Finding a balance in the treatment and prevention of obstetric fistula

With curly lashes and soft, full eyebrows, Almaz looks younger than her 20 years, even more so when she starts to cry. “I'm scared,” she says in Amharic, digging her nails into the palms of her hands. “I don't want to die.”

She is about to undergo surgery in the sleek, gleaming white operating theatre of Addis Ababa's Fistula Hospital, the world's most renowned centre for treating obstetric fistula, a term used to describe vesicovaginal or rectorvaginal fistula occurring after failed or obstructed labour.

Almaz (not her real name) is 1 of 2300 patients treated annually by the hospital's 6 doctors and, like many who arrive, is frightened and suspicious. She is also wary after spending a year alone in a hut, her husband having left her when she gave birth to a stillborn. She's been incontinent since, and rarely visited, except by her sister and friends dropping off food.

Almaz hopes to join the ranks of the 93% to 95% of women whose obstetric fistulas are successfully closed at the facility that has become a haven for Ethiopian fistula sufferers since being established in 1974 by Australian surgeon Catherine Hamlin and her late husband.

Fistula Hospital Chief Executive Officer Mark Bennett says that about 20% of patients continue to battle incontinence and other complications post surgery, because what's left of their bladder is too small to hold much urine. In rare cases, where the bladder has been completely sloughed out through the vagina and cannot be repaired, stoma surgeries are performed, explains Dr. Hailegiorgis Aytenfisu. For most women, though, surgery means “they can urinate normally. They can get married. They can even have another baby.”

It is a welcome outcome for women in Ethiopia, where obstetric fistula is so prevalent that a foundation established by Hamlin — who continues to perform surgery at age 84 — is in the process of building 5 more treatment hospitals. Three are already operational.

Skeptics wonder if the focus would better be placed on educational measures, given that obstetric fistula is essentially preventable with a cesarean section. But it's difficult to shift the focus when demand for treatment continues to rise.

It's a function of cultural, political and economic factors, Bennett says. Ethiopian women become susceptible to obstructed labour at a young age. Growing up in poverty, they're made to fetch water and till soil, and they don't get enough nutrients to satisfy the needs of their young bodies. “And a higher proportion of women in Ethiopia are small.”

But the clincher is that 85% of the population live in rural areas, often more than a day's journey — by foot, bus or ride from a stranger — from the nearest hospital. Roughly 95% of Ethiopian women give birth at home. “It's considered normal to give birth at home and it's probably considered normal that a certain percentage of women die giving birth,” says Bennett.

Another young woman, Werkenish (again, because of hospital policy, not her real name) surveys the garden that Hamlin built at The Fistula Hospital, which was featured on The Oprah Winfrey Show, and a smirk comes over her tribal-tattooed face as she reminisces about her life. She was betrothed at 10 and taken to her mother-in-law's to learn how to cook njera (an Ethiopian bread) and roast coffee beans.

She eventually developed a severe vesicovaginal fistula after 5 days of labour and spent a year seeming to constantly launder her sheets and clothing. One day, she told her husband to find another woman because she was no longer fit to be a wife. “My husband was disappointed but what could he do?” asks Werkenish, who now lives with her parents.

Most women with obstetric fistulas are ostracized by their husbands and, sometimes, even by their families. “Usually the first thing women will notice is that they're not invited for the coffee ceremony,” a daily ritual in Ethiopia, explains Bethela Amanuel, public relations officer at the hospital. The smell of stale urine and feces can be offensive, and with little understanding of conventional medicine, rural Ethiopians often see fistulas as a curse or the fault of the woman.

In reality, fistula happens because women don't have access to cesarean sections, and critics of Hamlin's well-funded organization say focus would more properly be placed on improving access to cesarean sections rather than surgical repair of fistulas.

“It's shameful that more fistula hospitals are being built when fistula is 100% preventable,” says Dr. Ronald Lett, the Addis Ababa-based director of the Canadian Network for International Surgery.

Dr. Yifru Berhan, an Ethiopian gynecologist and head of a medical school in the town of Hawassa, agrees. “It's unfortunate that we have hospitals to manage the complication but not to prevent the complication.”

There are signs, however, that management at the hospital are finally heeding such calls. “It seems a futile task if you keep sewing up women if you're not reducing the numbers coming,” says Bennett, noting that Ethiopia's expanding population is increasing the demand for fistula surgery.

In hopes of easing that pressure, the Hamlin Foundation is building 25 prevention clinics in addition to 5 treatment hospitals. Each clinic will be staffed by 2 midwives, who will encourage women to seek antenatal care. The foundation has also hired advocacy officers in recent years to speak at churches, markets and schools about the causes of fistula and how to prevent it. “It's important we teach the whole community,” says Amanuel, “because a woman might say ‚I need to go to the hospital,' but unless her husband agrees with her, she won't go.” The advocacy officers target traditional birth attendants (women who have experience cutting umbilical cords but no professional medical background), teaching them to recognize obstructed labour and identify women who shouldn't give birth vaginally.

But Amanuel predicts prevention will be a long and arduous task. “You have to make sure that people have transport to get to the hospital; you have to have good roads; you need antenatal clinics that are close enough for women to get to for a check up. You have to make sure there are schools so there is a choice for the girls. You have to make sure the nutrition value is different. You have to change the culture of early marriage.”

Women prone to fistulas are poor, rural and barely educated, living as they do in a culture which sees the schooling of girls as a “waste,” adds Amanuel, who grew up in Ethiopia's taxi-jammed capital. “They're the most voiceless members of our society.”