The UNFPA-led global campaign works to prevent obstetric fistula a devastating and socially isolating injury of childbirth, to treat women who live with the condition and help those who have been treated to return to their community. This campaign is active in over 50 countries working not only to prevent fistula, but also to give fistula survivors a way of reforming their life after treatment. The campaign focuses mainly on providing training and funds to support women living with fistula, and also programmes for survivors.
Over 2 million women worldwide have an obstetric fistula, with the majority of cases occurring in resource-poor countries. Afflicted women tend to be young, poor and have little or no access to medical care. Because they are incontinent, these women become ostracized and shunned by their community. Most obstetric fistulas are surgically correctible, although surgical outcomes have been poorly studied. Programmes that improve nutrition, delay the age of marriage, improve family planning and increase access to maternal and obstetric care are necessary to prevent obstetric fistula.
Sex and childbirth go hand in hand, but in many places for women, it can end in obstetric disaster causing the impossibility of ever having sex again. In January 2020 I visited the Addis Ababa Fistula Hospital in Ethiopia. (https://hamlinfistulauk.org/what-we-do/) The hospital has treated more than 50,000 women who suffered from obstetric fistula. An obstetric fistula is caused by prolonged labour during which time contractions continually push the baby’s head against the woman’s pelvis. The soft tissue caught between the baby’s head and the woman’s pelvic bone becomes compressed, restricting the normal flow of blood. The baby’s head enters the vagina, but the shoulders cannot pass through the bony pelvis. Without access to medical care to relieve the obstruction, the woman may remain in labour for days. The baby’s head compresses the vaginal tissue and there is widespread damage to the soft tissue. When the baby dies from asphyxiation, it is expelled, leaving a hole between the vagina and bladder or vagina and rectum.
Without an adequate blood supply, sections of tissue die, leaving holes–known as “fistulae” –between the vagina and her bladder or rectum. It is these holes that cause incontinence. If untreated, the woman will leak urine, faeces or sometimes both, uncontrollably, for the rest of her life. Most of these women lived too far from a hospital to have a safe and controlled birth. Women in rural Ethiopia with fistula become estranged from their husband/partner and leave to live with relatives, some have to divorce. Many lose social functioning, self-esteem, financial hardship and stigma. This isolation and abandonment have led some women to suicide. The Addis Ababa Fistula Hospital in Ethiopia has focused on preventing recurrent fistulas. They discharge cured patients with strict instructions that in their next pregnancy they must travel to a nearby health centre when they are close to in order to have a caesarean delivery.
Sex after fistula surgery is, of course, possible but a woman should not have vaginal sex for at least six months. This can be problematic with a demanding partner who hasn’t had sex with his wife for many months. These are parts of conversations from focus group discussions in Uganda:
When he is badly off he insists on having sex and after forcing you, you get wounds all over the place. In fact, penetration is painful. It’s actually rape because; there is no feeling at all but for him, he insists on having it done.
The few participants who still wanted to have sex were challenged by the fact that husbands divorced them to marry other wives. Women reported that in this setting, men are culturally the initiators of sex. Therefore, the women felt that being divorced and yet being unable to initiate new sexual relationships was a violation of their sexual rights. The women thought a fistula had stood in their way, even when they still had a desire for sex.
Our rights were violated. We don’t play sex; not because we lack feelings; … this condition [fistula] made our husbands- the custodians of sex, leave us for other women. Men no longer want to socialize with us and ask for love [sex] because of our condition …yet sometimes we have feelings for sex.
Most of the participants had completely abstained from sex. Others assumed that almost all women with a fistula were not having sex. The participants feared being talked about if sex did not go right and, hence, decided to avoid it altogether.
I feel I cannot be loved again. …In my mind I ask myself who will come to me and say that I love you when I am in such a condition. I lost hope of getting another partner in life.
There is an excellent set of programmes called FistulaFactFriday on YouTube
Hazel Slavin
External Examiner MA, MSc. Dip. Human Sexuality
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