by: Becky Richards, Delegate 2005
My first exposure to obstetric fistula was over twenty years ago in a rural medical clinic where a post partum patient presented with a condition that she described as “a bowel movement out my vagina.” Though this may sound shocking and nearly unheard of in the United States, obstetric fistula is all too common in East Africa.
Fistula is defined as an abnormal hole that opens between the urinary bladder and rectum (sometimes both) as a result of traumatic childbirth. In the U.S., most women have access to a skilled health care provider and/or alternative means to vaginal delivery. For example, a cesarean section intervention prevents the trauma of damaged tissues (fistula) caused by an obstructed and laborious childbirth. In African countries, however, the lack of modern medicine, supplies, and education contributes to the overwhelming number of women suffering from obstetric fistula.
In September-October 2005, a delegation of nine women from Utah, Florida, and California traveled under the direction of J’Lein Liese, President of the Foundation for Global Leadership, to Uganda and Rwanda, East Africa. The purpose of the mission was to learn, network, and understand the challenges of the people of underdeveloped countries. In Kampala, the capital city of Uganda, we met with representatives of the United Nations Population Fund (UNFPA). We made site visits to orphanages, teen outreach centers, AIDS clinics, villages, and a fistula hospital in the town of Masaka. All the site visits were of equal interest and importance to the delegation, but the topic of obstetric fistula was in glaring need of awareness by those who can assist in eradicating this treatable condition.
The delegation spent an afternoon with Dr. Maura Lynch, Consultant and Surgeon at the Kitovu Hospital in Masaka, Uganda. She spoke to the delegation about the newest wing (completed in April 2005) of the hospital dedicated to fistula patients. Dr. Lynch is a Sister of the Catholic Church from Ireland who has spent many years providing health care to underserved populations, and has devoted 18 years to the Kitovu hospital. She, along with the UNFPA and other key partners, promotes awareness of obstetric fistula in order to empower African women and educate African surgeons on performing fistula repair operations.
Dr. Lynch delivered a moving account of the traditions and culture of African women as it relates to fistula. The delegation, physician interns (from Ireland), and UNFPA representatives listened intently to the stories of suffering of young African women. There wasn’t a dry eye in conference room. She shared the cultural beliefs that physically and psychologically worsen the pregnancy-related disability of fistula. Many mothers who suffer from fistula are not only left with what is viewed as a shameful disability; they also mourn the loss of their baby. Husbands, families, and communities treat them as outcasts because of the leaking and odor, and the notion that they are somehow cursed. Alone, the women must cope with fecal and/or urine incontinence, infection, rashes (blisters), illness, depression and social isolation.
Dr. Lynch listed factors that contribute to complications in childbirth and obstetric fistula. Most of the women who are treated at the Kitovu hospital are from the local Buganda tribe. She stated that these women are small in stature and have narrow hips, which may cause obstruction in the birthing process. Also, in her opinion, carrying 20-kilogram baskets on their heads (a common practice) may increase the natural curvature of the spine that causes a bony obstruction in the birth canal. Bugandan women also suffer from extreme poverty, poor nutrition, and lack of education. Other contributing factors are early marriage (age 14) and the absence of what they call “ante care,” or as we call it, prenatal care.
Dr. Lynch candidly discussed African tradition: “Women of the tribes do all the work… The mothers carry babies on their backs while digging, planting, and cultivating the fields. They provide care for the family, and do all the cooking while the men watch the herds.” While providing for the family, “women feed their husbands, then the children, and finally her, if any food is left over.” In terms of childbirth, tradition places the sister or mother of the husband in custody of the wife during childbirth, or she must deliver alone. The husband is not present or involved. A pregnant woman is expected to deliver the child vaginally. If she must seek intervention during delivery or if the baby dies, the mother is viewed as unworthy.
Many Bugandan women must walk or take a bus to receive care during labor and/or complications of birth. At times during labor, an attendant (or two) will push on the mother’s abdomen to force birth. After hours of pushing, sometimes three or four days, bone constantly pressing against soft tissue of the bladder and cervix causes tearing of the bladder and rectum. Complications may cause the baby to die in the birth canal or be half born when the mother presents at the hospital. The baby typically dies in a complicated or lengthy labor. The baby’s head may collapse, even when the birth attendants cut the birth canal to make more space for the baby to be born. Shock, dehydration, and infection ensue. The mother may require a cesarean section yet most often the baby cannot be saved.
Dr. Lynch introduced the delegation to patients recovering from fistula repair in the new wing of the hospital. One young patient suffers from contactures caused by neglect and sitting for long periods of time. Foot drop and paralysis of the sciatic nerve are other potential results of prolonged sitting. Some of the patients are in training for small bladder exercises (in the U.S. we use the term Kegels) to avoid stress incontinence. Sling operations are performed for the more serious cases. With few resources and supplies, Dr. Lynch uses her creativity to design devices for foot drop made of rope and a spring. She creates a free-flow catheter drain by cutting the bag off a catheter to allow urine to drain into buckets to avoid bladder infections. After three days of recuperation, the patient is encouraged to walk, taking the hand-held bucket with them.
Dr. Lynch continued her presentation focusing on the positive outcomes for fistula patients. The UNFPA supports costs for fistula surgeries at the Kitovu hospital while patients are told that the surgery is free. She added that “African people are honorable and would not come in for treatment if there were a fee charged for services.” Women are also given a new dress when discharged from the hospital to give them a sense of pride and belonging as they reunite with their communities.
Surgeons from the U.S. and U.K. make trips of volunteer service to the Kitovu hospital to perform fistula repair operations and conduct training sessions for African surgeons. Three training sessions have taken place at the hospital since November 2004 that have included 160 repairs. Dr. Lynch noted that fistula is a “condition of the poor, so there is no incentive for the local African surgeons to learn how to perform fistula repair surgery.” She adds that “the education and awareness programs are changing the attitudes of local physicians.”
Follow-up care and counseling is provided to fistula patients and their families. They are advised to have cesarean section with future births rather than vaginal delivery to protect the fistula repair. Husbands are being educated on harmful beliefs and practices, and an increasing number of women are attending antenatal care clinics. Dr. Lynch stated “it is not a full recovery until the mother holds a live baby in her arms.”
The efforts of Dr. Maura Lynch and the Kitovu hospital have influenced change in the suffering of Ugandan African women. Financial support from the UNFPA and other organizations assists the campaign to encourage African surgeons and health care workers to learn how to care for fistula and provide education and services to the communities. An equally important message is to change the attitudes toward women and the restoration of dignity among the women who suffer from obstetric fistula.
To find out more about obstetric fistula and how you can help, visit the Americans for UNFPA web site at www.unfpa.org
Information on the Foundation for Global Leadership can found at www.foundationforgloballeadership.com
Foundation for Global Leadership Delegation 2005:
Lucy Jones Block, California Debbie Jones, Florida
Suzy Way, California Misty Goddard, California
Diana Thompson, Utah Sharon Liese, Utah
Becky Richards, Utah Crystal Anderson, Arizona
