Shameful neglect

Sunday August 17 2008

By Eve Mashoo

TINA AKULLO IS A PROUD 20-year old woman, but she has an embarassing problem — she cannot control her bladder and urine drips out uncontrollably.

She tries to hide her shame by wrapping herself with a “leso,” but this brings no relief as her stench drives away everyone around her.

Akullo is a war victim who fled Amuria district to an internally displaced persons camp in Soroti district after the Lord’s Resistance Army rebels killed both her parents in 2003 and raped her, making her pregnant

When the time to deliver came, two elderly traditional midwives were called but Akullo did not give birth. They shook their heads, saying, “It is complex... the baby is not coming out.”
One of the midwives’ stayed at her house to comfort her. That same evening, Akullo started complaining that her urine was leaking involuntarily.

Akullo had obstetric fistula, a devastating injury caused by pressure from a foetus that kills tissue in a mother’s body, creating a hole between the vagina and the bladder or rectum. This condition, though preventable, afflicts thousands of Ugandan women.

Akullo’s suffering was caused by prolonged obstructed labour, where the foetus’ head compressed the soft tissues — her vagina, bladder, and rectum — against the maternal pelvic bones. Delayed intervention made her vaginal wall sustain pressure necrosis, which left a hole between the vagina and the bladder (Vesico-vaginal fistula).

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For other women, the hole occurs between the vagina and the rectum causing recto-vaginal fistula.

As a result, the victim is left with uncontrollable leaking of urine and/or faeces, which causes a bad odour and wetness. Compounding this catastrophic psychological trauma, in almost all cases, the unborn baby dies.

“They call me euru (‘the stinking one,’ in Ateso language),” she said. “Even though I rarely move around the camp, people tease me, including children.”

However, after undergoing treatment, she did not comply with the doctor’s advice. She had sex before half a year ended and her fistula returned. The doctors have refused to work on her again.

She has now pinned her hopes on the foreign doctors who fly into Uganda annually from the US and the United Kingdom to offer their services for free.

Her misfortunes started with forced marriage arranged by her uncle.

“I was married and had to satisfy my husband sexually,” she said. “Now he has taken off because I stink.”

Many women are either unaware that surgical repair is possible, or cannot access or afford the treatment. Basic repairs are unavailable in sub-Saharan Africa, including Uganda, where the capacity to treat fistula cannot meet the demand for services. Left without treatment, women often live with this devastating condition for years.

According to research conducted by Uganda’s Ministry of Health in 2005, fistula cuts across women of all ages above adolescent. Internationally, Obstetric fistula causes 40,000 deaths, still births and maternal disability.

A FISTULA REPAIR COSTS ON average Ush400,000 ($300), a price beyond the reach of most patients. In Mulago Hospital’s private wing, a repair goes for Ush3 million ($1,851).

Dr Justus Barageine, a senior obstetrician, cites a shortage of skilled surgeons, equipment, drugs and other supplies. Many surgeons interviewed by The East- African said they lacked the confidence and skills necessary to perform fistula repairs.

According to Womendignity.org and engenderhealth.org, developing nations have a large population of women with fistula. About 130,000 new cases are registered worldwide annually. Currently, 3.5 million have this complication.

In Uganda, an estimated 2.6 per cent of women of reproductive age have obstetric fistula.

Mulago National Referral Hospital, the biggest referral centre in the country, from 1990-2005 recorded 2,500 patients and only 200 received repairs.

“This implied that we had a backlog of about 1,000 patients waiting for free surgical treatment,” said Dr Barageine.

According to Dr Barageine, some patients have waited for up to five years for treatment because of inexperienced surgeons.

Because of the increased maternal deaths, from 2005, efforts to reduce fistula cases in Uganda were intensified with support from the United Nations Population Fund, Engederhealth, Amref and the government.

Six hospitals were identified countrywide and were supplied with equipment and medicine, but not manpower. Mulago rehabilitated an operating theatre for fistula only.


From October to December 2005, about 60 patients were operated on, over 83 in 2006 and more than 110 in 2007. The increasing figures forced Mulago to begin community outreach at the end of June 2008 for patients to be operated upon in towns and districts.

THROUGH THIS CAMPAIGN, more than 200 patients were treated. Half of them were from Mulago, Kagadi, Gombe, Mubende, Mityana, Kayunga and Nakaseke hospitals.

For Akullo, there will be no giving birth again, not just because of her physical condition but the lingering effect of the trauma she has gone through.

“I don’t expect to get a child because I fear failing to push again,” she said.

Because of the increased maternal deaths, from 2005, efforts to reduce fistula cases in Uganda were intensified with support from UNPFA, Endegerhealth, AMREF and the government.
Six hospitals were identified countrywide and were supplied with equipment and medicine, but not manpower. Mulago rehabilitated an operating theatre for fistula only.

In October to December 2005, about 60 patients were operated, over 83 in 2006; more than 110 in 2007. The increasing figures forced Mulago to begin community outreach at the end of June 2008 for patients to be operated from towns and districts.

Through this campaign, more than 200 patients were operated. Half of these were from Mulago, Kagadi, Gombe, Mubende, Mityana, Kayunga and Nakaseke hospitals.

Most of the repairs reported were carried out by foreign doctors forcing national technical group on obstetric fistula to enforce comprehensive training of three obstetricians for Arua, Soroti and Mulago. In addition, obstetrics course is included in both the undergraduate and post graduate curricula. A fistula clinic runs every Friday for patients in Mulago.

However, patients can’t be sure of getting a bed because fistula cases are high and many times squeezed with/by post natal mothers. Sometimes the machines can fail to work due to poor quality or run out, like the ureta catheters.

Off the city, some NGOs like The Association for the Re-Orientation of Teso Women for Development (TERREWODE) and The Civil Society Capacity Building Programme (CSCBP) – EU funded, in Soroti district have preached about fistula in the Teso sub region and financed a number of women for treatment.

“The problem is really big and serious and many die silently. Talking about it has sparked dialoguing freely,” says Martha Ibeno, TERREWODE coordinator.

About 100 women have been repaired courtesy of TERREWODE and 70 are on the waiting list. Over Ushs. 400, 000 (US$300) is required per patient to carry out surgery which is unaffordable to most rural women.

In our neighbouring Ethiopia, women who can never heal are rehabilitated putting them in villages where they are able to engage in several income generating activities like farming, weaving and many others. And Uganda needs to also pick a leaf from them since the number of women with search a crisis is increasing rapidly.

“In the developed nations, Obstetric fistula was wiped long ago. It is only the developing world lagging behind,” said Dr. Barageine. “Until poverty is reduced, road networks streamlined, awareness campaigns conducted, and maternal health quality and funded, we will stagnate forever.”

For Akullo there will be no giving birth again not just because of her physical condition but the lingering effect of the trauma she has gone through. “I don’t expect to get a kid because I fear failing to push again,” she said.