“In my community, it is difficult not to see adolescent girls aged 15 to 16 years pregnant or as young mothers”, says 18-year-old Lucia Aiuba Amade from Quelimane in Mozambique's province Zambezia.

Childbirth at an early age is associated with greater health risks for the young mother. In fact, complications of pregnancy and childbirth are the leading cause of death in young women aged 15 to 19 years.

Teenage pregnancy often force girls to drop out of school, and expose them to the risk to develop a fistula.

Lucia is one of 783 mentors trained under “Rapariga Biz” - the first joint United Nations programme on sexual and reproductive health and rights for teenage girls in Mozambique led by the government with technical assistance by UNFPA, the United Nations Population Fund, UN's educational and scientific organization UNESCO, UN's children's agency UNICEF and UN's women's agency UN-WOMEN, funded by the Swedish International Development Assistance (SIDA).

In Mozambique, an estimated 2,300 new cases of fistula occur every year. This is largely due to the high rates of teenage pregnancy and early marriage. According to a survey by the Ministry of Health, 46 per cent of girls between 15 and 19 years are pregnant or mothers and 48 per cent of girls are married before 18 years.

Rapariga Biz aims to reach 1 million girls and young women of 10-24 years from 2016 to 2020 to address the pressing sexual and reproductive situation of girls and young women in the provinces of Nampula and Zambezia.

Mentors prevent fistula
“Our communities lack information about fistula, and the girls and young women are the ones to bear the consequences. Those living with fistula are isolated and discriminated against. We can help prevent this child birth complication under Rapariga Biz,” says Lucia Aiuba Amade.

Each mentor is leading a session with some 30 girls between 10-14 years or 15-19 years each week for six months in a safe space in the community identified by the girls and young women themselves.

In the first year, Rapariga Biz has reached a total of 23,518 women and girls.

In the safe space, they learn and discuss about life skills, solidarity, human rights, including the right to live free of violence and child marriage, sexual reproductive health, the consequences of early pregnancy and how to prevent it.

Fistula has a dedicated session: “We need to ensure that the girls and young women understand the causes and consequences of fistula to empower them to make informed choices and delay the first pregnancy,” says 22-year-old Amina Carlos Antonio.

Promoting the rights of teenage girls

“The key to eliminate fistula is prevention, specifically through prevention of child marriage and teenage pregnancy which sits at the heart of our efforts as UNFPA targeting the most vulnerable girls and young women. It is essentially about their rights to health and life,” says Bettina Maas, UNFPA Representative in Mozambique.

The ability to control the own fertility is fundamental to the empowerment and equality of women and girls. Apart from the preventive efforts, UNFPA is supporting Mozambique's Government in ensuring the availability of treatment and social reintegration for fistula survivors.

Mangochi District, Malawi – A phone call changed Nachilango Bisolomo’s life.

For 46 years, she had suffered from an obstetric fistula, a stigmatizing injury caused by childbirth complications. Fistula causes incontinence and can also lead to infections, chronic pain and other problems.

“Everywhere I sat, I left a mark, and people would come to see, and talk so much about my condition. I was helpless and could not do anything about this,” she told UNFPA.

Like many fistula survivors, she felt embarrassed and alienated.  “My life has been hell,” she said.

But then one day, Ms. Bisolomo’s son-in-law was at the Monkey-bay Community Hospital in Mangochi District, and he saw a ward full of women wrapped in 'chitenje', a fabric worn around the waist.

The women explained that they were fistula survivors. The hospital was holding an obstetric fistula "camp," and repairing fistulas free of charge.

He immediately phoned his mother-in-law.

Ms. Bisolomo quickly travelled the 300 km from Dedza District, and the next day, she underwent the surgery.

When she was wheeled out of the operating room, her niece, Anastanzia Paulo, cried tears of joy.

Ms. Bisolomo's long ordeal was coming to an end.

“One who has been punished”
Ms. Bisolomo was born Nasiwelo Bisolomo. She married early, and was pregnant by 18.

She had no idea that adolescent pregnancy increases one’s risks. Childbearing before the pelvis is fully developed can lead to prolonged and obstructed labour, the complication that causes an obstetric fistula.

At the time, Ms. Bisolomo lived over 100 km from the nearest hospital, so she gave birth at home. The labour was horrendous and long, and, tragically, her baby died in the process. Afterward, she was left with a fistula.

The loss was devastating – as was life with her condition.

She even changed her name to Nachilango, meaning “one who has been punished.”

“I accepted that I will be like this for the rest of my life,” she said.
Still, in some ways, Ms. Bisolomo was fortunate.

Many women with fistula are abandoned by their families and persecuted by their community. But Ms. Bisolomo’s family life was just beginning.

She and her husband managed to successfully have another baby, Natumani, who is now 45 years old. Her husband stayed with her until he died in 2012.

Then Ms. Bisolomo learned about the fistula camp, an initiative supported by UNFPA and organized by Mangochi District Hospital.

Forty-one women received care at the camp. Some were referred elsewhere for more specialized operations; over half were repaired and discharged.

“It took us almost three hours in the theatre to have her repaired,” Gonjezo Kumpatsa, one of the medical clinicians, said about Ms. Bisolomo. “It was a complicated condition, coupled with her age, but we are hopeful she will be healed.”

Treatment and prevention
Surviors like Ms. Bisolomo are now helping to spread the word that fistula treatment is available.

“We are able to mobilize more patients through the treated patients, who act as our ambassadors,” said Lydia Kasiya, a nurse and midwife technician.

Ms. Bisolomo plans to keep her name to send a message to other women.

“I don’t intend to change my name when I go back, despite being healed,” she said from her hospital bed, “because I want to still be an example to many that this condition can be cured.”

Since 2011, UNFPA, the Freedom From Fistula Foundation and AMREF Health Africa have supported the government in providing fistula treatment in Lilongwe and Mangochi.

Last year, fistula camps were held in Chikwawa, Mulanje and Mangochi districts, including at the Bwaila fistula centre.

But fistula repair services are not enough.

The condition is easily prevented through access to emergency obstetric care – usually in the form of a Caesarean section. In fact, the condition is so preventable that it has been essentially eliminated in industrialized countries.

UNFPA supports midwifery trainings, health centres and reproductive health supplies to bolster the availability of emergency obstetric care in remote areas around the world.

Meanwhile, Ms. Bisolomo’s family is determined to convince more women to seek proper health care.

“I am sure people will ask who this amazing traditional healer is,” said Ms. Paulo, “but I will tell them it’s the hospital, and it is a condition that can be cured.”

– Henry Chimbali

The story was first published on UNFPA website.

Abra sits quietly as she remembers the journey of her life. For 24 years, she has known suffering and great emotional pain. One day and one event changed the course of her life for over two decades.

On that day, many years ago, Abra went into labor. It was her fifth child, and she had managed all of her previous labors by herself at home. But this time was different. After struggling with the pain and pressure, she was taken to the hospital for a caesarian section. “There was no hope,” Abra remembers sadly. “Even the doctor lost hope.” The struggle was devastating. The baby died, and Abra remained in a coma for five days.

Abra dances her way into the hospital’s Dress Ceremony.

When she awoke, she learned that her husband had decided to leave her. Then, a few days later, she realized she was incontinent. The condition that Abra suffered from is known as VVF (vesicovaginal fistula). It is an injury caused by obstructed labor, and it results in a continual leakage of urine, feces, or both. Unfortunately, it is a condition that is much too common in developing countries, where women have little access to medical care.

The condition exacts a terrible emotional toll, as well. Abra was ostracized by her family, friends, and community. “Everybody in our area knows about my sickness,” Abra says quietly with downcast eyes. “All of them know.”

Over the years, people often mistreated Abra. They made signs and yelled insults at her. When she stood up, they often checked her clothes to see if they were wet. For a few years, she was able to stay with some relatives. However, when they died, she was on her own in the bush, secluded from the world. She was isolated from every kind of help and support – physical, mental, and emotional.

Abra says she only got through this time with God’s help. “In those times of challenges and pain, I did weep most of the time. I didn’t have anybody to come to my rescue. I spent most of my time in my hidden place, where I wept.” She struggled with depression that made it difficult for her to eat, and she longed for the day her suffering would come to an end. “So the only option is to wait for God’s time when I will join him after death, and it will be the end of everything. This was all I could tell myself before the ship came,” she says sadly.

Then, in 2010, Mercy Ships sailed into the port of Lomé, Togo. The arrival of the hospital ship brought hope for Abra – something she had not felt for a long time. Soon she was received a free successful surgery. After spending a few weeks in the ship’s hospital, Abra was able to go home.

She felt like a new woman, but her joy was short-lived. Tragically, a few weeks later, Abra was the victim of a brutal rape that ruined the surgical repair. She was back in the same nightmare she had experienced for two decades. “When my sickness came back, I was confused and lost,” Abra explains. Sadly, the ship had already left, and she had nowhere to turn.

Abra took refuge with her brother, who required her to be the housekeeper for the entire family. The work was very difficult for her. When she was unable to complete all the tasks, she was driven out of the home. She was only allowed to re-enter the house at certain hours to sleep. She had to awake every morning at 4:00 to leave the house and had to wait until late in the evening to return. She was not allowed to use the kitchen or even take a cup to drink from. She could not share in any of the food. Her brother’s family wanted to make sure she suffered because they were uncomfortable with her sickness.

No one can take Abra’s smile away. She is filled with joy.

Abra struggles to hold back tears as she recalls those days. “My brother did not agree with me. According to him, I’m telling a lie – I am not sick because I didn’t lose weight.” She quietly says a prayer and pauses before continuing, “My brother mistreated me. He mistreated me to the point that I got seriously sick.” The pain of her brother’s rebukes and abuse almost destroyed Abra’s spirit.

Finally, she found reprieve with her aunt. “She told me I smelled like a dead corpse before joining her. But the hands of God are upon me. Today I am here. I am still alive today,” she says.

Less than a year later, Abra’s daughter contacted her, telling her the wonderful news that Mercy Ships had returned! “For me, Mercy Ships has been sent from God to me, and I know that the ship is here to heal, I was hopeful. I didn’t know other people, too, have this sickness, I thought I was alone. But now, I know that I’m not the only one. I’m confident, and God is with me.”

Now, Abra has healed from her second surgery with Mercy Ships. She is living with her daughter and has been accepted back into the family. “I feel better now. No, rather, great! And I thank the Lord for the life of the medical team. May the Lord bless them, strengthen them, and give them long life. They will be blessed. God will reward them for ever and ever.”

Abra’s face radiates with happiness as she adds simply, “I have joy in me!”

Written by Nicole Pribbernow. Edited by Nancy Predaina. Photos by Debra Bell. Courtesy: Mercy Ships.

Abra sits quietly as she remembers the journey of her life. For 24 years, she has known suffering and great emotional pain. One day and one event changed the course of her life for over two decades.

On that day, many years ago, Abra went into labor. It was her fifth child, and she had managed all of her previous labors by herself at home. But this time was different. After struggling with the pain and pressure, she was taken to the hospital for a caesarian section. “There was no hope,” Abra remembers sadly. “Even the doctor lost hope.” The struggle was devastating. The baby died, and Abra remained in a coma for five days.

Abra dances her way into the hospital’s Dress Ceremony.

When she awoke, she learned that her husband had decided to leave her. Then, a few days later, she realized she was incontinent. The condition that Abra suffered from is known as VVF (vesicovaginal fistula). It is an injury caused by obstructed labor, and it results in a continual leakage of urine, feces, or both. Unfortunately, it is a condition that is much too common in developing countries, where women have little access to medical care.

The condition exacts a terrible emotional toll, as well. Abra was ostracized by her family, friends, and community. “Everybody in our area knows about my sickness,” Abra says quietly with downcast eyes. “All of them know.”

Over the years, people often mistreated Abra. They made signs and yelled insults at her. When she stood up, they often checked her clothes to see if they were wet. For a few years, she was able to stay with some relatives. However, when they died, she was on her own in the bush, secluded from the world. She was isolated from every kind of help and support – physical, mental, and emotional.

Abra says she only got through this time with God’s help. “In those times of challenges and pain, I did weep most of the time. I didn’t have anybody to come to my rescue. I spent most of my time in my hidden place, where I wept.” She struggled with depression that made it difficult for her to eat, and she longed for the day her suffering would come to an end. “So the only option is to wait for God’s time when I will join him after death, and it will be the end of everything. This was all I could tell myself before the ship came,” she says sadly.

Then, in 2010, Mercy Ships sailed into the port of Lomé, Togo. The arrival of the hospital ship brought hope for Abra – something she had not felt for a long time. Soon she was received a free successful surgery. After spending a few weeks in the ship’s hospital, Abra was able to go home.

She felt like a new woman, but her joy was short-lived. Tragically, a few weeks later, Abra was the victim of a brutal rape that ruined the surgical repair. She was back in the same nightmare she had experienced for two decades. “When my sickness came back, I was confused and lost,” Abra explains. Sadly, the ship had already left, and she had nowhere to turn.

Abra took refuge with her brother, who required her to be the housekeeper for the entire family. The work was very difficult for her. When she was unable to complete all the tasks, she was driven out of the home. She was only allowed to re-enter the house at certain hours to sleep. She had to awake every morning at 4:00 to leave the house and had to wait until late in the evening to return. She was not allowed to use the kitchen or even take a cup to drink from. She could not share in any of the food. Her brother’s family wanted to make sure she suffered because they were uncomfortable with her sickness.

No one can take Abra’s smile away. She is filled with joy.

Abra struggles to hold back tears as she recalls those days. “My brother did not agree with me. According to him, I’m telling a lie – I am not sick because I didn’t lose weight.” She quietly says a prayer and pauses before continuing, “My brother mistreated me. He mistreated me to the point that I got seriously sick.” The pain of her brother’s rebukes and abuse almost destroyed Abra’s spirit.

Finally, she found reprieve with her aunt. “She told me I smelled like a dead corpse before joining her. But the hands of God are upon me. Today I am here. I am still alive today,” she says.

Less than a year later, Abra’s daughter contacted her, telling her the wonderful news that Mercy Ships had returned! “For me, Mercy Ships has been sent from God to me, and I know that the ship is here to heal, I was hopeful. I didn’t know other people, too, have this sickness, I thought I was alone. But now, I know that I’m not the only one. I’m confident, and God is with me.”

Now, Abra has healed from her second surgery with Mercy Ships. She is living with her daughter and has been accepted back into the family. “I feel better now. No, rather, great! And I thank the Lord for the life of the medical team. May the Lord bless them, strengthen them, and give them long life. They will be blessed. God will reward them for ever and ever.”

Abra’s face radiates with happiness as she adds simply, “I have joy in me!”

Written by Nicole Pribbernow. Edited by Nancy Predaina. Photos by Debra Bell. Courtesy: Mercy Ships.

Kano State, Nigeria - I met Zainab Baubau, a 32-year-old fistula survivor, 19 years after the death of her son, an infant she lost during childbirth and developed an obstetric fistula.

At the age of 12, she was in labour for 48 hours, and while she waited eagerly to hear the cry of her baby, instead she heard herself crying for help. “I had prolonged obstructed labour, struggled with eclampsia, was unconscious for two weeks at the hospital and only survived to hear the sad news of my still birth and this illness.” She went on to say she felt alone because the life she knew was no longer hers.

Fistula is a condition that affects at least two millions of women worldwide, but most prevalent in developing countries. It is a childbirth complication caused by obstructed labour. It occurs when the tissues between the woman’s vagina and her pubic bone are damaged by continuous pressure from the infant’s neck trapped in the birth canal. The damaged tissue later falls off resulting in a hole through which the woman continuously leaks urine or faeces or both.

In Nigeria, an estimated 400,000 to 800,000 women are currently living with fistula and approximately 20,000 new cases occur each year. As part of the global Campaign to End Fistula, UNFPA in 2005 launched the “Fistula Fortnight” in Nigeria. It was a ground-breaking initiative that was aimed at expanding treatment options for the women and girls suffering from the condition. The initiative also supported the implementation of facility and community-based interventions to facilitate prevention of fistula and mobilize indigent women and girls to access free treatment and rehabilitation.

UNFPA has registered remarkable success in the focus areas of its fistula programming in Nigeria. It has supported free surgical repairs for Zainab and more than 6,000 women and girls living with fistula by 2016, achieving an average of 97 per cent successful repair rates to date. A total of 52 doctors and 94 nurses were trained to repair both simple and complex fistulae. In addition, comprehensive surgical equipment, including fistula repair kits, were procured and supplied to nine General Hospitals and three National Obstetric Fistula Centers throughout the country to support routine provision of fistula repair surgery. A total of more than 460 community educators and mobilizers – both women and men – were trained to provide counseling services to women living with fistula and their spouses. In addition, 40 social workers were trained to support women by providing necessary pre-and post-operative psychosocial counselling services to clients in the treatment and rehabilitation centres.

Hauwal Mohammed, a 35-year-old fistula survivor, also took part in UNFPA vocational skills acquisition and empowerment programme. At age 16, she was forced to drop out of school to marry a suitor. She lived with the condition for ten years after several failed attempt of surgical repair. She felt unworthy because everything she touched was considered dirt. “If I touch a plate they will discard it. I cried a lot,” she said. After the successful surgery, Hauwal was empowered to become economically independent and is now a proud tailor running her business. Hauwal is not the only one.

UNFPA has supported the economic rehabilitation of more than 350 successfully operated fistula survivors in addition to the social reintegration of more than 400 survivors with fistula deemed inoperable, through skills acquisition training sessions and provision of start-up kits.

Fistula is preventable, and can be avoided by delaying the age of first pregnancy; ensuring skilled birth attendance at all births and providing timely access to obstetric care for all women who develop complications during delivery. UNFPA will not stop until fistula is history in Nigeria.

- Lolade Johnson

The story was fist published on UNFPA Nigeria website.

United Nations, New York - Dr. Natalia Kanem, Deputy Executive Director (Programme) of UNFPA, the United Nations Population Fund, presented the United Nations Secretary-General’s report "Intensifying efforts to end obstetric fistula" to the Social, Humanitarian Cultural Affairs Committee (Third Committee) of the General Assembly in New York today.

Dr. Kanem noted that progress has been made in the past two years by integrating fistula into national health strategies, plans and policies. By the end of 2015, according to the report, at least 15 countries had developed national strategies for ending fistula, which is more than a quarter of all countries in which the UNFPA-led Campaign to End Fistula is active.

Harnessing the power of partnerships, efforts to end fistula have been integrated into many effective health initiatives focusing on maternal and newborn health. Dr. Kanem underscored the example of the Global Midwifery Programme, in which UNFPA partners with the International Confederation of Midwives, USAID, the African Medical Research Foundation (AMREF) Health Africa and others, to support countries strengthen their midwifery programmes and policies. Such a partnership is critical, noted Dr. Kanem, considering the vital role midwives play in saving the lives of mothers and babies and preventing severe maternal and newborn illnesses.

While the achievements made were commendable, Dr. Kanem added, it was necessary to galvanize collective action at the global level to accelerate progress. A point strongly emphasized in the Secretary-General's report is that fistula is almost entirely preventable when there is universal access to quality sexual and reproductive health care.

“Therefore, the persistence of obstetric fistula reflects not only severe health inequities and health system failures or socio-economic, gender, and cultural barriers facing women and girls, but it is a human rights violation,” Dr. Kanem said.

In order to tackle the underlying drivers of fistula and end this terrible scourge, it is necessary to eradicate poverty, reduce socio-economic and gender inequality, protect women’s and girls’ human rights, ensure universal access to health services and to education, and prevent child marriage and teenage pregnancy.

The report made a number of recommendations, Dr. Kanem said, including significantly accelerating efforts and developing a global action plan to end fistula within a generation. The report also calls for increased financial and human resources, such as skilled surgeons to repair fistula, and scaling-up three well-known and cost-effective interventions: skilled birth attendance; emergency obstetric and newborn care; and family planning.

“The world we want is a world where obstetric fistula no longer exists,” Dr. Kanem said. “If we commit to this ‘fistula-free world’ and to protecting the human rights, well-being, and dignity of each woman and girl everywhere, we can make every pregnancy and childbirth safe, eliminate the abomination of obstetric fistula and prevent this tragedy all around the world, once and forever.”

Chonyi, Kenya - At the bloom of her youth, 50 years ago, Jumwa Kabibu Kai, a resident of Kidutani, a small village in Chonyi, Kilifi County, Kenya, was psychologically prepared for the birth of her second child.

As she went into labour, Jumwa was all alone in her small hut crying her heart out but no-one was in sight. This is because her nearest neighbour lived three kilometres away. Kidutani is generally a marginalized area with poor infrastructure, including accessibility to a health facility.

Jumwa found relieve walking around her compound because in her heart she knew her neighbours would finally either hear her or come visiting. This went on for three days when her sister came visiting. Immediately, her sister mobilized a few neighbours who rushed Jumwa to hospital.

Jumwa could not comprehend what her doctor was explaining to her hours after the delivery “but something was definitely wrong”, she recalls. She had lost her baby, too.

“I returned home after a day at the hospital, extremely disturbed by the loss of my child. Then almost immediately I began passing urine uncontrollably,” she narrates. “I didn’t take it very seriously because I thought it was something normal. In any case, there were other women in the village with the same condition,” she adds. This according to her was “the beginning of 50 years of a long nightmare.”

Unknown to Jumwa, she had developed obstetric fistula – a hole between the birth canal and bladder or rectum that is usually caused by prolonged obstructed labour. It is both preventable and treatable, but fistula plagues the lives of thousands of women in Kenya every year, leaving them incontinent for urine or stool or both.

“I knew a bad spell was cast on me,” she states. “How can this be happening to me? I remember the bad smell, the wetness, the shame and worst of all the disappointment I saw in my family. The feeling was all too awful,” she adds.

After a while, and out of desperation, Jumwa began to seek help - any help from traditional healers, local dispensaries and religious groups, but without much success. In 2009, she heard of possible fistula treatment in Coast General Hospital in Mombasa, but she was late therefore she did not get the assistance. This devastated her losing all hope she had.

Signed a new lease of life
“At some point, I convinced myself that my condition didn’t have a cure, and so I had to learn to live with it,” she says. She would later learn through her 28-year-old granddaughter, Mwafungo, that she indeed was suffering from fistula and help was possible. Mwafungo, married and a mother of two, heard about the one-week fistula camp held at the Kilifi County Hospital in May 2016.

The camp organized by UNFPA, the United Nations Population Fund in partnership with the Kilifi County Government, the international non-governmental organizations Flying Doctors Society of Africa and Freedom from Fistula Foundation, the musical group Them Mushrooms, which partnered with the Campaign to End Fistula to raise awareness, and the Kenyan non-profit voluntary women's organization Maendeleo Ya Wanawake gave a once in a lifetime opportunity to women and girls, like Jumwa to receive free fistula repair as well as create awareness in the community about fistula.

“The past 50 years was hell on earth for me,” Jumwa, now aged 77, narrates. “I was completely isolated by family, friends and my whole community due to my condition, with some attributing it to witchcraft. Sadly, my husband too, left after I began suffering. I used to live alone in a hut in the outskirt of the village, with extremely minimal contact with anyone,” she adds.

Fifty years later, Jumwa cannot hide her joy and sparkling smile after the surgery.

“To be honest, I feel like I have signed a new lease of life,” she states. “I feel great. I feel young. I feel beautiful and wanted,” says an excited Jumwa before jokingly adding that now with her groove back, she expects to bump into a hunky single old man like herself and taste love one more time.

“I appeal to all women suffering with this condition to seek medical help. Fistula indeed is treatable,” she poses rather seriously.

During the one one-week fistula camp, 65 women were screened, while 32 patients were admitted and 30 surgeries done. Many of these women had faced discrimination and stigma with some being ostracized from the community they once belonged to.

Strengthening the health system

Kilifi County has one of the highest teenage pregnancy rates, which together with poor access to emergency obstetric and newborn care may lead to increased risk for obstetric fistula. To this end UNFPA is working with other stakeholders including the community leaders and the County Government to encourage girl-child education, prevention of child marriages and gender based violence.
UNFPA has built the capacity of Kilifi County Hospital by procuring maternal health equipment for both basic and comprehensive obstetric care, including equipment for fistula repair. UNFPA has also invested in the training of 35 nurses on emergency care and screening of patients as well as care before, during and after surgery of fistula survivors. This team will also act as mentors for their colleagues in the respective health facilities. Nineteen community health workers were trained in identification of fistula survivors and community sensitization. These community health workers are also acting as key architects in reintegration of the fistula survivors within the community.

The story was published first on UNFPA’s Kenya Country Office website.

Mulanje, Malawi – Alice Sabuni has been living with obstetric fistula since 1949, when she gave birth to her first child, at age 17, a year after she was married. Now 83, many of her recollections from those days have grown a bit hazy, but she vividly remembers being in labour – and pain – for two days before she was taken to a hospital.

As a result of the excruciating ordeal, she developed fistula – a hole between the birth canal and bladder or rectum that is usually caused by prolonged or obstructed labour. The condition results in chronic incontinence, infections and, all too often, fierce discrimination.

“Obstetric fistula is almost exclusively a condition of the poorest, most-vulnerable and most marginalized women and girls,” says UNFPA Executive Director, Dr. Babatunde Osotimehin. “It afflicts those who lack access to the timely, high-quality and life-saving maternal health care that they so desperately need and deserve, and that is their basic human right.”

In November, after 66 years of shame, hiding and discomfort, Alice discovered that she might finally have the chance to end hers.

Holding out hope for a cure
Globally, two million women and girls suffer from the devastating condition, and although it is almost entirely preventable, between 50,000 and 100,000 still develop the injury annually. In most cases, it can be repaired with a simple surgery, but in many areas women lack awareness of or cannot afford the procedure, and doctors are not properly trained to perform it.

And so, due to the stigma – and isolating stench – that often accompanies the condition, fistula condemns many women to a lifetime of being shunned by their family and community, and it is not unusual to find them living alone in huts on the fringes of their villages and towns, isolated, unemployed and alone. 

Despite living with her injury for the better part of a century, Alice says she is lucky. Unlike many women with fistula, her husband stayed with her for decades. And with help from him and her sisters, she was able to hide her injury from most of the people living in her small village, 60 kilometres from the city of Blantyre, and avoid widespread discrimination.

“I think this man loved me a lot because most men would not stay with a woman who had this condition,” she says. But even with her family’s help, some of the village residents did discover her condition. “There have been times when people thought she was bewitched,” says her niece, Shone.

However, Alice was always considered the strong one among her sisters, and even in the face of these pernicious, and possibly dangerous, rumours and the discomfort of her injury, she stayed determined. Over the years, she gave birth to five more children, supported her family by farming – despite her incontinence, and eventually welcomed 25 grandchildren into the world.

But still, even though her family had accepted her condition as permanent, she held out hope that with everything she had lived to see, she might live to see a cure.

Ending fistula one surgery at a time

In 2003, UNFPA launched the Campaign to End Fistula with partner organizations, and in 2007, the campaign came to Malawi, where at least 20,000 women are estimated to have obstetric fistula. As part of the campaign, UNFPA Malawi brings in foreign experts to train local clinicians on repair surgery, works to improve awareness of fistula and link women to care and holds rotating fistula camps around the country – during which women can access free fistula repair services.

In November, Shone heard on the radio that one such camp was coming to the Mulanje District Hospital, only a few hours away from their village, and though many members of the family were suspect that the treatment could work, she decided she had to get Alice there.

She succeeded. And Alice was among the 21 women who received surgery as part of the two-week camp.

“I am healed, save for a few emotional wounds that are taking time to heal. Where were you all these 66 years?,” she says. “I would not have suffered as much if I had received this treatment earlier. Regardless, I am a happy person now.”

The story was first published on UNFPA.org

Headlands, Zimbabwe – A year ago, Tuwede Adam (36) was sitting in her home dejected and sad having suffered from fistula for 19 years. In 1996, while giving birth at home during an agonizing 4 day labour at the age of 16, Adam suffered this birth injury that left her incontinent. Since this injury, she had lost her social life, ostracized by her community in Headlands in Zimbabwe’s Manicaland province.

“This illness troubled me a lot for so many years. I was ashamed because of my condition,” said Ms. Adam. “My life was about staying indoors…I could not go for community meetings where others were.  I could not go to church, even to attend funerals. My life was just about staying indoors or at home on my own…I just could not go anywhere where people were.”

However, today Ms. Adam sits in her home a much happier person. She was one of 145 women who received life changing fistula reconstructive surgery since August 2015 thanks to support from UNFPA Zimbabwe and its partners, the Ministry of Health and Child Care and the Women and Health Alliance International (WAHA). Three fistula repair camps have been conducted so far at Chinhoyi Hospital, a government run provincial hospital in the Mashonaland West province of Zimbabwe.

Ms. Adam was one of first women to undergo this surgery, which she says has changed her life significantly. She is no longer a social outcast in her community. She can now attend social gatherings, travel and visit relatives living across the length and breadth of Zimbabwe and now even has her own market where she sells various wares such as tomatoes.

“After my treatment I sat down and started thinking about what I could do to sustain myself. It was then the season of ripening of mazhange (a wild fruit). So I went and I picked some in the forest and came to this road to sell,” said Ms. Adam. “From the proceeds of the sale, I then bought a gallon of tomatoes which I sold at the market and on the roadside. I have been doing this then. The last time I made profit, I managed to buy laundry soap and cooking oil for my family.”
Before the surgery, Ms. Adam and her husband had tried everything they thought would make her better.
“I had gone to hospital to seek help, I had gone to some church prophets and traditional healers to try and get help but everything failed,” says Ms. Adam.

‘You should not rush to traditional healers’
Ms. Adam’s husband, Roddrick said his wife’s treatment opened his eyes to the importance of seeking medical care. “It was a lesson for me that if you are ill you shouldn’t rush to n’angas (traditional healers) or church prophets because some conditions require medical attention,” he says. “I encourage other women with similar conditions to go to the hospital instead of just staying at home and thinking of getting help elsewhere. I encourage other men with wives suffering from this condition, to be supportive as possible in seeking medical treatment.”

Life changing stories such as that of Adam continue to push for reconstructing the lives of many women. With over 500 women currently on the camp’s waiting list for free repair surgery, UNFPA Country Representative Cheikh Tidiane Cisse said that UNFPA is committed to supporting Ministry of Health and Child Care to address the problem of fistula in Zimbabwe.

“It is these heart rending tales from women such as Adam that really give us the urge to want to continue reaching out to many other women,” said Cheikh Tidiane Cisse.  “We will continue mobilizing for support for the Campaign to End Fistula so that we can restore the dignity of many other women who have fistula and prevent such birth injuries.”

Ms. Adams now looks to the future with renewed energy. She hopes to one day go into poultry or become a small scale subsistence farming, selling her produce at wholesale price in the capital city of Harare.

“I lost so much time over the years; I need to catch up,” she says with a smile.

- Bertha Shoko and Victoria Walshe

The story was originally published on UNFPA Zimbabwe’s website.

Kabul, Afghanistan  -  Within the gates of Malalai hospital hundreds of women, children and anxious men sit in the few sunny areas of the courtyard, bouncing sick babies on their laps, waiting. Inside the female-staffed maternity hospital, the halls resonate with the moans of women in labor while they share beds in crowded rooms humid with the stress of new birth.

Further down a maze of hallways, hidden at the end, is a silent space where seven women sleep under heavy blankets. Exhausted and worn as if ending months of weary travel, these women are recovering from fistula surgery, and more importantly, from years of exclusion from society. Because of the constant smell of urine that caused them heartbreak and shame, they were shunned from everyday life, unseen in daily life, and abandoned by their husbands.

Obstetric fistula is a devastating injury acquired during prolonged or obstructed labor without timely access to emergency obstetric care, resulting in a hole between the vagina and bladder or rectum, which leaves women leaking urine or feces. The fistula ward in the Malalai Maternity Hospital, supported by UNFPA, the United Nations Population Fund and Afghanistan’s Ministry of Public Health, is one of few places in Afghanistan women can receive free emergency obstetric care and surgeries by trained female surgeons.

Fistula surgery is the solution to a problem that often seems unapproachable in Afghanistan. In some ways, women with fistula issues are considered the lucky ones, surviving the high maternal mortality rate that haunts Afghanistan; though none of them would think of themselves as lucky. A lack of maternal care and education, malnutrition, child marriage, remote villages on rarely traveled roads, society’s powerless role for women, not to mention ever-raging war, all stack up against women who suffer this problem. 

Noorjahan, 67, lived with fistula for 49 years until her recent surgery. During those years she hid in one room, rarely leaving, sewing to make a living. Every morning, afternoon and evening she cleaned her soaked mattress and searched for plastic bags that she tied around her like diapers.

To find the fistula ward, Noorjahan traveled from far away to reach Kabul, a difficult task for an illiterate woman with obstetric fistula, hanging on a rumor she had heard about the existence of doctors who could help her. For four days she wandered the streets of Kabul before finally finding Malalai Maternity Hospital and the fistula ward inside.

Now, days after surgery, Noorjahan smiles.

“I can die now. My grandchildren will play with me. I am clean. I can practice my faith. I can live,” she says with a laugh that ends only because of the pain leftover from surgery.

While she drinks tea, delicately rearranging herself in her bed, she is visited by former patients who now are attempting normal lives and have returned to the ward for a check-up. They interact like war veterans, understanding the torment of their lives without having to speak of it, checking in with each other in the recovery room, and sharing each other’s silent tears after nightmares about the life before.

One such fistula veteran is Guldesta. She married at the age of 12 and had a son at 13 in the distant region of Pul-e Khumri. She had two daughters, then several miscarriages that led to an obstetric fistula. She lived with the injury for many years until her surgery at Malalai Hospital.

“People have told me not to take my daughter or daughter in law to a hospital when she is about to give birth, but I have never listened to them. I have seen so many problems and difficulties of fistula. I wasn’t able to sit a minute with my guests because I had a bad condition. I was sitting alone for days and nights,” she said.

Now, she is a mother-in-law with a grandchild.

Guldesta’s is a rarity in her community. Living in a three-room home without running water that she shares with over 15 people, she lives in a community where poverty is rampant and education is scarce. But through her own experiences with fistula and the doctors who helped her, she has made it her duty to educate others, starting with her own family.

“My daughter is too young to marry now, but I will see what the future brings us. My older daughter is married to a man in Jabulsaraj (a district in Parwan) and there are not many hospitals around. She is here now and I will take her to Malalai Hospital whenever she is about to give birth.”

Doctors who work with UNFPA and the Ministry of Public Health say that lack of education is at the center of the problem. Compared to the amount of women who suffer from an obstetric fistula in Afghanistan, very few have actually made it to Malalai Hospital for care.

UNFPA attempts to address the issue by supporting training of female midwives and doctors who can help women with preventing and recovering from this injury as well as educating men and women on the problems of child marriage.

“Women wouldn’t be allowed to come to the hospital if there were male doctors,” says Dr. Nazifa Hamrah, 51, a fistula surgeon. “All of my colleagues are women, so we are very comfortable and can focus on our work.”

The training of midwives to work is central to preventing fistula. UNFPA supports training of midwives who are selected from their rural communities through a process involving families, shuras and elders to make it a community decision to educate women as midwives, showing its importance to all involved. The process also ensures that future midwives return to serve the community once they have completed their education in the Family Health Houses that the community have built.

In these regions finding girls who have completed a 10th grade education is often difficult. An 8th grade education is required. But, through training, these midwives have become the heroes to women in their region, one doctor said.

Sina Alizada, 41, trained as a midwife in the mountains of Bamiyan. House calls were made by horse, the roads too treacherous for cars or motorcycles.

There are many issues related to fistula problems in Afghanistan that need more attention, explained UNFPA Representative, Bannet Ndyanabangi. “The isolation and stigma of the recovering women is not over even after medical treatment. The survivors need help to start making a living and for reintegration into their communities for a life of dignity and hope.”

- Andrea Bruce