"The sun should not rise or set twice on a woman in labour." Despite this proverb, endless labours before delivery are legion in Africa, where a majority of women give birth at home. When they finally come to the hospital, it is often not only too late for the newborn, but sometimes for the mother.

Among women who survive this ordeal, many emerge infirm. Obstetric fistula is one of the most serious consequences of obstructed labour and occurs when the soft tissues of the pelvis are compressed by the baby’s head. The lack of blood flow causes the tissues to die, creating a hole between the vagina and bladder, the vagina and rectum, or both. It results in urinary and/or faecal incontinence. Women with fistula live in shame and are often rejected by their own families and communities.

An estimated two million women live with fistula worldwide, most in Africa. This problem is largely hidden because it often affects young women who live in poor and remote areas, with very limited to no access maternal health care.

Women affected are like Zanaba, 16, a patient treated by MSF last year in the Central African Republic (CAR). At the end of her pregnancy, and after three days of intense pain, her mother went looking for a traditional birth attendant.

On the seventh day, Zanaba was brought to the nearest hospital after travelling the entire day on a motorcycle. When she arrived, the baby had already died. The young mother was saved but the prolonged, obstructed labour caused a fistula, which required a second surgery. “I did not know that fistulas exist and how the can occur. But I am glad that I receive the operation.”, she said.

Improve access to obstetrical care

On March 8 and 9, MSF will organize a workshop in Geneva to improve the management of fistulas. The meeting coincides with International Women's Day  and will bring together actors involved in fistula treatment: surgeons, experts working for MSF and for other organizations.
 
Fistulas are largely preventable and have disappeared in developed countries where there is universal access to obstetric care.

The operation to close a fistula is delicate and requires specific skills. Depending on the severity of the case, the operation may take several hours. In order to operate on fistula, a long and specific training is needed and there is only a few specialised centres in Africa.

Treating fistulas far exceeds the surgical aspect. Because of the flow of urine and faeces, affected women can develop multiple infections or skin diseases. Following childbirth, they may also have difficulty  walking  and, because of their exclusion, they are likely to suffer from malnutrition. After surgery, in case of residual incontinence, patients often require a physiotherapeutic rehabilitation. Psychosocial care is also needed in order to reintegrate the affected women into their communities.

Camps to treat fistulas

In their operations worldwide, MSF doctors have always been faced with women suffering from fistula. In 2003, MSF organized its first fistula camps in Ivory Coast and Chad, then, in subsequent years, in Sierra Leone, Somalia, Democratic Republic of Congo (DRC), CAR or Mali. These ad hoc interventions are continuing today in DRC and CAR.

“MSF usually works in insecure or war-torn countries. That is why we chose to set-up short projects," explained  Michiel Lekkerkerker, medical advisor for MSF in Amsterdam. "Fistula camps, as we call them, are installed for two months next to existing hospitals. Before we set up the camp, the population is informed so that women with fistula come for consultation. Then we hire additional employees and we prepare between 40 and 80 beds, usually in tents. The surgeon stays about one month on site and operates on several women a day. This method has the advantage of flexibility and it is easier to find a specialised surgeon for a short period. "

Three permanent centres in Burundi, Chad and Nigeria

Today, MSF treats obstetric fistula in three permanent centres in Burundi, Chad and Nigeria.

The latest location to open its doors is the  Urumuri centre, backed by the regional hospital in Gitega, in the heart of Burundi,  and opened its doors in July 2010. This is the first centre specialising in fistula in Burundi, able to treat women seven days a week and MSF has built four houses to accommodate the patients before surgery and during rehabilitation.

"This kind of project ensures a better monitoring of patients and it is possible to do research to improve treatment," said Geert Morren, surgeon and fistula specialist at MSF in Brussels and who operated on many of the women in Gitega. "The objective is to operate on 350 women per year over three years. This time frame should allow us to train three Burundi surgeons and to transfer our activities to the Ministry of Health."

In Burundi, in addition to the specialised centre in Gitega, MSF built a maternity unit in another region of the country. The plan is to prevent the occurrence of fistulas by improving the obstetrical care available in Burundi.

In Abeche, eastern Chad, the project “butterfly” started in 2008. The butterfly symbolises the transformation of women who lived secluded lives and can begin a fresh start after their operation. En 2009, MSF built a “village of women” to accommodate patients with fistula during their weeks long stay. During the first consultations, a preoperative evaluation is done to screen malnutrition cases that will be taken care of before the surgical intervention. After their operation. Counselling and rehabilitation sessions allow them to regain a place in society.

MSF works with a Chadian surgeon. Dr. Valentin Valandi, who graduated in Dakar, is specialising himself  in fistulas thanks to the visit of international experts. "Each case is different, I learn every day,” he said. “In Chad, too many women have already been operated upon inappropriately, which further complicates the procedure.”

In Abeche, MSF also supports the regional maternity hospital, next to its “butterfly” centre.The objective is to improve obstetric care in order  to prevent new cases of fistula  occurring because of poor management of difficult deliveries.

In Nigeria, finally, MSF works with the staff of the Ministry of Health at a hospital in Jahun in the north of the country. The teams provide obstetric and neonatal care to the local population. The objective is not only to reduce maternal and infant mortality but also to prevent and treat fistula. In 2010, the MSF team carried out 400 fistula repair surgeries. Upon discharge from the hospital, women receive six months of outpatient follow-up care to ensure the fistula has healed and that continence is maintained.

In 2010, MSF teams have operated and treated about 1000 women suffering from obstetric fistula.