Obstetric Fistula: Africa’s silent epidemic

While all women of reproductive age are vulnerable to suffer fistula, the underage girls who are victims of child marriages, female genital mutilation and teenage pregnancies are at highest risk.

Obstetric Fistula is a silent epidemic in Africa. It’s a hole in the birth canal caused by prolonged, obstructed labour due to lack of timely and adequate medical care. As a result of this, in most cases, the baby is stillborn or dies within the first week of life, and the woman suffers a devastating injury, which leaves her incontinent. While all women of reproductive age are vulnerable to suffer fistula, the underage girls who are victims of child marriages, female genital mutilation and teenage pregnancies are at highest risk.

It’s a deeply unpleasant condition, resulting in constant leakage of urine and feaces through the vagina. Naana Otoo-Oyortey from the diaspora charity FORWARD tells me: “It’s a health issue that’s exacerbated by social factors. Many of these girls will be excluded from community life and abandoned by their husbands and families, isolating them socially and economically.”.

Another diaspora charity, MIFUMI, sent me a number of case studies. Justus Osuku, a peasant from Gweri in Soroti district, married his wife when they were both 14, during the infamous Teso insurgency in the 1990s. They were living in the Internally Displaced Peoples Camps in Soroti when his wife developed the problem. He resisted the social pressure to send her away: “I loved her. I married her when she was normal. I did not see the reason to send her away at a time when she needed me most.”

He is unusual: the overwhelming majority of husbands send their wives away, citing reasons ranging from the unbearable smell to community stigma. FORWARD is conducting research in Sierra Leone to explore the impact on the lives of women and girls who are blighted by it. The research involves 45 women affected by fistula and their recommendations will inform policy and decision makers in Sierra Leone and beyond.

One of those women, Jamma, was 18 when she got pregnant. When the labour started, she went to the local health centre but the nurse was away so she had to wait for three days. She finally gave to a stillborn baby and developed fistula. She suffered from it for two years until her friend told her about the treatment in the town. Her friend paid for her transport but the journey was very difficult. Nobody wanted to sit with her because of the smell. She was abandoned, first by her husband and then her grandmother.

On 23 May this year the UN celebrated the first International Day to End Obstetric Fistula. There is a lack of evidence as to how many women worldwide are living with the condition, but they live mainly in Sub Saharan Africa and Asia, and number in the hundreds of thousands. In Uganda there are at least 200,000 such women and 1,900 new cases are reported annually, according the National Obstetric Fistula Strategy.

“It’s a poor person’s illness,” Evelyn Schiller of MIFUMI tells me. “The issue of transport in rural Africa makes it difficult - there are very few cars in these areas. Surgeries can be lacking basic equipment like surgical gloves, clamps and oxygen. It usually takes three or four surgeries to correct it because it’s a complex repair process. We need to improve health education and antenatal care, train doctors to repair them, and above all raise awareness.” 

Mother and son walk together near the Ethiopia-Somalia border. Photograph: Getty Images

Alan White's work has appeared in the Observer, Times, Private Eye, The National and the TLS. As John Heale, he is the author of One Blood: Inside Britain's Gang Culture.

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Scarred lands: visiting the villages Boko Haram left behind reveals the toxic legacy of terrorism

The progress and challenges of Nigerian communities rebuilding after Boko Haram’s insurgency begins to wane.

“Sometimes it’s when I go to bed that what happened comes back to me.” Two years ago, Boko Haram militants stormed into 23-year-old John Amida’s home late at night in a village in Gwoza, Borno State, northeast Nigeria. Shielding his eyes with his hands from the torchlight saved his life. He shows me the mark in the centre of his forearm where the bullet aimed for his head went instead.

“All my friends were either killed or abducted,” he says. “I don’t try to forget what happened because it’s not possible; it’s with you even when it is not in your mind. The best thing is just to keep on living every day.”

After a broadly effective 18-month military campaign, Boko Haram remains a deadly yet waning force. Many communities once occupied by Boko Haram are now liberated. In Adamawa, just south of Borno, over 630,000 people previously displaced by Boko Haram have returned home.

With them, over 170,000 internally displaced people (IDPs) now live in camps, or – like John and his family – in host communities. He and his family live in a home vacated and lent to them by a local. All over Adamawa, IDPs live in homes shared with residents or given to them temporarily in exchange for help, crops or token sums of rent.

Adamawa is a serene, largely rural, mountainous state. Even deep into the dry season, driving through the roads that cut between its vast countryside, its land is incredibly scenic. But within local communities, in more rural, isolated villages north of the state’s capital, Yola, the picture is more complicated.

Gombi, a small town a few hours’ drive from Yola, was recaptured from Boko Haram in late 2014. Much of what was destroyed in the insurgency – shops and small businesses – have been rebuilt or replaced. The local government buildings have been largely restored. The impact is still visible but, according to locals, decreasingly so.

But in less urban areas, like in Garaha, a village in Adamawa, rebuilt homes sit next to broken, abandoned houses, churches, mosques and buildings blackened by the fires that damaged them. Local government officials say the damage across Adamawa by the insurgency has set the state’s development back by a decade. Funding for rebuilding the state, which local governments complain is insufficient, is concentrated on urban areas.

According to Chief Suleimanu, a traditional ruler in Garaha, mental health issues are widespread but few are financially able to access support. While some people have been able to move on, others are still dealing with the consequences.

“Many couples and families have separated,” he tells me, detailing how in some couples one partner feels attached to their home while the other can’t face returning, or feel there is little to return to.

“The same with the children, some of the young people have gone to bigger cities like Kano or Abuja because of a lack of opportunities.”

Many returnees, who left camps in Cameroon to come back to Adamawa, are from families who have lived in their villages for generations. Their ancestral roots anchor them to their homes because their farmland is their main source of income. Non-agriculture-based industries provide few jobs. For many people, fleeing their homes meant abandoning their livelihoods.

As of 2015, 52 per cent of people in Nigeria lived in rural areas. Their relative isolation is a blessing and a curse. Larger rural spaces provide them with adequate land to cultivate their crops – but it also leaves them exposed.

During Boko Haram attacks on Garaha through to early 2015, there was minimal protection from security forces who often take hours to arrive.

For many people living in rural Adamawa, life is getting harder and easier at the same time. Armed herdsmen, mainly from the Fulani ethnicity have become a greater threat across Nigeria, partly due to tensions between land ownership and cattle grazing.

According to locals, killings by herdsmen have increased this year. But villages are addressing their vulnerability. Armed vigilantes, some of which formed due to the lack of military protection against Boko Haram, are increasing. The police services are often too far away or too under-resourced to protect them. But some vigilantes now have more weapons and vehicles due to help from state services and locals. It is not an ideal solution but it has made places like Garaha safer.

With this new-found relative safety, villagers have begun farming again. With cash grants and donated tools from charities like Tearfund, it has been easier for thousands of people to begin cultivating land. In many villages there are small, lively recreation centres where young people play snooker and watch sport. Many of their places of worship have been rebuilt.

But the situation is grimmer in communities where such charities are not present.  Without resources, state or non-government help, rebuilding is a real challenge.

Adamawa is a state maxing on its credit of hospitality, relative safety and appreciation of agriculture. A recession in Nigeria and a severe food crisis in the northeast have added pressures on returnees and IDPs. Liberated communities will need more help and attention before they truly feel free.

Emmanuel Akinwotu is a journalist based between Lagos and London who writes about Africa, migration, and specialises in Nigeria.