UGANDA: Surgery in Uganda that Restores Dignity to Women

Fistula is the name given to a hole between the bladder and vagina, or rectum and vagina, or both. This is what happens to the young girls of the developing world in countries such as Uganda when they suffer prolonged, unassisted, difficult labour and delivery in circumstances of poverty, malnutrition, isolation and ignorance.

The pre-adolescent girl, raped or rendered pregnant by a similarly unprepared teenager, is physically immature and psychologically unready to procreate and bear a child. When a small-statured woman has an obstructed, difficult labour over two to three days in rural conditions with no professional help, no antenatal care (less than 38 per cent of women in Uganda attend antenatal clinics or seek professional assistance) and without money for transport with poor roads and services, you can predict the outcome:
1. The baby dies (99 per cent of the time in fistulised women);
2. The mother is dehydrated, exhausted and infected – in many cases the native midwife or traditional birth attendant (TBA) will have tried to intervene or maybe tried a few of her ‘treatments'. TBAs are untrained, unskilled companions of women in labour;
3. The constant pounding and pressure of baby's head against the mother's delicate tissues and tight, bony pelvis result in severe damage to tissues of the walls of vagina, bladder and rectum (20 per cent of cases), resulting in fistula and incontinence of urine and stool.
h4. Loss of self-worth
Imagine this scenario:
* Being constantly wet, smelly, uncomfortable; full of shame, suffering a loss of self-worth and dignity; being deserted by your husband/partner and having to go back to your mother to live in an outside ‘lean-to' hut (because of the smell);
* Trying to come to terms with your baby dying;
* Having a lame step due to sciatic nerve crush damage (foot drop);
* Being shocked and dehydrated;
* Suffering haemorrhage;
* Suffering from infection.
Sixteen women die daily in Uganda from pregnancy-related causes – nearly all these deaths have preventable causes. The ones with fistulae are the survivors. More than 140,000 (Ministry of Health, 2008) girls with fistulae are presently awaiting repair and new cases occur daily. They do not know how they can be helped and are too ashamed to seek help in the first place.
I went to Nigeria to Dr Ann Ward, FRCOG, in Anua MMM Hospital, to train in fistula-repair surgery before going to Uganda in 1993. Kitovu Hospital has provided fistula-repair services since then.
I have welcomed surgeons and gynaecologists from the UK to Kitovu two-to-four times a year to undertake fistula-repair sessions. Some 30-40 women attended each time, but they had to find some funds to cover expenses because they were poor.
To help them, through funds from generous friends in the UK and Ireland, I helped to build a special unit. Since 2004, Kitovu has been recognised as the first Fistula Repair and Training Unit in East Africa sponsored by USAID, UNFPA, plus Friends of Kitovu and supported by the Ministry of Health in Uganda.
Over 1,300 fistulae have been repaired successfully, rendering these poor women dry and continent and with restored dignity and self-esteem. Many also have been successful in having a safe delivery (by Caesarean section) and live births after repair.
Since 2007, Africara Ireland has offered to help with fistula repair and prevention in Kitovu, and fundraising in Ireland has been successful in building a fistula operating theatre in Kitovu Hospital specially dedicated to fistula work, which was blessed and opened on November 22 last year.
Already, 120 successful repair operations have taken place in the new theatre. Now Africara is helping to fully equip the new theatre and we hope to increase our fistula repair to 1,000 repairs annually, on a more continual basis.
But for this, we need a full-time fistula surgeon (experienced in obstetric fistula-repair surgery). Since 2004, we have had four fistula-repair training workshops with trainers from the UK, Zambia and Ireland. Each session has successfully repaired over 60 cases (240-300 per annum) and training of two teams each session. A team consists of: one doctor (from government or the Mission Hospital); one anaesthetic officer, one theatre nurse and one ward (post-operative care) nurse.
We encourage at least two training sessions for the trainee doctor before being certified to perform repairs. Doctors from Uganda, Congo, Angola and Rwanda have trained in performing simple repair surgeries. They are encouraged to return to train further to master repair of some complicated fistulae.
These work camps were partially funded by USAID/UN Funds but funding was inconsistant and we had to look to Ireland and friends for help. Special thanks to all our donors.
Fistula repair and care of women with fistulae – accompanying them through surgery, physiotherapy (for dropped foot or sciatic nerve damage), recovery and re-integration into the community again – is one of the most satisfying, rewarding and worthwhile ministries in healthcare.
Now we need to tackle prevention through education, quality maternal services and emergency obstetric care.