After 10 years of working as an independent midwife in Cape Town South Africa I headed to Benin West Africa to spend 6 months working aboard the Africa Mercy. It is a hospital ship operated by the Mercy Ships Organisation bringing free healthcare to the world’s forgotten poor.

My experience of working in Independent practice in Cape Town, The Caesearn Capital of the world, involved a lot of work fighting for the right of woman to be able to birth vaginally, yes, as crazy as that sounds! And also being able to offer the woman the choice of being able to birth safely at home. My mind set was so much on moving away from the Medicalisation of birth which is rife in Private Sector medicine in South Africa, to promoting a healthy normal physiological approach to birth.

On the ship, due to my being a midwife, I was immediately drawn to the woman who came to the ship requiring fistula surgery.

The most common cause of a Vesicovaginal fistula (VVF) is prolonged obstructed labour which causes necrosis of the soft tissue in the pelvis, due to the bony symphisis pubis and the fetal head, or presenting part applying pressure on the soft tissue for a prolonged time. This causes a breakdown in the tissue resulting in a fistula. We most frequently saw Vesicovaginal fistula rendering the woman incontinent of urine but they can also have a Rectovaginal Fistula where the lady is incontinent of Faeces. Some woman suffer from both.

In the 6 month period I was there we had a number of different VVF surgeons who came to work with us. Each time we would have an experienced surgeon but they always had a trainee with them, as I am sure you would appreciate that it is a rare skill to develop the ability to do this surgery as it is found in the poorest countries of the world where the resources are few.

Each time a new surgeon arrived we would have a screening day to asses who was suitable for surgery. I found these days emotionally devastating. As I would sit there and hear these ladies history, your heart would literally break. You would hear one story after another of many pregnancies, few if any live children. Years of Incontinence, abandonment by husband and families due to the stench that surrounded them and totally isolation and poverty. I often used to think about taking an obstetric history when some one is booking for a pregnancy. If they told you of 1 stillbirth or devastating experience it would touch you so deeply, yet for these ladies it seemed like it was a series of loses and devastation.

To see the hope and longing in these ladies that perhaps they could receive healing, made one immediately begin to root wholeheartly for them . Their joys and sorrows became yours too. You would celebrate with them but you would also cry and feel their devastation when things did not go well. The ladies would be admitted onto the ship the day before their surgery. For many of them it was so daunting. They had never been on a ship, never seen electricity, never slept in beds raised off the floor. Never encountered air conditioning before, they found it freezing!

Their preparation for surgery would include good showers scrubbing with Chlorhexidene to try to reduce infection rates.

Dr Steve Arrowsmith, a real pioneer and passionate activist of the VVF cause was the first surgeon I worked with. He loves these VVF ladies. He did an amazing presentation for us on the ship and to see a grown man of 6ft2 standing there with tears streaming down his face because of his deep love and desire to alleviate these ladies suffering, as he describes the issues the world faces to eradicate VVF.

The ladies would come back from surgery with Foley catheters insitu. Depending on the extent of the fistula and the procedure involved, the ladies would need their catheters to remain in for various lengths of time. Anything from 3 to 21 days.

The post op care these ladies required was

• Good perineal hygiene. Twice daily Pericare
• Excellent Pelvic Floor exercises
• Prevent constipation with regular Laxatives
• Bladder training once the catheter was removed
• Most importantly they needed love and nurturing to know they were valuable and precious as so many had been so severely rejected
• Antibiotics for Symptomatic UTI’s

"The understanding that one must treat the whole person with a fistula and not just her injured bladder or rectum is the single most important concept in fistula care." (Wall et all 2005)

The dynamic in the ward was so wonderful as these woman formed a community of their own. They encouraged each other, shared their stories, soothed each other when tears were shed over disappointed hopes, even reprimanded each other when they were not following the rules accordingly i.e. slacking on their pelvic floor exercises.

The highest chance of a successful fistula repair is at the first operation. The success rate is 90 to 93 %. This is such a joy. To see woman who have been incontinent for anything from a few months to 17 or 20 years now being dry. The joy, the relief the hope fulfilled it is a great delight. Before the ladies left the ship after their treatment we would have a ceremony to celebrate their new lives. They would receive a new outfit and would sing and dance and rejoice. At this ceremony they were all given a chance to tell their story, to tell of how their heartache had lead them to this place but also the joy that lay ahead in becoming a normal member of society again. Many of the women when telling their story tell of how they contemplated suicide seeing it as the only way of escaping the hell they were in. For the majority of woman their husbands leave them, but their were a few woman who testified to the amazing love and support of their husbands. I almost never got through one of these ceremonies with out crying my eyes out. Your heart is stirred so deeply.

The sad truth is that for some of the woman the operation is not successful. The disappointment is so hard to manage. Also when they see others around them, dry, celebrating and going home. It is possible for woman to have many attempts at fistula repair, and the literature talks about this a lot. There was a young beautiful woman from Liberia who was a crew member on the ship, and she had required surgery 3 times before she was healed. The sadness for these woman who need further surgery is where will they get it, who will do it and how will they afford it? Unless an organisation like Mercy Ships comes to their neck of the woods again their hope of healing may never come.

The Midwife in me felt conflicted at times with the issues I was having to face when hearing these ladies stories. I had come from an environment when I spoke liberally of the belief that Birth and Woman’s bodies are God’s good design and that in the vast majority of cases it worked well. We were encouraging woman to have faith in vaginal birth and to feel confident and safe to birth at home if they had low risk normal pregnancies.

Now I was in an environment when due to birthing at home with no skilled attendee these woman had suffered such heartache. The hope for these woman was that more of them would birth in hospitals or facilities were they could receive ante and intrapertum care. Also to realise that for the woman of West Africa the most dangerous thing they may ever do in their lives is to birth a child. (Dr Steve Arrowsmith). Pondering all these things stirred in me, the injustice that a woman in these impoverished nations is so at risk when fulfilling her longing of motherhood whereas for us privilege ones the risk is so relatively low. I have never really considered my self an activist or having a political edge but unless we fight for the rights of these woman more of them will die, their babies will die and they will become incapacitated by the birth trauma’s that plague them.

I began to realise that we as the Midwives of the world have so many challenges facing us. We have the challenge of safe guarding the birthing process in the industrialised world, but we also have the very serious challenge of offering safe birthing and Motherhood to the woman in the poorest nations of the world. Let us not become discouraged or overwhelmed by the task ahead but I know the Sisterhood of the woman of the world are surely a force to be reckoned with and with the Midwives of the world committed and passionate to our task, we can change things for the better. What a challenge and also what a privilege!

I prayed a prayer a while ago, asking God to use my skills in a place where it would help to save Mum’s and babies lives. So now God in his wisdom, and to my excitement and anxiety, is leading me to Sierra Leone. It has one of the highest Maternal and Infant mortality rates in the world, and I will go there in January to assist Mercy Ships and The Ann Gloag Foundation to start a Maternity Hospital.

No one of us will change it alone but if each of us is faithful to do the little bit we are called to do, things will change and we could help to change the risk of birthing for woman from the poorest nations of the world. The challenge is not can we make a difference but it rather is will we?

I would like to take the chance to thank HCP for their support and sponsorship in assisting me to spend 6 months aboard the Africa Mercy based in Benin, West Africa.

Ine, from Holland with Elise and Josephine


Bonnie, a Canadian Nurse with Josephine


Ramatou(centre) with some others at their Celebration Ceremony.

Kate Christie

Is a Registered Nurse and Midwife in South Africa, as well as a Registered Midwife in the UK. After many years of working in Cape Town, South Africa as well as a spell in the UK as a Midwife she ventured off to work with the Mercy Ships Organisation aboard the Africa Mercy ship in Benin, West Africa.

Further References Re Fistula

www.worldwidefistulafund.org

www.mercyships.org