EngenderHealth Addresses Obstetric Fistula in Bangladesh

Project Brings New Hope to Women with this Devastating Childbirth Injury

For six long years, Lily’s mother, Mansura, scrimped and saved for her daughter’s operation. She worked tirelessly at odd jobs she could find through her network of family, friends, and neighbors in the densely populated city of Chittagong, denying herself anything that was not absolutely necessary to survive. When Mansura could not find work, she begged for donations to help her daughter. “This is the worst suffering that a mother can see her daughter live through. With God’s help, I am determined to help her,” she said.

Lily suffered from a devastating childbirth injury called obstetric fistula. Like many young women who develop this condition, she was a teenager when she married and became pregnant. She experienced obstructed labor for many days with only her mother-in-law and a Dhornee (a traditional birth attendant) by her side. By the time she arrived at the local health center, it was too late—the damage had already been done. The baby had already died and had begun to decompose. But not only had Lily given birth to a stillborn: The prolonged pressure of the baby’s head against Lily’s pelvis had cut off the blood supply to the soft tissues surrounding her bladder and vagina. The injured tissue then rotted away, leaving a hole, or fistula, which rendered Lily incontinent. Lily was left by her husband and returned home to the shantytown where her mother lives. Since then, she had leaked urine uncontrollably and had been confined to her bed.

A Common Problem
Fistula once was common all over the world, even in the United States. In most Western countries, it was eradicated around the turn of the century, thanks to improvements in emergency obstetric care and the easy availability of cesarean sections. Yet while fistula is preventable and treatable, the condition remains prevalent in developing countries, where poverty, early marriage, poor maternal health services, and lack of women’s education and rights are contributing factors. In Bangladesh, rural girls usually marry between the ages of 10 and 15 and become pregnant shortly thereafter. More than one-third of adolescent girls are pregnant or are already mothers. Almost two-thirds of women do not receive antenatal care, and 92 percent of births occur at home. Given this backdrop, it's not surprising that an estimated 60,000-100,000 women in Bangladesh develop obstetric fistula.

While it's been widely understood that fistula is prevalent in Bangladesh, reliable supporting data is scarce. Recognizing that an analysis of the situation is an urgent first step in addressing the problem, EngenderHealth and the United Nations Population Fund (UNFPA) undertook the first-ever situation analysis of fistula in Bangladesh in 2003. This groundbreaking initiative assessed service-delivery sites and interviewed women with fistula, their families, traditional birth attendants, service providers, and policymakers.

New Knowledge Brings New Possibilities and New Hope
Besides the sheer prevalence of the problem—of every 10,000 ever-married women, about 17 have fistula—the report revealed that a significant number of women living with fistula in Bangladesh are not aware of treatment possibilities that could change their lives. Many live alone, ostracized by husbands, family, and community. Some women interviewed were accused by community members of being afflicted with a curse.

Fortunately, unlike many women who have this stigmatizing condition, Lily was not completely ostracized. After Lily’s husband abandoned her, her mother took her in and became her devoted caretaker. Lily was even more fortunate that her mother learned about the availability of reconstructive surgery. It took her six years to save the money for the fistula repair operation, which costs $200-$300 dollars in Bangladesh, and in July 2004, Lily underwent her long-awaited fistula repair at Chittagong Medical College Hospital.

The EngenderHealth-UNFPA report concluded that in 2002 only 123 fistula repairs were completed in all of Bangladesh, revealing a great need to increase the capacity of health facilities and providers to treat the hundreds of thousands of affected women. The study outlined a parallel need for public awareness campaigns to both increase knowledge of fistula repair services and promote healthy behavior to prevent the occurrence of fistula in the first place. In addition, emergency obstetric services must be strengthened so that women can get the help they need when obstructed labor occurs.

A Chance to Live in Good Health
With funding from the U.S. Agency for International Development (USAID), EngenderHealth has taken immediate steps to follow through on the report’s recommendations. With support from the Ministry of Health and Family Welfare and other partners, EngenderHealth initiated a project that will strengthen fistula repair services while simultaneously working with communities to spread information and awareness about fistula prevention and treatment. Activities will include training surgical teams in fistula repair, upgrading hospitals where fistula services are offered, improving referral systems, and conducting community outreach campaigns.

It takes several weeks to know if surgery is fully successful, so Lily didn't yet know if she will be fully healed when she leaves the hospital. Yet she was grateful that she had been given the chance to live a new life. Though women whose repairs are successful can remarry if they wish, and most can bear children (caesarean sections are recommended to prevent a recurrence of fistula), Lily vowed she would take another path. “I will absolutely not marry again. I have had too much pain and heartbreak,” she said from her hospital bed. “All I want to do is to be able to leave the house so I can get a job and help my mother.” Through the work of EngenderHealth in Bangladesh, more women like Lily will get the chance to live the life they choose with dignity and in good health.