It is a difficult subject which, ideally, no one should ever hear about again. Obstetric fistula, with a number of new cases estimated at over 30,000 a year in West and Central Africa and only 3,000 treated, remains a nagging public health issue and a matter of human dignity.
A sanitary and social tragedy for women
This condition, which is often operated on by the famous Nobel Peace Prize winner Professor Denis Mukwege in his hospital in Panzi, refers to a puncturing of the vaginal wall caused by rape or labor complications due to the lack of access to treatment and cesarean sections. It results in leaking urine and feces for untreated patients. The consequences range from infection to potential kidney failure.
According to the World Health Organization (WHO), 2 million women around the world are living with this injury, including 600,000 to 1 million young girls and women in Africa. It leads to an unspoken social tragedy. Patients are in most cases rejected by their husbands, stigmatized by their community and associated with alleged acts of witchcraft. They are often forced to live in shame, isolation and extreme poverty.
Regional strategy for West and Central Africa
As a preventable disease with a taboo from another age, obstetric fistula can be easily treated and must end. The United Nations Fund Population (UNFPA) launched an appeal to donors in Niamey on 23 March 2021, during a forum organized with the wife of the outgoing President, Lalla Malika Issoufou, who is herself a doctor.
The objective: finance a regional strategy bringing together a variety of partners in 23 countries – NGOs, civil society, religious and traditional leaders, UN agencies, the African Union, regional communities and wives of Heads of State. Several of them came to Niamey to make a commitment to alert, treat and reintegrate women, by financially empowering them.
The wives of Heads of State, on the front line in Niamey
Fatima Madaa Bio, the wife of the President of Sierra Leone, strongly condemned child marriage which “can no longer be accepted as a cultural norm”. Hinda Déby Itno, from Chad, emphasized the low level of access to cesarean sections. She pointed out that between 2012 and 2020, 286 women suffering from obstetric fistula were treated on average per year, with an estimated number of women of between 250 and 750 untreated per year. It is still difficult for women living in rural areas to access the two treatment centers in Chad, one in the capital, N’Djaména, and the other in Abéché, the second largest city in the country.
In the Comoros, Ambari Azali, the President’s wife, pointed out that only 15% of women aged between 15 and 49 are aware of the disease, against 32% of the 35-49 age group. According to the Economic Community of Central African States (ECCAS), Cameroon has a prevalence of 20,000 cases, with 2,000 new cases per year and 600 women treated since 2016.
Lalla Malika Issoufou, for her part, spoke about prevention in Niger, with a measure for free mandatory schooling up to the age of 16 and “the need to break the misconceptions on early marriages”. In Niger, 500 cases of fistula are treated every year in 11 centers where treatment is free.
Zero new untreated cases by 2030
In 2003, UNFPA already launched a global campaign to end fistula in 55 countries, which supported 113,000 surgical repairs. The objective of the new regional strategy launched for West and Central Africa is to achieve zero new untreated cases by 2030 and 80% of old cases treated. Much remains to be done in a context that would not necessarily appear to be favorable. Indeed, one girl in ten in West and Central Africa is married before her 15th birthday and 42% of marriages take place before the age of 18. In addition, the number of centers that treat obstetric fistula ranges from zero in Cabo Verde to 16 in Senegal.
The appropriate responses correspond to several UNFPA missions: delay the age of the first pregnancy, extend access to healthcare, make it universal for sexual and reproductive health, convince of the need to give birth with a midwife present.
An investment study conducted by UNFPA puts the regional effort that needs to be made at $82.6 million by 2030, in order to prevent fistula in 42,000 rural communities through a community-based approach. This funding would also be used to train a health professional in each community, conduct targeted mentoring in 210 regional hospitals and, especially, treat 67,000 women and reintegrate 54,000.
Treating one patient costs $1,500
A survey conducted by our services in Burkina Faso, Chad, Côte d’Ivoire, Guinea, Niger and Senegal showed that women live with this injury for 7.5 years on average. The financial impact of the disease is estimated at $788 a year for each survivor and their family (loss of income, spending for treatment) and $192 for the health system. This amounts to a total of $7,350 per woman over a period of 7.5 years, to be compared with the total cost of treatment for each patient of $1,500.
The Korean International Cooperation Agency (KOICA) has been setting the example in Côte d’Ivoire since 2012. It has tackled the problem alongside the authorities and UNFPA, devoting $16 million to raising public awareness and the surgical treatment of 4,770 women. It is our responsibility to address this issue at the intersection of several Sustainable Development Goals (SDGs), to ensure that “no one is left behind”. And especially not the most vulnerable women.
By Mabingué Ngom, United Nations Population Fund Regional Director for West and Central Africa
The opinions expressed on this website are those of the authors and do not necessarily reflect the official position of their institutions or of AFD.