2nd December, 2009
‘If fistula was a condition affecting men, would it have taken us this long to do something about it?” Dr Eunice Kiereini, chairperson, Flying Doctors’ Society of Africa
Sarah Omwenga could easily have passed for a surgeon as she confidently took to the podium at the International Society of Obstetric Fistula Surgeons’ (ISOF) Conference in Nairobi this week. When she began to speak, her strong voice cutting across the room, the participants from across Africa, Asia, Europe and America fell silent, their undivided attention on the young Kenyan woman.
For the next 12 minutes, Sarah spoke of her ordeal with fistula, a condition caused by prolonged labour that leaves a woman unable to control the flow of urine, and sometimes stool as well. Young mothers whose bodies are not sufficiently formed to handle the rigours of childbirth, and women who cannot access qualified maternal health care, are particularly vulnerable to fistula, and to the disgrace, dejection and isolation that come with the demeaning condition.
Sarah became pregnant as a teenager after she was raped.
“I was in labour at home for 20 hours and then I was taken to the local dispensary, where I spent another 18 hours in labour. When the child finally came, it was dead,” she told the hushed room.
Three days after delivery, she realised she could not control her urine. “I stayed in hospital for two months, hoping for a cure, but I was told that my condition required a doctor from abroad.” With no money to pay for an operation, she went home to hide away from the world.
“My nights were full of tears. I felt trapped, lonely and dejected.” For 12 years, she suffered from the pain and discomfort of genital sores and the ever-present, humiliating stench of her own urine. The shame and the dejection finally drove her into depression and in 2007; she was admitted to the Moi Referral Hospital’s psychiatric ward. It was here that a doctor told her that fistula could be treated at the hospital. Sarah was thrilled.
“After the surgery I regained my life and my dignity. I survived physical and emotional trauma to become a living testimony of how our health system has failed. I now speak on behalf of shattered families and children devastated by the deaths of their mothers,” she said.
Sarah’s story reflected the struggle of more than two million women across the world who live with fistula. Today, she is an ambassador for the United Nations Population Fund (UNFPA), adding her voice to a global campaign to eliminate fistula in the world and restore the dignity of women who suffer in silence from a condition that could be prevented and cured.
The three-day Fistula Surgeons’ Conference, hosted by the African Medical and Research Foundation (AMREF), aims at sharing knowledge in the prevention and treatment of a condition that mostly affects developing countries and particularly Africa.
From Kenya to Pakistan, the story is the same: more women are developing fistulas because health care systems across the developing world are poorly funded, inaccessible and too expensive for most rural women. Thousands of lives are being shattered by the poor attention mothers receive at the hands of untrained birth attendants and in poorly equipped rural health facilities.
According to Conference Chair, who is also AMREF’s Outreach VVF surgeon, Dr Weston Khisa Wakasiaka, 90 per cent all fistulas occur in Africa.
“Fistula in Africa is linked to the status of the health care system, malnutrition, poverty and ignorance. Women must be empowered with knowledge and resources to take decisions that enhance their health,” said Dr Wakasiaka.
Statistics presented at the conference indicated that rural women were most affected by fistulas, with tough terrain and cultural factors making them particularly vulnerable. In Ethiopia, for example, women are sometimes forced to walk for up to three days to access health facilities. “Even when they can take public transport, some find it difficult to use public vehicles because of urine leakage,” observed Amare Desta, a public health officer at Yirgalem Hamlin Fistula Centre in Ethiopia.
The situation is compounded by cultural factors, added Desta, because men often deny their wives permission to attend ante-natal clinics during the farming season, preferring them working on the land. At least 9,000 Ethiopian women develop fistulas every year. Desta believes that public awareness campaigns must be intensified to educate health workers and the public on how to identify and prevent them.
“Although many men and women of reproductive age have heard about obstetric fistula, they are not aware of the risk factors. Besides, most women living with the condition are poor and reside in remote areas where they cannot access health care,” Dr Julius Onesmo from Tanzania observed.
Studies conducted by AMREF in Kenya’s Kibwezi District showed a high level of awareness about the importance of seeking maternal health services, but women were prevented from accessing them by the long distances to health facilities.
“Women are not opposed to delivering in health facilities. Most of them cannot access the facilities and even when they can, they are unable to afford the medical charges,” observed Dr Johnson Musomi of AMREF’s Clinical Outreach programme.
Jane Makona, a district public health nurse who has worked in Western Kenya, fears that complications like fistula will continue causing misery to women in rural parts of Africa.
Working in the interior parts of Western Kenya for the last 20 years, Makona has seen the population grow without a corresponding increase in health facilities. She has also seen the rural population getting poorer.
“The women rely on traditional birth attendants because they can pay them using maize or chicken. The tragedy is that most of these attendants are not trained to detect or prevent complications like fistula,” she noted.
Dr Anne Wamae, head of Child and Adolescent Health at the Kenyan Ministry of Health, said that even in situations where the children survive after prolonged and poorly managed labour, they often end up with brain complications or retarded growth.
“We are integrating obstetric fistula into safe motherhood initiatives and equipping hospitals across the country with medical kits and qualified personnel to treat fistula,” Dr Wamae said in a speech she read on behalf of Public Health and Sanitation Minister Beth Mugo.
A number of local, regional and international non-government organisations have tried to supplement government efforts, but more resources are needed to eliminate fistula. In Kenya, AMREF has since 1992 been at the forefront of creating awareness about fistula and treating women affected by the condition. The organisation repairs 2,000 cases annually in East Africa.
“We want to train as many health workers as possible so that they take over the responsibilities of doing fistula repairs. Today, 80 per cent of surgeries are carried out by health specialists from countries where we operate and we only assist where complications occur,” said Mette Kjaer, Country Director of AMREF in Kenya.
Dr Festus Ilako, head of programmes and deputy country director of AMREF in Kenya, observed that partnership with the community is critical in preventing and treating fistula cases.
Other organisations are using innovative means to alleviate the suffering of fistula patients. Anne Gloag of the Freedom from Fistula organisation has combined radio campaigns and the popular mobile phone money transfer systems in Kenya to reach rural women with fistula and provide them with bus fare to health facilities.
