International Women’s Issues: Obstetric Fistula in Niger

This post needs a bit of a warning. The way I see things, there are issues that affect everyone to varying degrees, and then there are issues that directly affect mostly women.  In an effort to counterbalance the mainstream view that “women’s issues” tend to mainly involve rape, domestic violence, maternal mortality, access to contraception and the like, I have stayed away from topics in that sphere. As I said in my first post, every issue is a women’s issue, and my columns thus far have been written with that idea in mind. At the same time, I am also concerned that I have been ignoring more serious issues. This is partially because, to be honest, it can be tough to read and write about some of these things.

This week marks a change in policy – the topic, fistula, is about as tough as they come. I am, as always, going to first explain the issue, then examine what women are doing to improve the situation, so I hope that this will continue to be, overall, an encouraging piece highlighting the advancements of women’s rights on a global scale. That said, the piece below contains a discussion of a painful and debilitating medical condition that is largely the result of poverty and cultural misogyny, so please only read on if you feel up to it.

Still here? Fantastic. While I am focusing this week’s post on Niger, please be aware that fistulas occur in much of sub-Saharan Africa as well as parts of Asia, so a lot of the information below is applicable to many countries. In Niger, the issue is particularly pressing, due to the low level of development in the country, coupled with a very high fertility rate. Specifically, Niger is rated 167 out of 169 countries on the UN’s Human Development Index, which combines life expectancy, education level, and per capita income to create a single statistic – it’s globally accepted as a valid indicator of a nation’s level of development. Niger also has one of the highest birthrates in the world, if not the highest. These two factors combined mean that there are an awful lot of incredibly impoverished women giving birth – about 50 babies are born per every 1000 people in Niger, every year. Only one-third of these babies are born in the presence of a trained health professional, and girls start giving birth very early – more than half of women aged 20-24 had already given birth to their first child by age 18.  All of these factors together contribute to the high rate of fistula among Niger women.

But what is fistula? If you’ve read this far without knowing, well, this next part may be sad and shocking. Obstetric fistula occurs during childbirth, when, after days of labor, the pressure of the baby’s head against the pelvic bone cuts off blood flow to the soft tissue pressed between the two, causing tissue death. This results in a hole between the birth canal and either the bladder or rectum, if not both, leading to chronic leakage of urine and/or feces. Infection and trouble walking due to nerve damage are also common side effects. Due to the length of the labor, the baby is frequently stillborn. Fistula is especially common among younger girls, whose bodies have not yet fully matured – in a survey from Niger in 1995, the average age of girls with fistulas was thirteen years old. Malnutrition and having undergone female genital mutilation (FGM) also make fistula more likely, as do certain cultural practices, including the seclusion of girls during pregnancy. Women with fistula are frequently ostracized by their communities and abandoned by their husbands. Globally, estimations of the number of women living with fistula vary between 2 and 3.5 million, with between 50,000 and 100,000 new cases every year. In Niger alone, there are thought to be about 800,000 women living with fistula.

In the developed world, fistula is all but eradicated, as C-sections are both safe and readily available in places where women have access to health care. In Niger, and other places where the majority of women give birth at home and without trained assistance, C-sections simply aren’t an option for the majority of the population.

So that’s the situation. International attention towards fistula is an interesting thing – in a landmark 1994 UN International Conference on Population and Development, obstetric fistula was not a topic, and the 200-page report created from the conference does not contain a single reference to fistula. Less than ten years later, in 2003, the United Nations Population Fund launched the Campaign to End Fistula, and there are currently dozens if not hundreds of NGOs dedicated to eradicating fistula in the developing world, several of whom are getting significant funding from major donors such as USAID and the Gates Foundation. The surgery to repair fistula usually costs between $300-$450USD. The approach to eradicating fistula is two-pronged, a combination of changing the situations that lead so many women to get fistulas in the first place, and performing the surgery necessary to heal women who already have fistulas. Not to be cynical, but fistula surgery is exactly the sort of project that international donors like: there’s virtually no debate as to whether it’s a good idea or not, and the results are easily quantifiable. “Two hundred surgeries performed” reads a lot better on a report to donors than talk of awareness-raising and trying to change cultural standards – though there are groups that do that as well.

In addition to the international organizations, there are local organizations who have been helping women cope with fistula, and working to prevent them, long before fistula became a hot-button topic in the international community.

Foremost among these women is Dr. Salamatou Traoré, who founded Dimol, which means “dignity” in Peulh, a local language. Dr. Traore founded Dimol in 1998, with the sole purpose supporting women with fistula on a variety of levels. Dimol runs a recovery center associated with a hospital in Niamey, Niger’s capital. There, women can prepare for and recovery from fistula repair surgery.  At the center, women can learn income-generating skills, so they can support themselves; and also about health and hygiene, and how to prevent fistulas from occurring or reoccurring. Once women have recovered from the surgery, they return to their villages and share this information with other women, becoming agents for change on their own. Dimol pressured the Nigerien government to provide C-sections free of charge to women who have had a fistula repaired and become pregnant again. Dimol is also very focused on changing the perspective of men in Niger, to encourage them to not engage in sexual relations with girls whose bodies are not mature enough to give birth, even if they are already married.

Additionally, there is ANDDH, the Association Nigerienne pour la Defense des Droits de l’Homme, or the Nigerien Association for the Defense of Human Rights. Founded in 1991, ANDDH covers a variety of human rights work, but they do pay specific focus to decreasing the prevalence of child marriage, via education and awareness of the negative impact of the practice. Eradicating child marriage would go a long way to decreasing the prevalence of fistula. They also provide hygienic supplies to women with fistula.

Finally, there is CONIPRAT, the Nigerien Committee Against Harmful Traditional Practices, which was formed in 1978 and is woman-lead. CONIPRAT seeks to eradicate FGM, a contributing cause of fistula. FGM was outlawed in Niger, partially in thanks to CONIPRAT, in 2003, and between 1998 and 2006, the rate of FGM in the country has been reduced by fifty percent. While only 2.3 percent of girls undergo FGM, 22 percent of fistula patients were victims of this procedure. A reduce in the prevalence of FGM means less fistula as well. Interestingly, Dr. Traore was once president of CONIPRAT, but left the organization to focus exclusively on fistula.

These groups, who have been dealing with this issue in this place for far longer than international donors, can hopefully serve as a support and guide as foreign funds come into the region. Fistula is a horrible and debilitating condition, but through the work of local organizations as well as international groups, hopefully one day fistula will be as rare in the developing world as it is in the developed world.

Next week, in honor of Thanksgiving, (and because, after this post, I’d like to focus on something a bit more positive) I’ll be looking at some recent advancements in women’s rights worldwide for which we ought to be thankful. If you’ve got any thoughts on what you’d like to see in this column, either in terms of specific issues or more generally, I’d love to see them in the comments!

Sources:

How many women have obstetric fistula?

“I Said to Myself, Why Not Create an NGO Focused on the Dignity of Women?”
Interview with Salamatou Traoré

Niger: Botch birth survivors battle fistula

Obstetric Fistula: Needs Assessment Report: Findings from Nine African Countries

Domaines d’activitiés – ANDDH (in French)

Rapport Annuel 2008 sur la Situation de Droits de l’Homme au Niger (in French)

Turning former practitioners against female genital mutilation in Niger

UNICEF: At a glance: Niger