September 14, 2007

Global health a passion for new Ob/Gyn faculty member

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New Vanderbilt gynecologist Andy Norman, M.D., spent 13 years in Nigeria, providing care and performing surgery on women who incurred injuries from prolonged, obstructed labor. (photo by Cat Norman)

Global health a passion for new Ob/Gyn faculty member

Unattended obstructed labor that goes on for days is not a common problem in the United States, where obstetrical care is widely available, but in Third World countries such labors happen all too commonly and the end result may be an injury to the urogenital tract that causes the chronic leaking of urine.

During labor the soft tissues of the pelvis are compressed between the baby's head and the mother's pelvic bone. The lack of blood flow causes tissue to die, resulting in a hole between the mother's vagina and bladder known as a vesicovaginal fistula (VVF).

Andy Norman, M.D., a new Vanderbilt gynecologist splitting his time between the Department of Obstetrics and Gynecology and the Institute for Global Health, spent 13 years in Nigeria, much of it providing surgical treatment for women with this injury and training physicians there how to prevent and repair such defects.

Norman came to Vanderbilt from a private practice in Boone, N.C. A graduate of the Medical College of Georgia, Norman says there are more than 2 million women who suffer from VVFs, and estimates he has performed about 500 repairs.

“In this country, when you see VVFs, they are related to hysterectomy or cervical or pelvic cancer treatment,” Norman says. ”In a Third World Country, they are almost always related to being in labor too long and having nowhere to go for a Caesarean section.

“Generally speaking, if a woman goes through a long labor with no professional help, the baby will die between the first and second day. In Africa the woman might be in labor two to three more days before something is done, before she is taken to a hospital.”

It is after delivery, when a VVF occurs, that the woman will begin leaking urine.

“They leak their urine all the time, day and night. Their clothes are wet. Their bed is wet. They are followed by the smell of urine,” he said. “Some of my patients had obstructed labor a week ago. Some had it 15 years ago and nothing has been done to help them.”

The injury affects more than the women's health, he says. It also leaves them with a stigma, and they often don't seek treatment because of the embarrassment associated with leaking urine all day, every day.

“In many instances, in the African context, women are almost like a commodity,” Norman said. “A man makes a deal with a woman's father, that he would give some cows or some money and the father would give him the right to marry his daughter.

“But if she has problems with her labor and doesn't give her husband a child, and was also injured during that labor, her husband could just divorce her and bring her back for a refund of the dowry, or bride price. The families are then faced with the formidable task of finding help for their devastated daughter.”

The fistulas are treatable and often preventable, but many women are unaware the treatment is available, or else they can't access or afford it, Norman said. Reconstructive surgery can mend the injury and success rates are as high as 90 percent for uncomplicated cases.

When surgery cannot correct the problem, women can undergo diversion procedures, where the urine is either brought out through a hole in the side into a bag or routed into the colon to be passed along with bowel movements. Women with repaired VVFs can sometimes have more children, but C-sections are recommended for subsequent pregnancies to prevent the recurrence of the fistula.

At Vanderbilt, Norman will provide both general gynecological care to patients at The Vanderbilt Clinic and will also do repairs for pelvic organ prolapse or urinary incontinence in women of post-reproductive age.

In his Global Health position, Norman will participate in research projects relating to HIV in pregnancy and HIV in cervical cancer patients. And he hopes to continue his work treating women with VVFs in Africa.

“I'll continue that work, even if I just do it myself,” he said. “But I hope to be a facilitator for anyone who has a heart for the maternal/child health needs of women in developing countries.

“My hope would be that in the global health arena, we can get some projects going for VVF treatment, education and prevention in a needful country. That's the hope.”