The backyard disease

January 6, 2011

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In France, the last case of obstetrical fistula was operated on in 1957. Since then, the phenomenon has almost disappeared in the Western world. But in countries where access to healthcare continues to be rudimentary, many women still suffer from fistulas. In Burundi, where the maternal mortality rate is among the highest in the world, several hundred cases are thus seen every year. In July 2010, MSF opened a centre to operate on such cases.

The backyard disease

Two hours' drive from Bujumbura, in the very centre of Burundi, the Gitega regional hospital lies in the hills at an altitude of some 1,850 metres. This is where MSF built the Urumuri (meaning "the light chasing darkness away" in Kirundi) centre, with the support of the Burundi Ministry of Health, to treat obstetrical fistulas. This disease continues to ravage populations in sub-Saharan Africa, essentially due to a lack of access to specialist healthcare for pregnant women. When access to this care is limited, obstructed labour during childbirth often results in the death of the mother or her baby, explains Dr. Geert Morren, surgeon and fistula specialist at Médecins Sans Frontières. If the mother manages to survive, the birthing process can cause necrosis of the tissues, resulting in the formation of an orifice between the bladder and vagina, the rectum and vagina, or the ureters and vagina. This is known as an obstetrical fistula.

This tearing leaves an indelible mark: urinary and/or fecal incontinence, which often leads to social exclusion. I lost my baby in childbirth, says Violetta, aged 23. A fistula appeared and I became incontinent. My husband could not bear it. He threw me and our three-year old son out of the house. Shortly afterwards, he got married to another girl in the village.

Pascasie, aged 32 and a mother of 8 children, also spoke of her experience. I contracted this fistula while I last gave birth. My husband then put me into quarantine because of the bad smells. When I walked through the village, my neighbours would cover their noses, right in front of me... And as I walked away, I would hear them laughing. These are far from isolated cases in Burundi, where fistulas are described as "the backyard disease". This image says a lot about everyday life for the women suffering from them. Struck by incontinence, they live hidden away from others, resigned to their fate and suffering in silence!

I have now been living with "it" for 12 years, explains Pélagie, 42. I thought it would never heal. One day, I went to a hospital in Bujumbura I had been told about since they operate on fistulas. But the cost of the operation was very high. Shortly after this visit, my husband died. And I lost all hope of ever finding the money for the operation! How could I find the means, as a widow? Today however, Pélagie has new reason to hope. My children heard the news on the radio. Médecins Sans Frontières had just opened a centre in the Gitega hospital where they were offering to treat women with this disease free of charge. With the help of my family and neighbours, I was able to find the money for transport and I went to the hospital.

Pélagie thus made it to the Urumuri centre, where she met Pascasie, Violetta and many other women who have the same condition. This is the first centre specialising in fistulas in Burundi, able to treat women all year round. Patients stay in four blocks built by MSF within the Gitega regional hospital itself. The centre's capacity is 58 beds. All the infrastructure can be found that is required for patients' comfort before and after the operation. A kitchen, a wash house, a toilet block, and an activities block. Located a short distance away from this "women's village" is the operating theatre, which has been working at full capacity since the centre opened in July 2010. The objective is to operate on 350 women every year, over a three-year period, says Chantal Dheur, MSF Mission Head in Burundi. This timeframe should also allow us to train three Burundi doctors in specialist fistula surgery.

Since March 2010, the Burundi Ministry for health has declared treatment to be free-of-charge for the women in question. It is thought that there are currently 10,000 women with the condition in Burundi. Across the continent, it is thought that this number stands at some one and a half million. But Dr. Morren, who has been operating on patients in Gitega since the Urumuri centre opened, remains optimistic. Obstetrical fistulas are perfectly avoidable if we invest in high-risk pregnancy testing, in care staff training, and in healthcare infrastructures. The main reason the phenomenon has all but disappeared in Europe today is that Caesarean sections are performed in good sanitary conditions in the event of obstructed labour.

Access to emergency obstetrical care, including access to high-quality Caesarean section care, is thus essential in order to eradicate obstetrical fistulas. For those unable to access the requisite care, Dr. Morren thinks that solutions other than an operation may exist, provided intervention occurs within six weeks of childbirth, when the size of the fistula is not too large. At present, in operational research, we are treating such "fresh fistulas" using a probe placed in the bladder which allows the fistula to close by itself. If this experiment works, this could be great news for future treatment! Effectively, since the technique does not require any surgical intervention, women could be treated directly in health centres, without the need to visit a regional hospital. The intervention would also cost much less than an operation. If it works, we could spread the technique to the hills and thus free these women from suffering, shame and social exclusion, the surgeon concluded.

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