MOCUBA, ZAMBEZIA PROVINCE, Mozambique â Beatriz SebastiĂŁo suffered in silence. She had no friends in the neighborhood or at school. When she went to church, she sat alone. When she went to the river, other women mocked her before leaving to bathe elsewhere.Â
In Mozambique, an obstetric fistula survivor's journey from "I was nothing" to "I am capable of everything"
MOCUBA, ZAMBEZIA PROVINCE, Mozambique â Beatriz SebastiĂŁo suffered in silence. She had no friends in the neighborhood or at school. When she went to church, she sat alone. When she went to the river, other women mocked her before leaving to bathe elsewhere.
She had become pregnant at 15 and because she lived far from the hospital, planned to give birth at home. After three days of labour, her parents had to raise money to rent a motorcycle to take her to the hospital, where she delivered a stillborn child. She developed an obstetric fistula, and when she became pregnant again, that child, too, was stillborn. But the fistula caused urine to leak, and the resulting smell isolated her from nearly everyone for the next six years.
A treatable, preventable condition
Obstetric fistula is a hole between the birth canal and bladder or rectum, which can cause incontinence, leading to social ostracization and attendant psychological issues like depression. The treatable and largely preventable condition is the result of prolonged, obstructed labour with no access to skilled care, often resulting in stillbirth. Girls whose bodies are too young to deliver a baby are particularly vulnerable.
Every year, there are an estimated 2,500 reported fistula cases in Mozambique, of the 50,000 to 100,000 cases globally. Since 2018, in partnership with the Government of Mozambique, UNFPA has supported the repair of more than 2,300 fistulas, recruited 28 fistula surgeons, expanded a real-time monitoring system of cases to 25 health facilities, and educated thousands of people about the causes and consequences of the condition.
A life transformed
Ms. SebastiĂŁo, now 28, had once sung gospel and six years after developing the fistula, received a fateful invitation to perform at a youth meeting. Encouraged by an uncle, she went, âbut as always, I was discriminated against. I was humiliated. People talked. Because of the looks, I stayed there shrunken.â She stayed alone in a tent because no one would share space with her.
Ms. SebastiĂŁoâs husband, Barcilai Artur (here in their living room), stood by her when many women with obstetric fistula are abandoned. Š UNFPA Mozambique
Then the youth coordinator, who also worked at a hospital, sought her out when she skipped practice, claiming illness. Finally, she admitted she had âa disease that made me pee involuntarily,â which is when she learned that what she had could be cured through surgery.
Ms. SebastiĂŁo was one of the rare fistula survivors whose family and husband did not abandon her. With their support, she had the operation and, for the first time in years, awoke without having wet the bed. âI donât know how to express what was in my heart,â she recalled. âI had emotions I donât know how to describe.â
She was no longer the person others fled from. She could wear skirts again, instead of covering herself with multiple layers of cloth. She started a small grocery business, something unthinkable before, and became an activist, holding chats with women in various communities to discuss fistula. She learned âto love that Beatriz from the past again,â she said. âWhen I had the disease, I was nothing. Now, I am capable of everything, able to fight for my well-being and raise my self-esteem.â
The contagious joy of a woman with a repaired fistula
Albertina Luis is a radio journalist and activist in Mocuba District. When her activism focused on domestic violence, she would meet women hiding behind their houses or in the cassava trees â not from abusive husbands but because they had obstetric fistulas. Ms. Luis underwent reproductive sexual health training and learned more.
Activist and radio journalist Albertina Luis educates women on the prevention and treatment of obstetric fistula through her broadcasts in Mocuba District. Š UNFPA Mozambique
Now, through regular broadcasts, she reduces shame and stigma surrounding obstetric fistula and lets women know how to prevent it, including avoiding forced, premature marriage and unintended pregnancy, and where to seek medical treatment. âDignity means being valued,â Ms. Luis, 50, said. âThe greatest wealth is health. In addition to being a right, it is power. I am freeing women who have lost their dignity for a long time.â
Dr. Armando Rafael, a fistula surgeon at Mocuba Rural Hospital, who operated on Ms. SebastiĂŁo, finds his work rewarding, knowing the suffering and marginalization patients have endured. âThe contagious joy of a woman when her fistula is repaired is incomparable,â he said.
During Ms. SebastiĂŁoâs long exile, women at the river taunted her with the cruel nickname âLake Bethesda,â a reference to the Bible's Pool of Bethesda that never ran dry. For her, the name takes on a different significance now: in Biblical lore, the pool was a place where miracles happened and people were healed.
End gender inequality! End health inequities! End fistula now!
Statement by UNFPA Executive Director Dr. Natalia Kanem on the International Day to End Obstetric Fistula
Last November, the world convened in Nairobi to celebrate the tremendous gains of the past 25 years in advancing the health and rights of women and girls. With a deep sense of urgency, purpose and hope, leaders from around the world â from presidents to the grassroots, from refugees to royalty, from youth activists to CEOs â committed to accelerating action to ensure sexual and reproductive health and rights for all.
Just six months later, that commitment is being tested like never before. As health systems struggle to respond to COVID-19, the pandemic stands to take a huge global toll on maternal and newborn health. Already, the crisis is compounding the economic, social and logistical barriers that women and girls face in accessing sexual and reproductive health services. Even where services are available and accessible, fear, misinformation and stigma related to COVID-19 are deterring some pregnant women from seeking obstetric care.
The absence of timely medical treatment will likely spur a dramatic increase in obstetric fistula, a serious childbirth injury resulting from prolonged, obstructed labour.
Poor women and girls in rural areas are especially at risk. The disproportionate incidence among the poor of this debilitating and sometimes life-threatening condition is a reflection of social and economic inequities and of unequal enjoyment of the right to health, including sexual and reproductive health. Even in the best of times, they are more likely to lack access to skilled health personnel. Child marriage and early childbearing are among other contributing factors.
While fistula has been virtually eliminated in developed nations, hundreds of thousands of women and girls in the developing world still live with this debilitating condition. As leader of the global Campaign to End Fistula, UNFPA provides funding and support for fistula prevention, treatment and social reintegration programmes. Since 2003, we have enabled more than 113,000 women to undergo obstetric fistula repair surgery.
However, we will need to accelerate efforts if we are to achieve our global ambition of ending fistula by 2030, the deadline for the Sustainable Development Goals. Towards that end, the response to the COVID-19 pandemic must ensure the delivery of essential sexual and reproductive health services, including midwifery services and emergency obstetric care.
On this International Day to End Fistula, the memory of the late Dr. Catherine Hamlin, who passed away in March this year, looms large. She dedicated most of her long life to treating women and girls with fistula, focusing not only on the physical injury itself, but also on the scars created by stigma and discrimination. Her charitable organization, Hamlin Fistula Ethiopia, has brought hope and healing to women and girls, raised global awareness of fistula and spurred innovative efforts to end it.
Let us work in Dr. Hamlinâs memory towards fulfilling her lifelong dream and our long-held aspiration to eliminate this preventable condition. In doing so, we will help protect the health and human rights of the poorest and most vulnerable women and girls.
Korean cooperation helps give Ivorian fistula survivors a new lease on life
BOUAKĂ, CĂ´te d'Ivoire â When Blandine was pregnant, she didn't go to the hospital for regular prenatal check-ups. On the day she gave birth, she delayed in going to the health centre. Her doctor told her that's why the birth had complications which resulted in her developing obstetric fistula.
Obstetric fistula is one of the most serious and tragic childbirth injuries. A hole between the birth canal and bladder and/or rectum, it is caused by prolonged, obstructed labour without access to timely, high-quality medical treatment. Fistula leaves women leaking urine, faeces or both, and often leads to chronic medical problems, depression, social isolation and deepening poverty.
To make matters worse, Blandine was dealt a triple blow because she also lost her baby and was soon left abandoned by her husband due to her condition.
Blandine suffered from fistula for three years until 2013, when she learned more about the condition while listening to a radio broadcast by the United Nations Peacekeeping Mission Radio in CĂ´te dâIvoire. She finally understood the cause of the pain and how to deal with her trauma. Blandine's mother then advised her to seek fistula repair treatment at a UNFPA-supported clinic in BouakĂŠ, 340 kilometres north of the Ivorian capital Abidjan.
The surgery was a success, and it turned Blandine's life around. She felt like she had been reborn from her ashes once her fistula healed completely.
"I have a new taste for life. I met another man and was able to have another daughter," she told UNFPA.
Blandine went back to school and earned a vocational training certificate. While she looks for a new job, she volunteers to raise awareness about fistula by sharing her experience with other women in her community. She urges them to get regular prenatal check-ups and always follow the advice of their midwife or doctor to prevent life-threatening complications in childbirth like fistula.
Blandine's treatment was made possible by an $8 million partnership between UNFPA and the Ivorian Ministry of Health, funded by the Korean International Cooperation Agency (KOICA). Since 2012, the programme has carried out almost 3,400 free fistula surgeries, with a success rate of 77 per cent.
âIn most cases, fistula survivors face stigma, are isolated by the community and cannot afford to take care of themselves," said Caspar Peek, UNFPA Representative in CĂ´te dâIvoire. "With surgery, fistula survivors find a way to get healed, to be reintegrated in the community and give a new direction to their life."
In CĂ´te dâIvoire, 26 per cent of births are not attended by skilled medical personnel, a factor contributing to the countryâs high morbidity and maternal death rates, including fistula.
Despite strong political will and efforts by development partners, the unmet need for fistula repair is still very high across CĂ´te dâIvoire. Fistula survivors are found in both urban and rural settings, and they face many obstacles to access health care in addition to the isolation and loss of dignity caused by fistula.
In order to achieve the ambitious goal of ending fistula by 2030, the way forward is to accelerate efforts on prevention and treatment and to raise awareness about how fistula impacts womenâs lives.
"Fistula is a medical condition that has severe social, psychological and human dignity repercussions. The victims often suffer in silence and total isolation," said Seo Dong Sung, KOICA country director in CĂ´te dâIvoire. "Through this project, KOICA wishes to stand with these women by curing them from fistula, by helping them to regain their dignity in the society, and most importantly by helping with the maternal health system to care for pregnant women in order to avoid the joy of maternity turning into a nightmare."
BARIADI, United Republic of Tanzania â Midwife Nuriat Koku Mtumbi remembers the day in March well: âIt was raining heavily and Adimu* had delivered her baby on her way to our facility. âShe was shielding herself under a treeâ when she gave birth, Ms. Mtumbi recalled.
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Adiumu was in excruciating pain, and bleeding heavily. She could barely move, âbut her mother managed to get her here,â Ms. Mtumbi said. The newborn was struggling to breathe.
Safe birth services save lives, prevent childbirth injury in Tanzania
BARIADI, United Republic of Tanzania â Midwife Nuriat Koku Mtumbi remembers the day in March well: âIt was raining heavily and Adimu* had delivered her baby on her way to our facility. âShe was shielding herself under a treeâ when she gave birth, Ms. Mtumbi recalled.
Adiumu was in excruciating pain, and bleeding heavily. She could barely move, âbut her mother managed to get her here,â Ms. Mtumbi said. The newborn was struggling to breathe.
âI worked quickly, drawing on what I had learned during my training,â Ms. Mtumbi said, âand managed to save both Adimu and her baby. I couldnât have done this before; I simply didnât have the skills or equipment.â
Ms. Mtumbiâs health facility â Nyangokolwa Dispensary in the Bariadi District â is one of 40 health facilities renovated by UNFPA between 2017 and 2019, with funding from the Korea International Cooperation Agency. The facilities have also received equipment and staff training.
Such efforts are critical for saving the lives and health of women and girls who experience complications of pregnancy and childbirth.
Preventing obstetric fistula
Tomorrow is the International Day to End Obstetric Fistula, which calls global attention to one of the most devastating childbirth injuries: Obstetric fistula is a hole between the birth canal and bladder and/or rectum, caused by prolonged, obstructed labour without access to timely, high-quality medical treatment.
This condition is almost entirely preventable, yet it persists among the most vulnerable and marginalized women and girls.
Ms. Mtumbi has seen the life-shattering impact of obstetric fistula on women in the community: âWomen suffer chronic incontinence; they are shamed and shunned by their community, and sometimes even divorced.â
The risks of experiencing such injuries, or even dying in childbirth, were higher before the facility was renovated in 2018.
Then, many pregnant women had to make the long journey to Somanda Hospital some 20 kilometres away. Some didnât make it, others faced injuries like fistula.
But since Nyangokolwa Dispensary was renovated, the number of pregnant women delivering there has skyrocketed. There are now more than 80 deliveries per month; the number previously hovered around 30.
Ms. Mtumbi says she is proud that women have confidence in the facility â something she shares.
Preparing for COVID-19
The COVID-19 pandemic has not yet reached the Nyangoolwa community, but the health facility is already implementing infection and prevention control measures.
New patient flow systems are in place at antenatal and postnatal clinics to ensure physical distancing. No more than three to five clients attend group education sessions, and they sit at least one metre apart.
UNFPA is set to support additional infection prevention and control training, and is procuring personal protective equipment and essential supplies for health facilities in priority regions.
AL HUDAYDAH, Yemen â Five years ago, Marwa* was a child bride living in the port city of Al Hudaydah. âI was almost 17 years old, and happy with my new life. I was a new bride and I got pregnant fast. I thought life was smiling at me,â she told UNFPA. She had no idea how quickly life would turn upside down.
In Yemen and around the world, obstetric fistula strikes the most vulnerable women
AL HUDAYDAH, Yemen â Five years ago, Marwa* was a child bride living in the port city of Al Hudaydah. âI was almost 17 years old, and happy with my new life. I was a new bride and I got pregnant fast. I thought life was smiling at me,â she told UNFPA. She had no idea how quickly life would turn upside down.
Like many other women and girls in Yemen, she gave birth at home. But her labour was obstructed â a potentially fatal complication. Eventually, she delivered a healthy baby boy, but suffered a traumatic injury in the process â an obstetric fistula.
âI had sudden diarrhoea and faeces coming out of my birth canal,â she said. âI started to ask myself, why was this happening? I could not comprehend it.â
An obstetric fistula is a hole between the birth canal and bladder and/or rectum. It occurs during prolonged, obstructed labour without access to timely, high-quality medical treatment. The injury can cause chronic pain and infections, social rejection and deepening poverty.
This was Marwaâs fate: A month after her baby was born, her husband divorced her. âI had become what he described as âruinedâ,â she said.
The most vulnerable women
This traumatic birth injury affects the worldâs most vulnerable women â those living in extreme poverty, without access to timely emergency care. Child brides are particularly vulnerable; childbearing in adolescence can increase vulnerability to obstetric fistula. Those with malnutrition and poor health also face heightened risks.
Hundreds of thousands of women are living with obstetric fistula today. The persistence of this condition is a sign of global social injustice and inequity.
And it could be worsening.
Today, as the world battles the COVID-19 pandemic, health systems risk being overstretched. Transportation barriers, movement restrictions, rising costs and other effects of the pandemic are making it harder for labouring women to reach safe delivery services. "The absence of timely medical treatment will likely spur a dramatic increase in obstetric fistula," said Dr. Natalia Kanem, UNFPA's Executive Director.
On 23 May, as the world observes the International Day to End Obstetric Fistula, UNFPA is sounding the alarm that the sexual and reproductive health needs of women and girls could be undermined. These services â including access to maternity care and safe delivery care â must be recognized as essential and life-saving.
Under the shadow of war
Marwaâs fistula was only the start of her troubles. Conflict had erupted in Yemen, throwing communities into poverty and hobbling the countryâs health system.
âThey told me to be patient and accept my fate⌠I was told that my life is over,â Marwa said, crying over the memory of that time. âI felt so sorry for myself, my youth and my newborn baby who would grow up without a father. I felt my whole life had been taken away from me. What did I do to deserve such fate? I asked that myself repeatedly.â
Marwa spent as much time and money as she could searching for a cure. âIt was useless. I knocked on many doors,â she said.
Finally, she visited a midwife named Naâama, who had received training from a UNFPA-funded programme. âShe was my last resort and my only hope.â
By chance, Naâama had taken a course on preventing and identifying obstetric fistula, and she knew just where Marwa could get care.
Naâama contacted the National Midwives Association, which runs a UNFPA-supported fistula treatment programme. Marwa was put on a waiting list.
âOne day they called me and asked me to travel to Sanaâa within a week.â
The fistula programme covered all her travel expenses. She was even able to bring her sister to look after the baby, and a male cousin; women often require a male guardian to travel within the country.
Marwa underwent a successful treatment surgery at Al Thawra Hospital.
Now, she says her life has been transformed. âI forgot all the pain I had gone through. I just felt joy and happiness,â she said.
Support needed
UNFPA has supported the establishment of three fistula units across the country. Between 2018 and 2019, more than 100 fistula surgeries were successfully treated free of charge.
But today, Yemenâs health system is on the verge of collapse. Humanitarian funding for programmes in Yemen has dried up, even as the country grapples with the arrival of the COVID-19 pandemic. Hundreds of reproductive health facilities have closer or are set to close in the coming weeks.
A pledging conference is scheduled to take place, virtually, on 2 June.
Sahar survived a painful experience during the birth of her daughter, Sondos. She was then determined to be part of the solution so other women in her community don't experience the same pain.
Two thirds of all reproductive health facilities in Yemen stopped working since the start of the war. This leaves millions of Yemeni women vulnerable to increased rates of maternal mortality and morbidity.
#WomenOnTheFrontline: the story of Sahar from Yemen
Sahar survived a painful experience during the birth of her daughter, Sondos. She was then determined to be part of the solution so other women in her community don't experience the same pain.
Two thirds of all reproductive health facilities in Yemen stopped working since the start of the war. This leaves millions of Yemeni women vulnerable to increased rates of maternal mortality and morbidity.
Read more about Sahar and women's lives in Yemen: https://bit.ly/2EbSD2I
Follow #WomenOnTheFrontline and join our call to prioritize women's needs in humanitarian response.
ISLAMABAD, Pakistan â âHelping women suffering fistula is my mission in life," Razia Shamshad said about the maternal injury from childbirth that she thought would ruin her life. âNo woman deserves to live in misery, especially when it is treatable.â
âNever give up hope,â fistula survivor tells Pakistani women
ISLAMABAD, Pakistan â âHelping women suffering fistula is my mission in life," Razia Shamshad said about the maternal injury from childbirth that she thought would ruin her life. âNo woman deserves to live in misery, especially when it is treatable.â
Ms. Shamshad, 29, was born in a small village in southern Punjab. Her family did not want her to go to school, so she had only received an informal religious education by age 13, when she was married off. Ms. Shamshad was already expecting her first baby within a few weeks of her wedding. Then, when she was six months pregnant, her husband died in a road accident.
Unable to afford proper medical care, Ms. Shamshad was assisted by an unskilled traditional birth attendant who was unable to manage complications. When Ms. Shamshad suffered an obstructed labour, the birth attendant did not summon medical help. Ms. Shamshad was in agony for four days, an ordeal that could have killed her.
In the end, her daughter was stillborn, and Ms. Shamshad suffered serious damage. She developed an obstetric fistula, a hole in the birth canal. Fistula leaves women leaking urine, faeces or both, and often leads to chronic medical problems.
The condition is preventable with timely access to quality medical care, such as Caesarean section. Tragically, it persists among the most marginalized women, with pregnant adolescents and undernourished women facing particularly high risks. And its sufferers are further marginalized, often facing ostracism and discrimination.
The Koohi Goth Womenâs Hospital performs fistula repair surgeries for
free since 1992. Š UNFPA Pakistan
"People would either avoid me or just make fun of me," she said. "I never felt clean."
A stroke of good luck
But Ms. Shamshad was able to put her life back together. Her relatives learned about free treatment available at the Koohi Goth Womenâs Hospital, which specializes in treating fistula and other conditions related to reproductive health. Two years after her ordeal, her family paid for her to travel to Karachi for care.
Ms. Shamshadâs condition was complex, and required multiple surgeries between 2010 to 2016. Even so, she has been able to regain her life.
âHer determination was exceptional. She was resilient and strong and was able to pull through the difficult process successfully,â said Dr. Sajjad Ahmed, who was trained by UNFPA to perform fistula repair surgeries.
Ms. Shamshad went on to meet her current husband. They adopted a little girl. And though she was not expected to be able to get pregnant again, she surprised everyone by conceiving. With regular prenatal care and a C-section, she had a healthy baby girl.
Combating fistula since 2003
In many ways, Ms. Shamshad was lucky. The story is very different for many fistula survivors in Pakistan, who are unaware that there is treatment available.
Ms. Shamshad lives with her family in Karachi. Š UNFPA Pakistan
In partnership with the Pakistan National Forum on Women's Health, UNFPA has established treatment centres for fistula patients across the country. UNFPA also supports campaigns to raise awareness about the importance of skilled obstetric care and ending the stigmatization of women with fistula.
UNFPA leads the global Campaign to End Fistula. Since 2003, UNFPA has helped perform over 105,000 surgical fistula repairs in more than 55 countries in Africa, Asia, the Middle East and Latin America.
âMy experience has given me the courage to help women who have lost all hopeâ
Today, Ms. Shamshad lives with her family in Karachi. She volunteers at the same hospital where she received the treatment that turned her life around. Ms. Shamshad helps new patients recover after their own treatment.
âI believe life experiences shape us into the people we need to become," she told UNFPA. "My experiences have given me the courage and drive to help women who have lost all hope because of fistula.â
Ms. Shamshad recently represented the hospital at the Nairobi Summit on ICPD25 in November 2019. She used her story to inform and motivate other women, to whom she has proven to be a source of encouragement.
From social outcast to future teacher: A Malawi fistula survivorâs story
LILONGWE, Malawi â Monica Kaleso loved to go to school. She studied hard and never missed class. Her dream of becoming a medical doctor was on course until 2013, when, at the age of 17, she began a relationship with a man from the same village of Kadammanja.
Later that year, Ms. Kaleso discovered she was pregnant. Her world crumbled.
Her boyfriend refused to take any responsibility. Ms. Kaleso was devastated. She eventually dropped out of school.
After going into labour, Ms. Kawelo struggled to find reliable transportation for the bumpy journey to the hospital. When she finally did arrive, she was unable to get immediate treatment. The hospital was small and the staff busy.
"The baby was very big and I was so young," she recalled, explaining that she experienced a prolonged, obstructed labour.
Yet she spent three days at the hospital before receiving help.
Tragically, the baby did not survive childbirth. And that was just the beginning of Ms. Kalesoâs problems.
The morning after returning home from the hospital, she woke up and noticed her bedding was wet with urine.
Ms. Kaleso had developed an obstetric fistula, an injury caused by childbirth complications. Fistula causes incontinence and can also lead to infections, chronic pain and other problems.
âI was too young to live this lifeâ
"I thought it was normal, but this occurred for almost a year,â she told UNFPA.
Like many fistula survivors, Ms. Kaleso suffered stigma and isolation. Her friends turned away when she approached them.
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Her hopes of going back to school after delivery faded.
Ms. Kaleso said life became unbearable.
âI did not even know if this condition could be treated or not,â she recalled. âI was too young to live this kind of life.â
But one day, as Ms. Kaleso's father harvested his tobacco crop, he heard on the radio that fistula treatment was available at the Bwaile Centre in Lilongwe.
UNFPA data show that 0.6 per cent of women aged 15 to 49 were living with this condition as of 2016 in Malawi. UNFPA has supported treatment for over 1,500 women in the country since 2011.
Many of these repairs have taken place through a partnership with the Bwaile Centre, which has a specialist surgeon and programme that helps survivors reintegrate into the community after treatment.
Ultimately, UNFPA and Malawi aim to transition from fistula repair to prevention. The condition is easily prevented through access to emergency obstetric care â usually in the form of a Caesarean section. In fact, fistula is so preventable that it has been essentially eliminated in industrialized countries.
Ms. Kawelo is now an ambassador for the Bwaile Centre. She helps seeks out other fistula survivors and helps them access treatment.
She has also been able to return to school. Her new dream is to finish her degree in education and teach mathematics.
âI consider myself very lucky," she said. "Some women have lived with this condition for more than 40 years, and others even 50 years or more.â
For Won Young Hong, UNFPAâs representative in Malawi, Ms. Kawelo's story demonstrates why adolescent girls need access sexual and reproductive health information and services.
âOne pregnancy can have life-threatening consequences, such as HIV and other sexually transmitted diseases, birth injuries including fistula, more children, and they are at risk of dropping out of school, and thus perpetuating the cycle of poverty,â Ms. Hong said. âIt is encouraging to see that Monica is back in school and pursuing her dreamsâ.
