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Beyond witchcraft

What is fistula?
Obstetric fistula occurs when the pressure of the baby’s head during prolonged and obstructed labour restricts blood flow to areas of tissue within the birth canal; the tissue may die, causing holes to form in it during the period after birth. This results in uncontrollable leakage into the vagina from the bladder or the rectum. At least 75,000 women are estimated to develop fistula every year, and most go untreated. At least two million women are currently living with this debilitating condition worldwide, often rejected by their husbands and communities as a result.


Stella Kawelama

Stella Kawelama is only 21 years old but she has experienced one of the most demeaning medical nightmares any woman could suffer from. For a year, she has been failing to control the flow of urine and faeces from her body due to a medical condition called obstetric fistula.

Kawelama, who looks young for her age, says she developed fistula soon after giving birth to a stillborn baby on 14 October 2007 – the baby was the young woman’s first child. She explains that she had been in labour for three days before her mother took her to Balaka Health Centre, where the medical personnel informed her that she had taken too long to get there and had therefore developed complications.

‘Women in my area usually give birth at home, mainly because of the long distances we have to cover walking to the health centre. It takes us about four hours to be able to access medical assistance,’ says Kawelama. ‘I was taken to the clinic as a last resort.’

The average person in Malawi travels 20 kilometres to reach the nearest health centre, according to government reports. Most rural roads in Malawi are unpaved and no cars go through them. This is a country where up to 65 per cent of the 13.1 million population lives below the poverty line of a dollar a day.

The health clinic that Kawelama ended up at could not help her with the delivery of her baby. ‘They told me that I had a complication and they sent me to a referral hospital in an ambulance, but that journey took us close to two hours. The hospital carried out a caesarean section on me but the baby had already died by then,’ says a sad-looking Kawelama.

She says she started leaking urine and faeces soon after the baby was delivered. The hospital personnel, however, told her they could not do anything since they had no specialists.

‘It was not a very strange condition for me since my old grandmother also fails to control the flow of urine and faeces from her body,’ she says.

Kawelama says her grandmother has had fistula for 35 years. She ended up with it when she was giving birth to a baby at the age of 40 – a baby that also was stillborn.

United Nations Population Fund (UNFPA) reproductive health officer in Malawi, Dorothy Lazaro, who is also a nurse/midwife, explains that obstetric fistula occurs when a pregnant woman experiences a very long labour. She says the medical condition is caused by prolonged pressure of the child’s head against the tissue in the mother’s pelvis.

‘The soft tissue eventually dies from the lack of blood supply and a hole develops between either the rectum and vagina or between the bladder and vagina. Because of this, women lose control of the flow of urine or faeces, and sometimes both,’ says Lazaro.

But Lazaro’s description of obstetric fistula eludes most Malawians. Kawelama initially thought she had been bewitched. ‘Everyone in my area says my grandmother was bewitched and I thought I was too.’ says Kawelama. Up to 40 per cent of the adult population is illiterate in Malawi; belief in witchcraft is common.

Another common Malawian practice that increases the likelihood of fistula is that the decision on when a woman in labour should seek medical help is left in the hands of her uncle, who is regarded as the ‘owner of the clan’. If the uncle is not around, then the likelihood of prolonged labour or death during childbirth is amplified because no other family member, not even the husband of the pregnant woman, has the mandate to send her to hospital.

Another traditional belief in Kawelama’s area, and in many others, is that every first baby should be delivered at home so that family members, including in-laws, can ensure that the husband, and nobody else, is indeed responsible for the pregnancy. When a woman is in labour, those helping her repeatedly ask her to mention the real father of the baby. The conviction is that if any complications develop then the woman has been having extra-marital relationships.

It is therefore not surprising that women with fistula are often rejected by their communities and become destitute; many are chased from their family homes and villages.

Since developing the condition, Kawelama has been staying with her grandmother on the outskirts of their village. ‘My grandmother has been an outcast since 1973 when she developed fistula,’ she says. ‘Nobody wanted to stay near her because of the bad smell from the continuous flow of urine and also because they suspected her of infidelity.’

Kawelama’s grandfather divorced his wife soon after the fistula developed and banished her.

The constant odour that Kawelama started producing and suspicions similar to those that attached to her grandmother also drove the young woman’s husband away.

‘He chased me out of the matrimonial home and I had no choice but to go join my grandmother,’ she says. ‘Even my parents and my siblings frowned upon me.’

Up to 138 women were identified as having fistula in Kawelama’s local area. UNFPA’s Lazaro says that such a great number derives from the tendency towards early marriage in the area.

‘Early marriages result in young girls giving birth before their bodies are ready to tolerate the strains of pregnancy and birth,’ says Lazaro. ‘We have come across pregnant girls as young as 13 and these are at a very great risk of developing fistula.’

Salvation for Kawelama came in October this year when Malawi’s Ministry of Health, with financial assistance from UNFPA, carried out sensitization meetings on fistula, informing the community that it is a curable medical condition and dispelling the harmful beliefs that abounded in the area.

‘Most people are not aware that fistula is reparable but at the same time, very few hospitals can provide repair services,’ says Lazaro. ‘It is also difficult to identify cases. But, together with the Ministry of Health, we are carrying out awareness campaigns, especially in rural areas.’

Stella Kawelama waiting for an appointment at Zomba General Hospital.


A ‘Fistula Week’, where women received free medical services with fistula and undergo operations to reverse the condition was organized by the Government and sponsored by UNFPA. It took place in October 2008 at Zomba Central Hospital, one of only four major hospitals in the country.

‘I jumped at the opportunity to try my luck at getting repaired but my granny laughed at it all, saying it would not be possible to get back to normal,’ says Kawelama. ‘I went to the hospital to be operated on during the Fistula Week but I had to wait for two weeks before being repaired because there were so many people wanting the operation.’

UNFPA brought in two specialists from the Netherlands and Kenya to carry out the repairs with assistance from 11 clinical officers who also underwent training at the same time. The Fistula Week turned into a Fistula Fortnight as women kept turning up to be repaired – 45 women received the free medical service and more continued to turn up at the hospital.

Malawi’s health and maternal indicators are pathetic – there was only one doctor and four clinical officers in the whole country who were qualified to carry out fistula repairs before the special week, according to Lazaro. The Ministry of Health indicates that up to 100 registered nurses leave Malawi each year for the developed world in their quest for higher-paying jobs. One doctor looks after 64,000 patients.

Malawi has no official statistics as to the numbers of women that are suffering from fistula, but the Government is currently carrying out a study to determine the scale of the problem.

UNFPA in Malawi is recommending fistula prevention programmes to be included within education systems and is seeking to ensure that girls remain in school for a longer time so as to avoid early marriages. The UN agency has also pledged to scale up youth-friendly health services to prevent early pregnancies.

Now that Stella Kawelama has been repaired, she is able to control the flow of excreta from her body. ‘You just don’t know how ecstatic I feel,’ says Kawelama, as she takes a stroll around the hospital grounds while recovering from the operation. ‘I can’t wait to be discharged and get back home to tell my grandmother about this miracle and to convince her to come for repair.’

Pilirani Semu-Banda is the correspondent for Inter-Press Service based in Lilongwe, Malawi.

To read about another woman cured of fistula – Mariama from Niger – go to www.newint.org/features/2009/03/01/niger/

New Internationalist issue 420 magazine cover This article is from the March 2009 issue of New Internationalist.
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