11. A retrospective study of patients from Addis Ababa Fistula Hospital in Addis Ababa, Ethiopa 1210 women total No prior history of obstetric fistula 96% caused by obstructed labor > than 3 days 93% fetal outcomes were still-birth 6
16. It is a Justice Issue Access to prenatal and obstetric care is limited Availability of skilled care and facilities to manage the birthing process is difficult to support The financial resources to sustain more medical care does not exist 8
17. Background Cultural role of women Labor intensive Agricultural lifestyle Low education Early Marriage < 16 years old Young Maternal Age < 16 years old Malnutrition in the country Inhibits height Smaller pelvis 9
22. Background Additional Contributing Factors: Inadequate health resources Lack of recognition that medical help is needed Limited transportation to medical facilities that are present in Ethiopia 11
23. Demographics Ethiopia 3rd highest population in Africa 89% rural living 47% of live below the poverty line Basis of economy: Rainfed Agriculture Exports: Coffee, Spices, Tea, Life expectancy 46 yrs 12
24. Inadequate transportation and roads Many languages are spoken throughout Ethiopia Average number of children per woman is 6.1 New law in place that limits foreign organizations and those that receive >10% of funding from participating in human-rights related work. 13
25. Daily Life: Ethiopian life is centered around religion, language and family. Food: -Protein: Beef, goat, lamb, chicken -Legumes and vegetables -Bread made of teff called Injera, served at every meal -Tea and Coffee For girls: -School is not deemed important for their role in the family and society at large -Expected to help in meal prep -Retrieve water from miles away everyday 14
26. Why obstetric fistulas persist: Cultural beliefs and customs devalue women Women are expected to marry early Begin having children soon after Obstetric care is given a low priority because women lack value in society Lack of preventative measures encourages early marriage and pregnancy Birth control is not taught in the school nor easily obtained 15
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28. Current Actions UNFPA current global campaign to end obstetric fistula http://www.unfpa.org/public/home/mothers/pid/4386 Engender Health (Bill & Melinda Gates Foundation) – Fistula Care Project http://action.engenderhealth.org/p/dia/action/public/?action_KEY=6953 The Hamlin Fistula Hospital in Addis Ababa, run on charitable donations http://www.hamlinfistula.org/ 17
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30. 19 A hut built by a women to live in after being rejected by husband and family due to the obstetric fistula she had. PBS documentary: ‘A Walk to Beautiful’
37. Sources for Images: Girl with jug: http://chora.virtualave.net/ethiopian-girl.jpg Pregnant image: : http://www-stu.calvin.edu/chimes/issue_images/100/11/n4.jpg Birth diagram: http://www.fistulacare.org/pages/images/General/obstructed.jpg Fistula Hut: http://obgyn.duke.edu/modules/ob_about/index.php?id=4 Women carrying water: http://www.waterencyclopedia.com/Da-En/Developing-Countries-Issues-in.html Young girl carrying wood: http://www.ywamethiopia.com/about_ethiopia.php Ethiopian Highland Farm: http://search.eb.com/eb/art-123298. 22
Editor's Notes
Introduction and music
Here is a map of Africa.
Bridget:An obstetric fistula is a term that refers to an abnormal passageway (imagine a hole) that develops and connects the vagina to another organ, like the bladder, urethra or rectum. WHICH are all naturally separate organs. If a fistula develops from the vagina to the bladder or urethra, urine can easily pass into the vagina where a woman has no control over its passage. If a hole develops from the vagina to the rectum, feces can then move into the vagina in the same manner where there is no control over the drainage. This hole is called an obstetric fistula because it occurs most often during a prolonged or obstructed labor. Prolonged labor is one that progresses at a slower than average for a typical birth. Obstructed labor involves a blockage or hindrance to the vaginal outlet.
Bridget:This chart reflects data taken from a retrospective study done in 1997 at Addis Ababa Fistula Hospital in Addis Ababa, Ethiopia. Retrospectivemeans that the data collected regarding obstetric fistulas came only from patients who presented at the fistula hospital for care: The study contained 1210 women who had not previously been seen or treated for obstetric fistula. Obstructed and prolonged labor were the cause of 96 % of the obstetric fistulas. As you can see in this chart, the duration of obstructed labor lasted for more than 3 days for the greatest number of women. 50% of the women who developed a fistula did so in their first delivery. 93% of the fetal outcomes were still-birth.
Bridget:Obstetric fistulas are a women’s health issue because they represent a physiological outcome related specifically to pregnancy and the birthing process. The lack of education for women - specifically with respect to reproductive health, presents another area of concern. The overwhelming presence of obstetric fistulas also demonstrates a lack of medical care available to Ethiopian and Nigerian women. Lastly, because culturally a woman’s worth or value is closely tied to her ability to have children and fulfill the physical role of wife.
Deb:This is a justice issue because it violates a humans rights. The majority of women affected by this condition live in the least developed parts of the world which includes Ethiopia and Nigeria. Access to proper prenatal and obstetric care is unlikely to be available to the greatest number of women at risk. These women are most likely to sustain complications from unmanaged reproductive care.The government finances that should be available in Nigeria, that could be invested in creation of better health care and facilities throughout the country are instead being used for other purposes. In Ethiopia, one of the poorest nations, the financial resources to support greater medical care throughout the countryside simply do not exist.Globally the education, skill and ability to prevent and care for fistulas exists. It is this disparity in the distribution of basic medical care that highlights the injustice of obstetric fistulas.
Deb:Both Nigerian and Ethiopian women share similar characteristics in regards to their background. Women are responsible for a larger proportion of labor in the home than men. Women do the cooking and cleaning; they also collect water for household, which is a very physical task. This picture is of the typical water container girls will use to go and collect the water and carry it back home. These containers are very heavy and girls begin this kind of labor intensive work at a young age. …..agriculturally women are involved with the weeding, harvesting and selling of the produce and goods at the market. The emphasis here again is the physical aspect of their daily lives. Their cultural roles take priority over schooling. For a girl to obtain a formal education it is extravagant in these societies. So much of their lives revolve around working that even if girls do go to school, they are expected to participate in daily household chores afterwards; an expectation not extended to young males. Because of these cultural expectations for girls to fulfill a more traditional lifestyle coupled with the preference to educate boys, girls don’t often stay in school.Young women are expected to marry at a young age. The average age of marriage for girls is under 16 years. Given the physically intense lifestyle of these women, their diet lacks the nutrition necessary to grow. The fullest potential for height in a women in these countries is not likely. Ethiopian and Nigerian women are shorter than women from more developed countries. At the age at which girls are expected to marry their bodies are yet prepubescent and developing. Specifically in the case of pregnancy, the pelvis of these young women are still immature and androgynous. The pelvic outlet necessary to allow for a vaginal birth has not yet developed, increasing the likelihood of an obstructed labor, where the infant cannot pass through the mother’s pelvis. Home births are the cultural standard for women in these countries. Due to the common practice of familial birthing, it is unlikely to have a medically trained person in attendance during labor.
Bridget:All of the risk factors that we’ve just outlined: Malnutrition, Physical lifestyle, Early age of marriage and subsequent motherhood, combined with cultural home birth contribute to the condition of obstetric fistulas. This is a diagram that shows how the presentation of the infant to the pelvis during labor can cause obstetric fistulas. The presentation is either not compatible with a vaginal birth OR the pelvis is too narrow to allow for the birth. Compression of the highlighted areas above in the vagina occur during contractions. Each time the head presses against the pelvic tissues during prolonged labors the blood flow to the surrounding tissues is compromised, meaning cut off. The inadequate blood supply to the surrounding tissue will die if this goes on for too long. If the tissue is compromised long enough to die, it will begin to sluff off and when this happens the result is origination of an obstetric fistula. The location of the injury (lack of blood flow / tissue dying) determines the type of fistula that can occur. If the tissue between the vagina and the urethra or bladder is continually compromised, the fistula will be a vesicovaginal fistula. This is the most common type of obstetric fistula to occur. The leaking of urine is often the first sign to a woman that she has an injury. If the tissue to the rectum is compromised and dies off, the fistula that can develop is a recto-vaginal fistula. In this circumstance, feces will leak frealy into the vagina as well. It is noteworthy to mention that a fistula such as these increases the chances of life threatening and reproductive issues.
Deb:Other factors leading to the prevalence of obstetric fistulas in Ethiopia and Nigeria exist, including the overwhelming lack of inadequate health resources. Both countries suffer from a lack of adequate obstetric care – both in terms of hospital facilities and the availability of general medical assistance for prenatal care, delivery and postnatal care. This lack of resources is compounded by the perceived lack of importance placed upon such things. Again, birthing is traditionally attended to by women in the community. Even when recognition of the need for medical care exists, transportation to those resources often does not. For example, an Ethiopian woman was interviewed at Addis Ababa Fistula hospital. Her name is Wobete. She was 11 when married and 13 when she became pregnant. She developed a fistula from both her rectum and bladder to her vagina. She was rejected by her husband sending her home to her parents. Her mother took her to a government health clinic in the province’s main town but they were unable to treat her. The nurses there suggested she get to the Fistula hospital in Addis Ababa. Such a trip not only required Wobete to endure a 3 day journey by bus, but also required her family to sell one of their cows in order to pay for the ticket to simply get her to the hospital. Once there, she was without money.
Bridget:3rd highest population in Africa89% live in the countrysideAddis Ababa is one of the few urbanized areas of the country.47% of live below the poverty lineThe average daily income of an Ethiopian is 40 cents a day (in US currency)Their work is agriculture in nature and dependent wholly on the weather/seasons. Exports: Coffee, Spices, TeaLife expectancy 46 yrs
Bridget:There are approximately 70 million people in Ethiopia. The construction of roads is a government function and the obstacles to furthering their development include a lack of funding and an unfriendly terrain. There are only 8.08 miles of weather-withstanding paved roads. There is only one train line in Ethiopia that runs from the capital to the country Dijoubti, at the Gulf of Aden.The land is expansive and mostly undeveloped. There are many ethnic and culturally diverse groups throughout the land. There are 70 languages considered to be mother tongues to Ethiopians. Consequently, language is a barrier to greater social communication.A new concern:There is a new law in place (2009) that limits foreign organizations and orgs that receive >10% of their funding from foreign sources from participating in human-rights related work.[ref: ethiopia yr in rvw 2009 britannica online]
Bridget:Ethiopian life is centered around religion, language and family.Food:-Protein: Beef, goat, lamb, chicken-Legumes and vegetables-Bread made of teff calledInjera, served at every meal-Tea and CoffeeHolidays: National Day, May 28Workers Day, May 1Known for Olympic runners
Bridget:Cultural and religious beliefs put control of women’s reproductive health largely in the hands of men. Given the relative lack of importance place upon women, obstetric care is given a low priority, which removes the opportunity for women to make appropriate health-related choices and seek out necessary medical care that could prevent them from injury. Instead, girls are expected to marry early and begin giving birth to children soon thereafter. This cultural pressure puts these young women in harm’s way.The lack of education also contributes to the ongoing unawareness of their physical development, their reproductive processes and the related outcomes associated with early motherhood.
Deb:Physical ramifications that take place as the result of this preventable condition rob the women who suffer from their right to bodily integrity and force many of them to live with a compromised physical condition. In addition, prolonged labor and a lack of access to prompt medical care decreases the likelihood of survival for both mother and child.Social consequences for this type of injustice are life changing for the women who suffer. The devaluation and marginalization that takes place is a violation of the women’s human rights.
Deb:The women remain silently in the background, mothers, sisters and friends of women who suffer; mourn the loss of time together, cultural connections and the support that comes from shared experiences. The women who life with O F find themselves ostracized from their community, left behind by husbands that no longer want them, and turned away by their families who cannot welcome them home due to the issues that come about from their chronic condition. The women become pariahs due to the constant leaking, the unrelenting soil and smell that accompany the condition and the various cultural stigmas that remain due to a lack of information regarding the true physical causes of the condition. Power resides with the groups that objectify these women. At the forefront of these populations are the men that are in charge. Without education, without help, and without the resource to obtain assistance, women who suffer from O F remain weak and oppressed.The lack of all of these things points to cultural systems that perpetuate the continued condition of weakness these women experience daily. We stand:Humbled by the wealth of resources we take for granted.Thankful for the access we have to medical care.Wondering who we would be without those resources.
Deb:A hut built by a woman to live in after being rejected by her husband and not allowed in her parents home due to her obstetric fistula. As Seen in documentary by PBS, ‘A Walk to Beautiful’
Deb:One of the most overt forms of oppression that is visited upon the women in my research is that of powerlessness. Their condition steals from them any opportunity to take part in their community and enjoy basic social participation that is a normal part of the life they have always known. Through no fault of their own, they find themselves physically compromised and lacking any prospect for improving their situation.Powerlessness is also experienced when the pregnancy that brought about the condition ends in the birth of a stillborn. Powerlessness to resolve the issues bringing about prolonged labor, powerlessness in losing the life of the child that has been growing inside her body, powerlessness in losing her place in the social community, losing her husband, her home and the life she has known….the oppressiveness of the situation seems never-ending. In addition to powerlessness, these women experience the oppression of marginalization. No longer fit to take part in the community socially, the usefulness of the women in terms of the day to day inner workings of society – cooking, cleaning, preparing meals, caring for the children of the community, etc. – is also negated. A woman’s usefulness is a very real, very important part of their culture. Without the ability to take part in the daily work of the group, a women’s value is reduced to nothing and she is effectively set aside. STOP
