The turmoil in northern Mali is thwarting efforts to treat and prevent obstetric fistula, say health experts and local NGO workers.
It is just one example of the fallout from the latest fighting between Tuareg rebels and the Malian army, triggered when rebels began attacking northern military posts in January. Since then, some 195,000 people are estimated to have been displaced by fighting, according to the UN Office for the Coordination of Humanitarian Affairs.
Obstetric fistula - a tear in the birth canal caused primarily by prolonged labour, resulting in chronic leakage of urine and/or faeces - is both preventable and treatable, and for years health workers in Mali have been working on both tracks.
The latest instability in the north has had both an immediate and a potential long-term impact on efforts to address fistulas, primarily in nomad communities: Many women in northern areas who were to have operations in early March did not, while prevention and training activities also took a hit.
One component of a project backed by the US Agency for International Development (USAID) in northern Mali is the quarterly “fistula care week”, in which women from northern districts are assisted in coming to the regional hospital in Gao, eastern Mali, for treatment. For the latest campaign running from 25 February to 3 March, about a third of the 30 women scheduled for operations did not show up and could not be reached, health workers said.
“We have lost contact with all the women we were following in Ménaka [one of the first areas attacked by rebels],” said Fatimata Touré, head of Gao-based NGO GREFFA whose work includes educating communities about prevention and treatment of fistula. She said fistula prevalence is highest in nomad communities and most of the women GREFFA assists are in Ménaka, a sub-region of Gao populated mostly by nomadic and pastoralist communities. “We don’t know where they are today - people from that area have fled in all directions.”
“Granted, we’re talking about communities who move regularly,” Touré said. “But when things are stable we know exactly where to find them during this or that period of the year.”
Ibrahim Oumar Touré, GREFFA’s coordinator for the prevention of early marriage and fistula, told IRIN NGO workers could not transport the women as they normally would because of the security situation.
“God alone knows how much these women with fistula suffer, and beyond that now we can’t get to many of them for treatment,” he said. “It pains me just to think about it…. It’s atrocious.”
GREFFA, which receives support in reproductive health and other programmes from Norwegian Church Aid, has also lost contact with the local women who collaborated with the NGO in year-round outreach efforts, Mr Touré said.
Mali, with the support of several donors and NGOs, has made significant strides in incorporating fistula prevention and care into local and national health structures, and health workers say the conflict threatens to set back some of this progress in northern communities.
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They noted a number of concerns, including the suspension of education and prevention efforts in some nomad areas, and the loss of contact with women who have had fistula treatment in the past and need close attention especially in childbirth.
Demba Traoré, coordinator of the fistula care project at NGO Intrahealth, said prevention is a major component of the work. “We know that early marriage [and thus childbirth] and excision are two major contributors to fistula,” he told IRIN. “We regularly talk with local authorities and traditional and religious leaders, who have a huge role to play in prevention. But with the current security situation we can’t continue this outreach in some areas.”
He said there is a concern that the incidence of fistula could rise because health services in some areas have been interrupted. “Even if under normal circumstances many of these women did not go to health centres, we had started to see an improvement there. Fistula is linked to a lack of obstetric care. Now we fear we could see a rise in new cases in these affected communities.”
A 2009 Malian Health Ministry strategy on fistulas says while the exact prevalence of the condition is unknown, it is estimated that 600 new cases occur per year. For years the aid agency Médecins du Monde has supported fistula care in Mali; it has a programme to support corrective surgery as well as post-operation psychological care in Mopti.
Obstetric fistula is a distinctly difficult condition to bear and to quantify, say experts. Women with fistulas are generally shunned by their families and communities. An indispensable component of any fistula care effort - including in Mali - is helping women post-operation to reintegrate into their communities and re-establish a livelihood.
Outreach in safer areas continues, as does fistula treatment at the Gao regional hospital, Touré of GREFFA said, though all the current patients are from Gao communities not affected by fighting. A principal aim of the fistula care project has been to make treatment available on a regular basis at the hospital, where three trained surgeons are based. “Even as we speak, women are receiving treatment,” he said.