By Deusdedit Ruhangariyo

I fear to attend village meetings because I smell of urine. People run away when they see me. It is so dehumanising that I feel dying is a better alternative,” says Jennifer from Rubanda, Kabale district.

Jennifer’s misery started after her first pregnancy. “I was in labour for four days under the care of a traditional birth attendant. In my village, it is normal for a woman to spend four days in labour,” she says.

“Eventually, I was taken to the nearest health unit, three miles away. I managed to deliver on the fourth day, but my baby had died. The doctors said I had developed abdominal distension due to difficult labour. On the second day, urine was leaking.”

Medically, this condition is called obstetric fistula. “A catheter was inserted to aid urination and allow the wound to heal, but this never helped as the people around me complained about the stench.

Three months later, I was hospitalised for three weeks, but did not heal. I went back home to face my fate.

For four years, Jennifer struggled with this condition until she heard of a woman with a similar condition who had been treated successfully at Mbarara University Teaching Hospital. Jennifer was also treated.

Dr. Godfrey Mugyenyi, an obstetrician/gynaecologist at Mbarara Diagnostic Centre and Mbarara University Teaching Hospital, says most women living with obstetric fistula struggle with depression, are abandoned by their partners, families and communities and live in isolation because they are considered unclean.

“But obstetric fistula can be treated,” he says. In 2009, the hospital operated on 36 women and 33 of them recovered. Every year the hospital gets consultant surgeons from the US to handle fistula cases.

Obstetric fistula is deeply rooted in women’s social, cultural and economic vulnerability. Most women with fistula are young and poor and live in rural communities with little or no formal education or influence.

Unfortunately, many women are not aware that surgical treatment is available. As a result, they live with the condition for years.

Treatment is not readily available in most developing countries where the demand for the services is high.

Dr. Musa Kayondo, a doctor at Mbarara Hospital, says: “The prevalence of obstetrical fistula is much lower in places that discourage early marriage but encourage and provide education for all and grant women access to family planning and skilled medical teams during childbirth.”

In Uganda, about 2.6% of women in the child bearing age have experienced obstetric fistula. Based on population data from the most recent census, this equates to a national prevalence of over 142,000 women.

According to the World Health Organisation (WHO), about 50,000 to 100,000 women develop obstetric fistula each year and over 2,000,000 women are living with fistula injuries.

Fistula was largely eradicated in developed countries in the late 19th century; however, it still affects three million women in developing countries.

Economic consequences “Poverty is the lead cause and end result because most women lose the ability to work and earn a living,” Mugyenyi says.

A patient says: “I am unable to do heavy chores. I can only wash clothes and sweep the courtyard. I do not cook because people think I am unclean. I can’t do gardening because my lower abdomen and back hurt.”

Some women have been neglected by their husbands due to the condition. “One also needs money to buy soap, clothes and sanitary pads,” a woman says.

Treatment
Treatment involves recontructive surgery. Successful surgery enables women to live normal lives and have children, but it is recommended that one gets a caesarean section for subsequent babies to prevent fistula from recurring.

Dr. Emmanuel Byaruhanga, a consultant gyneacologist/obstetrician at Mbarara and Ibanda hospitals, says surgery for uncomplicated cases has a 90% success rate.

The success rate for complicated cases is 60%. Post-operative care is important to prevent infection.

The cost, which includes definitive surgery, post-operative care and rehabilitation support, is estimated to be at between sh600,000 to sh1,000,000.

Challenges
Mugyenyi says there are many women in need of recontructive surgery but there are only a few trained surgeons.
Many women cannot access medical facilities and treatment or even afford transport fares to hospital. Most women are also not aware that treatment is available.

Prevention
Mugyenyi says the following measures apply to pregnancy and child-related complications, including obstetric fistula.

Immunise children against the killer diseases, especially the girls

Ensure that children receive the recommended meals and a balanced diet to prevent a contracted pelvis, the leading cause of obstetric fistula

Educate girls to prevent teenage pregnancy, to negotiate for safe sex and expose them to reproductive health issues like family planning

Attend antenatal care clinics to reduce pregnancy and childbirth-related complications

Hospital delivery is a must.
Availability of emergency obstetric care tools and well trained health workers.

How Fistula happens?
Obstetric fistula develops when labour isprolonged or obstructed. The head of the unborn child presses tightly on the tissue of the birth canal and against the pelvic/pubic bones, cutting off blood flow.

The surrounding tissues wear out and eventually rot, making urine and faeces to leak through the vagina. This happens within three to five days of injury.

Sometimes fistula are a result of rape or injuries caused by female genital mutilation, abortions or pelvic fractures.

Non scientific causes
Poverty: Many women find the cost of treatment, transport and distance a problem.
Lack of basic education
Early marriage and childbearing
Harmful traditional practices
Sexual violence.

Determinants
Lack of equipped health facilities with trained and skilled staff to carry out Caesarin-sections to remove the baby.
Giving birth at home alone or with medically unskilled and untrained birth attendants
Delay to seek help. Women seek medical help only when complications set in.
Negative attitudes and myths about the caesarean section. Women think it is for weak women.
A woman’s relationship with her partner or male decision makers also affects the kind of care and assistance she receive during child labour.
Women preferance for female health workers — the reason many consult traditional birth attendants if they cannot access them.