By Kemo Cham
Mary (not her real name) is in pains. She has just given birth, about a week ago, by caesarean section. Unfortunately she lost the baby. The young nurse`s concern though is less about her baby than her chance of survival.
“I don’t know if I will live longer. I am only surviving by the grace of God,” she says, explaining that after surgery doctors found that her bladder had ruptured and she complains of constant pain from two stitches says were done on her.
Mary`s condition is called Fistula, one of the most debilitating health issues the world over, but more predominant in poor countries like Sierra Leone, where campaigners say a worryingly very little attention is being paid to it.
Fistula or Obsteric fistula is associated with difficulty in child birth, often the result of lack of medical care during pregnancy. The condition is such that a hole develops either between the rectum and vagina, in which case it is called rectovaginal fistula, or between the bladder and vagina, vesicovaginal fistula. It is usually caused by prolonged, obstructed labour.
This condition has left many women lost their dignity and face stigmatization from their communities and even family members. It is more common and especially devastating among young girls. And given the prevalence of teenage pregnancy in Sierra Leone, where it is already at an epidemic proportion, the situation becomes an even greater concern, observes Augustine Kutubu-Kosia, Programme Manager at the Aberdeen Women Center (AWC).
AWC is one of only two centers in the whole of the country where surgery or any professional care for fistula sufferers is provided. The other center is in Bo, in the south of the country.
But since early last year, when the Ebola epidemic erupted, the center ceased its Fistula operation.
According to Kosia, AWC had been operating on between 250 and 300 patients annually.
AWC was transformed from what used to be called Mercy Ship, a religious inspired philanthropic mission which sailed across the world to deliver life saving medical services poorer parts of the world. In Sierra Leone it provided free fistula operations. When Mercy Ship ended its services in the country, the Scottish charity Gloag, took control of their facility in Aberdeen and still fistula was maintained as the key service provided at the center until it expanded into the general maternal and child health care recently.
The AWC is run through collaboration with the United Nations Population Fund (UNFPA) and the Ministry of Health and Sanitation (MoHS) which mostly provides the human resources in the form of nurses and other health professionals.
Gloag provides between 60 and 70 percent of AWC`s budget annually, which amounts to around US1.5M. Kosia says the year before Ebola [2013], they received US$200, 000 from UNFPA and they had to cut down on some of their services because the UN agency was forced to divert its funds in 2014 under the pressure of the Ebola epidemic.
However, it was through these collaborative supports that AWC has over the years expanded its operations from just fistula to four main services, including Outpatient services for children under 12, maternity care and family planning. The center does 100 deliveries a month, and 1200 deliveries a year, says Kosia. Plans are afoot to expand these services further.
The services at AWC are completely free, which makes access highly competitive, he adds.
Kosia also says majority of the fistula cases registered at AWC come from the rural areas, pointing to the illiteracy and poverty factors associated with the condition. The northern region of Sierra Leone, he says, records the highest number of cases.
The AWC prgramme manager cites a number of societal issues, including cultural practices which are also seen as contributing to the worsening of the condition in the country. He says in the north, Koinadugu has the worst record.
Iliteracy, poverty and fistula
Because of high illiteracy level, many women have suffered with the burden of Fistula for between 10 and 30 years without knowing it is either curable or preventable. The AWC therefore occasionally embarks on community outreach to seek out cases and offer advice.
“When we go to get people, our vehicles some times can`t even go to certain places. You can imagine if someone is in labour what happens,” Kosia says, adding: “By ensuring a proper maternal healthcare system we can prevent fistula.”
At the height of the Ebola epidemic, AWC was among one of the very few healthcare centers in Sierra Leone seen as safe. Kosia attributes this to the extra precaution they implemented. Also, he says, their meager budget allowed them to use one glove to one patient, among other infection prevention measures they undertook.
But there were other prices, notably the cutting down of the centre`s founding service – fistula surgerie. The alternative was to have risked the lives of the hundreds of patients, visitors and staff who come to the centre, he says.
Fistula may not be as life threatening as other health issues plaguing Sierra Leone, but it is the discrimination associated with it that concerns campaigners. The condition is particularly associated with odor emanating from uncontrolled leakage of urine or faeces.
Cultural practices which increase patients` inclination to trust Traditional Birth Attendants (TBA) over the conventional healthcare system poses a particularly serious limitations to addressing fistula in Sierra Leone.
Kosia says TBAs don’t normally have the expertise to handle complications. He also says many people associate it with witchcraft. Nurse Mary, mentioned at the top of this piece, for instance, initially called on a TBA when she thought she was going into labour. She says the baby`s head had come out, prompting family members to call on the old woman TBA in the area. But before she could arrive, the baby`s head went back in. That was when she was rushed to the hospital, where a C-Section was conducted.
Mary strongly believes her ‘enemies’ had casted spell on her.
It is this ignorance, which clearly is not only associated with poor villagers only, heightened by lack of awareness on the condition, which has led to many women and girls living with fistula for unbelievably long period of time – for as long as 15 years, says Prince Williams, consultant media coordinator for AWC.
The centre last Saturday joined the rest of the world to commemorate the World Fistula Day by embarking on a community outreach session that took its members to nearly half a dozen slum communities in Freetown with messages of prevention and timely treatment. Williams, who coordinated that outreach, speaks of a worryingly high number of young girls suffering from the condition.
Teenage pregnancy and fistula
At the AWC, Kosia says most of their patients for fistula are below 19 years and are mostly from the provinces.
“This is because in the provinces once you are 12, 13 years old, you are given to a husband…It is really painful to hear some of their stories,” he says.
But AWC`s family planning programmes also gives them an idea of potential hotspots for the condition in Freetown, where most of the center`s programmes are currently concentrated – Kroo Bay, Congo Town, Crab Town, all slum areas, and part of Aberdeen – where the week end`s outreach targeted. Williams says these communities are also known for high teenage pregnancy rates. Yet fistula is particularly serious among young girls because their reproductive organs are young, weak and fragile, so that they are susceptible to the condition.
This is how the UNFPA explains the condition: “The sustained pressure of the baby’s head on the mother’s pelvic bone damages soft tissues, creating a hole—or fistula—between the vagina and the bladder and/or rectum. The pressure deprives blood flow to the tissue, leading to necrosis. Eventually, the dead tissue comes away, leaving a fistula, which causes a constant leaking of urine and/or faeces through the vagina.”
At Saturday`s session, Williams says they saw girls as young as 14 and 13 pregnant. He says Kroo Bay was particularly exploding with teen pregnancy.
“Based on our experience, we realized that there is need for more sensitization especially among young girls,” he says.
The halt in the fistula operation at the AWC has obviously led to a backlog of cases. And the center, says Kosia, is contemplating a ‘surgery camp’ which will see them do a massive surgery exercise, so as to clear the backlog over the last year of the Ebola epidemic. The preparations towards this include the daunting task of getting a foreign surgeon to do the job, since there are no known Sierra Leonean surgeons with the expertise.
After surgery, fistula patients are supposed to put behind them their problems, but Kosia says this is hardly the case. In many cases, he says, acceptance back into the society proves difficult. AWC has introduced skills enhancement components into their recovery programmes for the women while they recuperate at the center.
The center`s fistula ward has a bedding capacity of 60 at every point in time. But because of high demand, which also points to the prevalence of the condition, those who have undergone surgery can only be held for a period of time, after which they will have to go home. They are advised strongly against sexual activities for up to a particular period of time. But some husbands have proved difficult to cooperate here, says Kosia. He explains that at that stage of the post-surgery recovery if pregnancy sets in the damage caused is even more extensive.
AWC has therefore thought of involving husbands of sufferers into its fistula reintegration programme, thereby letting the men be part of the process and know the dangers of forcing their wives into untimely sex.
© Politico 27/05/15
