Roads to rehabilitation

Asha Makocho steps out from the gloom of her small one-roomed apartment into the Tanzanian sunlight. She holds a turquoise and yellow shawl, its vivid colours contrasting against her otherwise dark clothing.

For two years, Asha was trapped at home in fear and loneliness by the medical condition known as obstetric fistula. This is where a hole develops between the vagina and rectum, or vagina and bladder, as a result of the pressure of the baby’s head against the pelvic bones during extended labour.

Asha, now 26, became pregnant for the first time at 23. Her boyfriend left her four months later. Alone and scared, she was in labour for four days. Like 90% of women who experience fistula, Asha’s baby was stillborn and she was left with what the World Health Organisation has called “the single most dramatic aftermath of neglected childbirth”.

Obstetric fistula is an embarrassing condition. It results in severe incontinence, with women leaking urine or faeces uncontrollably creating unpleasant odours and severe social stigma. It can also lead to infections, ulcers in the vaginal tract or difficulties in future childbirth, and has ended many marriages, according to Women’s Dignity, a Tanzanian NGO. Without the financial support of their husbands, and unable to work, many women are plunged into poverty.

In Tanzania as many as 10% of pregnant women contract obstetric fistula, according to a study by the Ministry of Health and Social Welfare. About 3,000 women develop the condition each year.

Social isolation

Asha paints a vivid picture of the devastating effects of extreme incontinence. “When I drank water it would just pour straight out of me,” she explains. “Once my friends learnt about this, they stopped coming to visit because of the smell. I couldn’t go out to church or to market. I tried not to drink water but that just made my urine so acidic I had burns on my thighs. I had to change my clothes every hour. I just cried and cried.”

No one in her village had heard of obstetric fistula. “I was at a dead end. Hope was gone,” she says.

However, thanks to the innovation and passion of a few small organisations, more women are living in hope again.

“Obstetric fistula is a treatable condition,” says Dr Vindhya Pathirana, obstetric fistula surgeon at a disability hospital in Dar es Salaam run by the NGO Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) and supported by CBM UK, the overseas disability charity, since 1997. “It can be treated through a simple operation under local anaesthetic.” The operation involves stitching the torn tissue around the fistula. The CCBRT ward is full with women who are waiting for a few weeks for the stitches to heal.

Treatment at CCBRT is free but getting the women there is another issue. “Tanzania is a big country. Getting to the hospital can cost nearly a fifth of the average annual income,” explains CCBRT deputy director Tom Vanneste. “Poverty is a major barrier to women getting treatment.”

CBM is helping fund CCBRT’s M-Pesa scheme – an innovative new project transporting women to the centre. M-Pesa is the phone company Vodacom’s mobile phone money-transfer service: M stands for mobile phone, pesa is Swahili for money. Under this scheme, regional representatives locate women with obstetric fistula and alert CCBRT, which transfers the money to pay for the woman’s bus fare by text message.

Since its inception in 2009 the number of women arriving for fistula treatment has increased by 40%. “The M-Pesa scheme reaches the poorest of the poor,” explains Mike Davies, head of programme development, CBM UK. “Just £30 could pay to transport a vulnerable woman to a clinic.”

Obstetric fistula is not just a Tanzanian problem. “There are about two million women suffering with fistula in the developing world,” says Dr Julitta Onabanjo, Tanzania United Nations Population Fund (UNFPA) representative. “But given the shame and secrecy, this figure is likely to be a gross underestimate.”

Meanwhile, the condition has been virtually eliminated in developed countries. In the UK, for example, the Department of Health reported only 119 women with the condition last year.

“Obstetric fistula is an issue of poverty and of rights,” says Onabanjo. “Birthing decisions are often taken by the husband or mother-in-law who can favour traditional practices. If something goes wrong it is too late… health education, therefore, helps women understand their rights.”

However, in Tanzania, women who do seek out medical help find a health system in disarray. Hospitals are few and far between and severely understaffed. One midwife in a maternity ward in Dar es Salaam would typically oversee 60 deliveries a day.

“The Ministry of Health has made efforts to prevent fistula by training health workers in emergency obstetric care and improving our hospital referral system,” says ministry representative Dr Azayo. Despite this, the government’s investment in health is still below the £25 a head suggested by the World Health Organisation.

Worldwide investment is not much better. A United Nations report released last month claims £473m will be needed to treat existing and new cases of fistula between now and 2015.

The UK government is recognising its role in eliminating fistula. International development secretary Andrew Mitchell explains: “This government has pledged to put women at the heart of our development and we are ensuring many more women have access to basic healthcare… It is heartbreaking that so many women suffering from fistula are left untreated and in isolation.”

For Asha the torment is finally over. She hugs her brightly coloured shawl around her shoulders; it was a gift she received when she left the CCBRT ward, a symbol of a new start.

Concrete solutions

“When you think of ways to improve women’s health, cement mixers are not the first things that spring to mind,” says Brenda Msangi, director of community rehabilitation at CCBRT. “But now lorry drivers are helping to save women from obstetric fistula.”

The clinic teamed up with the country’s largest cement company, Twiga, whose vehicles routinely travel to the rural areas medical services fail to reach. During the course of their travels drivers stop at doctors’ surgeries and talk to town leaders, spreading the word that fistula is treatable.

Women’s Dignity, another fistula project, uses popular theatre to reach other rural locations. They sensitise local performers and create theatrical performances designed to raise awareness about fistula.

“In some communities literacy levels are low and theatre is a powerful way to transmit our message” explains head of Women’s Dignity Christine Matuvo. “We use theatre to educate people about their health rights and dispel myths such as the belief that fistula is caused by witchcraft.”

The project also encourages towns to start Community Emergency Funds to help pregnant women who must buy their own delivery kit. Kits cost just over £1 and contain the gloves, antiseptic and instruments needed by a midwife.

“We found many women are not planning for the costs involved in pregnancy,” says Matuvo. “We encourage communities to open a bank account and deposit the equivalent of 40 pence per household. This pot of money can then be used if complications arise during pregnancy.”

These innovative solutions are ensuring that poverty and distance are no longer barriers to women suffering from fistula.

Down to business

Rehema, 60, sits nervously in the CCBRT fistula ward. She has lived with fistula for 40 years and today will find out whether she has been cured. News of a cure is a happy occasion but often it is just the first step on the road to recovery. Having lived, as Rehema did, for decades in isolation fitting back into society can prove difficult and the long-term psychological effects are not yet fully understood. Nevertheless many organisations are working to make the transition back into the community easier.

“One way to aid re-integration,” explains Gillian Slinger, co-ordinator of UNFPA’s Campaign to End Fistula, “is to equip the recovering patient with the income generating skills to gain socio-economic security and empowerment.”

The Mabinti Centre in Dar es Salaam is doing just that. In a series of small houses, linked by grassy gardens, ex-patients from the CCBRT fistula ward receive training in the skills needed to set up their own businesses.

“We train the women in sewing, screen-printing and beading as well as business management,” says Katia Telemans, head of the centre.

Eighteen women attend the centre at a time and stay for 18 months. When they leave they receive a starter kit containing a sewing machine, material and patterns.

Sitting in the garden, sewing coloured beads on tiny angel-dolls and surrounded by friends after years of isolation, the women work with ambition. “I will become a tailor, save my money and buy a house,” says 26-year-old Asha (left), a small beaded angel sparkling in her hand. “Now I have something to go back to.”

This was a finalist article in The Guardian’s International Development Journalism Competition 2010 and published in the newspaper as well as online.

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