Maternal health

For $ 300, a normal life

Some 2 million women worldwide suffer from obstetric fistulas, according to figures recently released by the UN Population Fund (UNFPA). Such injuries occur during childbirth; and the consequence is that women can no longer control their excretions.

[ By Catherina Hinz ]

The causes include childhood marriage, childhood pregnancies and female genital mutilation. Every year, 75,000 new cases are repor­ted, most of them in poor countries. In Ethiopia alone, 9,000 mostly young women are affected. Often, these women are first-time mothers who live in rural areas with a lack of medical care. Those affected by fistulas suffer a great deal, though a simple surgical intervention would give them all the relief they need.

To gauge a country’s maternal health, all you have to do is take a look at the problem of obstetric fistulas, says an African doctor. The more women suffer from this horrible childbirth injury, the worse the state of general maternal health is.

Women who suffer from this condition are often doomed to a similar fate. After days of labour, they give birth to a dead infant, sustaining such serious internal injuries that they can no longer control their bodily functions.

In Ethiopia, the situation is drastic. Medical assistance is rarely available when complications occur du­ring childbirth, or when the process of childbirth comes to a standstill. The next clinic or hospital may be several days’ walk away, and there is no guarantee that that clinic has trained personnel to carry out an emergency Caesarean. Many women die. Ethiopia’s maternal death rate is relatively high: 720 out of 100,000 live births. Still higher is the number of women who survive delivery, but who sustain serious injuries and permanent damage to their health, such as obstetric fistulas. Experts estimate that some 9,000 Ethiopian women are affected annually.

Obstetric fistulas occur during protracted labour, when the baby’s head puts so much pressure on a woman’s lower abdomen that the head is pressed against the pelvis. Circulation is cut off, parts of the tissue die off, and holes develop between the vagina, bladder and lower intestines. As a result, women lose control over their excretions. In addition to their bodily suffering, these women also become social pariahs. Since they smell of urine and excrement, no one wants anything to do with them. They become outcasts who live their lives in poverty and shame.

Pregnant too young

There are several reasons for fistulas. Aside from a lack of medical care during pregnancy and childbirth, the tradition of child marriage and the associated consequences of early pregnancy contribute to the problem. It remains common in Ethiopia to arrange early marriages for girls, who then become pregnant soon after their first period. Sometimes that occurs when they are merely 12 years old. Their bodies are not full-grown at that age, and chronic malnutrition exacerbates the problems. Often, the pelvis is too narrow for a normal birth, and that leads to frequent complications.

Female genital mutilation (FGM) also plays a role. FGM is common throughout Ethiopia, and while it does not cause fistulas directly, it does make them more likely. Other factors that must be taken into account are sexual abuse and rape, especially in Africa’s crisis- and conflict-ridden regions. However, addressing these issues is often taboo. There is very little data available, but there are reports of so-called trauma fistulas in Ethiopia.

Fistulas are a serious problem in Ethiopia; but the country is home to one of the few hospitals that specialises in treating and curing fistulas: the Fistula Hospital in Addis Ababa.

Fistulas are fairly easy to treat. According to the World Health Organisation, 90 % can be healed. The operation costs about $ 300, which includes post-operative care and physical therapy to strengthen the pelvic muscles. After that, women can usually lead normal lives again.

At the Fistula Hospital in Addis, some 1,200 women are operated on each year. This institution is supported by the Hamlin Fistula Research and Welfare Trust. Catherine Hamlin, an Australian physician, founded the hospital. She moved here with her husband in the 1950s with the aim of modernising the country’s midwife system.

Hamlin says she was shocked at how many women suffered from obstetric fistulas: “Countries with well-run health-care systems hardly have this problem, since a Caesarean section or another emergency measure is performed if there is any danger to mother and child. But in Ethiopia’s remote regions, women don’t have anyone to help them if there are complications during birth.” The hospital opened its doors in 1974, and since that day, about 32,000 women have been treated there free of charge.

Social rehabilitation

The hospital is considered a trailblazer in the region. Doctors from other African countries are trained here so they can help women back home. Besides medical care, the Fistula Hospital also offers services to help women integrate back into society. For instance, rea­ding, writing and needlework are taught. Patients are also made aware of women’s rights – that no one under the age of 18 is legally allowed to marry in Ethiopia, for example. Some patients are trained as nurses, and la­ter become employees of the hospital.

Far too many women, however, still lack access to treatment. And the flood of those seeking help never stops. Every day, new patients from rural Ethiopia arrive at the hospital in the capital. Many of the young women travel for days, making strenuous trips full of humilia­ting events. Some make their way on foot because bus drivers refused to take them as passengers; others have to spend their entire trip sitting on a bucket.

Experts agree that the number of victims will rise in coming years since the population is growing fast. Pre- and postnatal care cannot keep up with the demand, neither quantitatively nor qualitatively. That is the biggest problem.

Surgery in itself will never do, however, as Hamlin is aware of: “Through education, we have to remove the stigmas associated with obstetric fistulas.” Women with stillborn children and obstetric fistulas often become outcasts. “But well-informed village communities can prevent that from happening; and they would work hard to prevent child marriages,” the doctor says.

In a similar vein, it is hoped that informed people discontinue FGM traditions. In Ethiopia, change has set in – not least thanks to the work of the Fistula Hospital. Efforts like an information campaign run by the UNFPA, which has been fighting worldwide against fistulas since 2003, have also contributed to raising awareness. But Mulu Muleta, the hospital’s medical director, emphasises the positive role of the Ethiopian government. She told the science journal The Lancet: “At the policy level, women’s issues are a priority for the government.” Muleta speaks favourably of its efforts to improve maternal health.

The government supports the Fistula Hospital. Four outposts were set up in rural Ethiopia in order to take care of patients who live far from the capital. Poverty, the lack of trained personnel and poor road infrastructure, however, make the doctors’ work in these “mini fistula hospitals” more difficult.

Educating the people

It is difficult to reach women and to help them. Ignorance remains an obstacle. Many women and girls feel that they themselves are to blame for their suffering. They live isolated from the village community, hidden away in huts on the fringes of settlements.

Therefore, the work of aid agencies is very important. The German Foundation for World Population (DSW) addresses the issue in its awareness initiative for Ethiopian youths – especially for girls living in the Amhara Region, where DSW is acting in close cooperation with the local branch of the Fistula Hospital in Bahir Dar.

Local nurses are trained in the early detection and treatment of obstetric fistulas. At newly founded girls’ clubs, peer educators teach girls and young women on what causes fistulas, and how to protect themselves from unwanted pregnancies. Young people and nurses organise awareness workshops in which women and girls – and even community elders – are informed of what causes fistulas, and how to prevent and treat that terrible condition.

Victims are frequently in the dark on what is wrong with them. Mamitu is an example. “I was in agony for days. When the baby finally arrived it was dead,” she reports. A few days later, she understood that the loss of the baby was not all she had to cope with: “The entire bed was wet; it was horrible. Soon afterwards, they took me to a hut at the edge of the pond. Because of the smell, no one could stand being next to me. They said what happened to me was God’s punishment for my infidelity.”

Mamitu first told her full story to two young girls, educators who work in a neighbouring village. They had held a traditional coffee ceremony with members of the girls’ club to casually spur discussion of women’s subjects when an older woman had approached them and, pointing to Mamitu’s hut, said: “One of 'those people' lives over there.” The peer educators found the girl huddled on the floor inside her hut.

It did not take long for a nurse to examine Mamitu. She diagnosed the fistula the young women had been suffering from for years. Mamitu was then sent to the regional Fistula Hospital outpost. She became one of the 78 young women whom the programme has been able to help since it got underway in Bahir Dar in October 2006.

Obstetric fistulas would be entirely preventable if experienced and adequately trained midwives attended every childbirth and if emergency care were available in the case of complications. But it is even more important to raise awareness among the people in general, so that childhood marriage and teenage pregnancies will no longer endanger the life and health of girls.

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