Kristina Graff — Without proper care during childbirth, mothers can suffer lifetime of indignity

Imagine a mountain village in Tanzania. Tiny homes and farms pepper the steep hills, crisscrossed by narrow dirt footpaths that women, men and children use to travel to their fields, schools and markets in town. It is picturesque, remote and untainted by the trappings of industrialization and development.

Now consider a medical emergency. A pregnant woman goes into labor and plans to deliver her baby at home, aided by her mother-in-law and other female relatives. Things do go awry: two days later the woman is still in labor and needs an emergency cesarean section. The nearest road is miles away, and the nearest hospital even further. The only means of transportation is a bus that runs along the main road just twice a week. To get to a doctor the woman must descend the mountain, travel to the nearest road, and find a way to the hospital – all while in labor.

At each step of the way she and her family will encounter barriers: scraping together the money for transportation, borrowing a neighbor’s wheelbarrow or bicycle to carry her down the narrow mountain paths, hiring a car to drive her to the main road – often for a high fee – and traveling to the hospital by bus, flatbed truck or even on foot. When she arrives, hours or days later, her baby will have died. If she survives the journey, she will have suffered an obstetric fistula, a condition that will change her life.

Obstetric fistula occurs when women experience prolonged, obstructed labor and cannot get to a medical facility.  Put more simply, when a baby gets stuck in the birth canal for too many days or too many hours, the pressure of its head against the mother’s pelvic bones causes tissue to disintegrate between the vagina and the bladder and/or rectum. A hole forms, and the resulting condition is somewhat akin to incontinence: the mother leaks urine, and sometimes feces, uncontrollably from her vagina. The condition causes an unpleasant odor and can lead to nerve damage in the feet. Women with fistula are thus commonly ostracized from their families and communities, working, living and sleeping alone.

Fistula is the product of several socio-cultural, economic and infrastructural dynamics. The cultural tendencies to deliver babies at home, without prenatal care or any plan for medical intervention in the event of an emergency, is a contributing factor. Social norms that remove women from economic decision-making – including the choice of where to give birth, and when to use a family’s limited money on emergency health care – are another common culprit. Poverty exacerbates the problem, such that even those who wish to go to the hospital cannot afford the cost of getting there. On the societal level, fistula is borne of a lack of roads, reliable transportation and a functional health care system.

Fistula can be treated by surgical repair, and many women spend years saving money just to pay the bus fare to the hospital. Few doctors are trained to provide this service, however, and most women cannot afford the cost of the operation. Even when the repair is provided free of charge, getting the word out to the affected women presents a challenge: they tend to live in more remote locations, and they may not be able to pamphlets and flyers giving information on how to access fistula treatment.

International and local organizations alike are working to raise awareness of how to prevent and treat fistula, and they are training doctors to do repairs…but the demand for care far outpaces the supply. For every woman who learns that repairs are offered and gets to the hospital for treatment, several more will sustain the same devastating injury in childbirth.

The end to fistula will require infrastructural development to provide reliable transportation to and from the furthest corners of the poorest countries, a stronger emergency medical care system that trains primary-level providers to recognize and refer the signs of a high-risk pregnancy and obstructed labor, and a new social order that prioritizes women in economic and cultural decision-making. Only then can the women who live high up along the mountain footpaths count on the safe delivery of their babies.

Kristina Graff is the Associate Director of the Center for Health and Well Being at Princeton University. Her past focus has been on maternal and reproductive health problems that stem from gender inequities and economic disparities. Kristina has worked in sub-Saharan Africa, Asia, Latin America, and New York City. She spent a year in Tanzania working for the Women’s Dignity Project on fistula issues.

Editor’s note:  Bugando Medical Centre, which the Touch Foundation supports, is a center of excellence in East Africa on fistula repair.