Obstetric Fistula: A Medical Nightmare for Malawian Women

December 5, 2007

Pilirani Semu-Banda

Veronica Yakobe has been living a nightmare for more than two decades. Twenty-three years ago, during a prolonged labor when giving birth to her fifth child, the unborn baby was pressed so tightly in her birth canal that blood flow was cut off and the surrounding tissues died. Then a hole or fistula broke through the vaginal walls between the bladder and rectum. Obstetric fistula is serious medical condition which usually occurs during home births or in poorly equipped local clinics when access to emergency obstetric care is not available. Unfortunately, that was the case for Veronica. She has been unable to control her bodily functions since, and leaks urine and feces uncontrollably. In a bitter irony, after all that struggle, her baby was still-born.


These fortunate women await fistula surgery while many others go untreated. The destitute Yakobe, who comes from Malawi’s lakeshore district of Mangochi, became an outcast among her own community - no one wanted to get close to her because of the smell.
“I was forced to flee my own home. I settled on a plot adjacent to a cemetery on the outskirts of my village. I couldn’t stand the taunting from my own relatives and neighbors. Some were calling me a moving latrine,” says Yakobe. Despite her horrific medical condition, she has since given birth to three more children.

In this country where 40 percent of the adult population is illiterate, this middle-aged woman does not know how old she is.

What Yakobe does know is that in the last 23 years since the fistula developed, she has been to three government-run hospitals in the country trying to have the fistula repaired, but has been unable to find a competent surgeon.

Repairing a fistula is a delicate procedure that requires specially trained doctors. Then through a special initiative, a UN organization, the United Nations Population Fund (UNFPA), began providing financial and technical support to some hospitals in Malawi to offer fistula repair. Finally, in June, Yakobe found salvation from the tortures the fistula caused.
Dr. Mark Linden of Nkhoma Hospital, a mission medical center under the Church of Central Africa Presbyterian, restored Yakobe’s dignity through an operation. He was able to repair the damage that obstetric fistula had caused her.

“Some women have a combination of both these fistulas,” explains Linden. “They are leaking urine and/or stools continuously.” He worries, “They are often rejected by their spouses and community,”

Linden confirmed that obstetric fistula occurs due to prolonged pressure of the child’s head against a part of soft tissue between the mother’s pelvis. The soft tissue becomes necrotic (dies) from the lack of blood supply and breaks down.

The doctor says that obstetric fistula is preventable. So long as a laboring woman is monitored and transported to a suitable facility in the event of a problem, virtually nobody should have to suffer from it.

“Obstetric fistula is a serious problem in Malawi and repairs are only done in four referral hospitals: in Mzuzu, Blantyre, Lilongwe and Nkhoma,” says Linden. It is not known how many obstetric fistula cases there are, since no major survey has been carried out to assess its prevalence.

Fistula repairs started at Nkhoma in 2001. According to Linden, once they got UNFPA funding, they also began to get private donations and funding from the UK Department for International Development (DFID) which has enabled them to offer the treatment free of charge. He says the funds cover the patient’s hospital stay, food, and surgery as well as transport home.

Despite all the efforts by doctors like Linden, there is still some bad news: not all patients with obstetric fistula are successfully repaired. In 2001, Nkhoma hospital carried out repairs on 16 patients and 31 percent of those were not cured. Between 2002 and 2006, the hospital has recorded an average of 20 percent unsuccessful repairs.

In Malawi, where up to 65 percent of its 13.6 million people live below the poverty line, there was no means of transportation for 32-year-old Jostino Frank when she went into labor.

With UNFPA support, the Government of Kenya is working to integrate obstetric fistula into the country's ongoing Safe Motherhood programs. © Sven Torfinn/Panos/UNFPA •Frank lives in a village in Dedza, Central Malawi. The nearest hospital is a two hour walk from her home. Her mother-in-law assured her that she would help with a home delivery, but she could not handle the delivery when it became complicated.
“After struggling with labor pains for close to 12 hours, my mother-in-law eventually took me to a traditional birth attendant, but I had already miscarried by the time I delivered,” says Frank. This was Frank’s fifth pregnancy. She gave birth to her first child when she was 18.

Following her ordeal, Frank could no longer control her bladder; the government hospital closest to her home had no medical solution for her problem.

“[All they could do is tell] me to not have sex for six months but this did not solve the problem,” says Frank.

Just like Yakobe, Frank was shunned by her community.

“Only my husband was supportive. He took me to neighboring Mozambique to see a traditional healer but I wasn’t cured. It was only when someone in my village advised me to go to Nkhoma hospital that I got real deliverance,” she says.

It has been nine months since she received treatment and Frank is now three months pregnant. This time, she has vowed to leave her village and camp at the hospital as soon as she reaches her eighth month of pregnancy.

Doctor Linden advises women who have been repaired to undergo a caesarean section if they become pregnant again.

Nkhoma Hospital indicates that one of the major challenges in treating fistula repair is that so few communities are aware that the problem can be treated successfully.

Frank agrees as there are a lot of cultural misconceptions associated with the condition. She says most women with fistula and their families believe that they have been bewitched, which is why they are rushed to traditional healers.

Incredibly, some believe that women who get obstetric fistula are being dealt spiritual punishment for being too lazy to push out and deliver the baby. Others are accused of infidelity.

However the Director for Reproductive Health in Malawi’s Ministry of Health, Dr. Chisale Mhango, blames the high prevalence of obstetric fistula on early marriages that lead to too-early childbirth. He also cites the country’s inadequate infrastructure for childbirth as another significant factor.

We’re failing to cope with maternity cases in this country. Most women have no choice but to give birth at home with no medical care. They only go to hospitals after everything else has failed,” worries Mhango.

He says the government is trying its best to increase infrastructure for childbirth. A related statistic shows that currently 28 percent of mothers say they had not wanted a baby when they got pregnant. He says poor access to family planning services is what leads to this kind of situation.

Mhango says the country is only able to carry out caesarean sections on three percent of pregnant women per year, as opposed to the World Health Organization’s analysis that five percent of pregnant women need it. A developed country such as the United Kingdom in contrast, has gone to the opposite extreme by carrying out caesarean sections on 23 percent of pregnant women every year.

The UNDP says that Malawi is struggling with far too high a maternal mortality rate (over 1,100 per 100,000 live births) and a devastating infant mortality rate of 94 deaths per 1,000 live births.

20-year-old Londina Isaki sits in a waiting ward at Nkhoma Hospital as urine drips down her legs. Ten other women are also waiting to be repaired – some have waited for over two weeks.

Dr. Linden says fistula repair is only one of the many services offered at his hospital and that service delivery has not been easy since the hospital has limited operating time and human resources. Combined with the fact that Nkhoma is a mission hospital, it has difficulties making ends meet and depends on donors for financial support. The medical personnel at Nkhoma are overburdened with every kind of medical case, as it is the only hospital facility serving the needs of a population of 60,850

Malawi’s people suffer terribly from the country’s critical shortages of medical personnel. Up to 120 registered nurses leave the country every year for the US and UK for better-paying jobs. The ratios are staggering: currently, there is one nurse for every 50 patients, but there are even fewer doctors - one doctor is responsible on average for 64,000 patients.

According to the World Health Organization, an estimated 50,000 to 100,000 women develop obstetric fistulas each year and over two million women currently live with fistula injuries. In the meantime, the many women who begin first pregnancies when they are still just young girls and who endure baby after baby in rapid succession until their vaginal walls give out, must just get in line behind all the other Malawians with medical needs.