This article is part of a series by RH Reality Check in collaboration with EngenderHealth, Guttmacher Institute, the International Women's Health Coalition, the Fistula Foundation, the United Nations Population Fund (UNFPA), and the Campaign to End Fistula. All articles in this series can be found at this link.The series is being published during a time of renewed efforts by advocates and the public health community to increase U.S. international support for efforts to address obstetric fistula, a wholly preventable but debilitating and sometimes deadly condition caused most immediately by prolonged labor and too early or too frequent childbearing, but generally rooted in lack of access to health care and discrimination against women. Fistula affects the lives of individual women, their children and families, and also grossly undermines women's economic productivity and participation in society. The global public health community has called for comprehensive strategies both to prevent new cases and treat existing cases of fistula. Congresswoman Carolyn Maloney (D-NY) will soon introduce legislation intended to support a comprehensive U.S. approach to fistula as part of a broader commitment to reducing maternal mortality and morbidity worldwide.
It has been said that in an unequal world, women are the most unequal among equals. Obstetric fistula—a condition driven by a range of inequities in access to basic health services, nutrition, education and other basic elements— is a living example of this statement.
Obstetric fistula is…[jodi insert definition and link]. With more than two million women living with obstetric fistula and between 50,000 to 100,000 new cases each year, we must do more collectively to prevent and treat this condition.
This requires a focus on the human rights dimensions of public health problems.
Rose's story of surviving fistula in Uganda. Video courtesy of Engender Health and USAID.
Whether by choice, persuasion or coercion, many girls in the developing world have had sex before their 15th birthdays, often without adequate information or protection from unintended pregnancy or sexually transmitted infections (STIs), including HIV. For example, an estimated 60 million women between the ages of 20 and 24 in developing countries were married before 18. The Population Council estimates that this number will increase by 100 million over the next decade if current trends continue.
For girls, sexual initiation is more likely to occur in the context of sexual violence and forced marriage, both of which place them at high risk of pregnancy, and STIs, including HIV. In Ethiopia, for example, nearly 70 percent of young married girls are forced to have sex before they have begun to menstruate. Because their bodies are not fully developed and ready to bear children, these young girls are at high risk for injury and death during pregnancy and childbirth. In fact, complications from pregnancy and childbirth are the leading causes of death among girls between the ages of 15 and19 in the developing world.
Various factors are at the root of these grim statistics. Social norms that de-value girls and put a premium on the value of women as child bearers contribute to early marriage and sexual initiation. At the same time, huge disparities exist in access to health care and in health outcomes between women in high- and low-income countries, and between the rich and poor within most countries. In low-income countries, by far the bulk of those in need are poor women and their very young children. One-third of illness and death among women of reproductive age in these countries is caused by severe shortages in reproductive health services, basic services many of us in the United States take for granted: contraception, safe abortion, skilled birth attendants, emergency obstetric care, and diagnosis and treatment of sexually transmitted infections (STIs) including HIV.
When Yesmin was 12 years old, her parents found a good man for her to marry. They were poor, and they thought that it would be best for their firstborn daughter to marry early. Yesmin and her husband discussed that it would be best to wait a bit and let pregnancy happen later, but neither one knew about any family planning method. Yesmin became pregnant after one month of marriage.
Yesmin faithfully attended antenatal care. One Friday night, she began to labor. On Saturday night, her husband, mother, and father took her to the government health center. She was advised to go to the district-level medical college hospital, and her father paid the cost of the ambulance Sunday morning. On Sunday evening, health workers requested a bag of blood, and Yesmin's husband donated. The blood was given to Yesmin at the time she was delivering-and at that point, Yesmin lost consciousness. Yesmin spent nine days unconscious and catheterized in the hospital. When she awoke, she learned that the baby had been stillborn. Although the doctor encouraged Yesmin to remain in the hospital, her father had already spent his savings on her care. Her husband wanted to take her home, and at his request a hospital cleaner pulled out Yesmin's catheter.
Yesmin was fine on the day-long journey home, but that night she discovered that she was leaking urine, even though she had no urge to urinate.
Courtesy of Engender Health and USAID
These conditions are compounded by the failure to provide comprehensive sexuality education and health services for the largest generation ever of young people. One-third of the world’s population today is 19 years of age or younger, most of them in low- and middle-income countries where schooling, employment, and health care remain largely inaccessible.
Helping girls develop the skills and self-esteem to control their sexual lives and to marry and have children only if and when they are ready is but one part of the comprehensive package of health services and human rights protections women and girls need.
To address these needs, women’s groups throughout Africa, Asia, and Latin America have designed and implemented comprehensive sexuality education programs that reach hundreds of thousands of young people with information and skills to protect their rights and health, with the intention of reducing death and illness related from sexual and reproductive causes.
For example, in Nigeria, it is estimated that as many as one million women live with obstetric fistula, the majority of whom suffer from the condition from a young age. Local organizations throughout the country are working to educate girls on their rights, how to prevent unwanted pregnancies, and how to resist early and forced marriage. For example, IWHC’s longtime partner Girls’ Power Initiative in Nigeria reaches approximately 20,000 youth with programs that arm them with information about their rights, their bodies, and their responsibilities, as well as with life management skills. GPI helps young girls take a stand against harmful practices such as female genital mutilation and child marriage, and to recognize the warning signs of complications in pregnancy.
U.S. foreign assistance policies and programs can give a powerful boost to the burgeoning support for comprehensive reproductive health services, while also investing in very weak health service delivery systems common in Asia, Africa and Latin America. Similarly, local organizations led by women and young people that know the realities of women’s lives, can advocate effectively and hold their governments accountable, must also be supported and should be present at every policy table.
In May 2009, President Obama announced a $63 billion, six-year Global Health Initiative, stating that we can no longer “confront individual preventable illnesses in isolation.” The core principles underpinning the Global Health Initiative mirror IWHC’s vision and that of its partners worldwide: a woman-and-girl focused model of care centered on the realities and needs of local communities.
This approach, and a strong funding commitment, can go a long way in its own right, and also will leverage significant support from other government donors and multilateral partners. The United Nations Population Fund’s Campaign to End Fistula, which is already doing tremendous work on preventing and treating fistula, and the US Agency for International Development are key partners.
At this pivotal point of defining concrete actions to transform rhetoric into action investments in sexual and reproductive health services and rights, governments, the United Nations, and donors should take three priority actions:
- Provide services for women at each stage of their lives, prioritizing women's sexual and reproductive health. This means increasing funding for an integrated package of services: contraception; safe abortion, where permitted by law; maternity care; and diagnosis and treatment of sexually transmitted infections, including HIV, buttressed by human rights protections and comprehensive sexuality education programs.
- Remove fees for services so that women and young people with limited resources can access services in a timely manner.
- Ensure the full and equal participation of women and young people in all decision making processes
Securing women and young people’s health and human rights must, ultimately, be done at the country level, and most importantly, by women and young people themselves. Only then will we see an end to obstetric fistula and the beginning of the equality needed to ensure that everyone has the opportunity to enjoy a just and healthy life.