10 February 2013

Rwanda: Obstetric Fistula, a Social Death Sentence

For nearly twenty years, Bonifilda Mukarubuga has been living a stigmatized life due to an illness she doesn't understand -urine has been flowing out of her vagina and she cannot control it. "It has been a stressful situation for me and I have been very ashamed," the 73-year-old woman said last week when she was finally at Kibagabaga hospital for treatment.

Mukarubuga says the chronic illness developed when she fell down fleeing during the 1994 genocide, which caused damage to her uterus getting out. Ever since, she has lived isolated in her neighborhood of Cyabakamyi, Nyanza District.

"I couldn't let anyone else to know what happened to me because I had never heard about such cases," she explains.

In May 2011, after having found the courage to confide in a neighbor who was also a healthworker, the old woman was finally referred to Gitwe hospital for an operation that put an end to 17 years of chronic urinary incontinence. She went back to hospital last year in April and got treated, but signs of the problem started reoccurring since two months ago. "I hope now to see this issue repaired once and for all," she said at Kibagabaga.

Yet Mukarubuga's ailment is not uncommon. It is called obstetric fistula, a hole in the birth canal typically caused by prolonged labor without prompt emergency care such as a Caesarean section. The woman is left with chronic incontinence and, in most cases, her baby is stillborn. According to medics, most of the cases can aggravate when mothers give birth at their home with no medical support.

The chronic incontinence often has severe psychosocial and socioeconomic consequences that are brought on by social segregation - which in many cases results in isolation, feelings of shame and despair. Unable to control the flow of urine or faeces, such women are often abandoned by their husband and shunned by the community.

That is exactly the case of Christine Bamurange, 36, who has had the condition for 15 years. "It happened when I was giving birth for the first time, though the baby was stillborn. When my husband was informed, he simply abandoned me," she says.

Since then, it's been endless suffering for Bamurange, who never remarried or got another child, but lived in isolatation in Kayonza district. "Everyone is saying 'she smells so badly,' I can't attend any gathering," she explains.

Bamurange and Mukarubuga were among other several women suffering from fistula who, between February 2 and 14, have been undergoing free surgery at Kibagabaga hospital, courtesy of a team of American medics in collaboration with Rwandan colleagues. The team consisted of 30 medical professionals from the International Organization for Women and Development, Inc. (IOWD), a US-based non-profit organization.

According to Dr Christian Ntizimira, the director of Kibagabaga hospital, the ministry of health provides everything including transport, accommodation and meals for the patients so that they can get free treatment. The US medics also come with all equipment. More than 35 women with serious complications are expected to be operated though about 220 women had presented themselves.

According to medical professionals, the women still need follow up after two or three months following the surgery. "It really gets healed when a patient goes regularly for treatment," Ntizimira said, adding that all complications can be well fixed within six weeks.

Normally, the operation and follow-up treatment would cost between Frw 200,000 and 300,000.

"Fistula brings about isolation and many patients even fear to reveal their illness while most of them come from vulnerable families. That is why the health ministry is making a lot of efforts to encourage them to come for free treatment," explains Francois Habiyaremye, a professional in charge of non-communicable diseases.

The collaboration between Minisante, partners such as IOWD and other organizations ensures free fistula surgery three times per year, in February, April and October, since 2006. Habiyaremye estimates that on average 500 women are operated every year.

Meanwhile, routine services of fistula repair are being set up in various hospitals. "Eight doctors have been trained up to the level of repairing fistula and 80 nurses trained," Habiyaremye says, adding that they continue to train others while others get on-job skills when they are working with the foreign specialists. "We are working hard to treat all existing cases, and put in place preventive mechanisms to avoid new ones."

According to World Health Organization, between 50,000 to 100,000 women worldwide are affected by obstetric fistula each year. The exact number of sufferers in Rwanda is not known.

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