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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Emmanuel Macron's "moralisation of politics" comes at a heavy price for his allies

"Fake" jobs in French politics, season 3 episode 1.

Something is rotten in the state of France. No political party – at least none that existed before 2016 – seems immune to the spread of investigations into “fake” or shady parliamentary jobs. The accusations sank centre-right candidate François Fillon’s presidential campaign, and led to Marine Le Pen losing her parliamentary immunity in the European parliament (and proxy wars within her party, the National Front). Both deny the allegations. Now the investigations have made their way to the French government, led by Edouard Philippe, Emmanuel Macron’s Prime Minister.

On Wednesday morning, justice minister François Bayrou and secretary of state for European affairs Marielle de Sarnez announced their resignation from Philippe’s cabinet. They followed defence minister Sylvie Goulard’s resignation the previous day. The three politicians belonged not to Macron's party, En Marche!, but the centrist MoDem party. Bayrou, the leader, had thrown his weight behind Macron after dropping his own presidential bid in April.

The disappearance of three ministers leaves Emmanuel Macron’s cross-party government, which includes politicians from centre left and centre right parties, without a centrist helm. (Bayrou, who has run several times for the French presidency and lost, is the original “neither left nor right” politician – just with a less disruptive attitude, and a lot less luck). “I have decided not to be part of the next government,” he told the AFP.

Rumours had been spreading for weeks. Bayrou, who was last part of a French government as education minister from 1993 to 1997, had been under pressure since 9 June, when he was included in a preliminary investigation into “embezzlement”. The case revolves around whether the parliamentary assistants of MoDem's MEPs, paid for by the European Parliament, were actually working full or part-time for the party. The other two MoDem ministers who resigned, along with Bayrou, also have assistants under investigation.

Bayrou has denied the allegations. He has declared that there “never was” any case of “fake” jobs within his party and that it would be “easy to prove”. All the same, by the time he resigned, his position as justice minister has become untenable, not least because he was tasked by Macron with developing key legislation on the “moralisation of politics”, one of the new President’s campaign pledges. On 1 June, Bayrou unveiled the new law, which plans a 10-year ban from public life for any politician convicted of a crime or offence regarding honesty and transparency in their work.

Bayrou described his decision to resign as a sacrifice. “My name was never pronounced, but I was the target to hit to attack the government’s credibility,” he said, declaring he would rather “protect this law” by stepping down. The other two ministers also refuted the allegations, and gave similar reasons for resigning. 

Macron’s movement-turned-unstoppable-machine, En Marche!, remains untainted from accusations of the sort. Their 350 new MPs are younger, more diverse than is usual in France – but they are newcomers in politics. Which is exactly why Macron had sought an alliance with experienced Bayrou in the first place.

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