The joy of every mother on this planet is the birth of her baby. Like wise it is every mother’s wish and prayer to produce a bouncing baby. There are a number of women out there whose babies don’t live to their first birth, yet medical experts say that safe-motherhood means that no woman should die or be harmed by any pregnancy related complications. Statistics indicate that sharing one’s experience with others as a mother who lost a baby at birth is not all that easy.
Here is one who defeated all odds to tell what it means to lose a baby at birth and worst of all sustain damage on one’s bladder causing urine to flow [obstetric fistula] from the birth canal every now and then, for over a decade. In an exclusive interview with one Efrance Nalukwago of Nakasongola whom I met at Mulago ward 11 meant for women with “obstetric fistula”, she started on a sad note, I quote; “Unfortunately my baby did not even make a sound of crying as a sign to show that it was truly alive and I spent eleven years with a damaged bladder…,”Efrance wearing a pale face recalls her past as an expectant mother who experienced both a still birth and a damaged bladder due to teenage pregnancy.Like any other child in her teen all they think of is playing, unfortunately Efrance Nalukwago became pregnant at the age of 16 years. Like any other expectant woman, she too became excited that she was finally going to be counted as one of the mothers irrespective of being a minor.
In October 1998 Nalukwago began experiencing labour pains straight away from her home which is situated in a distance of 10 kilometres to the nearest and only health center in Nakasongola. The labour pains continued to intensify but there were no signs of her delivering from home. On realizing this, the husband and relatives who were so expectant that she could deliver from home, changed their mind and decided to take her to a health center for further management.
Inspite of the distance from home to the health center, Efrance had spent two days with delivery pains. These pains were so long. She was finally transferred to the health center after eight hours of searching for emergency transport. For the car that transported her to the health center, the family was charged a sum of Uganda shillings 20,000 after pleading for assistance.
After spending two consecutive days at the center, the health workers in Nakasongola advised her relatives that Nalukwago’s pregnancy condition was an emergency case that required a modern surgical technique such as cesarean operation, recommending that she should be transferred to Kiwoko hospital, in Luwero district to enable doctors intervene.
God was on her side; fortunately Nalukwago reached the hospital on time knowingly that she was due for a cesarean birth following a prolonged obstructed labour, coupled with the delay at the community level. “Shortly after the cesarean operation the doctors informed me that my delivery was a still birth, and on hearing this, I pondered over the tribulation I had gone through all that long and hence my agony”, she recalls her experience.
While still in hospital after five days, she started to feel constant flows in her bladder and bad smell arising from uncontrollable urine that made her to feel uneasy; this compelled her to inform the doctors about her worsening condition. As a teenager, she was frightened and severely depressed every time she thought of her baby and her worrying situation.
Fortunately the doctors assured her that a tube will be inserted in her bladder to contain the urine. Efrance further narrates that despite the insertion of the tube, urine did not go through the tube-passage, instead it continued to leak constantly from reproductive organs. She adds that this was coupled with the smelling beddings that became too difficult for her to stand. However, the doctors did their best to rectify the situation but all in vain.
“On the sixth day, as the doctors were discharging me from the hospital, my health condition was described by the doctors as obstetric fistula, some thing I did not understand being a rural woman; but they advised me to go back for further medical check up on a weekly basis!” Efrance lamented.
According to head of Urogynecology Division in the directorate of Obstetrics and gynaecology, Mulago Hospital, Doctor. Justus Barageine, who has treated patients, obstetric fistula refers to the abnormal communication between two body cavities for example the bladder and Vagina. The doctor adds that the occurrence of obstetric fistula is a condition which results from a failure to deliver normally or an intervention to deliver a baby following a prolonged or neglected obstructed labour.
Nalukwago’s condition of leaking urine from her reproductive organs, became part and parcel of her new life. “Leaking urine 11 years down the road terrorized me, because buying cotton wool became a necessity other than a luxury. Instead I resorted to using old bed sheets and big skirts that were cut into four small pieces to accommodate urine. I felt so bad most of the time because I was depressed as some of my relatives never wanted to be near me while others referred to me as a cursed woman and I became a laughing stalk”. She explains.
In addition, the rainy season meant disaster for Nalukwago, as her wet pieces of cloth could not be hanged in the compound thus becoming a nightmare. This meant that, looking for more than enough firewood that will also be lit and used to dry her clothes. There were also times when she failed to get firewood; it frustrated her to stay indoors since some of her relatives often referred to her as a socially outlined and bewitched person who has declined to consult the gods on how her condition could be prevented, conscious Efrance gives details.
On the other hand, the dry season was the most favorite season for her, saying that she braved through the sun to look for water some times covering a distance of three kilometers away from home. First of all reused wet pieces of cloths could be hanged and dried easily which she says, was an assurance that all is well with her, as she smiles. “However, padding was uncomfortable especially during the very hot weather, since I had to endure the smelling urine, and the padded piece of cloth generated heat which she says increased the friction between her thighs as she walks, carrying water on her head from the spring well eventually the frequent rubbing of thighs against each other developed into wounds on either side”. She recalls.
With this kind of condition, Nalukwago had to mix salt and warm water to massage the wound, and in absence of salt, local herbs commonly known as “Kamunye” were gently squeezed and applied onto the wound to massage it taking two days to heal completely. Efrance said that, “Upon returning home, I was abandoned by my husband who told me to find my way back to my parents and worst of it he referred to me as a person who wets the beddings and a failure in marriage!” Visibly almost shading tears, she continued to narrate that her husband immediately decided to marry another woman, leaving her helpless with no one to run to except her mother who dedicated her time to looking after the daughter [Efrance].
One day she was listening to radio back home this year, when she heard announcements calling upon women with this condition to visit Old Mulago hospital ward 11,where doctors do a cross examination for women with obstetric fistula. Efrance further told me that in the announcements it was described that the purpose of the medical check up was to assess the depth of the condition and the date for admission of patients was given. She went for the examination and after that she returned home and started working tooth and nail to raise money for the upkeep once admitted.
“Indeed God is a God of miracles!” She screamed due to excessive joy that she felt during the interviewing process. “Here I am today as a living testimony for other women to know that operation of repairing my bladder is one of the greatest miracles that has happened to me bringing relief, tears of joy, and celebration as I no longer smell urine hence my road to recovery this month, because I will have the freedom to move freely and associate with the society” She rejoiced.
Nalukwago was told to come back in September this year for another thorough examination. As we were chatting before the operation end of August 2008, she said that, she cannot wait for the d-day which was on Wednesday 3rd September 2008. “I was exceedingly grateful to the specialized doctors for restoring my life because urine was now a thing of the past”. She exclaims.
This calm lady observes that she will follow the doctors’ advice of not being involved in any relation with a man for a couple of months, something which she says is a short period, because this will damage her birth canal.
The Urogynecologist Dr. Barageine says that, one of the commonest cause of this condition is obstructed labour which accounts for more than 90%. When obstructed labour is neglected and prolonged, the woman reaches a time to push the baby and the baby is stuck for one reason or another, either the mother’s pelvic bones are small or the baby is big or the baby is positioned badly (breech) and it gets stuck in the birth canal.
“Once this condition happens for more than three hours, health experts say the obstruction is prolonged. While on the other hand it is neglected in a sense that no body intervenes, because if a doctor realizes that a woman’s labour is not progressing, then it becomes necessary to deliver her by a cesarean section, in order to prevent complications like obstetric fistula from forming”. Barageine argues.
However, the doctor reiterates that there are cases when the neglect is either on the part of the community, the service provider or it can be on the part of an individual. Just like the case of Nalukwago when the community especially the relatives did not effectively respond by taking her to the near by health center in time. Barageine cited an example of a pregnant woman in Katanga a slum area in Wandegeya, a Kampala city suburb, where a woman who had been in labour for three days without walking to the hospital, then such a scenario develops into neglect on the part of an individual who is a pregnant woman. This is partly attributed to beliefs, or cultural practices and poverty of not seeing the importance of going to a health facility or the held perceptions by some women that midwives are rude.
In Uganda, since the inception of medical practice during Albert Cook in 1897, cases of fistula have been reported and treated. The medical expert notes that, for the Ministry of Health to adequately respond to the problem, they did a survey for 15 years by reviewing hospital records from 1990-2005, in an effort to understand the magnitude of this problem.
“The health ministry found out that 8,000 cases had been recorded in all hospitals. Mulago reported 1,201 cases out of which 22% of the fistula cases had been operated on translating to 230 cases in fifteen years” he explains. He however, observes that there is still a big backlog of cases and even those who were operated on their fate were not known.
In addition, in 2004, United Nations Population Fund (UNFPA), Engender health among others spearheaded the global campaigns of ending fistula as well as using it as a catalyst for improving maternity services saying once you have fistula it means this is an indication that the maternity services were poor, saying this impacts on the country’s performance of addressing the millennium goal of reducing maternal mortality.
Further more, the doctor continues to say that this year alone, Mulago and its outreach hospitals registered 380 cases out of which 210 cases have been operated on. However, of the 380 cases, there is a short fall of more than 150 cases of fistula which he said are pending and waiting for a surgical operation. Thanks to the generosity of the development partners together with the health ministry who have made it possible to operate women with this condition.
Dr. Barageine pointed out that currently Mulago has three trained doctors, ten nurses who have been oriented and work in three shifts, external doctors who offer support to the hospital as well as young doctors who are rotating with in the department of Obstetric and Gynecology.
He observes, among the challenges faced by the department is the lack of the anesthetists (an expert who makes a patient sleep before the operation begins) and space. The latter is not enough for the patients; initially the department was given 6 beds and gradually upgraded to 14 beds saying they have always had occupancy of more than 200%. “We have a patient on the bed, some of them are under and then sometimes patients share both the bed and under the bed, therefore few patients are operated on but each time there is space the doctors end up operating 8 patients a week” he narrates. These patients spend a minimum of 17 days and an average of 20 days after the operation has been performed. The operation has a success rate of 90% in mulago
Dr. Barageine emphasizes that the department is under staffed and that they cannot increase on the number of health workers due to the structural problems and this increases the workload at the hospital. He says that most of the doctors who have been doing this kind of work have been frustrated due to the fact that they are not in position to follow their patients. In the first instance it is a time consuming operation which requires specialized nursing. The generosity of the development partners Engender Health and UNFPA have trained nurses in Kitovu Hospital in Masaka district and giving them written instructions such that they are able to follow up patients.
About vulnerability, the doctor says that young girls who have get married so early, it is an indication they have not been in school and are most likely to be children of peasants. When poor people get fistula, now a man does not want to associate himself with such a person who wets beddings. These women tend to be isolated and when they come for medical check up, they are depressed, have not attended any function. They fear to drink for fear of leaking urine which smells.
He further maintains that women who have had this problem and also lost their babies, it is most likely to be a double tragedy and stigmatization, because everybody in society does not want to associate with a woman who smells. These women have not attended any social event like a wedding and even going to church becomes a problem even though they desire to pray. So it is a big problem for them because they are socially outlined and want to be on their own.
Some of these women have been with this problem for as long as 50 years, leaking urine so they have not heard time to enjoy their sexual rights, and you find 80% of them don’t have babies because they have been divorced and can not remarry. Therefore, they have lived with fistula for more than 40 years and have reached menopauses and are old women who have produced one baby who has even died. Then you find them depressed, poor and even when they come, they fail to get transport back home.
The advent of mobile phones has improved communication in the country, with the advent of telephone, communication, some body call doctors and a Samaritan offers transport to enable the woman reach Kampala, but reaching the relatives home, the relatives abandon them. Therefore it is not a question of being young but poverty, poor people are poor and unable to access medical services saying they are poor both in the mind and financially, so it’s very difficult to decide when they come to hospital.
He continued to explain that additionally patients come with anticipation they will be healed and when they doctors tell them to come back after one month; they get angry, depressed and helpless. Those patients who will be operated on and succeed will want to go out and start mixing with society and sometimes it is a challenge restricting them. There are some patients who sneak out of the hospital and have sex prematurely which damages the birth canal. “Some of them when they are told to wait for three months before resuming sexual intercourse, even if they completely recover from the condition saying they cannot afford to remain poor so they resort to sex. In addition some of them have sexual intercourse and the following morning the women narrate their experiences to the doctors’ of how the men ‘supposed husband’ forced them to have sex” he explains.
There are also girls who are prostitutes whose livelihood is derived from selling their bodies for sexual favours in order to earn some money. These girls work in bars and find themselves completely healed and get some one who has offered to buy soap and in return of sex, therefore she indulges in sex and eventually breaks down resulting in depression which becomes a cycle.
How to prevent obstetric fistula? For the country to minimize this condition Dr.Baragaine advises that having a functioning health system which is blessed by political will, coupled with effective community mobilisers such that people get confidence in health system and the community will be able to use it.
The doctor stresses it with much concern that it is important for Ugandans to embrace Universal Primary Education (UPE) Programme such that girls are empowered and are able to stay in school for a long time saying this will help reducing teenage pregnancies. He estimates about 80% of patients with this problem have stopped schooling before completing primary seven, while 20% are senior one and two drop-outs. It is very rare to get senior four leavers, unless they have been injured but the department has not received any person from a tertiary institution. Therefore, he reiterates that educating girls up to senior four is another way of preventing fistula as well as fighting poverty of the mind and contributing to the millennium development goals of reducing maternal mortality. The Uganda Demographic health shows that, the number of women dying reduced from 506 per 100,000 live births in 2001 to 435 per 100,000 live births.
Campaign to end fistula UNFPA
Approximately 2 million women in Africa, Asia and the Arab region are living with the condition, and some 500,000 to 100,000 new cases develop annually. Just like Dr. Barageine said, the Technical Manager Acquire Project/Engender Health, Doctor Henry Kakande adds that, fistula is a signal that health systems are not meeting the needs of women.
Kakande says that Engender health is working with other development partners such as USAID and the Ministry of health as part of the collaborative campaigns in Africa, Asia and some Arab states and Uganda inclusive to prevent fistula and restore the health and dignity of the women. The campaign includes treatment, prevention and support to women who have been repaired to return to their communities.
Further reference check: Information contains the information for further reading http://www.endfistual.org/res/offc/mac/obs-fis/
