By Josephine Chinele (Lead Writer)
Jackline Chiwinga remembered the euphoria of waking up to dry bedding after her successful obstetric fistula repair surgery. Seventeen years old and married, for one year, she lived with stigma, gossip, and isolation due to the constant leaking of urine and the foul odour that followed her everywhere. However, everything changed when a Fistula ambassador reached out to her and recommended the Bwaila Fistula Care Centre in Lilongwe, Malawi’s Capital City.
Jackline developed obstetric fistula following an episiotomy done on her at Mponela Health Centre (situated in Malawi’s central region district, Dowa), after a three-day prolonged labour. Jackline said, “I wore makeshift pads made from pieces of cloth and changed them about eight times a day.” But that didn’t mask the smell. “I went to church in the early days of the condition. People literally moved away from me. The same happened whenever I found a group of people at funerals or village meetings. I decided to stay home. My husband was my only close friend”, she added.
Her fistula was repaired in September 2018. The 14 days she spent at the Fistula center were life changing. Jackline and other patients learnt basic business skills, reading and writing basics, sewing, knitting, fritter making and embroidery. She happened to be one of the patients that received free start-up equipment from the Centre. The start-up pack included two rolls of cloth, a sewing machine, one bottle of sewing machine oil, a roll of thread and tape measure.
Bringing hope to a hopeless situation
Obstetric fistula is a serious reproductive health problem which occurs as a result of prolonged obstructed labour. Women who experience obstetric fistula suffer constant urinary or faecal incontinence which causes social isolation of the victims, and severe physical and mental ill-health. “The condition is a burden mostly affecting the poor, illiterate and young women living in rural areas with limited access to information services”, said National Coordinator for Adolescents and Youth Sexual Reproductive Health Program, Hanz Katengeza.
One percent of Malawian women and girls of childbearing age have experienced the condition, according to the Malawi Demographic and Health Survey of 2015/16.
Bwaila Hospital started fistula repairs in 2010 with repair surgeries being done in the facility’s maternity theatres. In 2012, the Bwaila Fistula care Centre — then fully funded by Freedom from Fistula Foundation — was opened within Bwaila Hospital premises. It is a 45-bed capacity facility with three wards and one theater. In partnership with the United Nations Population Fund (UNFPA), the Centre has provided discharged patients with solar panels to light their homes and for phone charging businesses, some received barbershop equipment, while others, like Jackline, received a tailoring package.
Fistula surgeon at Bwaila Fistula Care Centre, Doctor Annette Chipungu said the facility repairs 250 to 300 fistulae per year, most of whom are vulnerable young girls with little or no support.
Volunteer fistula patient ambassadors
Most patients who visit the Fistula Care Center are referred by volunteer fistula patient ambassadors scattered across the country. There are 274 of them; some of them fistula survivors. Jackline’s husband, Paul Chiwinga has been a fistula ambassador since 2020. “Most men dump their wives because of this, but it’s wrong. I was under pressure to divorce my wife too, but I decided not to.”, he said. Since he became an ambassador, Paul has persuaded ten women from the 13 villages in his catchment area to visit the Centre.
The ambassadors first attend an orientation class, after which they are given T-shirts, mobile phones and bicycles to help them work effectively. Fistula Care Centre Programs Officer, Myna Pindeni said, “There is also a transport provision for both the ambassador and patient. This varies on location.” Their transport refund is courtesy of Freedom from Fistula Foundation.
UNFPA has been supporting the Bwaila Fistula Care Centre with resources to complement their activities since 2020. They work with implementing partners, government and non-governmental organisations, to identify women with obstetric fistula and ensure that they receive the necessary care and support.
UNFPA Representative for Malawi, Won Young Hong stressed the urgent need to deal with the underlying factors that encourage the development of fistula, such as teenage pregnancies, child marriages and inadequate skilled birth attendants, “A child bride has a higher risk of having fistula because her body isn’t ready for childbirth. There seems to be little interest in this area, may be because women aren’t dying from fistula. But this is a women’s dignity issue. Women need to live healthily without humiliation due to Fistula.”
UNFPA has also supported capacity building programmes for fistula surgeons and trained clinicians, midwives and anesthetists in fistula repair and management. They provided equipment such as fistula repair beds and supported the fistula ambassadors and traditional leaders program as part of program sustainability.
The Ministry of Health (MoH) acknowledged the prevalence of fistula among adolescents and young women and the lack of interest among health care workers to specialise in fistula management. Katengeza, said the government is developing a fistula strategy, which includes an implementation plan and indicators to track its progress. “The Ministry is also working with partners to ensure that fistula patients are assisted by trained personnel. We focus on prevention, management, rehabilitation and community support for repaired patients”, he added.
Other organisations working in the space
Amref Health Africa, an international NGO running programs in over 35 countries in Africa, also supported fistula repairs in Malawi. Amref Malawi Sexual Reproductive Health Manager, Charles Suya said the demand for fistula repairs was higher than the project could handle. The organisation supported 280 fistula repairs in Mangochi district and established a fistula repair facility at Monkey Bay Community Hospital within the district. Amref handled the repair aspect whilst its partner, UNFPA handled the psychosocial support in collaboration with the district hospital and community development office.
“We had challenges following up with patients. Some might have migrated to Mozambique or other districts. There is a likelihood that the women migrated to have new beginnings, where no one knew they had fistula. You know this is a dignity issue”, Suya said. “Even though there was a high demand for repairs, we couldn’t do more because the project had ended”, he added. The project ended in 2016.
UNFPA does not have a set target of the number of fistula repairs to be carried out, but the organisation wants to ensure that every woman living with fistula has their dignity restored. “Strengthening prevention would work well considering that Malawi is a limited resource country and fistula is very expensive to repair”, said Hong.
UNFPA and other partners are returning women’s dignity through the provision of fistula repairs. There is however a strong need for the Ministry of Health to lead other government agencies to go beyond treatment and management to prevention:
· government and its partners must support girls to stay in school, thus delaying and preventing early childbearing.
· there is also the need to work with traditional leaders to end child marriage and harmful cultural practices that promote early sex debut.
· through community gate keepers, youths need to be encouraged to utilise youth friendly health services, a platform that empowers them to make informed reproductive health decisions.
Obstetric fistula in Nigeria
Obstetric fistula predominantly affects the most vulnerable women in our society and all work done to reverse the condition has a great effect on a young women’s ability to life a fulfilled life. The UNFPA in partnership with the Federal Ministry of Health adopted a National Social and Behaviour Change Strategy for the Elimination of Obstetric Fistula in Nigeria (2020–2024). With almost 40% of women experiencing VVF coming from Nigeria, partnerships like this are incredibly important. Annually, UNFPA repairs about 3, 000 fistula cases in Nigeria. Gesse Vesico Vagina Fistula (VVF) Centre in Birnin-Kebbi is another organisation providing care for women with the condition. Inspite of these and efforts of the 11 other hospitals across the country that cater to women with the condition, a lot more still needs to be done.
Malawi, Nigeria and other countries where the condition still exists must learn from each other and incorporate into their interventions ways in which to, not only prevent the occurrence of fistula but also, ensure that support is available for those that need it.