For years I had followed the progress of the Fistula Hospital in Addis Ababa, Ethiopia, and of the hospital’s founder, Dr. Catherine Hamlin. I first read about Dr. Hamlin in Ms. magazine, saw her on "The Oprah Show," pored through her autobiography in two days and now, miraculously, here I was speeding through the streets of Addis Ababa on my way to meet her. I was excited, but more than that I was scared. Dizzy from the heat, dust and the sudden jolting of the taxi, I was hanging on for dear life. The taxi driver must have noticed my discomfort. He tried to reassure me, "I have driven many ferenji (foreigners) to the hospital,� he said. “Don't worry, I know where it is." I wasn't worried that he couldn't find the place. I was worried about getting there in one piece.

The Addis Ababa Fistula Hospital is an oasis in an overcrowded, fast-paced, dusty, dirty city. The grounds of the hospital are covered with green grass, lush bushes and flowering trees. As we approached the hospital we saw young women, some with small children or a family member, but mostly alone, dressed in little more than rags and lining the walkway leading to the hospital doors. At the feet of many were pools of urine. These women were waiting for a surgery that would make a dramatic change in their lives.

What is a childbirth fistula?
Although fistulas can also develop from female circumcision, unsafe abortion attempts or pelvic fractures, the most common cause is obstructed labor. About five percent of women worldwide will experience what is called obstructed labor, which means that the woman's baby will not fit through her birth canal because her pelvis is too small or the baby is too big or badly positioned. In countries with adequate medical services obstructed labor is treated, most often, with caesarean section. In places like Ethiopia where medical facilities can be literally days away and where the patient to doctor ratio is 1:80,000, there is no hope of a medical intervention. Instead the woman will endure days of excruciating labor. The baby's head becomes wedged in the mother's pelvis, cutting off the blood supply to the soft tissues of her bladder, rectum and vagina. The injured pelvic tissue soon rots away leaving a hole (fistula) between the woman's vagina and her bladder or rectum, or both. In most cases, the baby dies. After death the baby’s body collapses, allowing the mother to finally birth her dead baby. The lasting results of the fistula are noticed a few days after the birth when the woman has constant leaking of urine and sometimes feces. In most cases the husband tires of her smell and rejects her, sending her back to her family’s village. There, a small hut will be built and she will live out her days, receiving no visitors and too ashamed to leave.

Treating childbirth fistulas
Records of childbirth fistula go back as far as recorded history. Coins have been found in the pyramids of Egypt with pictures depicting childbirth fistulas. The first known written reference to fistula was found buried with a mummy at Thebes and dating back to 1550 B.C.E.
Here in America we have our own history of treating childbirth fistula. In the 1840s Dr. J. Marion Sims, a South Carolina surgeon who later became known as the “Father of Modern Gynecology,� was the first surgeon known to successfully treat a childbirth fistula. Although today he is hailed as a tireless hero, a remarkable physician and, as it says on his gravestone, “Surgeon to Empress and Slave,� his career bears another look.

Dr. Sims was trained as a general practitioner at Jefferson Medical College. He set up a medical practice in Lancaster, Minnesota, but after the deaths of his first two patients, moved to South Carolina. Dr. Sims was not trained as a surgeon yet records show that he performed surgery regularly and was actually the first doctor to ever successfully treat a clubfoot.

Sims became aware of the problem of childbirth fistula when a local plantation owner brought his seventeen-year-old slave, Anarcha, to Sims for treatment. Anarcha had been in labor for three days before her baby was delivered with the aid of forceps. No record can be found regarding whether the baby lived or died, but we do know that Anarcha suffered from a fistula that left her bladder and bowel incontinent. Sims conducted over 30 experimental surgeries on Anarcha, all without anesthesia. Becoming nearly obsessed with perfecting his technique, Sims turned to other slaves for a source of experimental fodder. Between the years 1845 and 1849 Sims ran a makeshift hospital that he built in his backyard, performing experimental gynecological operations on countless enslaved African women. After suffering unimaginable pain, many lost their lives to infection. Sims is also credited with inventing every woman’s favorite gynecological tool, the Sims retractor or modern day speculum. In order to aid him in the surgery Dr. Sims had a jeweler bend a silver spoon in just the right way so that it held open the vagina, allowing him to view the fistula. After numerous attempts, Sims developed a successful technique for fistula repair, documented his success and wrote an autobiography, thus securing his place as the “Father of Modern Gynecology.�

In 1855 Sims founded the Woman’s Hospital of New York. The hospital performed fistula repairs and surgeries for other childbirth injuries until it was closed in 1928. As surgeons around the country perfected the c-section, and health care and nutrition improved, childbirth fistulas became rare in the United States. The hospital was torn down and in its place was built the famous Waldorf-Astoria Hotel. But while childbirth fistula became a rarity in America and other developed countries it was still very much a reality in many other parts of the world.

The world’s second fistula hospital
As I entered the hospital Dr. Andrew Browning, a surgeon from Australia, interrupted his busy day to greet me and give me a tour of the facilities. Dr. Browning had just come out of surgery and asked me to wait just a minute while he grabbed something to eat before showing us around. Even as he hurried through his lunch he traded notes with other surgeons, gave orders to hospital staff and talked to patients. Dr. Browning started the tour by giving us a little history lesson of the hospital and its founders, the Hamlins.

Ethiopian Emperor Haile Selassie founded the Princess Tsehai Memorial Hospital in honor of his daughter who died from childbirth complications. Concerned that his country did not have adequate health care for birthing women, Emperor Selassie posted an ad in a British medical journal to recruit doctors interested in helping start a midwifery training clinic within the hospital. An Australian couple, Doctor Reginald Hamlin and his wife, Doctor Catherine Hamlin, read the ad and in 1959 decided to move to Addis Ababa, taking along their six-year-old son, Richard.

Very soon the Hamlins encountered their first cases of childbirth fistulas. They had read about fistulas and had a vague academic understanding of them but no direct experiences with treatment. Catherine Hamlin writes in her autobiography, A Hospital by the River, “We had read up on the problem, because we knew it occurred in developing countries, but we had never seen a case. The departing doctor, who had been performing a surgical procedure which gave some temporary relief but resulted in other long-term problems, warned us: ‘The fistula patients will break your heart but there is nothing you can do….’�

Without any previous experience or a teacher or even modern medical equipment, the Hamlins studied and practiced until they perfected the surgery. News traveled that the Hamlins could cure the fistula and soon the hospital was overrun with women needing surgery. The hospital could not house them all as they waited for an opening, some waiting for years. The Hamlins, with the help of the hospital staff, constructed makeshift housing in back of the hospital but soon even this couldn’t accommodate the overflow of suffering women. After hearing about the work of the Hamlins, Haile Selassie granted permission for the couple to buy land just outside Addis Ababa. The Hamlins set out on a worldwide fundraising tour and in 1974 they founded the world’s second fistula hospital.

The hospital today
Today the hospital is a model of efficiency, something rarely seen in African health care. The hospital staff is made up of former fistula patients who, for one reason or another, cannot return home. Because of the nature of the fistula, the floors are cleaned three times each day and all bedding washed twice a day. The simple but immaculate kitchen makes 400 injera (Ethiopia’s national bread) per day, feeding patients, family members and hospital staff. Dr. Browning showed us the main ward lined with over 40 hospital beds all filled with women either recovering from surgery or waiting for their turn. The hospital does about three surgeries per day. Each surgery can take between one and three hours and the recovery for these women is around two weeks. The hospital has a physical therapy room and a small classroom where recovering patients are taught to read and write and given instruction in basic health and hygiene, as well as education in women’s rights. Right outside the main ward construction was underway for another ward and a training facility for surgeons who come from other developing countries to learn this surgery. The hospital has plans for five small satellite hospitals in rural areas around Ethiopia.

As I looked from face to face I wondered, “How long did this girl suffer before arriving here?� “Will that girl go back to her village?� “And will this woman go on to have another baby to replace the one that died?� I met a young woman who had lain in her hut for nine years, too ashamed to go out, receiving no visitors other than her mother who brought her food and water each day. The doctors had cured her fistula but her legs were literally frozen from inactivity. She was now undergoing physical therapy to retrain the muscles so she can walk and return home to her family. Here, miracles like this take place every day.

More than 45 years after first arriving in Ethiopia, having survived a revolution, several coup attempts, drought and famine, 20 years of civil war and the death of her husband in 1993, Dr. Hamlin is still going strong. Well into her 80s she still performs three surgeries a week and continues to make the plight of the fistula pilgrims her mission. As the tour progressed I realized that I had been naïve to think I would be able to sit down and have a nice long chat with Dr. Hamlin. Clearly, the hospital and everyone here was too busy for that. But during the tour we did pass Dr. Hamlin in the hall. Tall and regal with a gracious smile, Dr. Hamlin greeted me, took my hand in hers and asked what brought me to Ethiopia. As I attempted to answer, she quickly dismissed my gushing admiration and rattled off instructions to a nurse passing by, her mind obviously on more important matters. She paused just a moment to bid me a “nice visit� and thank me for coming, then headed down the hall, back to work.

What about the future?
No doubt the women returning home to their villages after surgery with new skills and education have some impact on the other women of their village but not enough to change many of the conditions that contribute to childbirth fistula: child marriage, inadequate health care, inadequate education for women. The Ethiopian government, to their credit, does work to promote the education of girls. Every major city I visited had huge billboards encouraging Ethiopians to send their daughters to school. But this message rarely reaches the remote countryside and when it does, it is not well received. The reason women are not educated is primarily financial. When a family has to make a choice of whether to spend what little money they have on school fees for a son or a daughter they will inevitably choose the son. He has a much greater chance of finishing school, acquiring a job and, in turn, helping his family.

Occasionally, during my time in Ethiopia, I heard the argument that child marriage is part of the culture and that Westerners shouldn’t force their modern views on Africans. But culture is not static. Culture is always changing and is influenced, especially in our ever-shrinking world, by other cultures. Bits and pieces of the outside world, whether good or bad, are reaching even the most remote villages in Ethiopia. If they are to be influenced by the West let it be in the form of gender equality, self-determination and education of women rather than the endless pursuit of materialism.

How can you help?
Contact http://www.fistulatrust.org/Main/Hospital.html

Sources:
Brinks, Wendy “Monumental Mistake� http://www.scpronet.com

Hamlin, C., 2004. A Hospital by the River. Oxford, UK: Monarch Books.

Deborah Craig lives in Bellingham, Wa. with her partner, Negash and their two children, Makela and Mario. She teaches natural childbirth classes and enjoys collecting stories of birth rituals from around the world.

Copyright © 2005 Midwifery Today, Inc. All rights reserved.
Reprinted with permission from Midwifery Today, Number 76.
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