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Obstetric fistula: Robber of a woman's joy

BY: Zadok Kwame Gyesi
UNMISS transports fistula-affected women to Bentiu for treatment. Credit: UNMISS
UNMISS transports fistula-affected women to Bentiu for treatment. Credit: UNMISS

Obstetric fistula is one of the most disturbing childbirth injuries or medical conditions that affect women as a result of complications usually arising from the lack of surgical intervention for prolonged and obstructed labour. This condition leaves women incontinent, meaning they are unable to control their urine or faeces or both. Some studies indicate that in developing countries, for instance, over 85 per cent of obstetric fistula are mainly caused by prolonged, obstructed labour. Zadok Kwame Gyesi dives into this health condition affecting women of reproductive age, its causes, prevention and treatments.

For the purposes of confidentiality, I will use a pseudo name to refer to the person who graciously accepted to share her personal experiences of obstetric fistula with me for this article. Let’s just call her Maame Esi.

I met 34-year-old hairdresser Maame Esi, at an event at Jamestown in Accra in October, 2021. It was a durbar on sexual reproductive health organised by one health-focused, non-governmental organisation with support from a state agency. The theme for the event was not on fistula though, Maame Esi’s encounter with fistula came in handy as the speakers took turns to speak on various subjects—child marriage, teenage pregnancies, importance of antenatal attendance, assisted delivery or skilled delivery, breastfeeding, etc.

When Maame Esi was called to share the ordeal she went through when she delivered at home as a teen-mother for her first child, my curiosity and eagerness to hear her story was roof high. Anytime I hear about labour issues, my mind evokes memories of how a friend lost his wife in that process. So, when Maame Esi took the microphone to speak, I offered her all my attention. I didn’t want to miss anything.

Maame Esi comes from a small farming community in the Nanumba North District of Ghana’s Northern Region. She was stopped from schooling to assume the role of a wife at the age of 16. Junior High School (JHS)—form one, that is where she abruptly ‘completed’ her schooling.   

According to her, her pleas to her parents to allow her to continue her education fell on deaf ears as both mother and father, agreed to marry her off to a man who she claims was almost her father’s age. The man was about 48 years. Left with no option, she truncated her education and went to live with her husband in a different village. She was his second wife.

Not too long after she went to live with her husband, she took seed and was very optimistic of starting her own family. Little did she know that her pregnancy was bringing her pain instead of joy.

Maame Esi’s troubles started when she was made to deliver at home. Delivering at home was not a new phenomenon in the village. However, unlike other women in the village who delivered safely and without much rancour at home, Maame Esi’s delivery took several hours and nearly caused her her life. There was no car immediately available to take her to the hospital.

My child died and I bled for long when I finally delivered, she said.

As she recalled, after her delivery she realised she could no longer control her urine and faeces, something she previously controlled effortlessly but now didn’t understand.

I didn’t know what was happening to me. Initially I thought it will stop by itself within days but it persisted and my husband too was not around when I delivered. He had then travelled to Kumasi for work, Maame Esi narrated in Twi.

Sadly for her and to compound her misery, when her husband returned and she told him about her condition, he got angry and accused her of cheating. He maintained that her suffering and the difficult labour were the result of infidelity. He subsequently ejected her from their matrimonial home to go to her parents.

Read also: A survivor’s encounter with obstetric fistula

Read also: Eliminating cultural barriers to end Obstetric Fistula in Ghana

For Maame Esi, her condition soon became a subject of public ridicule.

Everything seemed to be working against me. It was very shameful, she said

Perceptions  

Maame Esi had suffered fistula but she was not familiar with it or where to go for help. Her condition was new to her family and due to its peculiarity, people thought it to be a spiritual affliction. Ignorance, rather than science, held this society.

They said I suffered the condition as a punishment for my infidelity to my husband and thus needed my husband’s genuine forgiveness in order to get healed, she noted.

I became the subject of many conversations, especially the very moment I passed by people. No matter the topic they are discussing, they changed to focus on me, she noted, and added that she even considered suicide as an option at some point.

As days turned into weeks and weeks into months and years, there was no hope for Maame Esi that she would one day get healed. She lived with the condition for three years.

Road to repairs

Maame Esi’s salvation came when some medical students from the University for Development Studies (UDS) in Tamale visited her community for a health outreach programme and discovered her.

She said one of the students directed her to the Tamale Teaching Hospital for repair surgery and that it was for free. She duly followed up and the doctors performed the surgery for free, and to her freedom.

I felt sad listening to Maame Esi’s story on fistula. She is but only one of the many cases of people who suffer fistula without knowing what it is or what to do about it and are therefore socially isolated and excluded in their families and communities, with many of them losing their livelihoods, self-esteem, respect or dignity as women.

What is fistula?   

An obstetric fistula occurs when a mother has a prolonged, obstructed labour, but doesn’t have access to emergency medical care, such as a Caesarean section (C-section). She often labours in excruciating pain for days. Tragically, her baby usually dies.

During her prolonged labour, the mother’s contractions continually push the baby’s head against her pelvis. Soft tissues caught between the baby’s head and her pelvic bone become compressed, restricting the normal flow of blood.

Read also: 28 Undergo free fistula surgery

Read also: Obstetric fistula: Sharing the untold stories

Without adequate blood supply, sections of the tissues soon die, leaving holes—known as “fistulae” —between the mother’s vagina and her bladder or rectum. It is these holes that cause incontinence. If untreated, the woman will uncontrollably leak urine, stool, or sometimes both, for the rest of her life.

Fistula Foundation, a global charity organisation with focus on fistula repairs, estimates that at least one million women in Africa and Asia “needlessly suffer from untreated fistula.” 

Similarly, Direct Relief, also a humanitarian aid organisation active in more than 80 countries, with a mission to improve the health and lives of people affected by poverty or emergencies, estimates that over two million women are suffering from fistula.

The World Health Organisation (WHO) defines an obstetric fistula as an “abnormal opening between a woman’s genital organ and bladder and/or rectum through which her urine and/or faeces continually leak”.

WHO also estimates that at least two to three million women and girls live with fistula while an additional 50,000 to 100,000 new cases are recorded each year in the developing countries.

According to the Global Fistula Map (GFM) that collates reports on fistula cases, between 2010 and 2013, only 60,280 women received fistula repair surgery.

Awareness

In December 2012, the United Nations (UN) General Assembly designated May 23 of each year as the International Day to end obstetric fistula. The event is used to create awareness about the condition and how victims could be helped.

Information sourced from the websites of the United Nations Population Fund (UNFPA) indicates that “victims of obstetric fistula are women and girls, usually poor, often illiterate who have limited access to health services, including maternal and reproductive health care”. 

The book, “Report on the Burden of Obstetric Fistula in Ghana”, published in 2015 by the Ghana Health Service in collaboration with the UNFPA, indicates that “While the most common cause of obstetric fistula is obstructed and/or prolonged labour, pertinent underlying factors such as poverty, lack of awareness, poor-health seeking behaviours, poor health and referral systems, poor transportation networks, scarcity of skilled birth attendants, and inadequate obstetric care services (infrastructure) can contribute to the occurrence of obstetric fistula.”

Fistula repairs  

Debrework Tesgera Beshah is a fistula surgeon. He is quoted in the book “The loss of dignity: social experience and coping of women with obstetric fistula, in Northwest Ethiopia” as noting that although preventable and virtually non-existent in developed countries, fistula continues to afflict many poor women and girls who lack access to timely and quality health services.

He said fistula leads to social marginalisation due to its devastating nature and that women who suffer from fistula in many instances experienced deep sense of loss, diminished self-worth and multiple social challenges.

He is of the view that because of the stigma attached to obstetric fistula, many women suffering from the condition are burdened with significant psychosocial and economic consequences.

Some studies say women suffering fistula feel shy to seek medical intervention or report to health facilities, thus making it difficult to determine the actual prevalence rate.

Education needed

Madam Georgina Amidu, a retired staff of UNICEF who led a project on maternal health known as Communication for Development (C4D), told me during an interview that though much progress has been made to address fistula, interventions have often failed to reach those most in need.

She expressed the worry that in some communities, obstetric fistula is seen as a punishment for evil doers or as a result of a curse, a situation she noted compels people to often seek help from spiritual healers instead of health facilities.

She also admonished health workers to respect the rights and dignity of those suffering from fistula and who seek medical attention in health facilities.

Ms Gladys Ofori-Mensah who is a Public Health Specialist also thinks that to ensure that all women and girls, particularly the poorest and most vulnerable, have adequate access to reproductive health care, efforts need to be intensified and urgent steps taken, even during public health emergencies.

For her, obstetric fistula could be prevented by improving the quality of maternal health care, education as well as empowering women and girls and their communities.

She noted further that addressing the economic and sociocultural factors that negatively affect women and girls as well as engaging men and boys on the issue will all help to prevent obstetric fistula in the country.

MS Ofori-Mensah told me that fistula was a health condition and not a disease as seen by many uninformed persons who considered the condition as a disease or curse from the gods and/or punishment for being unfaithful to one’s partner.

Northern Ghana    

Also sharing her views on the subject, Madam Mary Azika, a midwife and who currently works at the Bolgatanga Municipal Health Directorate in the Upper East region, said apart from prolonged and obstructed labour that mainly cause fistula, other factors such as rape and defilement can all cause fistula.

She said deliveries at home mostly result in fistula, explaining that if the baby’s head is big and is unable to pass through the birth canal but the woman is forced to deliver, it causes fistula.

She explained that the condition is quite prevalent in the five regions of northern Ghana due to the deprived nature of the regions, coupled with lack of adequate access to maternal healthcare services.

Read also: Help fistula patients to recuperate

Read also: Time to end obstetric fistula suffering - UNFPA Deputy Representative says

For Madam Azika, because of the difficulties women in northern Ghana encounter in accessing healthcare, “most of them deliver at home”, hence making them vulnerable to fistula.

She explained that fistula can happen to any woman whether they had given birth before or not, adding that preventing fistula “depends on how you manage your labour and where you deliver.”

She said if a woman delivers at a health facility and the midwives realised that the head of the baby is bigger than the birth canal, a C-section will be done for her in order to prevent birth injuries.

For Madam Azika, “Fistula can be prevented” and people need to be educated on why “they need to deliver at the health facilities instead of their homes.”

She however, urged women suffering from fistula to seek early medical attention since its treatment is free, and she is right, for the United Nations General Assembly in a statement issued in 2020, concluded that the occurrence of fistula is a violation of human rights and a reminder of gross inequities.