80 women benefit from free fistula repair-no more shame

Christine Katusabe slightly lifts the curtain at her hospital bed to confirm if the morning is here. When the first ray of light shoots through the window, she slowly turns her grey blanket and sky-blue sheets over to the other side, sits up and throws her head into her palms and looks at the other patients.

Her grandmother, having woken up 20 minutes earlier, peers into her 17 year granddaughter’s eyes, probably not seeing the beauty and innocence of a young girl, but trauma and shame. Katusabe passes urine uncontrollably because of an obstetric fistula. 

Christine Katusabe relaxes with her grandmother during the camp

A fistula is a tear between the birth passage and the bladder or rectum caused by obstructed and prolonged labor.  Dr Rose Mukisa Bisoborwa says during this time, the soft tissues of the pelvis are compressed between the baby’s head and the mother’s pelvic bones. The lack of blood flow causes tissue to die, creating a hole between the mother’s vagina and bladder or between the vagina and rectum, or both resulting in leakage.

Although Katusabe survived the fatal child birth experience where she had obstructed labor for a day and a half, she was left with a still born baby and trauma. 

“I would want to go back to school, study and become a nurse but because of my condition, I cannot. I have difficulty in walking and sitting and all the time, I want to eat,” the rather jolly Katusabe, who has borne this condition for two months, says. 

She gets off her bed and slowly motions towards the door. She is slightly bent and keeps her hands tucked in her brown shirt as if hiding something. Outside are more than 100 women crowded with basins, pieces of torn cloth and mats. The smell of the urine in their environs is unmistakable.

Like Katusabe, they too have obstetric fistulas and have come to Hoima Regional Referral Hospital to receive free fistula surgery courtesy of Engender Health and United Nations Population Fund (UNFPA). Engender Health is a global reproductive health organization working to improve the quality of health care with funding from USAID.

Dr Rose Bisoborwa, the country director for Engender Health-Uganda says ordinarily, fistula repair costs $ 400 (Shs 1m). 

Patients line up to receive treatment numbers during the camp

The camp is running for two weeks till 31^st May.

Consequences of damage resulting from obstetric fistula include depression, physical injury where a woman’s birth canal and bladder is ruptured thus frequent passing out of stool or urine or both and mental health dysfunction.

“Left with choric leaking of urine and stool, women with obstetric fistula are abandoned or neglected by their husbands and families, unable to work and ostracized by their communities,” Dr Peter Mukasa Kivunike, an obstetrician with UNFPA says. 

A fistula patient (L) being led to the theater for repair

A fistula patient for 40 years carries her 'weapon'-a basin at the camp where she hopes to be repaired

To contain the leakage, Katusabe uses two scarves interchangeably as pads. But she is met with yet another challenge; that of taking five liters of water daily which she cannot access. Her counselor, Betty Mujenje says this helps reduce the acid in the urine which may injure her skin. 

Counsellor Betty Mujenje(L) counsels Christine Katusabe, a fistula patient

The beginning of her woes;

In an area touched with poverty at every side, Katusabe, an orphan dropped out of school in Senior One at Kigolobya High School after her grandmother could not handle the school expenses any longer.

While working in her friend’s grocery store, she met Robert Amanyire, 29 who lured her into sexual intercourse.

“I knew I was not supposed to sleep with him but it happened accidentally,” she says in a timid voice further explaining that she even moved into his home in Nkondo village.

 But in the ninth month of her pregnancy, she moved back to Kigolobya, her grandmother’s home. Through the first day of her labor, Katusabe suffered a high fever and loss of a lot of blood but the quickest resort was a traditional birth attendant (TBA). Nevertheless, the labor and blood loss persisted that she was rushed to Kigolobya Health Centre IV.

She had a still birth and with little control over her system, she was left wet and dirty. Although she received support from her husband, she is battling depression and contemplating her future, she wonders when she will ever return to school. The day I met her, she was more than ready to undergo the fistula repair surgery after a comforting hour of counseling.

Like Katusabe, any woman is at risk of fistula if not assisted by a skilled health care provider. Young girls are particularly at risk because of pelvic bone immaturity and a small birth canal.

Fistula Repair and prevention;

Use of the partograph; 

A partograph is a low-tech tool that can substantially reduce the incidence of prolonged labor.

“Through its use, midwives and nurses can be alerted to the need to take action. This has the potential to reduce obstructed labor and its adverse consequences, including fistula,” Dr Odong Emintone Alyena a senior consultant obstetrician and gynecologist at Lacor Hospital explains. 

Immediate Catheterization

If a woman with obstructed labor arrives at the hospital and is believed to be at risk for obstetric fistula, immediate catheterization can help to prevent the fistula from developing. The catheter should remain in place until the end of labor.

Caesarean section (C-Section)

Timely C-Section is critical for women with obstructed labor.

“Doctors performing a Caesarean delivery must be competent so that they create an iatrogenic fistula where the bladder is accidentally cut resulting in an abnormal opening through which urine leaks,” Dr Bisoborwa says.

Community-based prevention

Activities include social mobilization and awareness raising campaigns, dramas and broadcasts about the importance of antenatal care and assisted delivery and support for transportation and referrals.

Sr Stella Kachope a counselor of women suffering with fistulas says there is need to sensitize men to get involved in birth preparedness and the importance of delaying first pregnancy up to 18 years.

The challenges;

The over 100 women at the camp have travelled from as far as Buliisa, Nangwali, Kyankwanzi, Apac, Bugweri and Kiboga that are at least 100 KM and at most 400 KM away from Hoima.

Dr Francis Mulwanyi Wambuzi the director, Hoima Regional Referral Hospital says travelling long distances are a common obstacle for these impoverished communities where proper healthcare and facilities are rare. Therefore many women live with this condition for years. For example Sarah Akugizibwe, 38 has lived with an obstetric fistula for eight years after losing her first set of twins. 

Sr Stella Kachope counselling fitsula patients at Hoima Regional Referral Hospital

Also, the hospital has inadequate emergency capacity in terms of supplies and medical staff compared to the backlog of patients.

“Hoima’s Health Centre IVs do not have doctors and at this hospital, we are only nine doctors and yet we are supposed to be 40 and there is only one senior obstetrician with no consultant in that field,” Dr Mulwanyi says.

Also, Hoima has a big migrant population from DRC and Kabale District who are unfamiliar with where to access medical services and end up facing delays in the community.

Unlike other regions like Masaka District that have private not-for profit, Hoima region does not have one and it is marred with power irregularities.

Fistula burden in Uganda;

The 2011 Uganda Demographic Health Survey (UDHS) estimates that 140,000 to 200,000 women in Uganda have the problem and 1900 new cases every year. Between 1500 and 2000 cases are repaired every year.

 The western region is leading in fistula rates with 5.4%, followed by that north at 3.6%, Central 3.4%, Eastern 1.1% and Karamoja with the least at 0.1%.

UNFPA has however over the past 10 years directly supported over 34000 women and girls to receive surgical treatment for fistula.