Working towards Fistula Eradication: An Issue of Rights, Development, and Dignity
By: Dr. Fikrejesus Amahazion
Obstetric fistula is one of the most serious and traumatic childbirth injuries occurring in the world today. In Eritrea, one of many countries where obstetric fistula continues to occur, there has been a strong and longstanding commitment to prevent and treat the condition, as well as to rehabilitate and empower fistula survivors.
A hole between the birth canal and bladder and/or rectum bladder that causes uncontrollable urinary incontinence or feces to leak, obstetric fistula robs affected women and girls of their health, fundamental rights, and basic dignity. The development of obstetric fistula is directly linked to one of the major causes of maternal mortality: prolonged, obstructed labor, which can occur as a result of a lack of access to timely, high-quality medical assistance or emergency intervention during childbirth.
The array of physical, social, and psychological consequences of fistula are devastating, with the lives of those afflicted with the condition being characterized by tremendous pain or suffering and chronic medical problems. In particular, the condition can lead to frequent skin infections, ulcerations, kidney disease, painful sores, infertility, and even death if left untreated. It can also lead to segregation and isolation; misperceptions and the smell from constant leakage of urine, feces, or both, isolate women who are often shamed and stigmatized, abandoned or neglected by their friends, families, or neighbors, and ostracized by their communities. Women and girls with the condition may also suffer from depression and suicidal thoughts, along with other serious mental health issues. Additionally, those suffering from fistula are often unable to work or continue with viable livelihood opportunities. As a result, they may be forced into further poverty, greater vulnerability, and a decreased quality of life.
According to estimates from several international organizations, more than 2 million women and girls live with untreated obstetric fistula worldwide, with between 50,000 to 100,000 women and girls around the world developing obstetric fistula every year. Although obstetric fistula has been virtually eliminated in developed, industrialized countries (one leading factor is that these countries possess high-quality health care systems and skilled professionals who can perform Caesarean sections), many women and girls in parts of sub- Saharan Africa (SSA), Asia, the Arab region, Latin America, and the Caribbean are living with this injury (or at risk). Additionally, even while women of all ages may be at risk of experiencing obstetric fistula, young girls are particularly vulnerable because their bodies may not be ready for childbirth and the pelvis may not yet be fully developed.
As with many other countries in SSA (and across the broader developing world), obstetric fistula continues to be an issue of concern in Eritrea. The prevalence of fistula in Eritrea is estimated at approximately 34 per 10,000 women, with prevalence higher among females under 18 years of age. Additionally, obstetric fistula contributes to maternal deaths (the overall maternal mortality ratio was estimated to be approximately 184 per 100,000 live births in 2019, while globally it is estimated that obstructed labor accounts for up to 6 percent of all maternal deaths). Furthermore, a considerably large percentage of obstetric fistula cases result in stillbirths.
Addressing obstetric fistula remains a vital part of the country’s larger reproductive and maternal health efforts, with Eritrea aiming to eradicate the condition in the near future. Similar to many of the country’s other highly successful health-related interventions, Eritrea’s efforts to address fistula are based on a comprehensive and multifaceted approach.
The Ministry of Health (MoH), in close cooperation with a number of local and global partners, provides women and girls with fistula-free repair services, coverage for transportation, and a comprehensive rehabilitation program. Eritrea’s National Fistula Diagnosis and Treatment Center (NFDTC), based in Mendefera, is dedicated to treating and rehabilitating victims of fistula. It is equipped with modern equipment and provides free diagnoses, treatment, care, and accommodation services to patients from different regions of the country. Over the years, repair and rehabilitation treatments have maintained a high success rate, ultimately helping to restore survivors’ health and hopes and empowering them to reclaim their lives and dignity.
A critical part of the overall treatment process is a follow-up, with women and girls receiving regular check-ups to ensure they do not redevelop the injury again. Fistula survivors also have access to psychological, emotional, economic, and social support in order to help them fully recover from their ordeal. In addition, the MoH, the NFDTC, and various other partners work together to provide survivors with counseling and promote their reintegration into the community (e.g., by offering life and job skills training). Importantly, communities are also targeted for engagement, in order to reduce stigma and misperceptions, as well as to raise general awareness about the importance of antenatal care and delivery within health facilities.
In addition to repair and rehabilitation, prevention is a part of holistic efforts to address the condition. Notably, many of the interventions that promote reproductive and maternal health or women’s rights are also key for preventing obstetric fistula.
National laws and firm enforcement measures prohibit harmful, traditional practices, such as female genital cutting/mutilation and child or underage marriage, while there is increasing community awareness and understanding of their dangers. Although these practices were once highly pervasive across Eritrea, they are now far less common – in fact nearing elimination – and thus contributing to reducing the occurrence of obstetric fistula.
With obstetric fistula closely associated with poor access to and quality of care, Eritrea’s progress in expanding access to health and quality of care has been vital. The country has constructed and renovated many health facilities, as well as considerably increased the number of doctors and health professionals. There are now 335 health facilities distributed across the country (comprising hospitals, health centers, health stations, and clinics) – a nearly fourfold increase from 1991, while the number of doctors has been increased from 100 in 1997 to 291 by 2021. Across the same period, the number of nurses rose from 625 to 1,474, assistant nurses from 1,220 to 2,918, and specialized doctors from 5 to 74.
Distribution has also been improved, with more health workers now serving in rural and hard-to-reach areas. Approximately 80 percent of the population lives within a 10-kilometer radius of a health facility and 70 percent within a 5-kilometer radius.
Parallel to these advancements, there has been steady national progress with regard to the proportion of births attended by skilled health personnel. In 2019, the proportion of births attended by skilled health personnel was approximately 71 percent (it was around 6 percent at independence), while the percentage of pregnant women attending at least one antenatal care visit is now about 98 percent, up from less than 20 percent at independence.
Finally, some of the other deeper or underlying factors that contribute to women’s and girls’ marginalization and are linked with the occurrence of obstetric fistulae, such as lack of access to education, persistent poverty, and gender and socioeconomic inequality, are also being addressed. For instance, massive strides in education for women and girls in Eritrea have played a pivotal role in promoting their agency, autonomy, and decision-making enhanced their understanding and utilization of health services, helped to raise the age of marriage, and contributed to allowing them to better control the number, timing, and spacing of their children and avoid unintended pregnancy.