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Fistula: Marker of Gender Inequality

Susan Anyangu-Amu

NAIROBI, Sep 9 2010 (IPS) - Though it is relatively easy to prevent, obstetric fistula continues to have devastating effects on the lives of millions of women globally. A regional policy document has been developed to address the root causes of fistula in East, Central and Southern Africa.

Obstetric fistula is caused by extended pressure of the child’s head against the soft tissue in the mother’s pelvis during childbirth.

The tissue eventually dies from the lack of blood supply, and a hole develops between either the rectum and vagina or between the bladder and vagina.

According to Dr Odongo Odiyo a reproductive health specialist, fistula leaves a woman unable to control the flow of urine or faeces.

“These women are stigmatised in the community. Their husbands and families often abandon them. They are unable to work and have to rely on a family that shuns them,” he says.

The factors that contribute to fistula arise from overlapping areas of inequality for women. Very young women or girls face a higher risk of fistula because their bodies have not fully developed; the continuing practice of early marriage in many parts of the continent, and the frequent absence of family planning place women at risk.

“Obstetric fistula is essentially a burden of the girl child. Deprived of her right to basic education and proper nutrition, the innocent girl child is plunged into an arranged marriage for which she is neither physically nor mentally prepared,” Odiyo says.

Women’s low status means the decision to spend precious money on fees for medical care – or even transport to the nearest facility – is deferred as long as possible. Many women across Africa give birth at home, and the absence of a skilled attendant increases the risk that the danger signs of obstructed labour will be missed, and there will be no one to take appropriate emergency measures.

Odiyo manages family and reproductive health programmes for the East, Central and Southern African Health Community (ECSA-HC) – an organisation that fosters and encourages cooperation in health in the three regions. The organisation estimates that there are at least 100,000 women with fistula in rural areas of Ethiopia alone, many of them developing the condition at an early age.

Odiyo says in Uganda, where the average distance to a health facility is 20 kilometres, a lack of good roads means women are unable to reach medical care when they need it.

Another tragic cause of fistula is sexual violence, such as in the conflict zones of the Democratic Republic of Congo (DRC) or in Kenya’s post election upheaval in 2007/2008

According to United Nations Population Fund estimates, there are two million women in developing countries with untreated obstetric fistula. At least 50,000 to 100,000 new cases occur each year. Reliable data is thin due to shame and stigma, but fistula is said to be most common in poor communities in sub-Saharan Africa and Asia where access to medical care during pregnancy and childbirth is limited.

Before the 20th century, fistula was also common in Europe and the United States. Today, it is almost unheard of in high-income countries or those where obstetric care is widely available.

ECSA-HC has formulated a regional policy document to address the causes of fistula. The policy document will be presented to health ministers ahead of the upcoming summit in Zimbabwe in October.

“The overall goal of the regional policy on fistula is to provide a framework for leadership and coordination of the countries’ responses to fistula,” says James Watiti, who steers research, information and advocacy at ECSA-HC.

Odiyo says the continuing incidence of fistula points to a failing in the health care system. The hope is that the new policy will offer guidance to governments on what should be done to prevent the condition.

The policy document calls on governments to focus on building of roads to ensure people can reach hospitals easily. Hospitals must have the necessary drugs and equipment as well as enough qualified staff.

Governments are also urged to ensure there is appropriate information to educate the public on the importance of seeking medical care from skilled healthcare workers. Cultural practices such as early marriages, female genital mutilation should be outlawed.

Countries are also encouraged to set aside dedicated funds towards reproductive health and child health: like poverty, the disease burden falls disproportionately on women and children, and funding should reflect this.

Governments will also need to focus on the poor and concerns of malnutrition. While corrective surgery is available for survivors of fistula, ECSA-HC recommends more attention should be on addressing the causes.

Dr Iteerswaree Thacoor, a gynaecologist/obstetrician working for the Mauritian ministry of health, says governments must address the issues that force women to deliver at home, on lack of education among girls and poor nutrition.

“In Mauritius we are doing well with regards to maternal health because most women deliver in hospital. This is because the government has concentrated on bringing health facilities closer to the people,” Thacoor told IPS.

“Treatment for pregnant women and their newborn babies is 100 percent free in government facilities. The government also encourages corporate organisations to contribute at least two percent of their profits to social ventures particularly in the health sector.”

The policy also calls on governments to focus on gender based violence and child sex abuse because they also lead to fistula.