ADDIS ABABA, Ethiopia—Kumbe Seboka, nine months pregnant, sat quietly in the hospital parking lot, clutching her medical information card in one hand and cradling her swollen belly with the other, as if to keep her unborn child from escaping.
Her first pregnancy, two years ago, had ended in heartbreak: three days of excruciating labor, then a stillbirth and finally a ruptured bladder that for three months issued a steady trickle of urine that ran down her legs and wet her clothes, bed, everything.
The humiliating injury is called obstetric fistula, a tear in the tissue between the vagina and adjoining organs, caused by prolonged labor in small, undernourished women—and now almost unknown outside the poorest countries of Africa and Asia. While the last recorded case in the United States was in 1895, researchers believe that 9,000 women will develop fistulas this year in Ethiopia alone.
Kumbe was fortunate. After consulting with a village doctor, her husband rented a car, and together they made the daylong journey from their remote northern hamlet to the capital, Addis Ababa. There she was treated by doctors at the first hospital in the world—and for decades the only one—dedicated to repairing fistulas.
Now, at age 25, she's healed and about to be a mother.
"I have been eager for this child," she said. "Everything is because of this hospital."
Founded in 1974 by two Australian gynecologists, Catherine Hamlin and her late husband Reginald, the Addis Ababa Fistula Hospital has performed more than 32,000 free operations on women from across Ethiopia. More than 90 percent of patients, like Kumbe, fully recover and can bear children again.
The couple performed the first fistula operations in Ethiopia as volunteers in 1959. Now the hospital, with support from nonprofit foundations and private donors, has grown into an internationally recognized center for fistula research and has trained doctors from 28 countries to perform the simple, life-altering surgery.
Their work has helped raise the profile of the debilitating but long neglected injury. In 2003 the United Nations Population Fund launched a worldwide "End Fistula" campaign, which is now working in 35 poor countries in Africa, Asia and the Middle East. In recent years Sudan and Nigeria have opened centers for fistula repair.
Last year the U.N. campaign appealed for $78.3 million in funding over five years to reach its target of eradicating the fistula problem by 2015. But that will require a substantially bigger commitment from donors, who gave $4.9 million in 2005, the last year for which figures were available.
Although the U.N. estimates that more than 2 million girls and women worldwide are living with fistula, most Americans are unlikely ever to have heard of it. That's because the childbirth complication that causes the injury—when the fetus becomes lodged in the birth canal—has long been resolved with a Caesarean section in Western countries.
But most births in Africa occur at home, and even simple medical procedures are well beyond the reach of poor families. In Ethiopia, as in so many developing nations, there's a vast shortage of doctors, and only 163 registered obstetricians for a population of 74 million, according to government figures.
The hospital treated about 2,000 fistula cases last year. But administrators believe at least 20 times as many cases exist in the countryside.
The risk of difficult pregnancies is especially great in Ethiopia, with its predominantly rural, patriarchal society. By the age when American girls start to attend preschool, girls in the countryside are already pressed into household labor, hauling buckets of water to help their mothers. Soon after that, they're handed the daily task of grinding grain with heavy stones to prepare injera, the spongy bread that's the staple of the Ethiopian diet.
"By the age of 8 they can carry weights that I can't carry," said Ruth Kennedy, a 54-year-old midwife at the hospital.
Hard labor and poor nutrition conspire against rural girls, who grow up sinewy and stunted. But in traditional practice, girls are often married off by age 12 and expected to bear children within a few years. Their undersized pelvises are ill equipped to deliver fully formed fetuses, producing devastating complications, hospital nurses said.
Some patients arrive at the hospital having endured up to seven days of labor. At the end, the baby's head collapses and it emerges stillborn.
The stuck fetus blocks blood flow to tissues in the pelvic wall, eventually tearing a hole. Within hours the mother begins to leak urine and, in extreme cases where rectal tissue is also damaged, sometimes feces, nurses said.
Without treatment, women can leak from their vaginas for the rest of their lives, making it difficult for them to live among family and friends and forcing them to the margins of their close-knit communities.
"Very few of their husbands keep them. They are spoiled," Kennedy said. "In a survivalist society, these little women become a burden."
That's what happened to Melise Brehanu, who was 18 when she developed fistula trying to give birth to the child of her middle-aged husband. For three days, as the fetus struggled to get out, two midwives yanked at her body like a wishbone.
The injuries to her bladder and kidneys were extreme. But the insults were yet to come.
"I smelled," she said. "No one talked to me. All my friends hated me. No one understood the condition," she told an American reporter.
For several months Melise lay at home in bed in a fetal position, wracked by depression and trying desperately to stop the constant dripping of urine. She awoke one morning to find that her mother-in-law had thrown her things out of the house. Her husband finally brought her to a nearby clinic, where someone arranged for her to be transported, alone, to the capital.
By the time she reached the hospital last month, she'd been suffering for nearly two years. Doctors labored for hours but couldn't seal the tear. Away from her bedside, while the unschooled young woman in panda-bear pajamas stared blankly at the ceiling, a nurse whispered that she'd never regain normal bladder function and could never have a child.
It all would have been different, the nurse said, if Melise had early access to a medical procedure that costs less than $300.
"If this had happened to men, or to the rich, or to the educated, or in the West," Kennedy said, "it would have been resolved a long time ago."
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ON THE WEB:
The Fistula Foundation: www.fistulafoundation.org
United Nations Population Fund's "End Fistula" campaign: www.endfistula.org
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(c) 2007, McClatchy-Tribune Information Services.
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