Fistula Support Program - The ACQUIRE Project : EngenderHealth

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There are two types of fistula, obstetric and traumatic.

The majority of fistulas found in Guinea are obstetric, meaning they are caused by problems during childbirth. During prolonged obstructed labor, without medical intervention, the pressure of the infant in the birth canal causes the tissue to die and a hole to form, either between the vagina and the rectum or the vagina and the bladder or urethra. Obstetric labor can occur as a result of a breach, or other difficult, presentation of the infant or normal presentation if the pelvis is too small. It can also occur as a result of an in appropriate obstetric intervention that punctures the internal organs. In the vast majority of obstetric cases, the infant does not survive the trauma of delivery.

The vaginal canal can also be ruptured by violent rape. In the Guinean Forestiere Region, thousands of women and young girls have experienced sexual violence at the hands of rebels coming from neighboring countries of Sierra Leone, Liberia, and Cote D’Ivoire. Hospital statistics from Kissidougou for the period 1998-2000 indicate that over 30% of the fistula cases seen there were traumatic.

Largely unknown in the Western world, obstetric fistula is very rare and quickly treated where health systems are functioning. However, in developing countries, poverty and poor nutrition, early marriage and pregnancy, female genital cutting, and low quality and use of health services for childbirth combine to result in a large number of women suffering from obstetric fistula. It is the lack of access to medical care during childbirth that has the greatest effect, as a caesarean section would relieve the pressure allowing the healthy birth of the child. Thus, it is the presence of fistula that tells us where health systems are failing. For young women, the lack of access to education and family planning and the inability to make decisions regarding their own marriage, pregnancy, and health care are aggravating factors. The proximity to the civil wars in Sierra Leone, Liberia, and Cote D’Ivoire, where violent rape was used a means of intimidation and warfare and again the lack of access to medical care for treatment, explains the presence of traumatic fistula.

Women who suffer from a fistula face the dual stigma of their failed pregnancy or rape and of the odor that constantly surrounds them due to the constantly leaking urine or feces, or both. Because of the lack of understanding and social stigma surrounding fistula patients, they are often rejected by their husbands’, families, and society. Living on the margins of society, hidden from view, their rejection, shame, and the awkwardness of their condition prevents them from participating in communal life. Hampered by their condition and rejection, they are often left with no choice but to rely on charity. The physical and emotional hardships lead some to suicide.

The number of fistula patients in Guinea is unknown. These women are almost by definition poor, rural women, and hidden on the edges of society, making an accurate count impossible. Fistula is also widely misunderstood in these communities, so that there if often no precise word for the condition. It is referred to as the “childbirth injury” or the “urine problem”. Women with fistula may be called simply “destroyed women”.

With field support from USAID, EngenderHealth responded to those needs with the launch of the fistula support program in January 2006. It’s objectives are to: Increase access to and utilization of comprehensive fistula treatment services, including counseling, rehabilitation, and reintegration. Increased provider skills and ability to diagnose, treat, and refer fistula clients. Increased sustainable capacity of the project sites for fistula treatment and prevention. Increased community awareness of the causes of fistula, treatment, and prevention options.

Surgeries started in February in Conakry and March in Kissidougou. As of the end of June, 134 operations have taken place, 48 in Conakry and 86 in Kissidougou.

Of those operated on, the surgeons are proud to announce that 42 fistula patients are now healed in Conakry and 69 are now healed in Kissidougou.

Now I’d like to take a pause to tell you about Mouima Koundouno. Fifty-years old, she was in the Maternity Ward at the Kissidougou Hospital for a follow-up visit after the surgical repair of her fistula, three months prior. As a young woman, Mouima gave birth to one living son before undergoing a prolonged obstructed labor that resulted in a stillbirth and the obstetric fistula that caused her to incontinent for 28 years. When, a few days after her disastrous delivery, her husband discovered that she was constantly leaking urine, he rejected her. Returning to her parent’s village, wrapped in layers of cloth as a diaper, Mouima was so ashamed of her condition, she almost never left her hut, even to go to the fields. Considered unclean, she was not allowed to prepare food or, as a Muslim, to pray. Her mother, and later her son, brought her food and other needs. But Mouima, tired of the constant leakage of urine, choose to eat and drink as little as possible. Because she suffered from constant dehydration and malnutrition, she often fell sick. Many fistula patients adapt this practice of self-deprivation which indirectly leads to their short life expectancy without treatment. Mouima was lucky to survive, with the support of her son, who is now grown.

Speaking to Professor Bobo, the project’s local expert fistula surgeon, however, he will tell you that his ability to cure fistula is not the only answer – prevention must also be a component. And listening to Koumba Camara, shown here with Dr. Sitan, this becomes evident. Koumba, like 62% of women in Guinea, gave birth at home without a skilled attendant. Married and sent into her husband’s family as a young child, Koumba had her first pregnancy at 17. She struggled through 4 days of obstructed labor, never leaving her mother-in-law’s house. The assistance she received was a mixture of leaves ground together into a paste, which she was told to eat to speed the delivery. When the baby arrived, a stillbirth, Koumba was tired, weak, and wounded. Her husband declared her ruined and sent her away.

I met Odia Camara in May, as she recovered from surgery conducted during a practical training session with the surgical teams at Ignace Deen and one of the fistula experts from the Geneva Foundation. She explained that this had been her fourth fistula intervention. The first intervention cured the fistula between her vagina and rectum, however, Odia had a second fistula, to her urethra. Two subsequent interventions, by untrained surgeons, failed to cure her incontinence. Many of the fistula patients in the EngenderHealth program report having previously undergone multiple unsuccessful interventions in small hospitals and health clinics in Guinea and neighboring countries. While they were charged only a small fee, the surgeons were untrained. Not only are these operations rarely successful, they are dangerous and cause heavy scarring of the vaginal tissue, making subsequent interventions more difficult.