Obstetric fistulas: Not a problem in countries with good health care. But many women around the world lack access to the right treatment. This Saturday the United Nations want to draw attention to this disease.
Genet was 13 when they married. A thin girl from a village in the north of Ethiopia. She became pregnant when she was 14. The labor went on for four days, and the old women from the village told her to squat down and it would be quicker. So she crouched until her legs died. The child was stillborn.
Almaz, who lives near Addis Ababa, was 27 and her family refused to take her to the hospital to give birth. It is too expensive. Only when it became apparent that the child in her womb was dead and that Almaz would not be able to deliver it was she taken to a health center.
Camille was raped and pregnant by a police officer in eastern Congo. Her husband threw her out of the house. She lived in a dilapidated hut at the beginning of the forest. She gave birth to the child alone, and it took three days.
Severe birth injuries: Millions of women worldwide suffer from obstetric fistulas
On May 23rd, United Nations Day to End Obstetric Fistulas, imagine you are Genet, Almaz, Camille. They would have been married early. At an age when your body is not yet trained to give birth to a child. Or maybe educated, but you are malnourished. Or else you’ve been circumcised, your labia sewn shut, and the tissue inside you is scarred and easy to tear.
You get pregnant. There is no obstetric practice or clinic near you. In any case, you would not have time for prevention because you would have to work in a field until the day of labor. Then labor starts, but the child is stuck in the birth canal. His head presses on the tissue of your vagina, the wall that separates the vagina from the bladder and rectum. Keep pressing until the tissue dies and there are holes in your vagina wall.
Persistent stigma: Many women in African countries are cast out due to obstetric fistulas
You go into labor for two days, three days, sometimes five days, the baby is long dead, but it’s still stuck. At some point your family raised money to take you to a clinic, where you would be removed from the body of the dead child and told you would be incontinent from now on. Urine, and in the worst case feces, will run out of your body. Unstoppable, day and night. You will smell bad. The flesh on your inner thighs will become infected from the urine.
Imagine you come home after this ordeal and your family or husband tells you that there is no more room for you in this house. Because you stink. Because you have no more value. You cannot find work in your condition because wherever you go the smell wafts around you. So go somewhere where you can at least find shelter. In a cave. Or an abandoned house. There they live in secret like an animal and hope for merciful souls who will bring them food. If you can’t take this anymore, you kill yourself.
That sounds awful, doesn’t it? Obstetric fistulas are what has happened to between two and three million women in the world, and an estimated 150,000 women are added each year. How many exactly, even the World Health Organization (WHO) cannot say, because only clinical cases are reported. The number of unreported cases is likely to be much higher.
On May 23rd, the United Nations proclaimed International Day for the Ending of Obstetric Fistulas
It’s not that this condition is incurable, even with little effort. You can sew these “holes”, at least if you are trained to do so. Fistula surgeons with steady hands and experience need just two hours. And everything is fine again.
But it is not you, not us, who have to endure a birth with these traumatic consequences. But women in poor countries in Africa and Asia, women without a voice, without a face and are considered worthless for the national economies and for global development. A third of them die under such births, and most of the others live somewhere where they are invisible.
Fistulas have existed since women gave birth. Researchers found them on a 2,000-year-old mummified woman’s body. An Amsterdam surgeon succeeded in suturing up a fistula for the first time in 1663. The American gynecologist Marion Sims experimented on slaves in the 19th century and sutured up a number of fistulas with success, which is why he is regarded as the father of fistula surgery, but not as a human doctor.
The day
According to the World Health Organization (WHO), between two and three million women worldwide suffer from obstetric fistulas because they do not receive adequate medical help during the birth of their children.
International Birth Fistula Ending Day is celebrated annually on May 23rd to raise awareness of the disease. It was launched in 2014 by the United Nations. Further information is available at www.un.org/en/observances/end-fistula-day
So it’s a millennia-old medical problem. Millennia of sedentary people inventing the wheel and railroad, industrial revolutions, men flying to the moon, doctors replacing hearts and enlarging breasts, finally the internet was invented. But in which it was not possible to build up a worldwide system of obstetrics and to found enough clinics in which one can sew tears in vaginal tissue.
Obstetric fistulas are actually easy to cure – but there is a lack of understanding and medical care
In Europe too, women sustained serious birth injuries for centuries, and children were commanded dead. From 1935 to 1950, however, a great deal of knowledge and money was invested in European health systems to end maternal mortality and thus the occurrence of fistulas. Obstetric fistulas are a thing of the past in Europe and other Western countries since there were hospital births, pregnancy examinations, midwives and caesarean sections.
Today it is the poorest of the poor who suffer from fistulas. The fact that it was not possible to avoid these birth injuries worldwide is just one example of the serious differences between the health systems in rich and poor countries. Maternal mortality and fistulas, precisely because both could be prevented with simple means, are indicators of the failure of national health systems – and global engagement for women in poor countries.
Although far fewer women worldwide are now dying during childbirth – maternal mortality has been reduced by 38 percent – the goal of almost abolishing maternal mortality, which the United Nations set itself in 2000, is still a long way off.
Obstetric fistulas: a millennia-old medical problem
According to estimates by Unicef and the WHO, either a mother or a child still dies every eleven seconds during childbirth, 2.8 million per year. And again, these are not women in the rich countries of the western world. In Germany, four to seven women die each year as a result of birth problems. In the countries of sub-Saharan Africa there are 1,000 women per 100,000 live births, the highest number in Sierra Leone with more than 1,000 women per year.
Women with fistulas are virtually absent from these numbers and efforts, and there is little public awareness of the issue. No pharmaceutical company can earn money from it, and no scientific team can make a name for itself. The number of organizations dedicated to the fight against fistulas is manageable, as are the donations to fight them.
A report on the topic
Four years ago, our author Andrea Jeska first wrote about the worldwide problems caused by obstetric fistulas. You can read her FR7 report on affected women here.
But not only the health system is to blame, the social structures are also to blame. Women with fistulas are stigmatized and very few dare to go public. The likelihood of finding out about possible help is particularly low in rural areas. The United Nations Population Fund, UNFPA, has named women with fistulas the most dispossessed, outcast, powerless women in the world.
United Nations: May 23rd is International Day for the Ending of Obstetric Fistulas.
Maternal mortality and birth injuries are related. Using available data, Saifuddin Ahmed of Johns Hopkins University in the United States, one of the few experts on both, estimates that the number of maternal mortality multiplied by three is the number of fistula cases per country. In an interview with the Frankfurter Rundschau, however, Ahmed emphasized that there has been progress in some countries, namely where governments are investing in obstetrics and the training of doctors. In many cases, the fight is only a question of financial resources.
The example of Ethiopia shows what money can do. At the beginning of the 21st century there was almost no other place in the world where so many women died in childbirth as in the East African country. Nobody counted the seriously injured survivors. Since then, with an improved health system, largely funded by the United Nations and Western governments, Ethiopia has reduced maternal mortality rates by 45 percent, a true success rate. The number of fistula cases fell accordingly. If you take a closer look at the statistics, however, you can see that the successes relate to the urban areas. The rural regions are undersupplied. How much is shown by these figures: In Germany there is one doctor for 226 patients, in Ethiopia one for 33,500 patients.
By treating obstetric fistulas, Ethiopia has reduced maternal mortality by 45 percent.
The number of clinics in which fistulas can be sutured is also shockingly small. Statistics that appeared in an article in the scientific magazine “The Lancet Global Health” show that only a few of the 29 affected sub-Saharan states have the possibility of medical help. And wherever they are, an average of 110,000 affected women per country are treated in 2000.
Genet was operated on at the Fistula Hospital in Addis Ababa. The clinic is considered one of the best in the world for the surgical removal of fistulas. But Genet could not be cured, the three fistulas she had suffered turned out to be too big, and the ureter was destroyed. Since then she has lived in a facility for women with fistulas. Everyone there shares the same fate. They don’t have to be ashamed of their smell among themselves. Genet likes it there, there is a big garden and the women keep chickens.
Almaz was also operated on in that hospital, after three hours her fistulas were sewn up. She did not return to her family, whom she had chased away after giving birth. She stayed in Addis Ababa and works in a café there.
Millions of women do not receive adequate treatment after giving birth.
Camille’s baby survived birth, a rare occurrence. Camille was found in her hut by people who took her to the Pansi Hospital in Bukavu, a city in eastern Congo. There she received psychological help and enough food to regain her strength. When she was emotionally and physically stable again, she was operated on.
The Pansi Hospital has also given many incontinent women a new life. The surgeon and Nobel Prize winner Denis Mukwege and his team operated on around 60,000 patients there, most of them with success. During her healing process, Camille took a sewing course at the clinic and then received a sewing machine from an aid organization. She did not return to her family either, but started her own business in Bukavu.
