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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Battle for Mosul: will this be the end of Islamic State?

The militant group's grip on power is slipping but it has proved resilient in the past.

The battle for Mosul is the latest stage in the long struggle to defeat Islamic State. The group has been around since the late 1990s in one form or another, constantly mutating in response to its environment. Undoubtedly its ejection from Mosul will be a significant moment in the group’s history, but it is unlikely to be its final chapter. The destruction of the group will only be complete when some fundamental changes occur within Iraq and the war in Syria comes to an end.

IS’s roots go back to a training camp established by the militant Islamist Abu Musab al Zarqawi in the late 1990s in Herat, Afghanistan. Founded as an army to overthrow the apostate regimes of the Levant, it fled to northern Iraq in the wake of the US-led invasion of Afghanistan post-9/11 where it re-established itself as a force alongside Ansar al Shariah, a hardline Salafi jihadi organisation.

As American attention shifted from Afghanistan to Iraq, the group was ideally placed to become one of the leading lights in the post-Saddam Iraqi insurgency. Brutally announcing itself to the world in August 2003 with successive attacks on the Jordanian Embassy in Baghdad, the UN headquarters and a Shia shrine in Najaf — the latter being the deadliest attack in Iraq that year with a death toll of 95 — the group grew to assume the mantle of al-Qaeda in Iraq. By 2006 this brand had become somewhat damaged through the brutal sectarian campaign the group waged, and when its founder, Zarqawi, died it sought to reinvent itself as the Mujahedeen Shura Council. This incarnation did not last long either, and eventually it assumed the title of the Islamic State of Iraq (ISI), alongside a more Iraqi leadership.

This was the start of a diffcult period in the group's history. Its excesses in Iraq (including indiscriminate slaughter of Shia Muslims to stir sectarian hatred and filmed decapitations of prisoners) lost it local support and led to the tribes in Sunni Iraq rising up and supporting the government in Baghdad's fight back against the group. By 2009, when the west abruptly stopped paying attention and withdrew from Iraq the group was largely perceived as in decline, with the Shia Muslim-led Iraqi government appearing to slowly assert itself more effectively across the country.

The terrorist attacks by the group continued. And the new government started to advance an increasingly sectarian agenda. These two played off each other in a downward spiral that was given a fresh boost of blood when the civil war in Syria erupted in 2011. Drawing on its existing networks (that were leftovers from when Syria was used as a staging point by the organisation to launch attacks into Iraq), the leadership sent a cell to Syria to explore what opportunities existed within the emerging fight there. This cell became the seed that grew into Jabhat al Nusrah and ultimately IS – a label the group adopted when in June 2013 IS leader Abu Bakr al-Baghdadi decided it was time to reveal this link between his Iraqi group and Jabhat al Nusrah. This led to divisions and the breaking up of the two organisations.

For IS, however, it was the beginning of an upward trajectory, building on this division to grow itself substantially in Syria (with Raqqa as its capital) and in 2014 taking over Iraq’s second biggest city of Mosul. We then reach the apex of IS’s success and the biggest expansion of the group yet.

It now seems that this growth had a shelf life of just two-and-a-half years. As the group appears to be losing Mosul, it is likely that we will see the beginning of a period of retraction. But this will not be its end – rather, it will flee back to the hills and the ungoverned spaces in Iraq and Syria from where it will continue a persistent terrorist strategy in both countries. Here it will bide its time until the moment presents itself to rise up. Waiting until the governance in Iraq and Syria fails its people again, the group can paint itself as the protector of Sunnis and once more build on that group's disenfranchisement to win supporters and occupy a space vacated by local governments.

IS's grip on power might currently be slipping but as history has shown, it has waxed and waned depending on the context it is operating in. We are now going to see a period of withdrawal, but unless attention is paid by the global community, it will expand again in the future.

Raffaello Pantucci is Director of International Security Studies at the Royal United Services Institute (RUSI). Visit his website at http://www.raffaellopantucci.com