In 2018, Julienne Nyirandinabo had her third child, a baby girl, through a caesarean birth.

In two days, the new-born baby and her mother were back home, where her two excited older children and husband were waiting.

The excitement was short-lived.

Nyirandinabo, 35, recalls how she suddenly started experiencing an overwhelming and constant leakage in her private parts. The leaking would quickly soak her underwear so much that urine would suddenly drip down her legs.

"It’s as if my bladder had developed a life of its own. I had no control. The urine would come out on its own volition, and this time, not through the urethra but through my vagina,” she says.

Within 10 days, Nyirandinabo checked into Kibagabaga Hospital where she was then transferred to the University Teaching Hospital of Kigali.

Upon further diagnosis, it was discovered that complications related to her caesarean section delivery had resulted in obstetric fistula.

For the next six months, Nyirandinabo would go on to have three operations, but unfortunately, the operations could not fix her problem.

Stuck in hospital for over six months, her weight dropped from a healthy 75 kilogrammes to a miserable 30. Looking back, Nyirandinabo says that she was convinced that she was about to die.

But what is fistula?

Considered one of the most serious childbirth injuries, obstetric fistula is a hole that forms between the birth canal and bladder, or rectum, as a result of prolonged, obstructed labour (where the baby is blocked when descending through the birth canal). It can also develop from a poorly executed C-section.

As a result, women living with fistula are left leaking urine, faeces or both.

Locally known as ‘kujojoba’ (leaking), fistula patients are often accompanied by an overwhelming strong odour. As a result, most of these women are plagued by stigma, isolation, poor mental health, and poverty among other challenges.

According to the Maternal Health Task Force, a project of the Women and Health Initiative at the Harvard T.H. Chan School of Public Health, evidence suggests that over the last decade, the number of caesarean births has shot up and with it, a growing number of c-fistula cases resulting from unsafe surgery.

For surgery to be considered safe, the task force says that it must involve a team of well-trained surgeons and other healthcare providers, a supportive health system and it must adhere to evidence-based policies and guidelines among others.

Unfortunately, in low-income countries, as the number of women having children from health facilities increases, the overwhelming numbers sometimes rarely match the number of experienced healthcare providers available.

Fortunately, obstetric fistula is not only preventable but most women who are able to access skilled surgical repair surgery can be treated and given a fresh start back to normal life.

Fixing fistula

Slightly over one decade ago, the government started making steps towards getting the women that need fistula surgeries the help and support that they need.

One such initiative was taken in April 2010 when the Ministry of Health invited the US-based International Organisation for Women and Development (IOWD) to Rwanda to begin a fistula repair programme.

Started by Barbara Margolies, a retired American English teacher, IOWD has over a decade led a team of over 30 volunteer experts in obstetrics and gynaecology, paediatrics, nursing, and anaesthetics to do fistula surgeries, among a catalogue of other health issues.

Thrice a year (February, May, and October), the teams are joined by Rwandan gynaecologists and medical students to give hundreds of women fistula reparation and uterine prolapse surgeries, and an opportunity to regain their dignity within their societies.

Immaculee Kantengwa is a midwife at Kibagabaga Hospital and has been in charge of coordinating the work of the IOWD team in Rwanda since 2010.

Working alongside the team, Kantengwa was present in 2018 when Nyirandinabo was invited for a consultation and later, when she had her fourth and finally successful surgery.

Nyirandinabo is one of the more than 1,208 women that have received surgery so far and resumed normal life. Over that period, IOWD has also conducted 5,496 consultations. Like Nyirandinabo, all the women are treated free of charge.

Call to action

Kantengwa explained that although there are those that have fistula as a result of childbirth injuries, a significant number of the women they receive have fistula, dating decades before due to having unassisted home births.

"There are some women who have lived with fistula for a very long time. Many don’t know what it really is and are even not aware that treatment is possible. Others choose to suffer in silence due to the attached social stigma and shame,” she said.

This has prompted IOWD to find innovative ways to take the services to areas closer to communities where the patients are likely to be.

This May, the team of more than 30 IOWD volunteers visited Kayunga Health Centre where they examined women for cervical cancer and provided fistula consultation.

Besides consultation and surgery, the team works closely with local healthcare providers to provide hands-on training to ensure the sustainability of the programmes.

Kantengwa explains that the IOWD goal is to empower local healthcare providers to take ownership of fistula treatment and care, ensuring that the knowledge and skills are transferred to local doctors who can continue to address the problem independently when the teams have left.

"The IOWD team collaborates with the doctors to provide hands-on training and share their expertise in diagnosing and repairing obstetric fistulas. They train the local doctors on surgical techniques, pre-operative and post-operative care, and strategies for preventing and managing complications,” she explained.

Additionally, the team flies in all the equipment that it uses during the mission and donates to the hospital at the completion of the mission.

The World Health Organisation estimates that roughly two million girls and women live with fistula and an additional 50-100,000 develop the condition each year.

However, these numbers could likely be higher.

In Rwanda, there is little to no data highlighting just how grave the issue of obstetric fistula currently is. However, there are a few studies that can provide a glimpse into what the country is dealing with.

For instance, in 2020, a five-year study by Richter A.L indicated that of 2,091 women that sought consultation, 630 (30 per cent) were diagnosed with obstetric fistula.