Ntchisi, Malawi-Although Marita Vula was in pain, she tried as much as possible to ignore it. The 28-year-old was experiencing her first labour pains. Marita had waited for this moment and couldn’t wait to a be a mother.

“When I got married, I stayed for three years without a child,” says Marita from Kambola village in Ntchisi. “In our culture, one is expected to have a child as soon as they get married.”

However, try as they could, Marita couldn’t get pregnant. This displeased her in-laws who took every opportunity to remind her that they wanted grandchildren.

On this particular day, Marita’s husband was tending their maize field. When he heard the news that her wife was in labour, he hurried back home.  Since the hospital was too far, he decided to take Marita to a traditional birth attendant to help her deliver.

“That was the only option we had that time,” recalls Marita, adding, “I didn’t see the labor coming that soon and hadn’t planned to travel to the hospital.”

Access to maternal services still a challenge

For hours, the traditional birth attendant tried to help Marita to deliver but without luck.  In desperation, the traditional birth attendant prepared some herbs, which she said would help ‘push the baby out’. Instead of helping her give birth, the herbs made Marita lose a lot of blood.

“My husband became worried and he rushed to the nearby village to hire a car,” she said. “When he came back, I had passed out. The next thing I remember was in a hospital. The look on my husband face told me that something terrible had happened.”

Marita arrived at the hospital semi-conscious. Medical staff had to perform a caesarian section to save both mother and child. Unfortunately, the child didn’t make it. Her husband had to break the sad news to her.

“This was devastating news. I was looking forward to holding my child in my hands,” says Marita.

Although Marita recovered well, she could no longer control her urine and she kept wetting herself. The prolonged labour caused her to develop a hole between the birth canal and the bladder. As a result, she developed obstetric fistula.

“When I returned home, my husband’s attitude towards me changed,” she says. “He started sleeping in his own bed.”

A ray of hope for women with fistula

For eight months, nothing changed. Eventually, her husband disappeared only for Marita to learn that he had married in another village.

“I was okay with him sleeping on another bed,” she says. “But running away from me was the last thing I expected from him. He was responsible for the pregnancy and I couldn’t have developed fistula if it wasn’t for him.”

With time, Marita soon learnt to accept her condition. One day, as she was listening to the radio, she had a testimony of a woman who was successfully treated of fistula. She listened with interest and learnt that the operation was done at Bwaila Fistula Centre in Lilongwe.

Marita saved enough money for transport to seek for treatment at the Centre. The waiting list was long. She stayed at the Centre for a month and finally got repaired of fistula.

Helping fistula survivors reintegrate in society

“The support I received from the fistula centre transformed my life,” says Marita, who is now a fistula ambassador in her community. “I have moved from being a social outcast to become one of the community respected tailors.”

As one way to help her reintegrate in her community, the Bwaila Fistula Centre with support from the European Union funded Spotlight Initiative, trained Marita and other 48 fistula ambassadors in tailoring. The ambassadors’, including Marita, were each given a sewing machine to help them establish tailoring shops for income generation.

Today, Marita is a well-known tailor in her community. She sews’ dresses, suits and all type of uniforms. In a good month, Marita makes about US$80. And when its wedding season, her earnings goes up to more than US$100 per month, she says.

“I am saving money to buy iron sheets for my house,” she says. “I have lived a difficult life and now just want to make the best of what I have.”

In 2021, UNFPA successfully lobbied for the re-opening of the Bwaila Fistula Centre after it was converted into a Covid-19 isolation centre. The closing of the Centre inconvenienced hundreds of women suffering from fistula from getting treatment. Since re-opening, the Centre with support from the Spotlight Initiative, has successfully repaired 90 women suffering from fistula.

Joseph Scott, Communication Analyst

The Ministry for Foreign Affairs of Iceland and UNFPA have signed a $7 million landmark agreement to help end obstetric fistula in Sierra Leone and improve the lives of the women and girls suffering from this preventable condition. Sierra Leone has one of the highest lifetime risks of pregnancy-related mortality and morbidity, including obstetric fistula. 

Obstetric fistula is one of the most serious and tragic childbirth injuries. Women suffering from obstetric fistula are often stigmatized and isolated from their families and communities. They face significant socioeconomic challenges and often do not have access to social-economic development opportunities in their communities. 

“Obstetric fistula is a neglected health and human rights tragedy that affects the most vulnerable women and girls. It is embedded in gender inequalities and social norms and constitutes an impediment to women and girls’ empowerment.” says UNFPA West and Central Africa Regional Director Argentina Matavel-Piccin.

In recent years, Iceland has been supporting the Government of Sierra Leone in its efforts to prevent and treat obstetric fistula, with the aim to improve access to quality maternal health services to prevent and manage obstetric fistula. This new landmark agreement will provide medium- to long-term support to end obstetric fistula in the country, and is part of the global Campaign to End Fistula launched by UNFPA and its partners in 2003. 

The five-year programme will take a comprehensive and integrated approach to obstetric fistula, by addressing the gender and other social norms, and health systems challenges contributing to the occurrence of obstetric fistula. The new partnership will strengthen the referral system for surgery and social reintegration initiatives, and will focus on documenting best practices to help shape other existing and future programmes.

By the term of the programme, the capacity of the country’s health system will be strengthened to improve adolescent girls’ and women’s access to integrated sexual and reproductive health services for prevention, treatment and social reintegration of obstetric fistula. 

“Iceland has been a firm supporter of the Global Campaign to End Fistula for more than a decade – both financially through UNFPA and through our advocacy efforts for sexual and reproductive health and rights at the international level,” said Thórdís Kolbrún Reykfjörd Gylfadóttir, Minister for Foreign Affairs and International Development Cooperation of Iceland. “We are very proud to be part of this programme and work together with UNFPA and the Government of Sierra Leone toward the elimination of obstetric fistula in the country.”

“Our long-standing partnership with the Government of Iceland plays a critical role in supporting UNFPA’s ongoing campaign to end obstetric fistula in Sierra Leone and globally, and in restoring women’s dignity worldwide,” said UNFPA’s Matavel-Piccin. 

MOCUBA, ZAMBEZIA PROVINCE, Mozambique – Beatriz Sebastião 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. Sebastião, 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, “but as always, I was discriminated against. I was humiliated. People talked. Because of the looks, I stayed there shrunken.” She stayed alone in a tent because no one would share space with her. 

Then the youth coordinator, who also worked at a hospital, sought her out when she skipped practice, claiming illness. Finally, she admitted she had “a disease that made me pee involuntarily,” which is when she learned that what she had could be cured through surgery. 

Ms. Sebastião 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. “I don’t know how to express what was in my heart,” she recalled. “I had emotions I don’t know how to describe.” 

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 “to love that Beatriz from the past again,” she said. “When 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.”

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 – not from abusive husbands but because they had obstetric fistulas. Ms. Luis underwent reproductive sexual health training and learned more.  

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. “Dignity means being valued,” Ms. Luis, 50, said. “The 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.” 

Dr. Armando Rafael, a fistula surgeon at Mocuba Rural Hospital, who operated on Ms. Sebastião, finds his work rewarding, knowing the suffering and marginalization patients have endured. “The contagious joy of a woman when her fistula is repaired is incomparable,” he said. 

During Ms. Sebastião’s long exile, women at the river taunted her with the cruel nickname “Lake Bethesda,” 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.

The most vulnerable women

Under the shadow of war

Support needed

BOUAKÉ, Côte d'Ivoire – 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.

ISLAMABAD, Pakistan – “Helping women suffering fistula is my mission in life," Razia Shamshad said about the maternal injury from childbirth that she thought would ruin her life. “No woman deserves to live in misery, especially when it is treatable.”

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. 

"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 Women’s 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. Shamshad’s condition was complex, and required multiple surgeries between 2010 to 2016. Even so, she has been able to regain her life. 

“Her determination was exceptional. She was resilient and strong and was able to pull through the difficult process successfully,” 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.

And many more women and girls are at risk.  Access to reproductive health services remains a challenge for women in Pakistan. Only an estimated 52 per cent of women give birth with the help of a skilled attendant, leaving them vulnerable to complications like prolonged, obstructed labour.

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.

“My experience has given me the courage to help women who have lost all hope”

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.

“I 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.” 

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.

"Never give up hope," she told them.

LILONGWE, Malawi – 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. Kaleso’s 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.

‘I was too young to live this life’

"I thought it was normal, but this occurred for almost a year,” she told UNFPA.

Like many fistula survivors, Ms. Kaleso suffered stigma and isolation. Her friends turned away when she approached them.

​

Her hopes of going back to school after delivery faded.

Ms. Kaleso said life became unbearable.

“I did not even know if this condition could be treated or not,” she recalled. “I was too young to live this kind of life.”

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.

Soon after, Ms. Kaleso underwent successful surgerical fistula repair.

Back to school

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 – 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.

“I 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.”

For Won Young Hong, UNFPA’s representative in Malawi, Ms. Kawelo's story demonstrates why adolescent girls need access sexual and reproductive health information and services.

“One 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,” Ms. Hong said. “It is encouraging to see that Monica is back in school and pursuing her dreams”.

– Henry Chimbali

KABUL, Afghanistan – “I saw myself as the living dead,” 50-year-old Laila* told UNFPA. She suffered terribly while giving birth in Pakistan 27 years ago. The prolonged, obstructed labour left her with an obstetric fistula – one of the most serious injuries that can occur during childbirth.

The fistula – hole between the birth canal and bladder or rectum – can cause pain and chronic infections. It also causes incontinence, which often leads to women’s social isolation.

Yet the injury has been eliminated in much of the world through modern emergency obstetric care. Those who continue to suffer from obstetric fistula tend to be among the most marginalized and vulnerable.

“At the beginning, I was ashamed to tell anyone that I had fistula. Most of the time, I could not take part in social gatherings because I smelled bad,” Laila recounted.

As can be the case for fistula survivors, Laila lived with the injury for decades.

A new life

According to a 2015 survey, approximately 3 per cent of ever-married Afghan women have experienced obstetric fistula. Contributing to this high prevalence are the country’s high rates of child marriage and adolescent birth – early childbearing increases the risk of complications.

Poor access to health services also plays a key role. Only 51 per cent of births in Afghanistan take place with the help of a skilled birth attendant.

But there is help.

Years ago, Laila moved from Pakistan to Paghman Province in Afghanistan. Then one day she learned about the Malalai Maternity Hospital in Kabul, where surgical fistula repair is available.

Afghanistan’s only expert fistula repair surgeon works at the Malalai centre, along with four additional surgeons who provide basic fistula operations.

The treatment was a success, she says. “The operation has given me a new life," she said.

“Live a normal life”

Twenty-year-old Farah* also suffered a prolonged labour during childbirth at her home in Afghanistan’s Faryab Province six months ago.

“My life became very hard. I could not talk to anyone about my condition because of shame,” she recounted to UNFPA. “It made my life completely unbearable.”

The injury caused pain and bleeding, as well.

“I could not work, sleep or walk as I did before. I was not able to go out because of bleeding. I was not able to sit on the ground, on chairs or on carpets because of my illness.”

She isolated herself. “I could not gather with my relatives and family members because of my bad smell. I was fed up of my life. I should have been working in the home with cooking, cleaning and doing laundry as a housewife but was not able to do any of that properly. I felt incapable and useless in society.”

Fortunately, her family stood by her.

“They knew that I had fistula but they never changed their behaviour towards me. They never left me to suffer alone,” she said.

Not long ago, one family member learned about the Malalai fistula centre and helped Farah get treatment.  

“I am happy, healthy and hopeful again after the operation,” she said. “I am a capable member of society once more and can start over with my child, husband and family members and live a normal life.”

Helping others

UNFPA helped to establish the Malalai fistula treatment centre in 2007, and continues to provide support to its operations. UNFPA covers the cost of treatment, medication and transport for patients, and supports training for the hospital’s expert fistula surgeon.

There are also four additional surgeons providing fistula repair in two other provinces, Herat and Jalalabad. Since 2010, more than 600 surgical fistula repairs have taken place in collaboration with the Afghan Ministry of Public health, including 45 this year.

Still, across the country there is a major shortage of surgeons able to perform these operations. In addition, rehabilitation and reintegration programmes – which can help survivors overcome social isolation – are not available.

Farah wants to help other women avoid her ordeal.

“I would like to encourage every woman suffering from obstetric fistula to seek help without any concern and shame,” she said. “I also want to tell them to be careful not to go through childbirth without a skilled birth attendant to assist during delivery.”

*Names changed for privacy reasons
 

DHARAN, Nepal – At the age of 17, Palesh Devi Rajdhobi was married off to a man she had never met. One year later, she gave birth to her first child. Then another, and another. When she was pregnant with her sixth, she knew something was wrong.

“By the time I was taken to the hospital, it was already too late. Two tragedies befell me. I had a stillbirth and started leaking urine constantly,” Ms. Rajdhobi told UNFPA.

After a prolonged labour, she had developed an obstetric fistula, a hole in the birth canal that renders women incontinent, unable to control their urine, faeces or both. Left untreated, the condition can cause infection, pain and a host of other problems – including social isolation and depression.

“I was thinking that I would leak urine throughout my remaining life and there was no cure for my suffering. I was always ashamed to leave the house because of the smell,” Ms. Rajdhobi said.

Fistula is one of the most serious childbirth injuries. And it is almost entirely preventable. 

With access to maternal health care – particularly, caesarean sections – the injury has been largely eliminated in much of the world. 

Yet it still afflicts the most marginalized women and girls, those without the money or ability to receive quality obstetric care. Girls who become pregnant too early, such as child brides, are especially vulnerable. 

Today, more than 2 million women in the developing world are estimated to be living with the condition.

“Nobody would insist on visiting health centres for pregnancy check-ups back then,” Ms. Rajdhobi explained. “There were no means of transportation. We had to walk at least four hours to reach the nearest health facility.”

Shunned

For more than two decades, Ms. Rajdhobi lived with fistula. 

The social isolation she suffered as a result was particularly unbearable. Instead of going to the market and visiting friends and family, she was confined to the privacy of her home, too distraught to encounter community members who spoke ill of her.

She is not alone.

Nara Maya Rai, now 64, was left with the debilitating childbirth injury after her third pregnancy. 

“[Back in] that time,” she recalled, “a pregnant woman in our village had to be carried four hours in a bamboo basket, and then three hours in a vehicle if she were to be taken to a hospital.”

Ms. Rai lives roughly 400 kilometres from the nearest large city. After developing an obstetric fistula, she, too, was ostracized from her community. “When I would go close to a village assembly, some of them would cover their noses and ask where that bad smell emanated from. I would wash my clothes several times a day.”

Hardest to reach

These stories are all too common – in Nepal and throughout the developing world. According to UNFPA data, an estimated 50,000 to 100,000 new cases of obstetric fistula develop each year.

As the leader of Campaign to End Fistula, UNFPA provides technical guidance, medical supplies, training and funds for fistula prevention, treatment and social reintegration programmes. UNFPA also strengthens reproductive health care and emergency obstetric services to prevent fistula from occurring.

In Nepal, UNFPA is supporting BP Koirala Institute of Health Sciences to provide free surgery and post-operative care to women who live with the injury. Over 30 women have already received treatment, of an estimated 200 to 400 who suffer from fistula each year in Nepal.

UNFPA is also working with its partners to raise awareness of the condition.

“In rural areas, many women and girls living with fistula do not receive any family support and never seek treatment, because they don’t know what is wrong with them and where to seek service,” said Maiya Bhattarai, a community mobilizer who orients women on obstetric fistula. 

“We particularly engage women who are hard to reach, such as those living in rural areas and who are poor,” she said.

Tears of happiness

Ms. Rajdhobi and Ms. Rai are two of the women to receive free reconstructive surgery from the UNFPA-supported campaign in Nepal.

For them, life without fistula brings more than freedom from pain. It brings freedom from isolation.

“It was like walking out of prison," Ms. Rajdhobi said, still remembering the day she left the hospital. "I was in tears of happiness.”

                                                                                                                                   – Santosh Chhetri