ZOMBO – The 2014 study revealed that two million women worldwide are living with genital fistula with an annual incidence of 50,000–100,000 women.
Study says globally, 99% of the 289,000 maternal deaths are in low-income countries. For each maternal death, 15 to 30 other women are left with serious morbidities including fistula, a preventable condition.
A genital fistula is an abnormal hole between the urinary tract or rectum and the genital tract, through which urine and/or faeces continually leak. A genital fistula is referred to as obstetric if it results from the process of labour or its management. When a fistula is from the urinary system it is referred to as Urogenital fistula.
The study added that in Uganda, the national prevalence of fistula is 2% among women aged 15–49 years.
While speaking to press on May 26, 2022 ahead of International Day to End Obstetric Fistula in Zombo district, senior fistula surgeons said that the condition in the district and the region follow prolonged and obstructed labour. They said that Uganda’s annual incidence of the condition nears 2000 mothers and that every year they operate about 1900 mothers.
Dr Emintone Ayella Odong – Senior Consultant Obstetrician & Gynaecologist and Senior fistula surgeon, Dr Odar Emmanuel – Obstetrician & Gynaecologist and fistula surgeon and Dr Warom Innocent, an internee fistula surgeon were at Warr Health Centre IV in Zombo district where they spent five days operating about 35 women with fistula.
“Usually if the baby is not lying well, a mother can fail to push. In that circumstance, if there is no skilled health worker to help, the woman will end in with fistula.”
The experts revealed that today, 30% of women in Uganda are still delivering on their own which has increased the risk of fistula.
Normally, doctors say, the condition victims suffer uncontrolled leakage of urine or stool and they are smelly.
As a result, they will not appear in public and even in their own homes, they will not sit with the rest.
“That’s why some of us have developed a passion to see that we restore this dignity,” said the surgeons.
They, however, said that although the condition is still a big challenge in Uganda and can only be treated by surgery, the surgeons are very few.
“About thirty (30) trained but a half are practicing. As you see us here, we are the only one in the greater north able to repair this fistula,” said Dr. Odong.
He attributed the cause to the indecency of the job, saying that if you have no passion, you cannot do it.
“This is not a nice career because you are in the middle of urine and stool, in the legs of a smelly lady and you are dealing with poor people who cannot pay you anything, should I be interested in it?”
Dr. Odong also said that it is still a challenge that very many people think there is no remedy for fistula, “so we need to continue sensitizing communities so that they know that services are available.”
He asked fistula victims to seek counseling and guidance on how to prevent infections from the health workers.
“Ideally, they should drink a lot of water, at least five litres per day. Also they should not to pad themselves all the time as it causes irritation. Just walk freely so that the urine flows freely. Also, don’t hide, talk about it people will help you.”
He commended United Nations Population Fund – UNFPA as the major development partner for equipping the region (West Nile) with the equipment for surgery.
Speaking at the stakeholders meeting at the District Health Offices to forge a way and come up with some rules on how to prevent fistula in the district, Ms. Acirocan Christine – Assistant District Health Officer – Maternal Child Health, Zombo said that teenage pregnancies have contributed much towards fistula in the district.
“These teenagers, their pelvis are not well developed and you find that during delivery it is usually difficult to force the baby through and eventually they get tares which develop into fistula.”
She said that the best remedy is to keep girls at school and also encourage those who are pregnant to seek healthcare very early.
“We need to come up with more rules of how to prevent these teenage pregnancies, this will help us too much in-fighting fistula with in the district and the country,” she said.
Also, she said the condition can be caused by malnutrition. “When a child has ever got malnourished whereas she grows up, you find that the hips or the pelvic bones are not well developed and as such during delivery you find so many complications that come up and she is really forced to push these babies and.”
According to her, most expectant mothers in the district seek healthcare late.
“People tend to stay at home and they are deceived, we are going to help you push, and eventually by the time they reach the facility it is already late.”
Ms. Acirocan revealed that Zombo has about 57 fistula cases that are being worked upon “and more than 100 of them were already operated in previous years which indicates a very high number in the district.”
She revealed that most of these cases are ages from of 15 to 19, “beyond 20 years are very few.”
Mr. Onegu Jinaro, chairperson LC3 Athoma sub-county attributed the increasing cases of the condition to the lots of night activities like “disco operating areas and some small kiosks which are having small sets of radios” who divert attentions of young people, to dance around and eventually have sexual intercourse thus early pregnancies.
He also decried the lack of proper healthcare services, revealing that in his sub-county, they don’t have any health facility.
“What we call a health facility in my county is a VHT. The nearest healthcare one can seek services is 22km away from sub county headquarters.”
“You find challenges of transport coupled with the high level of poverty within the population. It gives a lot of diversionary issues on the process as somebody is referred to seek services from a 22km away health facility,” he said.
Mr. Jinaro also revealed that although the sub-county has managed to put up a by-law, they have no any single enforcement unit, pleading to have a police post.
Officiating at the commemoration of the international day to end obstetric fistula at Zombo Primary Lower playground on Friday 27th, Minister of State for Health – General Duties Anifa Kawooya Bangirana said that everyone has a critical role in the elimination of Obstetric Fistula in Uganda.
This year’s commemoration was under the theme, “End Fistula Now: Invest in Quality Healthcare, Empower Communities!”
She said that currently, Uganda has an estimated 75,000 women living with fistula in the community with about 1,900 new ones added annually.
“However, only 1,500 women get the opportunity to access reconstructive surgery. Some also get reintegrated back into society after receiving psychosocial support and empowerment through various income-generating services.”
“The above numbers clearly show that there are more new numbers of women who get fistula than those repaired. Therefore, our approach has to change to address this perennial back-log,” added the minister.
Kawooya said that over the years, Uganda has been grappling with the challenge of having mothers deliver with a skilled provider in hospital.
According to her, currently, about 7 in 10 mothers deliver in the health facility which is a great improvement compared to 25 years ago at 4 in 10 mothers.
She said that the government is working on improving services in the different regions at all levels through improvement of infrastructure, capacity building of human resources for health, provision of commodities among other things.
UNFPA Country Representative, Dr. Mary Otieno said that over the past few years, they have closely followed several life-changing stories of women and girls in Uganda, who are survivors of obstetric fistula and some of whom have been successfully repaired after living with this terrible and treatable condition for years.
She said that when the fistula is left untreated, it can lead to infection, and sometimes infertility.
“Sentenced to a life of misery, stigma and isolation – husbands and families abandon them, communities ostracize them, employment opportunities vanish – they can suffer from mental health issues and deepening poverty.”
Dr. Otieno said that other than causing shame and loss of dignity at individual and household level, the condition also puts social and economic strain on the woman or young girl and their family.
She noted that ending fistula is of high priority to UNFPA, and it is a key step to achieving the global Sustainable Development Goals by 2030.
According to her, the condition has virtually been eliminated in wealthier countries, “so we know that it can be eliminated in every country, Uganda inclusive.”
Dr. Otieno revealed that working with their partners in the Campaign to End Fistula, they have made progress towards eliminating fistula through effective prevention, treatment and social reintegration.
In Uganda, UNFPA and other partners have supported the Ministry of Health to ensure delivery of quality obstetric fistula treatment and care services, including training of Fistula Surgeons and Nurses.
“…. fistula is not only a hole in a woman’s birth canal but indeed a hole in the healthcare system. Therefore, to end preventable deaths and illnesses, we must collectively act to address all primary causes, including eliminating poverty; addressing inequalities and disparities that leave our women and girls behind; preventing child marriage and early childbearing; and promoting education at all levels, to mention a few. These are fundamental human rights, which must be protected and fulfilled.”
Dr. Otieno called for easily accessible health facilities, adequately staffed with skilled health workers and available life-saving medicines; all of which ensure timely delivery of services as close to the communities as possible
She also wants engagement of traditional and religious leader champions to challenge negative social norms and cultural practices that deny women and girls health and well-being.
The country representative also wants effective community participation, including the active involvement of men as advocates for timely access to quality health services, and enrolment and retention of girls in school at all levels.
What victims say
Acirocan Molly 48, a mother of four has been living with the condition for the past seven years and gave birth amidst the pain.
She said she was feeling a lot of pain in the womb and she could hardly experience menstrual periods.
“Whenever I would stand, the urine would start leaking.”
Previously, Acirocan had tried to seek medical help but she was told the only cure was surgery, something she declined to accept since she wanted more children.
Until of late, when she heard about the coming of experts to Warr Health Centre IV and consented the removal of uterus.
“Before the operation, I was asked if I want more children and I told them the four children I have are enough for me. I consented for the removal of my uterus. Even my husband accepted because we want our children to study.”
“I am now okay and I want to advise women out there having same or related challenges to seek help from health workers.”
Acirocan says there are many women in her community with similar conditions but they fear to go for an operation because they believe an operation kills.
Akumu Amilliana 52, mother of eight said her pain started in the waist, after long labour of her fifth child, causing problems in movement.
Akumu narrates that she was by herself heading to the health center before she delivered on the way “but it was a very difficult delivery”. “When the baby’s head was coming I felt sharp pain. After, I just returned home and later shortly I started experiencing urine leakage.”
“I couldn’t go for urinating but urine could just come by itself every time.”
Akumu says she had never sought medical help because “I feared how I could start explaining to the people yet I am not hearing other mothers talk about it. I feared the community would laugh at me,” she said.
She says she was also afraid of doctors shouting at her for taking long to go for service but also she was unable to move to the medical center being far.