Fourth International Consultation On Incontinence. Vesicovaginal Fistula In The Developing World.

The incidence of VVF globally is anywhere from 10,000-50,000 cases, depending on methodology of surveys with a worldwide prevalence of approximately 2 million cases. Dr. DeRidder presented a graph from the 2005 World Health Report that showed maternal mortality as a surrogate risk indicator for VVF. Rates are highest in sub-Saharan Africa and likely reflect common risk factors including poverty, young maternal age and limited access to prenatal care. Dr. DeRidder presented a 2007 study from Nigeria that showed the number of cases surgically corrected dependent on external funding to the surgical clinic.

The etiology of VVF was reviewed including the obstructed labor complex, iatrogenic injuries, cases of abuse/rape and traditional practices such as Gishiri cutting. The obstructed labor complex was highlighted as the primary cause in the developing world and consists of not only VVF but also a high incidence of fetal death, vaginal scarring, complex urologic injuries, secondary infertility, neurological injuries (foot-drop) and pelvic floor injuries, among others. VVF can have devastating consequences for women in the developing world, and Dr. DeRidder highlighted two publications from 2007 that showed a divorce rate of 36%, a fetal death rate of 85%, and frequent maternal loss of self-esteem, depression and suicidal thoughts. Women with VVF are often ostracized from their communities. Dr. DeRidder presented two recent publications showing a 97-100% incidence of mental dysfunction in  women with VVF based on the GHQ-28 questionnaire. This dramatically decreased after fistula correction.

Obstetric fistula is an injury to a woman's reproductive organs, usually occurring during prolonged, obstructed labor and without Caesarean section which would relieve the problem. Tears in the vagina occur which also tear other organs, producing leakage of urine and feces. Labor that lasts several days creates pressure on tissues, which cause tissue death. After 2 to 3 days of obstructed labor, the infant usually dies, but even so the labor may continue several days or more if medical treatment is not provided. It is painful, dangerous for the mothers, and devastating to their lives if left untreated.

To tell the story of women hiding in shame in a remote corner of Africa posed inherent problems in the making of "A Walk to Beautiful." How could we show their loneliness and isolation while at the same time time entering their intimate space? How would we follow a woman smelling of urine on a long bus ride to Addis Ababa, Ethiopia's capital, and remain true to the experience she and so many like her have endured? At the end of a day of shooting, how should we respond to 10 people suffering from various illnesses lined up outside the family compound hoping to get help from us—foreigners with cars and money?

Getting at the truth is our goal as documentarians, of course. But by virtue of our presence—crew, camera, microphone—the truth becomes invariably distorted. For decades, nonfiction filmmakers have confronted this conundrum, and our film shoot in Ethiopia was no exception. Could we capture the harsh reality these voiceless women experience?

A hidden agony

I first visited the Addis Ababa Fistula Hospital in the spring of 2004. The idea for a film about the hospital and women with obstetric fistula came from a New York Times op-ed column by Nicholas Kristof entitled "Alone and Ashamed" (May 16, 2003). A friend of Steven Engel, head of Engel Entertainment, where I've worked for 12 years, brought the piece to Steve and said, "What are you going to do about this?"

Steve took the question to heart, and after discussing it with our development team, he decided to embark on the company's first feature-length documentary. We, his staff, were with him from the start. We are mostly women, and learning of the secret and excruciating suffering that millions of women experience, we felt compelled to begin this journey.

Vesico- and Recto-Vaginal Fistulas

At the same age as Swiss girls start their final years in school or begin an apprenticeship and experience their first romances, thousands of young women, especially in Africa, already have to live through terribly painful labour without any medical help.

A pelvis that is not fully developed or in some way bent, or an awkward position of the baby can mean that labour goes on for a long time, sometimes for 5 days or more. During these days, the young mother experiences unbelievable pain and agony, which often results in a stillbirth.

The constant pressure of the baby’s head into the pelvis and the birth channel means that the blood circulation is disturbed, creating lesions in the tissues around that area. An opening then develops between the bladder and the vagina, and sometimes between the vagina and the rectum. Urine and sometimes fecal matter cannot be controlled anymore, which means that a bad, humiliating smell follows the woman everywhere she goes.

The consequences of such childbirth injuries are a catastrophe for the women concerned. They suffer constant pain due to infections. In addition to coping with the loss of their baby, these women are often abandoned by their husbands, avoided by the people of their own village and forced into isolation. Often the problem is misinterpreted as a sexually transmitted disease, for which the woman herself is to blame.

WHO reckons that 2 Million women in Third World Countries suffer from childbirth injuries, and that the number increases by 50’000 – 100’000 every year. Poverty, malnutrition, hard physical work, no education, too few Health Centres, long distances, no transportation, marriage and circumcision of young girls, discrimination of women – these are all factors that have something to do with obstetric fistulas.

In many Third World Countries, the woman’s role is to satisfy the sexual needs of her husband, to give birth to children, and to work hard in the house and in the fields. Childbirth injuries make it impossible for a woman to fulfill these duties, therefore her self-respect and self-confidence are destroyed. The mere right to exist in the village society is put into question.

Vesico- and Recto-Vaginal Fistulas

At the same age as Swiss girls start their final years in school or begin an apprenticeship and experience their first romances, thousands of young women, especially in Africa, already have to live through terribly painful labour without any medical help.

A pelvis that is not fully developed or in some way bent, or an awkward position of the baby can mean that labour goes on for a long time, sometimes for 5 days or more. During these days, the young mother experiences unbelievable pain and agony, which often results in a stillbirth.

The constant pressure of the baby’s head into the pelvis and the birth channel means that the blood circulation is disturbed, creating lesions in the tissues around that area. An opening then develops between the bladder and the vagina, and sometimes between the vagina and the rectum. Urine and sometimes fecal matter cannot be controlled anymore, which means that a bad, humiliating smell follows the woman everywhere she goes.

The consequences of such childbirth injuries are a catastrophe for the women concerned. They suffer constant pain due to infections. In addition to coping with the loss of their baby, these women are often abandoned by their husbands, avoided by the people of their own village and forced into isolation. Often the problem is misinterpreted as a sexually transmitted disease, for which the woman herself is to blame.

WHO reckons that 2 Million women in Third World Countries suffer from childbirth injuries, and that the number increases by 50’000 – 100’000 every year. Poverty, malnutrition, hard physical work, no education, too few Health Centres, long distances, no transportation, marriage and circumcision of young girls, discrimination of women – these are all factors that have something to do with obstetric fistulas.

In many Third World Countries, the woman’s role is to satisfy the sexual needs of her husband, to give birth to children, and to work hard in the house and in the fields. Childbirth injuries make it impossible for a woman to fulfill these duties, therefore her self-respect and self-confidence are destroyed. The mere right to exist in the village society is put into question.

Second Chances

Having a baby can be one of the most joyous events in a woman's life. Yet for the millions of young women in the developing world who develop severe injuries called fistulas from obstructed labor, it's the beginning of a living nightmare, one that can last the rest of their lives. Since 1974, when she and her late husband Reginald established the Addis Ababa Fistula Hospital in Ethiopia, Dr. Catherine Hamlin has given her all to curing fistulas and restoring life to these women, many of whom are just teenagers. In this interview, conducted at the fistula hospital by "A Walk to Beautiful" codirectors Mary Olive Smith and Amy Bucher, Hamlin talks about just how heartbreaking this tragedy can be for poor women—and how miraculous the cure.