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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Letter from Donetsk: ice cream, bustling bars and missiles in eastern Ukraine

In Donetsk, which has been under the control of Russian backed rebels since April 2014, the propaganda has a hermetic, relentless feel to it.

Eighty-eight year-old Nadya Moroz stares through the taped-up window of her flat in Donetsk, blown in by persistent bombing. She wonders why she abandoned her peaceful village for a “better life” in Donetsk with her daughter, just months before war erupted in spring 2014.

Nadya is no stranger to upheaval. She was captured by the Nazis when she was 15 and sent to shovel coal in a mine in Alsace, in eastern France. When the region was liberated by the Americans, she narrowly missed a plane taking refugees to the US, and so returned empty-handed to Ukraine. She never thought that she would see fighting again.

Now she and her daughter Irina shuffle around their dilapidated flat in the front-line district of Tekstilshchik. Both physically impaired, they seldom venture out.

The highlight of the women’s day is the television series Posledniy Yanychar (“The Last Janissary”), about an Ottoman slave soldier and his dangerous love for a free Cossack girl.

They leave the dog-walking to Irina’s daughter, Galya, who comes back just in time. We turn on the TV a few minutes before two o’clock to watch a news report on Channel One, the Russian state broadcaster. It shows a montage of unnerving images: Nato tanks racing in formation across a plain, goose-stepping troops of Pravy Sektor (a right-wing Ukrainian militia) and several implicit warnings that a Western invasion is nigh. I wonder how my hosts can remain so impassive in the face of such blatant propaganda.

In Donetsk, which has been under the control of Russian-backed rebels since April 2014, the propaganda has a hermetic, relentless feel to it. If the TV doesn’t get you, the print media, radio and street hoardings will. Take a walk in the empty central district of the city and you have the creeping sense of being transported back to what it must have been like in the 1940s. Posters of Stalin, with his martial gaze and pomaded moustache, were taboo for decades even under the Soviets but now they grace the near-empty boulevards. Images of veterans of the 1941-45 war are ubiquitous, breast pockets ablaze with medals. Even the checkpoints bear the graffiti: “To Berlin!” It’s all inching closer to a theme-park re-enactment of the Soviet glory years, a weird meeting of propaganda and nostalgia.

So completely is the Donetsk People’s Republic (DPR) in thrall to Russia that even its parliament has passed over its new flag for the tricolour of the Russian Federation, which flutters atop the building. “At least now that the municipal departments have become ministries, everyone has been promoted,” says Galya, wryly. “We’ve got to have something to be pleased about.”

The war in the Donbas – the eastern region of Ukraine that includes Donetsk and Luhansk – can be traced to the street demonstrations of 2013-14. The former president Viktor Yanukovych, a close ally of Vladimir Putin, had refused to sign an agreement that would have heralded closer integration with the EU. In late 2013, protests against his corrupt rule began in Maidan Nezalezhnosti (“Independence Square”) in Kyiv, as well as other cities. In early 2014 Yanukovych’s security forces fired on the crowds in the capital, causing dozens of fatalities, before he fled.

Putin acted swiftly, annexing Crimea and engineering a series of “anti-Maidans” across the east and south of Ukraine, bussing in “volunteers” and thugs to help shore up resistance to the new authority in Kyiv. The Russian-backed rebels consolidated their power base in Donetsk and Luhansk, where they established two “independent” republics, the DPR and its co-statelet, the Luhansk People’s Republic (LPR). Kyiv moved to recover the lost territories, sparking a full-scale war that raged in late 2014 and early 2015.

Despite the so-called “peace” that arrived in autumn 2015 and the beguiling feeling that a certain normality has returned – the prams, the ice creams in the park, the bustling bars – missiles still fly and small-arms fire frequently breaks out. You can’t forget the conflict for long.

One reminder is the large number of dogs roaming the streets, set free when their owners left. Even those with homes have suffered. A Yorkshire terrier in the flat next door to mine started collecting food from its bowl when the war began and storing it in hiding places around the flat. Now, whenever the shelling starts, he goes to his caches and binge-eats in a sort of atavistic canine survival ritual.

Pet shops are another indicator of the state of a society. Master Zoo in the city centre has an overabundance of tropical fish tanks (too clunky to evacuate) and no dogs. In their absence, the kennels have been filled with life-size plastic hounds under a sign strictly forbidding photography, for reasons unknown. I had to share my rented room with a pet chinchilla called Shunya. These furry Andean rodents, fragile to transport but conveniently low-maintenance, had become increasingly fashionable before the war. The city must still be full of them.

The bombing generally began “after the weekends, before holidays, Ukraine’s national days and before major agreements”, Galya had said. A new round of peace talks was about to start, and I should have my emergency bag at the ready. I shuddered back up to the ninth floor of my pitch-dark Tekstilshchik tower block. Shunya was sitting quiet and unruffled in his cage, never betraying any signs of stress. Free from Russian television, we girded ourselves for the night ahead.

This article first appeared in the 05 February 2015 issue of the New Statesman, Putin's war