Rite and Reason: Women with obstetric fistula can be ostracised by family and community

Angola is a beautiful and complex country. Located on the western coast of Southern Africa, it boasts 1,600 kilometres of coastline, interior hills and mountains, an eastern high plateau and the Namib Desert. It is home to 34.5 million people and is the sixth largest economy in sub-Saharan Africa given its oil production, accounting for half of the country’s income. However, more than a third of its population are estimated to be living on less than the international poverty line of US$2.15 (€1.98) per day.

Recently, I travelled to Angola to learn about good practice in the prevention of obstetric fistula in this expansive country, with Irish Spiritan Fr Edward Flynn and Eirene Carson, a midwife of 40 years working in the UK’s National Health Service. Obstetric fistula is an abnormal opening between a woman’s birth canal and her urinary tract and/or rectum that is caused by a prolonged or obstructed labour, leading to urinal and/or faecal incontinence and other medical complications.

There are longer lasting psychological and emotional impacts that heighten the trauma and deny the woman her dignity. Women who develop fistula(e) often deliver stillborn babies and can become infertile. This is particularly traumatic in contexts where a woman’s status as a mother is her distinguished social role.

Many women are abandoned by their husbands. They are neglected, stigmatised, abused and ostracised by their family and community. This weakens their self-esteem and threatens their capacity to survive. They are unable to attend religious services or other community and social events due to the “foul smell” emitted from the “leaking” associated with fistula.

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Some women self-isolate to escape the shame. Their economic vulnerability is heightened, thereby threatening their livelihood. In UN 2030 Agenda terms, the women are a cohort of our global society who have been “left behind”.

[ Obstetric fistula remains one of the most neglected human-rights realities ]

The visit to Angola was an opportunity to reflect on the situation of women living with obstetric fistula, to explore reasons why women continue to experience fistula and to understand the ways in which fistula can be prevented. Most of the women live in rural areas or informal settlements at the edge of cities. There is limited access to safe and affordable maternal health and often the cultural preference is for a home delivery overseen by “aunties” or traditional birth attendants.

Key to the prevention of obstetric fistula is education and awareness of the importance of safe maternal care. Through local NGO partner Votoka, meaning ”rise up”, the team met women living with fistula – some for more than 20 years. We talked to fistula survivors who had been “healed” through fistula repair surgery and met dedicated “fistula ambassadors” raising awareness in remote communities about fistula prevention and supporting access to fistula surgery. For a woman to be “healed” through surgery is transformative and life-giving.

During their time in Angola a team of surgeons and nurses gathered at the Walter Strangway Hospital in Cuíto in the province of Bié for a fistula repair campaign, where 99 women registered for surgery. This is one of several campaigns held throughout the country annually.

It is estimated that there are 20,000 women in Angola living with fistula. Each year 1,000 more women are added to this number. The capacity to repair fistulas is less than 600 per year. This means that not all women who live with fistula can access repair surgeries, and some fistulae require more than one operation. Not all surgeries are successful.

There are just 0.2 doctors per 1,000 of the population and many are not skilled in obstetrics. At the Centro Evangélico de Medicina do Lubango (CEML) in Huíla province, we met young surgeons being trained in obstetrics and fistula repair. Trainee nurses and midwives are not exposed to obstetric fistula in their academic curriculum. A positive consequence of the visit to Angola was the invitation for Votoka to train student nurses about obstetric fistula and how to prevent it at the Instituto Técnico de Saúde in Cuíto.

Given the long distances from medical facilities, an important response is the development of “waiting houses”, where women at risk of a difficult birth can reside while waiting for appropriate ante- and postnatal care. Women recuperating from fistula repair surgery can also avail of this facility. Women at CEML were also learning new livelihood skills post-fistula surgery to support their reintegration into their communities. These facilities were also being developed at the evangelical mission hospital in Caluquembe in Bié province and at the new Hospital Materno Infantil in Luanda.

Amri, along with a coalition of individuals and groups are campaigning for the prevention of obstetric fistula and to ensure that the women impacted are not left behind. Contact justice@amri.ie for more information.

Dr Toni Pyke is the Justice, Peace and Ecology co-ordinator with the Association of Leaders of Missionary and Religious of Ireland (Amri). She has worked on international development and gender issues in the US, Nigeria, South Africa, Uganda, Zambia and Ireland, and has lectured at Maynooth University and the University of South Africa.