MSF fistula camp in Boguila, Central African Republic (CAR). MSF midwife Sigrid Kopp sits with a fistula patient to make sure she drinks enough water. Patients must drink large amounts of water before and after surgery so that their urine is not concentrated. Approximately two million women in Africa have a fistula, which is a hole between the vagina and the bladder or rectum, through which urine or faeces leak continuously. Fistulas can be caused by prolonged obstructed labour and childbirth or sexual violence in addition to lack of medical facilities. Women with fistulas are often outcasts from their communities because of the smell associated with the leaking of urine/faeces, and in some cases they are abandoned by their husbands. Chances for women to have their fistula repaired are slim, as many hospitals or health clinics do not have the proper instruments or knowledge and skills to carry out such a procedure.

What problem did these women have?

“Pregnant women in remote areas often have difficulty accessing health facilities where skilled staff can support them during delivery, or have no access to health centres at all. The biggest problem is known as “the three delays”: delay in recognising a prolonged labour, delay in referral or getting to a health facility (due to lack of transport or lack of a proper road, bridge etc) and delay in an appropriate response from the health facility.

“A prolonged obstructed labour can result in an obstetric fistula, which is when an abnormal connection forms between the bladder or the urethra and the vagina. This can then result in incontinence. Often there are social ramifications to this, for example their husband or family may abandon them, leaving them in a situation of social isolation.”

Can it be solved?

“The physical problem can be addressed by a specialised surgeon. Although the operation itself is not complicated, it requires a surgeon who is specifically trained and experienced in carrying out this type of surgery.

“Volker Herzog, the surgeon on the project in Central African Republic, regularly performs three surgeries per day, along with the surgical team.”

What was your role?

“My job was to set up the camp, put a team together and make sure we had the right facilities (clean drinking water, beds, toilets etc). Before my arrival, the team on-site would get together the women who needed surgery. I then trained the team on how to provide the women with curative support, especially for during the long post-operative care. After surgery, the women have to stay in the camp for three to five weeks to recover. Apart from the curative care, we focused on prevention and raising awareness for the problem. We gave training on prevention and management of obstructed labour, and how to recognise and care for fistulas, as well as awareness sessions to traditional birth attendants and the community.”

Spirit

“A fistula camp is full of unbelievably sad stories. Each and every woman had experienced an obstructed labour and, in most cases, had lost a child during delivery. And then, after all the pain and suffering, she is left incontinent, abandoned and outcast by her community. Their stories are all very touching. In the camp, the women are glued together, sharing the same fate. There is a great empathy and understanding among them. All the patients and their caretakers supported the patients who came alone. You could feel the spirit of respect, help and support in the camp.”

Drinking like an ox

“There is one woman in particular, who I will never forget. She had had seven pregnancies and seven deliveries, but all of the children had died. She had had a fistula for over 20 years, and she was also half-blind and could not hear very well. She was a tiny old lady and she had come alone, without anyone to support her or take care of her. In the beginning, we had our doubts: would she be able to tolerate the tough drinking regime of four to six litres per day, in order to prevent infections? However, every midwife in the camp immediately "adopted" her and all the patients loved her. We all supported her and encouraged her to drink water, which sometimes annoyed her terribly: "Je doit boire comme un boeuf!" she would say, or “I have to drink like an ox!!” In the end, her operation was successful. To see her joy and relief was an overwhelming pleasure.”

Looking back, how do you feel?

“I found the work very rewarding, as contact with the patients was very close. After all those weeks I felt like I had a bond with every woman. There is joy, the women are very grateful and relieved. They feel have had their lives, dignity and well-being given back to them.

“But there were also hard moments and tears, for example, when in some cases it wasn’t possible to close the fistula. When I left, the women all came out to the airstrip to wave me off. The sight of them waving to me as the plane took off - that is definitely an image that is burnt on my heart and mind.”

Sigrid describes what took place in one of the MSF fistula camps, from mid-November to the end of December 2010 in Boguila, a town in western Central African Republic. Sixtyfive women were operated on. It is the second of two fistula camps that MSF organized in the country, the first of which in 2009. A third camp is planned for late 2011. In Boguila, MSF runs a hospital and supervises a number of health centres in the surrounding area. Between 85 and 88 per cent of fistula operations are successful.