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Fistulas make women outcasts but surgery can help them return to full lives.
For those already afflicted, Medecins Sans Frontieres surgeon Said Abubakar reconstructs the vaginal walls using whatever tissue is available — sometimes even the outer labia.
The patient is strapped into stirrups, her hips elevated above her head, and given a spinal anaesthetic while Abubakar operates directly through the vagina. Making a woman continent again may come at the expense of narrowing the vagina such that sex, let alone child birth, will be impossible — a dilemma Abubakar must often explain to patients.
The operation is often described as simple but in fact it is an art form, with every case different, specialists say.
“I was chief trauma surgeon for many years in a clinic in Germany,” explained Dutchman Waaldijk. “I’ve been a war surgeon in Cambodia and I’ve done reconstructive surgery on leprosy patients, and believe me, fistula is the most difficult surgery I’ve ever encountered in my life. It’s like operating on the sole of a foot through the top of a high boot.”
Not all of Medecins Sans Frontieres’ cases have been caused by obstructed labour. Nana, 16, was subjected to the traditional practice of gishiri. A year ago, the back wall of her vagina was sliced apart — without sterilization or anaesthetic — to enlarge it to her husband’s satisfaction. The man who did the cutting, known as a Wanzami, or “barber,” cut too deeply and went right through to her rectum.
“I had no choice,” Nana said. “My husband … wasn’t happy with the way I was doing sex.”
There are enough sad tales to fill a book, yet the 32-bed ward is a surprisingly bright and upbeat place where women float around, catheters protruding from beneath their brightly coloured traditional dresses. Music and dancing is a major part of their rehabilitation and therapy.
The idea is eventually to hand the project over to the Jigawa state government, possibly in three to four years, with a well-trained staff. Nigerian state and federal governments’ progress has been, “in one word, slow,” said MSF’s medical adviser on women’s health, Bronwyn Hale.
There are individual instances of progress. But ahead of April elections, issues like fighting corruption and improving air cleanliness dominate the agenda — maternal health hasn’t rated much mention.
Representative Carolyn Maloney (D-N.Y.) has been pushing the issue in the U.S. Congress, but for most part maternal health advocates feel the issue has been shamefully neglected.
“Every year 500,000 women die ... in childbirth — that’s more than died in the (Boxing Day) tsunami and yet no one is doing anything about it,” said Dr. Catherine Hamlin, an Australian-born gynaecologist and pioneer in fistula repair who set up a clinic in Ethiopia in 1959 and has worked there ever since. “These are young women with their whole lives ahead of them and they die in labor or they get a fistula, in which case they wish they’d died. It’s a terrible thing to happen to a woman to be incontinent with her body waste.”
Rural African women remained “second-class citizens,” she said.
The last fistula treatment center in the U.S. closed in 1859. It was in New York, on the site now occupied by the Waldorf-Astoria. Ironically, the average cost of a room today — between $300 and $400 — is the same as the cost of a fistula repair operation in Nigeria.
“I don’t think any patient is more grateful than a fistula patient,” said Dr. Hamlin. “It’s marvellous to see that joy. It’s like a new life starting again.”