(March 2004) Wobete Falaga, who is from a village in the northern Gojam province in Ethiopia's Amhara region, was only 13 when she became pregnant. Married at 11, just before her first menstrual period, her small underdeveloped body was not ready for the stress of childbirth. After five days of grueling labor at home, her child was finally born, but it was dead.
As a result of the long, strenuous labor, Wobete suffered crippling injuries. There was a hole, or fistula, between her bladder and vagina and another between her vagina and rectum. The damage left her body unable to control its normal excretory functions, and urine and feces were constantly dripping down her legs. Her husband quickly rejected her, sending her home to her family.
Wobete's mother took her to the government health clinic in the province's main town, Bahir Dar, but the nurses there said they were unable to treat the girl. They advised Wobete's mother to take the girl to the capital Addis Ababa as soon as possible and said if her condition remained untreated, she would face death from infection and kidney failure. The family sold a cow to pay for the three-day bus journey and arrived penniless at the gates of the Addis Ababa Fistula Hospital with Wobete.
These are common tales for the hospital's founder, Dr. Catherine Hamlin, an Australian gynecologist who has spent the last 44 years in Addis Ababa and is a pioneer in performing surgery for women with obstetric fistula.
"All the women who reach the gates of the hospital feel that their lives have been ruined" says Hamlin. "They have no self-worth and have become social outcasts from their community at a very young age through no fault of their own. They've suffered all this injury unnecessarily because they haven't got enough obstetric care in the provinces."
Defining the Problem
Reliable data on obstetric fistula are hard to come by because of the stigma associated with the condition. Describing it as the most devastating of all pregnancy-related disabilities, the United Nations Population Fund (UNFPA) says obstetric fistula affects an estimated 50,000 to 100,000 women around the world every year and is particularly common in sub-Saharan Africa, where populations face challenges to obtaining quality health care. The World Health Organization estimates that at least 8,000 Ethiopian women develop new fistulas every year.
The condition occurs when a woman — usually one who is young and poor — has an obstructed labor and, lacking a skilled birth attendant and emergency obstetric care, does not get a Caesarean section when she needs it. The obstruction may occur because her pelvis is too small, the baby is badly positioned, or its head is too big. Underlying causes include childbearing at too early an age, poverty, malnutrition, and lack of education.
In an effort to prevent and treat the condition worldwide, UNFPA is spearheading a global campaign whose partners include governments, health care providers, and organizations such as the Addis Ababa Fistula Hospital, EngenderHealth, Columbia University's Averting Maternal Death and Disability Program, the International Federation of Gynecology and Obstetrics, and the World Health Organization (WHO).
Every year in Addis Ababa, Hamlin's hospital treats 1,200 women who have obstetric fistulas. Hospital records indicate that most patients come from the Amhara region, which — according to a survey by the National Committee on Traditional Practices of Ethiopia— has the highest number of early marriages in the country. The 1997 National Baseline Survey points out that girls in Amhara are promised for marriage in infancy, when they are 4 or 5 years old, and even in utero. The 2000 Demographic and Health Survey for Ethiopia shows that, among women from Amhara who were 20 to 49 years old at the time of the survey, the median age at marriage was 14.5 years — the lowest regional median age in the country.
Fortunately, most fistulas can be corrected surgically, even after several years. Though the $450 operation is far beyond what most patients can afford, the Addis Ababa Fistula Hospital offers free bed and surgery.
"The success rate of surgery to mend a woman's fistula injuries is actually quite high," says Hamlin. "In about 92 percent of the cases, we can close the hole in the bladder and in the rectum." However, about 10 percent of the women who have been operated on come back for further surgery to correct a condition known as stress incontinence.
"After we have closed the fistula, although there is no urine leaking from the hole, it is still leaking from the normal channel because their muscles have all been damaged due to the stress of labor. If they cough or laugh, the urine runs out," notes Hamlin.
Another category of women, known as "inoperables," make up a small percentage who cannot be operated on because their bladders are either missing or have shrunken.
"During long labor, the blood supply to the bladder can be cut off, resulting in it dying. So we can't repair a bladder that is nonexistent. Or, it's shrunken to the size of a thimble that will never hold any urine," Hamlin explains.
The surgeons then perform an ileal conduit operation, which involves taking a part of the bowel and turning it into a bladder. The patient is left with a permanent urostomy (a urinary diversion). The tubes from the kidneys are put into the small bowel and it drains from the stoma or opening in the abdomen into a bag outside the abdomen. Women with stomas require frequent medical attention. Instead of returning to their villages, many of them remain at the hospital and work as medical assistants. The hospital currently has 40 former patients working as nurses' aides and, with funds from the Australian government's aid arm, AusAid, recently built a residential and agrarian village outside Addis Ababa to be used as a permanent home for incurable women.
Finding New Lives
Since many of the women with obstetric fistulas cannot read or write, the Addis Ababa hospital provides literacy training on its premises for those who are healing from their surgeries. "Simply repairing the fistula injuries and returning women to the same conditions that made them ill in the first place would be self-defeating," says the hospital's administrator, Ruth Kennedy.
The hospital also has a joint program with the Ethiopian Women Lawyers Association to advise patients of their rights, telling them that they do not need to marry early and should be going to school instead. When the women are fully healed and ready to return to their villages, the hospital's health workers join them on the bus trip back home to make sure they are not rejected by their families or ill-treated by their husbands.
"We accompany them on the buses and make sure they reach home. These women have no money and we don't want them ending up as beggars or prostitutes in Addis Ababa," explains Kennedy.
But Hamlin admits it is difficult to alter traditional practices in the villages unless the people themselves initiate change. She says it is alarming when a few women who have had their fistulas repaired successfully keep coming back with repeated injuries after giving birth to dead babies. The hospital gets at least 10 such cases a year.
"In these cases, the women have often got new husbands who display the same behavior as their previous ones. Her new husband forbids her to have her baby in the hospital and insists she have a home birth like other village women. She's got no say and is completely under the thumb of the man," says Hamlin.
Reaching Into Communities
For this reason, the hospital plans outreach centers and intends to work with women's groups in the provinces to alert communities to the dangers of early marriage, potential complications of childbirth, and the critical need for emergency obstetric care in the case of complications. These centers will also let women know about the availability of fistula repair and perform emergency surgeries. Fistula patients who have gone back to their villages after surgery in Addis Ababa will also be able to get medical support from the outreach centers.
The Bahir Dar center in Amhara region, whose building was donated by a private individual, is to open soon, and the Mekele center in Tigray region, funded by AusAid, will open by the end of the year. Also in the pipeline are centers in Yirragalem, in the south, and Harar, in the west of the country. Operating costs for the Yirragalem center will be funded by the Norwegian Agency for Development (NORAD) and the Harar outreach will be financed with funds raised by the hospital itself.
Hamlin sees the outreach centers as the first step in the campaign to end fistula. "It will be many, many decades before we finally eradicate fistulas from Ethiopia. But we need to start somewhere and, hopefully, these outreach centers will pave the way," she says.
Sonny Inbaraj is an Inter Press Service journalist currently on assignment in Ethiopia.
Central Statistical Authority, Ethiopia, and ORC Macro, Ethiopia Demographic and Health Survey 2000 (Addis Ababa, Ethiopia, and Calverton, Maryland: Central Statistical Authority and ORC Macro, 2001).
K.A. Harrison, "Obstetric Fistulae," paper prepared for a 1989 WHO Technical Working Group, as quoted in Jane Cottingham and Erica Royston, "Obstetric Fistulae: A Review of Available Information," WHO/MCH/MSM 91.5 (Geneva: WHO, Maternal Health and Safe Motherhood Programme, 1991).
Christopher Murray and Alan Lopez, eds. Health Dimensions of Sex and Reproduction (Geneva: WHO, 1998).
National Committee on Traditional Practices of Ethiopia, 1997 Baseline Survey on Harmful Traditional Practices in Ethiopia (Addis Ababa: National Committee on Traditional Practices of Ethiopia, 1989).
United Nations Population Fund (UNFPA) and EngenderHealth, Obstetric Fistula Needs Assessment Report: Findings From Nine African Countries (New York: UNFPA and EngenderHealth, 2003).