Imagine a world free from obstetric fistula. Seven years from now, in 2030, that is what is going to happen in countries which will have complied. The UNAIDS global target is to end obstetric fistula epidemic as a public health threat by 2030.

The world will then gather for an international celebration and announce the end of obstetric fistula. But the million-dollar question is: Is it possible for this ambitious UN’s visionary goal to happen in Uganda, seeing fistula sink into oblivion by 2030?

This was the main gist of the one-day dialogue on obstetric fistula last Thursday at Pacific Grand Hotel in Lira City, courtesy of the Association for Rehabilitation and Re-Orientation of Women for Development (TERREWODE).

Fistula survivors entertaining the audience during the dialogue

This is an NGO that pioneered the elimination of obstetric fistula through collaboration with the Ministry of Health to manage the disease in Uganda with a specific focus on supporting treatment through camps and reintegration as well as empowerment of women with fistula.

Obstetric Fistula is a devastating childbirth injury that leaves women and girls incontinent and often stigmatized and isolated from their families and communities.

According to Dr William Waweru from Soroti referral hospital, the condition is caused by prolonged and obstructed labour without access to timely, high-quality medical treatment, which can result in a hole between the birth canal and the bladder or rectum.

This hole causes the woman to continuously leak urine, faeces or both, often leading to chronic medical problems, and severe physical and emotional trauma, including social isolation and stigma and deepening poverty. Waweru says ninety percent of pregnancies involving fistula end in stillbirth.

The dialogue attracted over 40 district leaders from the Lango sub-region (Lira city and district, Oyam, Oluke, Amurata and Dokolo districts: Amolatar, Apac, Oyam, Kole, Dokolo) who included DHOs, RDCs, LC5 chairpersons, CAOs, women councils, district speakers and district community development officers (DGDOs).

 While opening the dialogue, Okello Richard Cox McOrik, the Lira District Chairperson, said there are high prospects of achieving the UN’s goal. “However, good words and intentions do not kill a snake. In striking a note of hope, some parameters must be considered. We have to look at the statistics, trend, commitment, challenges and tools at hand,” he said.

TERREWODE ED Alice Emasu Seruyange

Being upbeat about Uganda meeting the target, Okello stressed that we must be empowered to develop sustainable eradication plans, including access to safe delivery and emergency obstetric services.

“If we try out these three cost-effective solutions we can mitigate or even prevent obstetric fistula: timely access to high-quality emergency obstetric and newborn care, trained professionals with midwifery skills at childbirth, and universal access to modern contraception,” said Okello.

He decried early/child pregnancy which is alarming in northern Uganda, judged by the available statistics. If the underage girl doesn’t handle her pregnancy carefully during giving birth, obstetric fistula might occur, he said.

“This is a war we need to fight together as leaders. It is our responsibility to sensitize young girls that it is bad to engage in sexual intercourse when they are still young, which might result in pregnancy, which is dangerous. We must also sensitize our communities to stop child marriages,” emphasised said Okello.

He noted that the most stupid thing is to allow a young pregnant girl to give birth at home or to be attended to by the traditional birth attendant. Let her go to the nearby health facility for services if we have to avoid such scenarios of getting fistula,” he elucidated.

Dr Samuel Ojok, District Health Officer (DHO), Dokolo District is also optimistic that fistula can be eliminated as long as we change the mindset of people in our households who marry off young girls, a thing that could affect our goal.

“A girl child should be empowered with education because an educated girl is likely to delay sexual activities/ getting pregnant. It is also important to empower the communities that still nurse the mindset of encouraging early-age marriage. Delivery must be at the health facility,” Ojok said.

He further stressed that a good girl/woman starts from the womb, meaning a mother should have good antenatal care and should be well-fed so that she delivers a healthy baby girl. And the girl should be well fed so that she grows up more than five feet, otherwise lower than five feet the person is prone to obstetric fistula.

Fistula survivors staged skits, educative music performances and testimonies, which depicted challenges experienced by women and girls grappling with fistula--stigma and discrimination and lack of transport to reach health facilities. The performances also encouraged fistula victims to seek support and treatment.

During the dialogue, district leaders expressed mixed views. While some expressed pessimism about achieving the UN’s targets by 2030 due to various structural bottlenecks that need to be dealt with, like neglecting fistula by some facilities, others accepted that conditions to succeed are quite visible.

Alice Emasu Seruyange, Founder and ED TERREWODE, said that they organized the sub-regional workshop for district leaders from the Lango-sub region to inspire fistula survivors’ participation and facilitate the integration of fistula in the local government budgeting and work plan development process.

“We believe that this will give opportunity for the establishment of stronger collaborative mutual partnership between district local government teams, the survivors and other women to start a conversation on budgeting and prioritisation of fistula and other childbirth injuries,” Emasu said.

She nevertheless regretted that the presence of obstetric fistula is primarily an indicator of poor emergency obstetric care, the condition which is prevalent among poor and marginalized women who lack access to quality maternal health care services, including skilled birth attendants, and quality medical interventions.

“TERREWODE’s approach is to empower survivors to actively participate in community development programs for effective response and prevention of fistula, and to improve maternal health outcome,” she noted, adding, “Survivors are central in such workshops as they increase awareness and better understanding of the fistula challenges in our communities, accomplishing this through MDD and through sharing experiences/testimonies.”

Emasu clarified that survivors desire to be involved in the fight against obstetric fistula by acting as mentors to expectant mothers especially teenage mothers as these are the most vulnerable.

They (survivors) involve in increasing awareness of fistula by supporting the medical team (midwives and nurses) during awareness and prevention events in communities. All the fistula solidarity groups are led by survivors and their objective is to use MDD as a medium for awareness, she said.

STATISTICS

According to a report from the Ministry of Health, Uganda has one of the world’s highest maternal mortality rates, with 336 maternal deaths per 100, 000 births. Consequently, 6,000 women and adolescent girls die every year from preventable causes during pregnancy and childbirth while 1,900 end up with obstetric fistula conditions.

Adolescent girls in Uganda are especially vulnerable, according to the report. Uganda has one of the highest teen pregnancy rates in the world at 25%. Fifteen percent of girls are married by the age of fifteen and 49% are married by the age of eighteen.

Sadly, 82% of secondary school students in northern Uganda have been sexually assaulted, and only 25% of adolescents are enrolled in secondary school.

BARRIERS TO FISTULA RESPONSE

Apart from the risk of complacency, challenges in obstetric fistula intervention include prejudices, gender discrimination and social marginalization. All these create additional risks resulting in fistula disproportionately occurring among impoverished, underserved and marginalized women and girls.

Gender and socioeconomic inequalities, the denial of human rights and poor access to sexual and reproductive health services, including quality maternal and newborn health care, and the failure of health systems to provide quality sexual, reproductive and maternal health services are falling short in ending fistula.

Families marrying off young daughters to alleviate the perceived burden of caring for them, especially in the anticipated economic fallout of the pandemic, are big contributory factors to ending obstetric fistula.

Prevention programs.

Countries will need to use the powerful tools available, hold one another accountable for results and make sure that no one is left behind. Fistula interventions that can be easily carried out include tracking prevalence by health systems, correcting gaps in care and ensuring universal access to a competent health workforce. National health plans must also address gender discrimination and other factors making women and girls more vulnerable to maternal mortality and disease.

Bold political leadership and investment could eradicate fistula. Ambitious partnerships and scaled-up investments are imperative to ending fistula by 2030. Global commitment to fistula prevention and holistic treatment, including surgical repair and social reintegration and rehabilitation. Obstetric fistula is preventable; it can largely be avoided by delaying the age of the first pregnancy; the cessation of harmful traditional practices; and timely access to obstetric care.

Tackling the risk factors 

Emasu suggests that if leaders at all levels come on board, the resurgence of obstetric fistula can be averted. There is also a need to improve maternal health, strengthen health systems, and enhance the quality of care, reducing health inequities and increasing the levels and predictability of funding. All these are crucial to ensure that no one is left behind.

Efforts should be made by the international community at the global, regional and national levels to end obstetric fistula, those efforts should be intensified using a human rights-based approach.

New strategies will be required in the post-COVID-19 recovery period to address the expected backlog of cases. With this possible future scenario of preventive measures in danger, now more than ever, it is important to call on the international community to use the International Day to End Obstetric Fistula to significantly raise awareness and intensify actions towards ending obstetric fistula, as well as urging post-surgery follow-up and tracking of fistula patients.

CONCLUSION

According to an obstetric fistula expert, Dr Amandwa Nemaoan, former commissioner from HOH, if all sectors of Government collaborated, prioritized and budgeted for obstetric fistula, and communities play their role in spreading awareness, we shall witness a steady decline in the incidences of obstetric fistula and its consequential burden mitigated, meaning Uganda will be sitting at the table with successful countries seven years from now to celebrate a world free from fistula.

TESTIMONY OF A YOUNG VICTIM OF FISTULA.

Jackline Akulu, 19, from Amugu in Alebtong district dropped out in P7 after her father decided to pay for a cheaper tailoring course rather than secondary school. Akulu’s father re-married and decided to focus on financially supporting Akulu's step-siblings.

Jackline Akulu, 19, fistula survivor

Akulu completed her course but her father did not buy her a sewing machine which forced her into marriage at the age of 17. Akulu conceived in the same year of marriage. She spent three days in labour before going to Aromo Health Centre.

Her labour pains intensified and were later referred to Lira Referral Hospital, a five-hour journey, only to return home after a stillbirth. Two weeks after her being discharged, Akulu reported back to the hospital with concerns over water frequently leaking through her private parts and opening sutures.

The nurses informed Akulu that the ‘wound’ would resolve on its own and that the leaking was simply water that had been given to her during delivery. With no improvement after a further two weeks, Akulu sought a second opinion where she was diagnosed with fistula and sent back home as the doctor was not able to treat her.

A male member of TERREWODE’s Fistula Solidarity Group from Akulu’s area heard of her story and referred her to Terrewode Women’s Community Hospital (TWCH), specialized in obstetric fistula management, where she received free surgery services which are the main method for repairing obstetric fistula.

She also received socio-economic empowerment. Today, Akulu, free from fistula, is focused on using the skills she learned to identify an income-generating activity and finally buy herself a sewing machine.