Eritrean women waiting for surgery in Massawa

(WOMENSENEWS)–When Maureen Snider looks back on her first trip to Africa, she remembers the beautiful, brightly colored garments worn by the women of Eritrea, a small eastern African country that borders the Red Sea.

She also remembers the women’s shame as theirclothes were stained by urine leaking out ofthem every time they stood up.

Snider, 51, a nurse since the age of 19, traveled to Eritrea in February with a group of five doctors and one recent college graduate as part of the Eritrean Women’s Project, a gynecological surgery mission to repair the physical damage caused by prolonged labor, a condition known as obstetric fistula.

Led by Dr. Mary Lake Polan, the chair of Stanford University’s department of obstetrics and gynecology, the group performed free fistula reparation surgeries on about 50 women in the arid coastal city of Massawa.

“Some of the women were terrified,” Snider said. “One woman held my hand through the whole operation, and at one point she looked up and told me, ‘I will be promised to you.’ She meant, ‘If I get through this okay, I will do anything for you.'”

Caused by Protracted Labor

Fistula is a condition caused by difficult, protracted labor in which the fetus’ head presses against the mother’s pelvis so hard that it cuts off the blood supply to the area and kills the surrounding tissue.

The result is a small, abnormal pipe-like opening, or “fistula,” usually between the bladder and the vagina, that causes the woman to leak urine and stool uncontrollably. The smell and the rashes and infections are further reminders of a devastating labor that more often than not results in stillbirth.

In the United States, fistulas have gone the way of tuberculosis and polio; if they occur at all, they are quickly treated by a doctor opening up the fistula channel to promote healing from the inside out. Surgery to repair a fistula usually only takes about 15 minutes, Snider said.

Yet in parts of the world where poverty has limited or eliminated women’s access to natal care, the fistula problem is dire. According to the New York-based United Nations Population Fund, nearly half of all women in the developing world give birth without any medical assistance. The World Health Organization estimates that two million women are currently living with fistula, and the problem is increasing at a rate of 50,000-100,000 new infections each year.

Ostracized by Condition

“I would ask women in their early 30s how many stillbirths they had had,” Snider said. “Sometimes it was as many as five and they had been incontinent for eight years. Many of these women had been ostracized; they weren’t even part of their own families anymore.”

It was this social isolation–due to a problem so easily treatable–that prompted Stanford’s Polan to create the Eritrean Women’s Project.

Polan first became aware of the situation in Eritrea in 2000, when she traveled there to research women’s health issues for her master’s degree in public health. She came back to California intending to set up a surgical mission to the capital city, Asmara. In October, 2002, she and three other doctors went over there and treated 37 women.

“There were still more lined up outside,” she said. “When we left, I knew we hadn’t yet done what we needed to do.”

The second trip, to the coastal city of Massawa this past February, was even more successful. Many of the women the group treated had heard about the doctors’ visit and had traveled huge distances to get to the hospital, sometimes walking for days, Polan said. She and her colleagues hope to return to Eritrea next spring to work on a community medical project and continue training Eritrean doctors and nurses to perform the surgeries.

Internationally Recognized Problem

The fistula problem extends far beyond Eritrea, and has received international recognition. In 1994, at the International Conference on Population and Development in Cairo, 179 countries acknowledged that empowering women and meeting people’s needs for education and health–including reproductive
health–should be of utmost importance on both a local and global scale. The countries pledged that by 2015, there would be universal access to reproductive health care, including family planning, prevention of sexually transmitted diseases and assisted childbirth to lower the incidence of fistula and other health risks.

As the 10-year mark approaches, that promise has not been fulfilled. Efforts have been made, including generous funding from the Seattle-based Bill and Melissa Gates Foundation, and various projects led by groups such as the U.N. Population Fund and EngenderHealth, a nongovernmental organization in New York City that works to support and strengthen reproductive health services around the world.

Yet advocates and doctors such as Polan feel the problem is being sorely neglected

To help increase awareness, a documentary team from New York City traveled to Niger in August 2003, to make a film about obstetric fistula that would inform the public through the powerful, often heartbreaking stories of real women coping with infant loss and debilitating medical problems.

“Funding from industrialized nations, including the U.S., has just not been meeting the commitments of the Cairo conference,” said Lisa Russell, an independent filmmaker and international public health specialist who directed and co-produced the film, “Love, Labor, Loss.”

The documentary follows a group of women who have come to Niamey National Hospital in Niger to have their fistulas repaired. As their stories unfold, the film also addresses the larger reality of life in Niger, where girls as young as 9 are forced into marriage and motherhood, and where education and adequate reproductive care are often denied.

Niger Has World’s Highest Fertility Rate

Niger was a logical choice, Russell said, because it has the highest fertility rate in the world. According to the CIA World Factbook, in 2004 the average number of children per family was 6.8. “It seemed like women there are all either pregnant or walking around with a baby on their back,” Russell said.

Initially, the film will be released to the nongovernmental organization community in September or October, to coincide with the 10th anniversary of the Cairo conference. After further fundraising efforts and a second trip to Niger this fall, her team hopes to put together a longer film for mainstream broadcasting.

The film was financed by groups such as the Washington- and Los Angeles-based Feminist Majority Foundation and the U.N. Population Fund.

On July 16, the Bush administration announced that it will block all $34 million congressionally-approved funding to the Population Fund, the third year funding has been withheld from the agency, due to the administration’s claim that the fund supports forced abortions and sterilizations. The fund strongly denies the allegations.

Russell hopes that despite that funding controversy, fistula will emerge as a unifying reproductive health issue, rather than a divisive one.

“This isn’t a teen pregnancy, abortion or AIDS issue,” she said. “Nobody is going to argue that the health of a mother should not be valued.”

Robin Hindery is a recent graduate of the Columbia Graduate School of Journalism, and a writer for Women’s eNews in New York City.

For more information:

The United Nations Population Fund–
Campaign to End Fistula:

Stanford University School of Medicine–
Eritrean Women’s Health Project:

Love, Labor, Loss:

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