“It’s been three years now, I can’t wear underwear, urine is always leaking. I have developed sores on my genitals that aren’t healing because of the moisture. I dread going out in public. The last time I went to a gathering, people distanced themselves from me because of the bad smell, it repelled them. I’m confined to this house so I can bathe each time I soil myself. My entire family believes I was cursed, they say no one has ever had a disease like mine before.”Nyaradzai, a 19-year-old womanfrom Mashonaland West Province, Zimbabwe.
Obstetric Fistula: A Devastating Condition that is Preventable And Treatable
Based on desktop research and qualitative field research carried out in Zimbabwe between January 2018 and October 2020 this report focuses on women and girls in Zimbabwe who have experienced obstetric fistula while giving birth. Described as the “most devastating birth injury” by both the World Health Organization (WHO) and the United Nations Population Fund (UNFPA), obstetric fistula is an abnormal communication between the urinary tract or the gastrointestinal tract and the genital tract, produced by obstetric causes, typically prolonged and obstructed labour.
Obstructed labour associated with obstetric fistula has been identified as a major cause of maternal mortality worldwide, and in as many as 90% of cases, women who experience obstetric fistula also suffer a still birth. WHO has stated that obstetric fistula is preventable; by reducing the number of early and unplanned pregnancies, ending harmful practices (such as “child marriage”), and ensuring access to quality emergency obstetric care, especially access to caesarean sections. When access to quality treatment is available, obstetric fistula is also curable. With expert care, surgical success rates of treating obstetric fistula are as high as 90%.
Obstetric Fistula Affects the Most Marginalised
Globally, obstetric fistula affects between 50,000 and 100,000 women every year, with low income countries in Africa and Asia bearing the highest burden. In Zimbabwe, the actual rate of obstetric fistula is not known, but given that the latest Multiple Indicator Cluster Survey from 2019 indicates that the country’s maternal mortality ratio is among the highest in the world it can be expected there is a devastating prevalence and incidence rate of obstetric fistula in the country.
The findings of this report indicate that the impact of obstetric fistula on both physical and mental health of women and girls is catastrophic. Often resulting in the continuous and uncontrollable leaking of urine and/or faeces, obstetric fistula can lead to life-changing stigmatisation, and has far reaching consequences on women and girls’ physical wellbeing, social and marital relationships, mental health, and economic capacity.
In 2015, repair of obstetric fistula was established as a public health intervention in Zimbabwe. Despite this, our research shows that access to maternal healthcare which could prevent obstetric fistula as well as treatment for obstetric fistula has remained limited for many women and girls in Zimbabwe. This has been largely due to the fact that obstetric fistula appears to affect the most marginalised members of the society: poor, young and often illiterate girls and women in remote regions of the country.
Zimbabwean Government’s Failure to Prevent Obstetric Fistula and Human Rights Abuses
Amidst an ever-worsening economic situation in Zimbabwe,as well as the country’s consistently low healthcare budget allocation, Amnesty International found that the government of Zimbabwe has failed to assign sufficient resources to the health sector,and despite declaring a policy of free maternal services, has not funded or operationalised relevant initiatives. The lack of ambulances and high fuel prices, further compounds delays that women and girls experience reaching and receiving care at health facilities. The situation is urgent as the country weathers the impact of the COVID-19 crisis and barriers to maternal health services are increasing.
Amnesty International also found that various economic and cultural challenges undermined women’s agency to make decisions on where to give birth. A preference for home births was influenced by traditional practices and/or the costs associated with giving birth in health facilities, limiting women’s access to quality intra-partum care. However, in some cases,home births were found to expose pregnant women and girls to dangerous health complications and violence. This report documents serious abuse that may amount to torture and ill-treatment of women and girls committed by private individuals,during labour at home. Women and girls were left with life changing injuries and often hospitalised for weeks or months and faced astronomical bills as a result. The government of Zimbabwe has an obligation to investigate these cases.
Discrimination, Isolation and Economic Vulnerability
The report further indicates that the lack of information about the causes and treatment of obstetric fistula increased women’s risk of discrimination and abuse within their families and communities. Most women had lived for years with obstetric fistula, or undiagnosed conditions of incontinence related to childbirth, with many thinking they were the only person with the condition.
The fear of stigma and discrimination because of their health status led most women to try and keep their condition hidden and they all faced isolation and enormous barriers to health information and treatment for obstetric fistula. In most cases, women were also unable to work, and were thus pushed further into poverty because of their maternal injuries. Their health status also increased the risk of domestic violence, including economic abandonment. Without financial assistance and support, it is impossible for most women to afford the essential health commodities needed to bath, wash clothes, and prevent blisters and sores.
Positive Public Health Interventions Overshadowed by Covid-19
The Ministry of Health and Child Care Fistula Programme provides a positive start for a national information campaign and the treatment of people with obstetric fistula. Women who have received surgery for fistula expressed a desire to be “ambassadors” and work with community members to provide information and help change attitudes. As participants at Amnesty International’s community drama and dialogues stressed,“we must teach each other that it [obstetric fistula] is curable”. Raising awareness about the causes and treatment of obstetric fistula can assist in dispelling myths and superstition that women with obstetric fistula have been bewitched.However,despite the success of the Ministry of Health and Child Care Fistula Programme in providing surgical repair for obstetric fistula, promotion of the program has yet to reach all health facilities, throughout the country.
The advent of the COVID-19 pandemic has adversely affected programming for obstetric fistula in Zimbabwe. The fragile gains registered in previous years have been progressively reversed, as evidence has shown that lockdowns and aggressive state responses have further decreased the impact of the Ministry of Health and Child Care Fistula Programme. A study published in April 2021 by Chimamise et al.noted that because of restrictions imposed due to the pandemic,only 25 women had repair surgery in 2020, compared to 313 in 2019.
Conclusion and Recommendations
Ultimately, the prevalence and incidence of obstetric fistula in a country are indicators of the failure of a health system to deliver accessible, timely and appropriate maternal care to women and girls, violating the rights to health of such persons. This report finds that the experiences of fistula patients in Zimbabwe indicate a failure of the Zimbabwean government to uphold sexual and reproductive health rights and the rights to equality and privacy and to be free from torture and other ill-treatment of women and girls in the country, in direct violation of various commitments it has under international and regional law as well as its own Constitution.
In holding the government of Zimbabwe to these obligations, Amnesty International recommends that the government should urgently increase efforts to prevent obstetric fistula, as well as increase efforts to identify and treat women with maternal morbidities, including obstetric fistula,by adequately funding and operationalising a comprehensive public maternal health care policy;ensuring such policy is in line with the international standards of availability, accessibility, acceptability and quality.
Importantly, the policy must be contextualized to the COVID-19 crisis. The government of Zimbabwe is also encouraged to take immediate action against any acts of violence and ill-treatment inflicted on women during childbirth and ensure that neither third parties nor harmful social or traditional practices interfere with women and girls’ rights to sexual and reproductive health, including enacting legislation to prohibit child marriage.
The international community is strongly encouraged to provide technical and financial support for these initiatives.
Read the full report here (1MB PDF)
Source: Amnesty International