Healing old wounds

The Incredible Journey of the Unfortunate women with Obstetric Fistula

The Fistula Hospital is an Ethiopian landmark. Located in Addis Ababa, the hospital and the Hamlin Fistula Centers were founded by Catherine Hamlin (MD) and her husband Reginald Hamlin (MD) in 1974. In the time since then, Hamlin and her work have become well known throughout the world. The hospital provides service for women suffering from obstetric fistulas, often caused by extended labour without access to medical care. Women with this condition often find themselves isolated from their communities and families, with no way to support themselves. The treatment they get at the hospital often gives them a new lease on life, as EBR’s Kiya Ali observed.

Kelem Tesfaye, a 24 year old woman from Dessie, is one of the many women in Ethiopia who were married before the age of 18. She was just 13 years old when she was forced to marry, an arrangement made by her parents. A few months later, she got pregnant. Although she didn’t really understand what motherhood would mean, she was still excited, happy and eager to meet her child. However, her delivery didn’t go as expected. “I was in labour for three days,” she says. “It was very hard.”

At the end of the ordeal, Kelem’s baby was stillborn. She also found herself suffering from a condition that affects millions of women worldwide: an obstetric fistula.

Obstetric fistulas are most often caused by obstructed labour, during which the mother cannot access skilled medical care. Obstructed labour can happen if the baby is too big, or poorly oriented, or the pelvis is too narrow to allow the baby’s head to pass safely through the birth canal, as is the case with many victims of early marriage, like Kelem.

The pressure of the baby’s head for a prolonged time on the blood vessels supplying the tissue of the vagina, bladder, urethra and rectum cuts off the supply of oxygen and leads to the death of the affected tissue. A hole called an obstetric fistula develops between adjacent organs, from which urine or faeces or both constantly leak. According to some studies, around 93Pct of obstetric fistula survivors give birth to stillborn babies.

After her childbirth experience, Kelem found herself struggling to find someone to help her. “My case was beyond the capacity of the hospital I went to. They wrote me a referral to the Mekelle fistula hospital,” Kelem explains.

After she got medical treatment she went back to her husband. But like many women with the condition, Kelem’s husband left her. Her parents died soon after her diagnosis, so she had no choice but to stay with her siblings. To make things worse, the treatment didn’t fully cure her: she found that the urine leakage from which she suffered hadn’t fully stopped.

“I have one brother and six sisters. All of them were intolerant of me. My brother physically as well as verbally attacked me and finally threw me out of his house,” Kelem says. The society that she grew up also ostracised her, and she was forced to leave the place she was born. When she remembers her experiences, even now, her eyes fill with tears.

Kelem’s journey is a showcase of the ups and downs women with fistulas go through in Ethiopia. In fact, when Catherine Hamlin (MD) and her husband, the late Reginald Hamlin (MD), who established the Addis Ababa Fistula Hospital, came to Ethiopia in 1959, it was the suffering of women like Kelem, who found themselves with nowhere to turn, that persuaded them to stay in the country.

When Hamlin and her husband first came to the country, their primary aim was to address the shortage of maternal health training and services. Based at the Princess Tsehay Memorial Hospital, they became pioneers in performing surgery for women suffering from obstetric fistulas.

During their contract period, Reginald and Catherine operated on 300 fistula patients. “We were touched and appalled by the sadness of our first fistula patient: a beautiful young woman in urine-soaked ragged clothes, sitting alone in our outpatients department away from the other waiting patients. We knew she was more in need than any of the others. And so we saw the first of many fistula sufferers,” Catherine wrote, in a piece published in the Guardian in May 2014.

Later, the need for such services became so overwhelming that it led them to establish the Addis Ababa Fistula Hospital to serve women with child birth injuries. “It was established with the hope of eradicating obstetric fistula from Ethiopia,” explains Aschalew Tadess, communications expert at Hamlin Fistula Hospital. Since its inception Hamlin Fistula Ethiopia has treated almost 55,000 women suffering from obstetric fistulas.

According to the World Health Organisation, around two million women in developing countries live with fistulas. The Ministry of Health estimates that there are between 36,000 to 39,000 women in the country living with fistulas, and that between 3,300 and 3,750 new obstetric fistula cases occur every year. Only a fraction of them can get treatment. Obstetric fistula is one of the major causes of maternal mortality.
Hamlin Fistula Hospital Addis Ababa is found in the Torhailoch area of Addis Ababa, and covers 6,000 square meter. The hospital compound is clean and nestled in a grove of trees, offsetting the urban surroundings. New patients wait on a veranda near the gate, while patients awaiting their turn for surgery and medical treatment sit in the holistic center while chatting, watching television and doing handcrafts and those who just get out of surgery are seen lying at the hospital beds.

At the moment, the hospital is capable of serving 4,000 patients every year. However, only 2,500 to 3,000 victims come to the hospital and for medical treatment annually. “The majority of women who suffer from fistulas are found in rural areas. They don’t have the communication channels to get the necessary information regarding fistulas and our hospital. Although we are working on awareness creation, patient identification remains our biggest challenge” explains Aschalew Tadess, communication expert at Hamlin Fistula Ethiopia.

According to the Ethiopian Demographic and Health Survey 2016 report, only four in 10 women aged 15- 49 have heard of obstetric fistulas in Ethiopia. Less than one percent of women report that they have experienced the condition.

The lack of education and awareness of obstetric fistulas, and the inability of many medical facilities to treat the condition, creates an environment where sufferer, like Kelem, find themselves isolated from their communities due to the smell created by leakages, the mistaken perception of venereal diseases, and in some cases, infertility. Many of the patients seeking treatment at the fistula hospital also concurrently suffer from psychological issues. In addition, the lack of medical, sanitation and water facilities in close proximity to many rural dwellers causes the problem to get worse.

“Almost all the fistula survivors who come to our hospital are from rural areas. As a result most of them can’t find water from nearby. They have to walk long distances to fetch water. This can exacerbate the situation, and lead them to more horrific life,” Aschalew stresses.
The Hospital currently works in three major areas. The first area is treating patients by providing the necessary medical facilities and personnel. The other is prevention. Since its establishment in 2007, the Hamlin College of Midwifes has trained 145 students from various parts of Ethiopia’s rural areas for free. The cost of training midwifes is USD4,000 for one student and it takes four years to graduate. However, graduates have the responsibility to serve their home communities for four years. “Since they know the local language it is easier for them to communicate with women who are found around their residence,” Aschalew says.

The third area is rehabilitation. The rehabilitation centre has two sections. Every survivor of fistula is given holistic training for one month during their stay at the Hospital after surgery. However some of them have to undergo diversification surgery. These patients get three months’ training. The idea is to provide the women with skills and resources to rebuild their lives that are too often destroyed by their illness.
In addition to medical treatment the patients can also access chaplaincy services. “As a result of the discrimination and hardship they have been through, many of the patients blame their God for what has happened to them. Thus we provide them with spiritual support, talking with them, reading the Bible and praying together,” Zenebe Mesfin, chaplain at Hamlin Fistula Addis Ababa, said. “We also call religious leaders if they need them, or during the last minutes of their life. This is especially important for patients who are not near their homes.”
For as much good as the hospital does for the community, they face various challenges as well. The annual cost of running the Fistula Hospital is between six and seven million dollars. It gets all of its running costs from donations, mostly raised by a board of eight trustees, including the Catherine Hamlin Fistula Foundation, established by Hamlin in 2012. Being fully dependent on charity is the biggest challenge for Hamlin fistula Ethiopia. “The major hardship we are experiencing now is being completely dependent on donations. However, we are working to develop strategies that would allow us to raise our own money,” says Aschalew.

Still, there are silver linings for many of the women who come to the hospital looking for help, even though their lives take turns they never imagined. One of them is Manayesh Amare, a 28 year old woman who lost her unborn children six times because of delivery complications, including fistula. Her first childbirth experience was when she was 15 years old. Like Kelem, it was a very difficult experience, and resulted in her losing her child. “One year after I got married I had a stillborn baby. I was very sad but when I figured out that I couldn’t control my urine I was very shocked,” Manayesh tells EBR.

At the time, since she didn’t have the money, the doctors and nurses at the clinic where she had gone for diagnosis collected money and sent her to Hamlin Fistula hospital in Addis Ababa. She underwent surgery and recovered. Ten years later, after repeatedly trying to carry a pregnancy to term, she finally reached the eight month mark. “During my eighth month of pregnancy, something unexpected happened. I suddenly went into labour. My husband and my neighbours took me to the nearby hospital. However, I lost my child for the sixth time and I developed a fistula again.”

She has currently finished her treatment and is getting ready to go home. In spite of her many losses and her surgeries, Manayesh is still optimistic about her new life. “I am so happy that I can sleep on a dry bed now,” she says with a smile.

At the heart of it, that is what the Hamlin hospital and health centres provide for women: a new start. Once they have recovered from their treatments and have undergone training, many of the women find themselves with futures that are even brighter than before.
For her part, Kelem is still hopeful about the future despite her continued suffering. Kelem got pregnant again three years after her first childbirth experience and fistula, she was ecstatic over this second chance at being a mother. Yet her happiness was distorted during her labour, when she again developed a fistula, for which she is currently awaiting treatment.

This time, though, there was a silver lining to the cloud. “I had a C-section,” she tells EBR. “My daughter will be three years old in a month. Even though my boyfriend rejected his daughter and me I’m so happy to be a mother.”

8th Year • Mar.16 – Apr.15 2019 • No. 72