In the urology ward of the Central Hospital in Maputo, Mozambique, 25-year-old Maria Armaldo is patiently waiting for her surgery. This will be the fourth attempt to repair her obstetric fistula, a condition she developed almost a decade ago during her first pregnancy. She hopes that this surgery will be successful.
“I have been in pain for the past nine years, and I just hope it will be over soon so I can return home to my village,” says Ms. Armaldo.
Maria is not alone in the ward; she is surrounded by other women awaiting surgery for fistula—a condition that results from prolonged or obstructed labour and leaves women with a hole between the vagina and rectum, the vagina and bladder, or both. The painful condition causes incontinence and, when left untreated, can lead to chronic medical problems.
The physical pain of fistula is compounded by the embarrassment and social stigma that often arises as a result of incontinence. Unable to afford or access treatment, many women live for years with the condition. These women are among the poorest and most vulnerable, and often live in rural areas where health facilities are sparse.
“The major causes of fistula in Mozambique are deeply rooted; the fact that 70 per cent of women deliver outside health facilities puts them at higher risk of maternal mortality and morbidities,” explains Dr. Igor Vaz, a urologist who has worked on fistula since 1986 and has treated more than 1,000 fistula patients.
The good news is that, in most cases, surgery can repair the injury. The average cost of fistula treatment and post-operative care is $300—a relatively low price for a potentially life-transforming surgery.
More complex cases like Ms. Armaldo’s, which requires expert care, account for approximately one in five fistula patients in Mozambique.
“We simply lack sufficient health personnel to treat the existing cases, especially the most complex ones. Besides the lack of infrastructure, the impact of poverty also contributes to the magnitude of the problem in Mozambique,” Dr. Vaz explains.
The Maputo Central Hospital treats up to 20 fistula patients every month. The complex cases—about two per month—are assigned to Dr. Vaz, one of the few surgeons in the country with the expertise to perform such surgeries.
“We receive extremely complex fistula cases from all over the country; they are generally more prone to recurrence and we usually have to operate again,” Dr. Vaz says, noting that a difficult fistula repair surgery can take up to eight hours.
Ms. Armaldo’s health condition is also a source of concern. She is one of the many examples of how the combination of early pregnancy and home delivery can increase women’s risk of developing fistula. She was only 16 when she became pregnant.
“I delivered at home with my mother’s help. For three long days I pushed. It was very sad to see my dead baby when I finally delivered,” recalls Ms. Armaldo.
After five years of misery, unable to control the flow of urine and faeces, Ms. Armaldo was abandoned by her boyfriend and ostracized by her community. She couldn’t finish her studies or find a job.
“I just stayed at home at my mother’s house. It was a terrible period until I discovered that I could be treated,” reflects Ms. Armaldo.
Marianna Carlos, age 20, lies in a bed next to Ms. Armaldo. She too is being treated for complex fistula. Last month, she underwent her third operation. Now she is looking forward to returning to her village.
“I have been here since February and I hope to go home soon. I would like to study and see if I can be of help to other girls with fistula,” says Ms. Carlos.
“In Mozambique, 41 per cent of pregnancies occur among 15-19 year-olds, and early pregnancy is a risk factor for developing fistula. The country’s maternal mortality ratio is also very high: 500 women die per 100,000 live births,” says Dr. Amir Modan, UNFPA’s Sexual Reproductive Health Team Leader in Mozambique.
The country has no official statistics on how many women are living with fistula; however, high teen pregnancy and maternal mortality rates signal that girls and women are not getting the sexual and reproductive health services they need. As long as women’s health needs are neglected, fistula will continue to be a serious problem in the country.
“Family planning and sensitizing the communities through various communication channels is part of the solution if we want to put an end to fistula, especially among young women,” says Dr. Amade Ibrahimo Nazir, the National Director for Reproductive Health at the Ministry of Health.
Family planning is critical. It allows girls and women to prevent early pregnancies, increase birth spacing and limit their total number of pregnancies, which in turn reduces the incidence of fistula and other maternal and infant injuries and deaths.
The Mozambican government is committed to reducing fistula by expanding prevention, treatment and social integration efforts. The country’s National Integrated Plan to achieve Millennium Development Goals (MDGs) 4 and 5 includes measures to prevent fistula, and the issue has gained additional momentum with the development of the country’s new Family Planning Strategy (2010-2015).
To complement the existing plans and strategies in the area of maternal and reproductive health, the Ministry of Health is now collaborating with partners to develop a four-year fistula strategy. “Our focus will be on improving services for fistula treatment, sensitizing the communities about fistula and the possibility for treatment, and establishing social integration services,” Dr. Nazir explains.
“Putting an end to fistula will not only make the future brighter for young women, but society at large will benefit too. When girls are educated, healthy and can avoid child marriage, unintended pregnancy and HIV, they can contribute fully to the development of their society,” Dr. Modan says.
Ultimately, UNFPA and its partners aim to make fistula a thing of the past, so that young generations of girls grow up without knowing the pain and humiliation that accompany the condition, and benefit from sexual, reproductive and maternal health care throughout their adolescent and adult lives.
Helene Christensen reported from Maputo, Mozambique, with support from Rachel Murchison and Emily Dally. Photos: Pedro Sa da Bandeira, 2011.