April 10, 2012

A near-death experience for African women

According to the most recent UN statistics, women in sub-Saharan Africa are about 100 times more likely to die in labour than in developed countries.

But some of the women who survive childbirth, barely, still face the possibility of dying socially. Prolonged, obstructed labour without timely surgical intervention can create obstetric fistula, a hole in the bladder or rectum that causes chronic incontinence.

The condition has been present in the continent since ancient times: the earliest recorded fistula case was found in a 4,000-year-old Egyptian mummy. The consequences are devastating: after going through the agony of days of labour, the woman is left with a constant leaking of urine, feces or both. Usually the child she was hoping to give life to dies in utero.

“Besides the physical suffering associated with fistula, there is the psychological damage and social exclusion that usually follows,” says Dr. Nestor Azandegbe, Reproductive Health adviser at the Sub Regional UNFPA Office for West and Central Africa.

The stigma that still surrounds fistula has proven a challenge difficult to overcome and constrains treatment efforts. Most of the survivors don’t even know treatment for fistula exists. Many are either too ashamed to talk about the problem or too frightened to seek help, as they fear they would be even more stigmatized if they reveal their condition.

“These women are likely to feel as they are cursed or have fistula as a result of infidelity," explains Dr. Pierre Fouda, a pioneer of fistula treatment in Cameroon. “You can see these women abandoned by everybody, and rejected by the community because of their condition.”

The number of fistula cases reflects the quality of obstetric care that is available to women.
Fistula patients are the ‘lucky’ ones who survived labour, but they are left scarred for life Africa is home to the largest proportion of the two million fistula cases in the world.


One of the main challenges in the region is to ensure that all births are safe. “We all know what needs to be done to avoid maternal death and disability. Pregnancy should be a magic moment for mothers and societies,” says Dr. Azandegbe. “However, what we still see is lack of access to information and quality care, and this all becomes a nightmare for mothers, babies, families and communities.”

Experts say some basic conditions should be in place to help prevent maternal death and disabilities such as fistula. Pregnant women should have access to skilled attendants and well-equipped facilities, so that they will have the timely and appropriate care when serious complications arise, as they do in about 15 per cent of deliveries—a figure that may be even higher for women who have HIV or who are weakened by the too-frequent pregnancies, malnutrition or other poverty-related stressors.

Providing quality obstetric care to all women, as called for by international agreements, is a challenge in many parts of Africa. Most of the women living in remote rural areas don’t have access to the care they need. Poor health infrastructures, lack of transportation and economic and social constraints significantly affect health prospects, especially in the area of maternal health.

According to UNFPA country data in the Republic of Congo, for example, the precarious conditions and poor access to health centres are among the main reasons why few women are able to receive adequate medical follow-up during pregnancy and birth, thus increasing the risk for complications, such as obstetric fistula.

In Madagascar, a recent government study identified the lack of knowledge and harmful traditional practices as two of the major causes of fistula in the country.

Early marriages leading to adolescent pregnancies also increase the risk of complications. In Gabon, the majority of childbearing women became pregnant for the first time before turning 19—a significant proportion before turning 16, a UN study says.

Teenage pregnancy leaves young women more vulnerable to childbirth-related conditions, not only because of their physical immaturity, but also because young girls tend to hide the pregnancy due to shame and fear.

Gender dynamics also play a role. In Ethiopia, according to a 2010 USAID report, 93 per cent of women deliver at home without the assistance of a skilled birth attendant, like a midwife.

“This is something common in rural and remote areas in many African countries,” says Idrissa Ouedraogo, UNFPA adviser on gender. “Giving birth is seen as a trivial moment in a woman’s life, no medical care is needed if you are a ‘real’ woman,” he explains. “Moreover, in many cultures women are supposed to endure pain without complaining, so they can be considered strong”.

Other traditional practices common in some African countries, such as female genital mutilation/cutting also increase the risk for complications at childbirth. The most extreme forms of the practice, which include infibulation of the vaginal tissues, can cause haemorrhage and infection.

Political instability in many countries also hinder efforts to eliminate fistula, as it increases the risk for unintended pregnancies and many other problems that add to the vulnerability of women and poor maternal health.

Possible changes

Many African nations have partnered with UNFPA to prioritize fistula as a public health issue. In Eritrea, the government has spread a “fistula free” movement, and together with the United Nations and partners, it is facilitating the access to fistula services to clear the backlog of existing cases.

Comprehensive Community Based Rehabilitation in Tanzania (CCBRT), the largest provider of fistula surgery and a UNFPA partner in the country, is revolutionizing the field through an advanced “mobile phone plan” to transfer money and facilitate the transportation of fistula patients as they seek treatment.

In Sierra Leone a new programme is revolutionizing how women are identified and referred for fistula treatment. Women from remote areas can call a toll-free phone number and talk to specialized nurses about their symptoms, who then determine if the women are eligible for fistula treatment. In the first two months of the hotline, 119 patients were able to undergo fistula surgery.

In Guinea Conakry, rural medical insurance schemes, managed by the women themselves in remote areas, are providing motorbike transportation in case of obstetric emergencies.

Other initiatives, such as investing on fistula training in Ivory Coast and identifying traditional leaders to work as advocates to fight fistula in Guinea, are also leading to positive changes and community mobilization, bringing information to areas never reached before.

The lack of resources, another common challenge in many African countries, is being circumvented with alternative strategies to mobilize financial and social support.

Cote d’Ivoire, for instance, is working with UNFPA to develop stronger international partnerships, bringing together private and governmental donors to fight fistula.

The Government of Mauritania is developing partnerships with national organizations, such as the Midwives Association. In Guinea an ambitious alliance with rural radio broadcasters is spreading information about fistula prevention and treatment.

Other countries, such as Ghana and Liberia, are using celebrities as a resource, counting on national goodwill ambassadors like Miss Ghana and Miss Liberia to help end fistula and mobilize resources to get women recovered from this dreadful condition.

Read the article originally published by UNFPA Africa.

Esther Huerta reported from Senegal (UNFPA Africa Sub-Regional Office) with contributions by Janet Jensen.


Cover photo: Aminata, approximately 19. At the time of the photo, she had already undergone one fistula repair but would still need a second surgery to repair the fistula in her birth canal. During her last pregnancy, her fourth, she was in labor for one day at home in the outskirts of Bo, Sierra Leone, before the family decided to bring her to the hospital. When she finally arrived after almost three hours of travel, she noticed that her baby was not moving anymore. Angeline Martyn, Friends of UNFPA.