A fistula patient receives care at a specialty center.
MANGWE DISTRICT, ZIMBABWE – Two years ago, deep in the rural Mangwe district along the border of Zimbabwe and Botswana, Sabina Moyo found herself wondering whether she would die after giving birth to her baby at home.
“People say every pregnancy is different and the labor pains will not be the same,” Moyo says. “But I knew something was wrong when after hours of excruciating pain, nothing had happened.”
Moyo says her husband loaded her into a donkey-drawn cart and took her to the local Plumtree Hospital more than 20 kilometers (12 miles) away.
Moyo gave birth to a stillborn baby at the hospital. Soon after, she discovered that she was leaking urine while in the hospital recuperating.
Nurses told her that her labor had led to an obstetric fistula, a medical condition in which a hole develops between the vagina and either the rectum or bladder. But the staff at the small, rural hospital told her they had no experience treating the problem. They could not do anything for her.
For two years, Moyo has suffered from constant incontinence from what’s known locally as the “urine curse.” She must wash herself, her clothes and her blankets continually. But says she can only go to the borehole to obtain water after sunset to avoid being seen.
“The amount of water I collect is only enough for basic use,” she says, which makes it difficult to maintain sanitary living conditions.
She says she was once a respected woman in her community, but now she survives on subsistence farming and handouts from well-wishers.
“When I discovered I had the curse, I could never have predicted the amount of prejudice I would have to deal with,” Moyo says. “I was suddenly a pariah. Friends stopped visiting, neighbors avoided me, and little children laughed at me and called me the smelly witch.”
She says she feels abandoned by her entire community, including her husband. She says he left her under the guise of looking for work in neighboring Botswana.
Maternal mortality has increased in Zimbabwe, especially in rural areas where trained maternal health care professionals are rare. As a result, complications from childbirth, such as obstetric fistula, are also on the rise in rural provinces. Last year, the government waived fees for women to deliver in public hospitals, but the policy does not extend to treatment for complications, leaving many without care.
Deputy Prime Minister Thokozani Khupe lamented in an April 2012 statement that the maternal mortality rate in Zimbabwe had increased from 725 deaths for every 100,000 live births in 2007 to 960 deaths for every 100,000 live births.
Dr. Rabson Dombo, an obstetrician based in Matebeleland South province, where Moyo lives, says her case highlights the challenges women face in rural Zimbabwe. Poor access to water and proper sanitation exacerbate weak maternal health care.
“These women travel distances of more than two kilometers (1.2 miles) carrying water buckets on their heads, some pregnant and some with babies strapped on their backs,” he says, “so the amount of water they can collect without neglecting their other duties at home is only enough for basic use.”
The distance to health centers also prevents them from obtaining maternal care.
“Distances to rural health centers are long,” says one senior hospital official, who asked to remain anonymous. “Ideally, they should be 10 kilometers (6.2 miles) and below, but it’s much more.”
Cost is also an obstacle.
“Some cannot afford to come to deliver at the hospital, where there is a waiting mothers’ shelter,” the official says, referring to shelters where pregnant women can wait for days or even weeks.
These challenges are perpetuating home deliveries without trained assistance, advocates say.
“It has become one of those areas where it is difficult to convince women with strong traditional and religious beliefs about the need for adequate reproductive health, especially here in rural areas,” says Sibatshaziwe Khabo, a nurse and midwife based at Plumtree Hospital.
The Ministry of Health and Child Welfare’s 2007 Zimbabwe Maternal and Perinatal Mortality Study found that women who go into labor at the homes of traditional birth attendants and faith healers, are often in danger, as are there infants.
Between January and August 2011, there were 310 home deliveries in Mangwe district alone, 30 of which were stillbirths later brought to Plumtree Hospital, according to hospital records. There were 21 early neonatal deaths and seven maternal deaths in the district, which the hospital official says is a microcosm of the health care crisis nationwide.
Women and children have been the most affected by the deterioration of the health system, according to the Ministry of Health and Child Welfare study, which called the country’s maternal and perinatal mortality rates “unacceptable.”
For each woman who loses her life, many more will suffer injuries, infections and disabilities from pregnancy or childbirth complications, says Dr. Kudzai Ndebele, an obstetrician in a private practice in Bulawayo, Zimbabwe’s second largest city.
This includes obstetric fistulas, which develop as a result of childbirth, obstructed labor or intense sexual violence, Ndebele says.
“Women who survive such traumatic experiences will go on to continuously leak urine or stool unless the damage is repaired,” he says.
The condition is notorious for leading to social isolation.
“These women end up completely alone because of the unbearable smell,” he says. “They are continuously leaking urine or in some cases stools, so their social exclusion is guaranteed.”
Fistula is one of the indicators of major reproductive health challenges in Zimbabwe’s rural districts, Dombo says.
“The sad reality is that cases of obstetric fistula are on the increase in rural Matebeleland South,” Dombo says.
Ndebele says obstetric fistula can be corrected, but few women come forward because of the community’s skewed perception of the condition.
“As long as they label it ‘a curse,’” he says, “the women will suffer in silence or go to traditional healers to try and remove the curse.”
Dombo says treatment is extremely limited in rural areas so he is forced to refer fistula patients to United Bulawayo Hospitals for corrective surgery. But while delivery is free in the public hospitals here, treatment of such complications is not covered.
Moyo says she wishes to have her condition corrected. But she can’t afford to travel to Bulawayo for the corrective surgery, let alone pay for the procedure.
She says she would also be too embarrassed to travel in a bus full of people with the stench of her incontinence.
This is a common thought process, Dombo says.
In 2012, the Ministry of Health and Child Welfare mandated hospital officials to stop charging maternal fees to encourage more women to deliver outside the home. Fees previously ranged from $50 to $200 depending on the method of birth.
“Our call for revitalizing the primary health care in general and the removal of user fees maternal care in particular will go a long way in addressing the unacceptably high rate of maternal and infant mortality in our country,” Khupe said in her statement.
But this waiver doesn’t extend to fees for treating complications from childbirth, like fistulas, Dombo says.
“In as much as the scrapping of maternity fees is a positive move for these women,” he says, “it does no good for those with complications, as they still have to pay for the correction of complications.”
The 2007 ministry study states that it will be difficult for the country to meet goal five of the United Nations Development Programme’s Millennium Development Goals, which seeks to reduce maternal mortality by three quarters by 2015, if progress is not made.
Health professionals agree that the country has a lot to do to ensure the safety of women before, during and after childbirth.
“There is a lot of work we need to do, especially for rural women, concerning reproductive health,” the senior official from Plumtree Hospital says.
Khupe called in her statement for the improvement of reproductive and maternal health for women.
Meanwhile, Moyo says she is no longer hopeful for the future.
“I lie on my wet bedding every night and long for death with every fiber of my body,” she says, “and I’m always disappointed every morning when I wake up.”
