Experiences with Obstetric Fistula in Rural Uganda

She lost her baby 20 years ago. It was a long labor, lasting four merciless days, followed by a seemingly longer trip to the hospital on the back seat of an antique motorcycle, culminating in a desperate cesarean section, with only one life left to save. Two decades later, it is not the brooding absence of a long lost child that lingers on her features, but rather the accumulated sorrow of a life sullied by an unrelenting shame, wasted by pain and disability, and suffered in a complete and despairing isolation. Sitting obliquely on the hard-packed, red African soil in the shadow of a banana tree, she wore a faded green dress and gave off an odor of ash, charcoal, and urine. She described her experiences living with obstetric fistula and how she was certain she would bear that curse until her death. The local name for it is “okudabadaa” or “kaisemainhe”—words in the Ugandan language of Lusoga for “flowing” and “bladder,” respectively, appropriate descriptors of a condition that results in chronic incontinence. Obstetric fistula is characterized by an abnormal passageway between the vagina or uterus and internal organs such as the bladder or rectum, leading to persistent leakage of urine and/or feces through the vagina. Obstetric fistula is predominantly caused by neglected obstructed labor. If the labor is unrelieved by a prompt cesarean section, the baby typically dies, and the prolonged pressure of the baby’s head compresses the mother’s soft internal tissues against her pelvic bones, resulting in a lack of local blood flow, death of the surrounding tissue, and the development of a fistula. In places where fistula is common, women either are unable to obtain a cesarean section or receive one too late, after the fistula and fetal death have already occurred. The persistent incontinence and the rank odor that result, together with myriad other possible outcomes, such as secondary infertility, chronic infection, excoriation of the skin, and neurologic injury, are debilitating and humiliating enough in and of themselves, but a far more devastating outcome awaits most of those with obstetric fistula. Such women frequently find themselves abandoned by their husband and family, shunned by society, and barred from employment. That the condition is essentially an affliction of the very poorest of society