I have given birth twice. Neither time was much fun, what with the mind-blowing pain of induced contractions, ineffectual epidurals, and (on the second occasion) having the baby yanked out with forceps after an hour of midwives and doctors kneeling on, and then rummaging elbow-deep in, my uterus.
So, no. Childbirth: not quite what I’d been prepared for.
But at no point, however, did I think that I was going to die in the process. At least, not literally. That would have been a bit dramatic, right?
For me, yes.
Try telling that to the 289,000 women who do die every year in childbirth or from pregnancy-related causes.
One woman, every two minutes.
We are bombarded with statistics, so if that feels a bit anonymous, try personalising it: each one of those women could be your mother, partner, sister, aunt, daughter, niece – you.
Going into labour, and not coming out the other side.
Feels a bit medieval to me.
But depending on where you are reading this, maybe it’s a daily reality. If you’re in a developing country, you’re 14 times more likely to die in childbirth than in a developed country. Especially so in sub-saharan Afrrica, where the rates are the worst:
Maternal mortality is one of the Millennium Development Goals (MDGs: international yardsticks on development) on which we’ve made the least progress. There’s a whole other blog post to be written on why that might be, but on the up side (if there is one) at least there’s recognition and therefore resource being put into tackling it.
But the MDGs, and their successor the Sustainable Development Goals, are entirely silent on maternal morbidity. That, despite the fact that for every woman who dies in childbirth (one every 120 seconds, remember: how long has it taken you to read this far?) there are an estimated 20-30 who suffer debilitating injuries or infection.
Take, for example, obstetric fistula.
Yes, you heard me. Fistula.
I don’t blame you if you’re making a funny face: it’s a funny word. A good name for a brand of fish food, say, or a fictional baddy. Think: Harry Potter and the Fistula Fiend.
Obstetric fistula does indeed sound nasty on paper. But it’s even nastier in real life for the estimated 1-2 million women worldwide who suffer from it.
Before I lose you to wikipedia, let me explain what it is.
Fistula occurs as a consequence of complicated or prolonged childbirth, during which the baby’s head rubs at the fragile tissue of the birth canal, creating holes between the vagina and either the rectum or bladder.
I appreciate that sentence feels like it’s hooked straight from Gray’s Anatomy, so here’s a diagram to help you visualise it:
Prolonged childbirth stems from an awkward size or position of the baby: 75% of women with fistula go through more than three days of labour (three days!).
Childbirth is also harder going when the woman is too weak or too young to deliver (oh yes: those child-bearing hips that your aunty Gladys is so proud of: well, they’re not just a family heirloom. They need time and nutrition to develop).
And fistula can also be the consequence of damage inflicted from sexual violence such as rape or deliberate insertion of weapons (bayonnets, pistols) into the vagina. You know, as you do.
That is why fistula happens. But what does it mean for the woman, when it happens?
Well, picture this. You’ve been in labour, probably excrutiatingly so, for hours, possibly days. The baby is stuck. You don’t die in childbirth (hurrah for you!) but when the baby finally is delivered, it is likely stillborn.
So: your baby is dead, you are grieving, your body is physically exhausted from pregnancy and labour. And then on top of all of that, you then find that you are leaking urine or faeces through your vagina. You no longer have control – and/or awareness – of when you need to go to the toilet.
I have tried to put those shoes on, but I can’t. I can’t imagine it. The occasional trickle when my post-baby pelvic muscles react badly to a sneeze with a full bladder: that doesn’t really cut any kind of comparison.
Have a read instead of this:
How is that sort of experience survivable, physically or emotionally?
Perhaps it might be made a little more bearable with support from your family and friends. But in countries where corrective surgery is unavailable or too expensive, women with fistula are mostly shunned. If your partner leaves you, as is often the case, you then also face financial destitution. And if you are one of the frequent cases of fistula occurring in young women, then you may be looking at decades of this lonely, painful and humiliating existence.
And yet – surprise, surprise – obstetric fistula can be easily a) avoided and b) treated.
We know that, because it no longer exists where there is:
- a low risk of violent rape, forced or early marriage;
- skilled medical care during and after birth, including the possibility of a c-section, and facilities within easy travelling distance;
- surgery available to correct damage done by complicated births.
But that kind of checklist is only possible where the mother (and baby’s) life are valued. Where the status of women justifies investment in reproductive health resources, and protection against harmful traditional practices. And in countries with the means to provide (access to) healthcare and train specialist doctors or surgeons, especially tricky in rural areas.
Clearly not the status quo: as proven by the estimated 50-100,000 new cases of fistula every year, of which 90% will go untreated.
Several organisations are trying to correct this sorry situation. They do great work to raise awareness and funding for surgery or training. Have a look for example at the Fistula Foundation, the Campaign to End Fistula, Operation Fistula, or the World Wide Fistula Fund.
Fistula is also part of the work of the big health agencies, such as UNFPA or the WHO. And we now have an international End Fistula Day (23 May: another one for your diaries, please) and the excellent interactive Global Fistula Map to illustrate why and where fistula is still happening.
That’s good. But (spot the recurring conclusion) it isn’t enough.
We need more: to support those suffering from it, to provide surgical expertise, to break the taboo. But we also need to try to stop it happening in the first place. As complicated and sensitive as underlying factors such as poverty or discrimination are, a specific target on maternal morbidity in the new SDGs would be a good start.
Fistula has rightly been called “the biggest problem you’ve never heard of.”
Well, now you have.
Spread the (F) word.