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Recurrent fistulas: Uganda’s successes and challenges

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Victoria Adokorach lives in Bidibidi Refugee Settlement. The 30-year-old was married, but after the birth of her first child in 2014, she suffered an obstetric fistula and her husband abandoned her. 

“I went through prolonged labour and at the end of it, I was leaking urine and faeces non-stop. The doctors performed corrective surgery, but the problem persisted. One night, I was having sex and the faeces leaked out and stained my husband. He lost his sexual urge and I believe it was at that point he decided to get another wife,” she says.  

After her husband left, Adokorach lived in isolation for six years. She was stigmatised by the community because of the smell that constantly hung around her. 

“I realised I was pregnant after my husband left and I delivered my second child with this condition. Even my relatives could not bear to be near me. Only my mother comforted and provided for me,” she laments.

Only after Amref Health Africa organised free fistula surgical camps in the six districts of the West Nile region in partnership with the Ministry of Health, Adokorach was successfully operated on. 

The delay
An obstetric fistula is an abnormal opening between a woman’s genital tract and her urinary tract or rectum.

The condition, which often leaves women leaking urine, feaces, or both, is caused by prolonged obstructed labour, which may result in birth injuries.  

Three delays are fatal to pregnant women; the first is the delay in deciding to give birth in a health facility.

The second delay is infrastructural, such as lack of transportation to the hospital. The third delay occurs when a woman is already in the hospital but does not receive adequate care on time. Teenage mothers are affected the most because their birth canals are not yet well developed and their pelvises are narrow. 

Fistula can be treated through corrective surgery and many not-for-profit hospitals, and government facilities have held medical camps where surgery is free. However, some women continue leaking even after surgery. 

Dr Emmanuel Odar, a fistula surgeon and consultant gynaecologist at Arua Regional Referral Hospital, says the hospital is now performing urinary diversion procedures to contain the continuous flow of urine among women with irreversible fistula. 

“When the nerves are damaged, we divert the urine so that it does not come through the bladder. Instead, it goes through the intestines and flows out with the stool. After this four-hour procedure, women who are damaged beyond repair can remain dry,” he explains.  

Dr Odar adds that the urinary diversion procedure has been scientifically approved and is being used all over the world. The operation costs $400 (Shs1.4m). 

However, with help from the government and partner organisations, affected women are still getting the service free of charge.

“We have had successes in the treatment of fistula in the West Nile region because there has been improved service delivery at Health Centre IVs. We used to get 20 referral cases of fistula at Arua Regional Referral Hospital per month. Now, we only receive four,” he says. 

Fistula can be treated through corrective surgery and many not-for-profit hospitals, and government facilities have held medical camps where surgery is free. PHOTO/FILE

Today, with a clear referral system, hospital deliveries have gone up to about 80 percent compared to 40 percent in 2006. Importantly also, Health Centre IVs can now perform caesarean sections, which reduces the delays in referral.

“West Nile is one of the regions that are high-risk areas for obstetric fistula because of the teenage pregnancy rate. Younger mothers, especially those who give birth at home due to lack of transport to health facilities,” Dr. Odar says.

The Ministry of Health estimates that at least 200,000 women are living with fistula with 1,900 new cases every year.

Dr Alex Wasomoka, the assistant commissioner for hospitals, says the West Nile and central regions have the highest number of urinary fistulas at 17 and 15 percent respectively, while Rwenzori and Karamoja sub-regions have the least number of birth injuries in the country.

“About 1,500 surgical operations are conducted every year in both government and private hospitals to repair fistulas. While the only way to repair fistulas is through surgery, having skilled birth attendants, who can make referrals for complicated cases quickly, can prevent the condition. It is also important for healthcare providers to closely monitor mothers during labour,” he says.

One of the biggest challenges in the treatment of fistula is the limited human resources. Uganda has only 25 surgeons trained to perform this corrective fistula surgery, leading to a backlog of cases. 

Mental health 
Obstetric fistula is not only a childbirth injury. It is a public health and human rights issue. Survivors of fistula have been known to be abandoned to the consequences of the psychological trauma they have suffered. 

A 2019 study, “post-effects of obstetric fistula in Uganda; a case study of fistula survivors in Kitovu Mission Hospital (Masaka), Uganda,” revealed that several women continue to experience stigma, rejection and live in fear arising from past traumatic experiences of how they were treated by both their family members and the general community the time they suffered from fistula.

For those who are rejected and abandoned by close family members including their spouses, they continue living in isolation and consequentially develop an attitude that looks at relationships as meaningless. 

As a fistula survivor, Mercy Angucia says stigma in the community is hindering many women from coming out to reveal that they are suffering from this condition.

“They keep to themselves, in their homes for fear of being detected by other people. There is one woman in my village I am trying to convince to come out and have surgery. So far, she has refused. She hides whenever she sees me. But, I will not give up on her because a few months ago, I was like her,” she says.

The study also found that some fistula survivors still suffer from secondary infertility, the prolonged delay and or inability of the fistula survivor to conceive and give birth to a child. For some like Adokorach, remarriage is out of the question, yet their husbands abandoned them.

“After I healed, I was able to deliver another child, although it was through a caesarean operation. The doctor advised that the repaired part would tear if I had a virginal birth, and then, I would need another operation to repair it. Even now, if I want to have more children, it will have to be through a caesarean operation,” Angucia says.

The World Health Organisation (WHO) estimates that more than two million women live with fistula worldwide. In Uganda, though, it is now apparent that a comprehensive and holistic approach is needed if we are to continue experiencing a high success rate of eliminating the condition. 

This includes encouraging expecting mothers to attend antenatal sessions and deliver in health facilities and the provision of timely and adequate health care to women in labour. Also, after corrective surgery, a holistic approach is needed to restore the dignity of the affected women and reintegrate them into society.

Can fistulas be prevented?
According to, there is nothing you can do to prevent most fistulas. 

However, healthcare providers may be able to prevent obstetric fistulas; those that develop as complications of childbirth. This type of fistula can develop when you are in labour for too long or do not have access to emergency care (such as a C-section). 

Access to such care is unequal around the world. The World Health Organisation (WHO) and others are working to prevent obstetric fistulas by increasing access to medical resources.