. In this case, what I've tried to do is depict all the risk factors and pathways (at least based on my own research) that influence the development of the VVF before conception right until adolescence. Now, with this knowledge in mind, kindly scan through the conceptual framework again, as this would serve as the basis of our discussion going forward.

Distal Determinants

Understanding the Paths

If you look carefully, you'll observe that there are broken lines with arrows (about ten of them) marked I-X. These are the pathways or paths through which the Distal Determinants (exposure variables that exist within different phases of life, from before conception till adolescence) interact with factors (biologic, physical and social) also within different phases of life to produce bio-social responses which ultimately influence the development of a VVF. However, at this point, it is important to note that when referring to the different phases of life, our point of reference is the female subject who has developed a VVF. In other words, what we're simply doing is evaluating each phase of her life in light of certain exposure variables from before conception until she's an adolescent; and how they culminate in the development of the VVF. The table below breaks it down and helps to provide more clarity.

When referring to the different phases of life, our point of reference is the female subject who has developed a VVF. In other words, what we're simply doing is evaluating each phase of her life in light of certain exposure variables from before conception until she's an adolescent; and how they culminate in the development of the VVF.

A number of studies have shown associations between the listed determinants and their respective bio-social responses.

A number of studies have shown associations between the listed determinants and their respective bio-social responses.

Paths (I) and (II) represent two separate biologic pathways through which decreased maternal height and low maternal pre-gestational weight before conception (I); and Low Birth Weight (LBW) during pregnancy (II); are associated with decreased adolescence height.

Path (III) represents a socio-biologic pathway through which low family income and socioeconomic status during infancy and childhood (III), are associated with delayed age at menarche (first occurrence of menstruation); and decreased adolescence height.

Paths (IV), (V), (VI), and (VII) are predominantly social pathways through which poor socio-economic conditions affecting the family and in some instances the mother during infancy and childhood, influence the educational attainment of the female child later on in life, as well as early adult social positions which in this case is early age at first marriage.

Path (VIII) is a biological pathway through which poor nutrition (chronic malnutrition) during infancy and childhood, influence the age at menarche, development of pelvis and height.

Path (IX) represents another biological pathway during the early adolescence period which associates delayed menarche at puberty with short height and incomplete growth of pelvis.

And lastly, as clearly depicted, Path (X) is the combination of all biological and social responses from before conception to adolescence, that culminate in eight distinct exposure variables (features) in the adolescent period namely: short height, delayed age at menarche, immature pelvic bones, illiteracy, early age at first marriage, High or low parity, lack of decision making power and delay in seeking care; all which influence the likelihood of the development of a VVF later in life.

Exposures May Affect Risk of VVF in Multiple Ways

I'll like to start by saying that the life course approach is not merely an accumulation of risks across life phases as timing is also critical. For this reason, exposures may affect the risk of VVF in multiple ways.

1. Critical Period

The Critical Period is when "an exposure acting during a specific period has lasting or lifelong effects on the structure or function of organs, tissues and body systems which are not modified in any dramatic way by later experience." Although Critical Periods are common during fetal development, they can occur later in life, especially in the presence of Effect Modifiers (we will discuss this briefly below). Are you familiar with the thalidomide tragedy that occurred in the late 1950s and early 1960s, and led to the birth defect crisis? Well, it's a clear example of an adverse exposure to thalidomide, occurring during a Critical Period (Fetal Development), and resulting in irreversible damage (birth defects).

2. Effect Modification

Effect Modification occurs when a variable modifies an observed effect of a risk factor on a disease. In other words, Effect Modifiers change the association of an exposure with the outcome of interest. Looking at the predominantly biologic pathways (I-II); the association between decreased maternal height and decreased adolescent height seems pretty straight forward. It wouldn't come as a surprise if a woman who's short has a daughter who ends up being short as an adolescence. I mean, it could be genetic.

However, the real question is how are low maternal pre-gestational weight and LBW associated with decreased adolescent height? Do all women who have low pre-gestational weight end up with adolescents with decreased height? The answer is most likely, "No."

What about LBW babies? Would all LBW babies end up with decreased adolescent height? Again, I doubt it. So the question is, what could be responsible for these associations? The answer could be an "Effect Modifier." By this statement, I mean that perhaps the presence of a third unknown or unidentified variable unique to each exposure variable (which in this case is low maternal pre-gestational weight and LBW) could be responsible for the observed outcome (decreased height).

Effect Modification occurs when a variable modifies an observed effect of a risk factor on a disease. In other words, Effect Modifiers change the association of an exposure with the outcome of interest.

However, having said that, I'll still like to bring to your attention a population based birth cohort study which sought to investigate the influence of biological and social backgrounds on height of adolescence girls at age 19.Though the researcher found associations between socio-economic status, malnutrition and delayed menarche with height at age 19, the analyses showed that birth weight was a stronger predictor of height at age 19; even stronger than weight gain during infancy at ages 2-4 years. Based on these findings, I am further persuaded that LBW during pregnancy is indeed a critical period in the life course. Whether LBW in of itself is capable of resulting in decreased height, or requires the presence of Effect Modifiers is open to further debate.

3. Chains of Risk

Here, we're referring to how one exposure tends to lead to another. Within this framework, the set of determinants which I think demonstrate this concept are the predominantly social pathways (IV-VII). For example, low family socio-economic status and income will lead to poor educational attainment; and poor educational attainment will lead to early age at first marriage; which in turn will increase the likelihood of prolonged obstructed labor due to immature pelvic bones, and ultimately the VVF. There are suggestions by some authors that such links are likely probabilistic rather than deterministic and also possibly sequential.

4. Additive and Trigger Effects

When viewing the whole conceptual frame work from before conception to adolescence, one could suggest that the VVF is a culmination of all exposures from before conception until adolescence (X). This is known as the “Additive Effect." Whereas, when referring to the "Trigger Effect," we're talking about what started it all.

According to one author, chains of event are important from a preventive perspective as they can help identify points of intervention where series of risks can be broken to establish a new life course. The author further states that whereas stopping the additive effect will have health benefits and possibly result in residual damage that will remain throughout life; preventing the trigger (which in my opinion from this framework is low socio-economic status); will decrease the chances of adverse risks associated with exposures experienced earlier in the chain.

Whereas stopping the additive effect will have health benefits and possibly result in residual damage that will remain throughout life; preventing the trigger will decrease the chances of adverse risks associated with exposures experienced earlier in the chain.

Proximal Determinants

While the distal level of the framework focuses on risk factors that place an individual or population at greater susceptibility to proximal risk factors (refer to conceptual framework); the proximal level illustrates risk factors that have a direct impact on individual health status. In this framework, the proximal determinants are: Cephalopelvic Disproportion (CPD) and prolonged obstructed labor. This is where understanding the natural history of events that follow in the biological system is critical. During prolonged/obstructed labor, the soft tissue of the vagina is trapped between the fetal head and bonny pelvis (CPD). If compression is not relieved, the tissue becomes necrotic and usually between three and ten days postpartum, it sloughs off and a fistula develops between the bladder and the vagina.

Modification of Outcome

Healthcare encompasses availability, accessibility and quality of Emergency Obstetric Complication (EOC) services. In this framework, It modifies the relationship between CPD/prolonged obstructed labor and obstetric fistula; as timely intervention has been shown to prevent the latter from occurring.

Conclusion

The VVF is a debilitating disease which primarily affects girls in developing countries. As complex as the association between exposure variables at various life stages may seem, the role of family background within the context of socio-economic and educational status in determining the outcome is critical. This for me is a starting point in seeking out ways to prevent this debilitating condition.

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This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2020 Ejeagba Chinonso Chioma