Fighting Fistula in the Horn of Africa

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Dr Shukri in action, under the watchful eye of Dr Rassen — photo by Sarah Winfield

Fighting Fistula in The Horn of Africa:-Hawa* was just sixteen when she went into labour. As a nomad, living in a rural area, there were no midwives, no doctors, no healthcare professionals to call on.

So, when the labour became obstructed, Hawa’s mother piled her on to the back of a truck and headed in the direction of where she thought there might be a hospital.

Two days later, barely conscious and haemorrhaging profusely, Hawa finally arrived at a district hospital.

A nomadic family travels east in rural Somaliland — photo by Sarah Winfield
A nomadic family travels east in rural Somaliland — photo by Sarah Winfield

Without a resident obstetrician, the hospital staff were at a loss to know what to do, and so called a doctor from another city. Another day passed, and Hawa’s condition worsened.

At last, the doctor arrived, removed Hawa’s dead baby by forceps, rupturing her bladder and literally shredding her vagina in the process.

The result: a double obstetric fistula leaving her leaking urine and faeces. Two days later, Hawa arrived at the Edna Adan Hospital in Hargeisa. Very septic, very anemic and at death’s door, the doctors had little hope that she would make it.
There is no greater indicator of the many ways in which the world continues to fail the poorest, most vulnerable women than the degrading condition of obstetric fistula.

A childbirth injury, fistula is the product of wider development and human rights issues: poverty, lack of education, healthcare, gender inequality, early marriage, and more.

The tragedy is that fistula is both preventable and treatable. Yet of the one million women worldwide suffering the condition, less than 20,000 per year receive the surgery they so desperately need.
An obstetric fistula is a hole between the vagina and rectum or bladder caused by prolonged or obstructed labour. The condition leaves a woman incontinent of urine or faeces, or, in Hawa’s case, both.

Aside from the physical consequences, the stigma is such that many women are forced to live in isolation, abandoned by their spouses, families and communities. The damage to a woman’s mental and emotional well-being is immense. Having lost all self-respect, many also lose the will to live.
In the developed world, thanks to the availability of trained midwives, emergency obstetric care and C-sections, fistulae of this nature are rare.

In large parts of the Horn of Africa, though, the biggest challenge is the lack of healthcare infrastructure. Wherever women are attended by relatives or traditional birth attendants during delivery, there is a likelihood of fistula formation as well as high levels of maternal and neonatal mortality.

And for those suffering the condition, there are few options in the way of prevention or treatment. Most cannot afford surgery, or even the cost of transport to a hospital with the medical expertise needed.

Dr Shukri in action, under the watchful eye of Dr Rassen — photo by Sarah Winfield
Dr Shukri in action, under the watchful eye of Dr Rassen — photo by Sarah Winfield

In large parts of the Horn of Africa… the biggest challenge is the lack of healthcare infrastructure. Wherever women are attended by relatives or traditional birth attendants during delivery, there is a likelihood of fistula formation as well as high levels of maternal and neonatal mortality.
As Hawa’s story shows, the quality of treatment is also critical, as, too often, inadequately trained doctors do more harm than good. In the case of fistula repair, the most crucial variable in terms of outcome for the woman is the competence of the surgeon, developed through years of training and experience.

At the Edna Adan Hospital, for several years, resident doctors have been trained under the watchful eye of visiting fistula surgeons, and, most recently, thanks to FIGO (the International Federation of Gynecology and Obstetrics), at the Hamlin Fistula Hospital in Addis Ababa.
Happily, with the support of the Fistula Foundation, Hawa and 14 other women from Somaliland, Djibouti, Ethiopia and Somalia suffering debilitating childbirth injuries received treatment during the hospital’s recent surgical camp.

I will never forget visiting the ward of recovering patients soon after surgery was finished. Although still tender, the appreciation expressed by patients for the care given moved me deeply. One lady from Somalia commented that not once in her whole life had she experienced such care and comfort: a bed to sleep on, running water, nutritious food.

The sense of community amongst the women was palpable. Each had endured so much and yet, such was their strength and courage, they had not lost hope.
In another room lay a very sore Hawa, tended by her loving mother and mother-in-law. Although still healing, and with a long road of recovery ahead, I sensed that Hawa knew she had turned a corner. Finally, her dignity had been restored, and a new life was within grasp.
*For reasons of privacy, the patient’s name has been changed

Sarah Winfield @SarahWinfield

Sarah Winfield
Sarah Winfield

Filmmaker, educationist & serial volunteer with a zeal for international development. Camfed Communications Manager; Edna Adan Foundation Trustee.

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