On March 8 and 9, MSF is organizing a workshop in Geneva to improve the treatment of obstetric fistula. This condition, a cause of great shame, affects two million women worldwide, mostly in Africa.

"The sun should not rise or set twice on a woman in labour." Despite this proverb, endless labours before delivery are legion in Africa, where a majority of women give birth at home. When they finally come to the hospital, it is often not only too late for the newborn, but sometimes for the mother as well.

Among women who survive this ordeal, many emerge infirm. Obstetric fistula is one of the most serious consequences of obstructed labour and occurs when the soft tissues of the pelvis are compressed by the baby’s head. The lack of blood flow causes the tissues to die, creating a hole between the vagina and bladder, the vagina and rectum, or both. It results in urinary or fecal incontinence. Women with fistula live in shame and are often rejected by their own families and communities.

An estimated two million women live with fistula worldwide, most in Africa. This problem is largely hidden because it often affects young women who live in poor and remote areas, with very limited to no access maternal healthcare.

Those affected include women like Zanaba, 16, a patient treated by MSF last year in the Central African Republic (CAR). At the end of her pregnancy, and after three days of intense pain, her mother went looking for a traditional birth attendant.

On the seventh day, Zanaba was brought to the nearest hospital after travelling the entire day on a motorcycle. When she arrived, the baby had already died. The young mother was saved but the prolonged, obstructed labour caused a fistula, which required a second surgery. “I did not know that fistulas exist and how they can occur. But I am glad that I receive the operation,” she says.

CAR © Sarah Elliott/MSF
Thirty-two year-old Robertine has seven children and suffered a fistula four months ago when she was in labour for 24 hours.

Improving access to obstetrical care

On March 8 and 9, MSF will organize a workshop in Geneva to improve the management of fistulas. The meeting coincides with International Women's Day and will bring together actors involved in fistula treatment: surgeons as well as experts working for MSF and for other organizations.

Fistulas are largely preventable and have disappeared in developed countries where there is near universal access to obstetric care.

The operation to close a fistula is delicate and requires specific skills. Depending on the severity of the case, the operation may take several hours. In order to operate on fistula, a long and specific training is needed and there are only a few specialized centres in Africa.

Treating fistulas goes beyond just surgery. Because of the flow of urine and feces, affected women can develop multiple infections or skin diseases. Following childbirth, they may also have difficulty walking and, because of their exclusion, they are likely to suffer from malnutrition. After surgery, in case of residual incontinence, patients often require physiotherapeutic rehabilitation. Psychosocial care is also needed to help reintegrate women into their communities.

Camps to treat fistulas

In their work worldwide, MSF doctors have always been faced with women suffering from fistula. In 2003, MSF organized its first fistula camps in Ivory Coast and in Chad, and then, in subsequent years, in Sierra Leone, Somalia, Democratic Republic of Congo (DRC), CAR and Mali. These ad hoc interventions are continuing today in DRC and CAR.

“MSF usually works in insecure or war-torn countries. That is why we chose to set up short projects," explains Michiel Lekkerkerker, a medical advisor for MSF. "Fistula camps, as we call them, are installed for two months next to existing hospitals. Before we set up the camp, the population is informed so that women with fistula come for consultation. Then we hire additional employees and we prepare between 40 and 80 beds, usually in tents. The surgeon stays about one month on site and operates on several women a day. This method has the advantage of flexibility and it is easier to find a specialized surgeon for a short period."

CAR © Sarah Elliott/MSF
Esther (centre) developed a fistula in 2008 after being in labour with her daughter Abigail for 12 hours. She came to the MSF project in Boguila for surgery to repair the injury. Her husband accompanied her.

Three permanent centres: Burundi, Chad and Nigeria

Today, MSF treats obstetric fistula in three permanent centres in Burundi, Chad and Nigeria.

The latest location to open its doors is the Urumuri centre. Backed by the regional hospital in Gitega, in the heart of Burundi, the centre opened its doors in July 2010. This is the first centre in the country specializing in fistula. Staff treat women seven days a week and MSF has built four houses to accommodate the patients before surgery and during rehabilitation.

"This kind of project ensures a better monitoring of patients and it is possible to do research to improve treatment," says Geert Morren, a surgeon and fistula specialist with MSF who operated on many of the women in Gitega. "The objective is to operate on 350 women per year over three years. This time frame should allow us to train three Burundi surgeons and to transfer our activities to the Ministry of Health."

In Burundi, in addition to the specialized centre in Gitega, MSF built a maternity unit in another region of the country. The plan is to prevent the occurrence of fistulas by improving the obstetrical care available in Burundi.

In Abeche in eastern Chad, the project referred to as “butterfly” started in 2008. The butterfly symbolizes the transformation of women who lived secluded lives and who can begin a fresh start after their operation. In 2009, MSF built a women’s village to accommodate patients with fistula during their weeks-long stay. During the first consultations, a preoperative evaluation is done to screen malnutrition cases and take care of them before the surgical intervention. After their operation, counselling and rehabilitation sessions allow the women to regain a place in society.

One of the people MSF works with is a Chadian surgeon, Valentin Valandi, who graduated in Dakar, Senegal. Valandi is specializing in fistulas thanks to the visit of international experts. "Each case is different, I learn every day,” says Valandi. “In Chad, too many women have already been operated upon inappropriately, which further complicates the procedure.”

In Abeche, MSF also supports the regional maternity hospital, next to its “butterfly” centre. The objective is to improve obstetric care and thus prevent new cases of fistula occurring because of poor management of difficult deliveries.

In Nigeria MSF works with Ministry of Health staff at a hospital in Jahun, in the north of the country. The teams provide obstetric and neonatal care to people in the surrounding area. The aim is not only to reduce maternal and infant mortality but also to prevent and treat fistula. In 2010, the MSF team carried out 400 fistula repair surgeries. After release from the hospital, women receive six months of outpatient follow-up care to ensure the fistula has healed and that continence is maintained.

In 2010, MSF teams operated on and treated about 1,000 women suffering from obstetric fistula.

CAR © Sarah Elliott/MSF
Women recover in one of the tents at the MSF fistula camp in Boguila, CAR. Sixty-five women had their fistulas repaired during the six-week camp in 2010.