The Right to be Safe: Fistula, Maternal Health and Dignity in Tanzania


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A photographic exhibition presented by Maggie Bangser at her talk upon receiving a honorary doctoral degree from Amherst College in 2009.

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The Right to be Safe: Fistula, Maternal Health and Dignity in Tanzania

  1. 1. An unknown problem An estimated 2 million girls and women live with fistula worldwide. Each year there are an additional 130,000 new cases. In other words: every four minutes somewhere in the world a girl or woman gets a fistula. Sources: World Health Organization, 1998 L. Lewis Wall, The Lancet, 2006 I never heard of fistula before I got one. I thought I was the only woman in the world leaking urine and faeces. Now I know there are so many other girls and women with fistula! photos: Mwanzo Millinga
  2. 2. 70 percent of the girls and women in the ’Risk and Resilience’ study got their fistula at the age of 20 or older. For many, this was not their first delivery. Source: Women’s Dignity, EngenderHealth, et al., 2006 Don’t think fistula is only a young girl’s problem. I got fistula when I was 29 years old. I am 54 now, and am so happy I will finally get surgery and be dry.
  3. 3. The disgrace of fistula The majority of the women in the fistula study isolated themselves from other community members, remaining in their homes as much as possible and forgoing public events like funerals, celebrations and visiting neighbours. Source: Women’s Dignity, EngenderHealth, et. al., 2006 “I feel shame. They laugh at me. They turn their lips up, and others leave the moment I enter to take my tea with them.” photo: Mwanzo Millinga
  4. 4. Alone, but not neglected Although fistula makes it difficult for women to participate actively in their community, they are not abandoned. All the women in the fistula study received some form of help from their family or community. Source: Women’s Dignity, EngenderHeallth, et. al., 2006 My husband has paid for everything – the bus, the hospital, the medicines….He saved my life, but it will take him years to pay back the loans.
  5. 5. Precious water One out of three Tanzanians report that their family did not have enough clean water over the past year. Source: Afrobarometer 2005 “Imagine you have fistula. You have to walk six hours to get one bucket of water. Now, you have to decide how you are going to use the water – for washing, drinking, bathing, and cooking, or for yourself.”
  6. 6. Being ready The majority of the women in the fistula study wanted to deliver their baby at a health care facility of some sort. However, fewer than half set aside money – ranging from USD 3.50 to 50. Preparing for delivery was difficult, due to lack of money and the hospital being too far away. Source: Women’s Dignity, EngenderHealth, et. al., 2006 I was prepared for my baby – I’d saved some money, I knew where to go and my husband asked a neighbour to bring me there on his bicycle. All women in my village should have a plan like this. photo: Mwanzo Millinga
  7. 7. photo: Sala Lewis Theory vs. reality According to the official guidelines of the Ministry of Health and Social Welfare in Tanzania, antenatal care services should include: physical examination from head to toe; check for blood count, blood pressure and urine; screening for syphilis and HIV; provision of tetanus toxoid vaccination; anti-malaria medicines and iron supplements; health education, including information about pregnancy, labour and delivery. However, reality is often different. For example, out of every ten of the poorest women in Tanzania, only four have their blood checked during antenatal care. For the wealthiest women, almost 9 out of 10 receive this service. If only I had been told that my blood pressure was Sources: Ministry of Health (RNC/NMCP) JHPIEGO, 2004 too high, I would have gone to Demographic and Health Survey 2004/05 the hospital for delivery.
  8. 8. Access to health services More than half of the poorest women in Tanzania say they face big problems in accessing health care because the facility is too far away and they need to take transport to get there. Source: Demographic and Health Survey 2004/05 When my family realized I needed professional help, I had to walk four hours to the main road. There I waited for a bus, but only one passed and it was already full.
  9. 9. Safe delivery In Tanzania, one woman out of every 66 who give birth, will die. In the USA, one woman out of 5,882 dies during childbirth. A caesarean section can save the life of a woman who has an obstructed labour. In Tanzania, 65% of government hospitals provide caesarean section, but no health centres or dispensaries provide this life-saving service. The nearest hospital to my village is Sources: World Development Report 2006 40 kilometers away. I can get to the local health National Institute of Medical Research, Ministry of Health and Social Welfare, 2006 centre, but it cannot do operations at all.
  10. 10. Professional help In rural areas of Tanzania, there is usually one medical officer caring for 45,000 people or more. In Ruvuma region, there is just one doctor for 250,000 people. In Dar es Salaam there is one doctor for 14,700 people. In Germany there is one medical doctor for every 280 people. Sources: Ministry of Health Personnel Census 2002, draft World Development Report 2004 I was lucky. I got to a hospital with a nurse and a doctor who took good care of me. But I know women from my village who have died during childbirth because no one could help them.
  11. 11. photo: Dorthe Friis Pederson How healthcare ranks Tanzania spends $12 per person per year on health. This compares to approximately $6,000 in USA, $3,100 in Australia, $70 in China, and $33 in India. The maternity ward was packed with women – on beds, on the floor, everywhere. There were only five Source: World Development Report 2004 nurses. I saw one woman deliver without any help.
  12. 12. photo: Dorthe Friis Pederson Money well spent Spending 8 percent of Tanzania’s annual health budget on required delivery kits, skilled health workers, and emergency obstetric care would ensure all pregnant women a safer childbirth. What is more important – education, water, Sources: UNFPA infrastructure, or healthcare? The budget is limited Tanzania budget estimates, 2006 and we have to make choices. Difficult choices.
  13. 13. Less income, more expenses Almost half of Tanzanians live on less than 1 dollar a day; almost three quarters live on less than 2 dollar a day. In poor families, everyone has to contribute to the household income. “Our income has decreased because only my husband is working. There are times when we don’t have food. Washing daily is costly, you must buy the Source: World Development Report 2006 soap. This money could be used for other things.”
  14. 14. A costly service Half of the poorest women in Tanzania say that getting money for treatment is their single biggest obstacle while seeking health care. Twenty five percent of the wealthiest women also experience this problem. Money determines where one gives birth. I didn’t have enough money to deliver in a health Source: Demographic and Health Survey 2004/05 facility, so I delivered at home.
  15. 15. Unhealthy practices More than 60 percent of Tanzanians believe that the current government is fighting corruption well. At the same time, if you ask 7 Tanzanians if they paid some kind of bribe to get medicine or medical attention in the past 12 months, one person will say ‘yes’. Sources: Afrobarometer 2005 “The nurse at the facility told me, ‘If you don’t pay Tshs 15,000 (US$15) you will never get a blood transfusion. If you have to die, better die.’ ”
  16. 16. photo: Dorthe Friis Pederson The right to information Widely disseminated messages about health rights – including respectful treatment by health workers, and mechanisms of complaint – can enable citizens to demand their rights and hold government accountable. Very few people are aware of their health rights. It’s important that they know, so they can demand them.
  17. 17. photo: Dorthe Friis Pederson One man’s voice Speaking out against bad health services is risky. You will be remembered. But individual acts of courage can bring change to thousands. How can the clinic staff deny a desperate young woman transport for the sake of US$ 6?