Village health teams can offer hope to women with Fistula

By Joan Kabayambi

Jennifer Nayiko 29 years, a resident of Kawempe has been 'leaking' for 10 years.  She has gone from doctor to doctor to try and stop the flow, but her condition gets worse by the day. 

It all started 10 year ago, at a health centre in Kampala where she had a difficult delivery and lost her baby. Each day is a reminder of the emptiness she feels as her very life ebbs from her body. Jennifer has lost her family, friends, energy and money.  She has lost hope for her womanhood; the ability to conceive and suckle a child. This has left her rejected, abandoned and ever leaking urine, unclean, smelly.   When I met her last week, this is all she had to say: “No one is supposed to touch me, eat what I cook, or buy what I sell. I am always referred to as the stinking woman.  The house I live in, the chair I sit in, the utensils I cook with – are all unclean.  Oh how I long for a human touch; and nice words spoken to me”.

Jennifer’s condition is what is known medically as obstetric fistula (Akawago). Fistula is the most devastating and serious of all childbirth injuries that often leave women stigmatised and isolated from their communities. It happens because most mothers give birth without the help of skilled attendants. Consequently, many mothers (usually young girls) have complications from pregnancy and childbirth.

An increasing number of fistula cases now occur due to medical injury, either through the use of instruments during surgical operations or during instrument assisted delivery of a big baby. A study I carried out in Mulago Hospital, in 2009, showed that 35% of mothers who got fistula were having their second to sixth child and were between 25 and 59 years of age. The causes of these fistulae were hospital procedures and accidental injury to bladder and rectum by medical personnel.

The Uganda Demographic and Health Survey of 2011, estimates 142,000 women have experienced fistula; there is an increase of about 3,000 new cases recorded every year. Along with government health facilities, some NGOs are running clinics to treat fistula patients. Still, the treatment facilities are inadequate to help all the women. Fistula transforms women into pariahs in their own communities. “It is like leprosy” explains Dr. Justus Barageine, a fistula surgeon who has helped to treat more than 1,000 cases since he begun fistula surgery work in Uganda.

In supporting the fistula client, village health teams (VHTs) can be one promising strategy. VHTs can use a comb-through approach to offer a standard package of material and psycho-social requirements to enable many of the women with this condition to cope and prepare for surgery. The idea to use VHTs and community / family support groups is to reach every pregnant mother and follow them up and also reach every fistula patient that there is in the community. Social re-integration (i.e. process of supporting recovering fistula patients to fully go back into society with alternative ways to earn an income) can be effectively achieved through counseling, economic empowerment, and the use of fistula survivor and family networks and groups. Finally, the idea is to use fistula as a powerful entry point for advocacy for behavioural change to end gender inequality, illiteracy, maternal and childhood malnutrition, and early marriages.

VHTs can help women effectively integrate into the communities through one-on-one counseling, giving them the tools to withstand negative influences as well as cope with the stresses of mainstream society. To deal with the condition, the affected woman has to be repaired holistically - emotionally, economically and physically.

The writer is a Makerere University School of Public Health-CDC Fellow.