At Treichville public hospital in Côte d’Ivoire’s commercial capital, Abidjan, Joséphine Gba sits in the corner of the waiting room holding her crying three-month-old baby. In her late twenties, Gba travelled to Abidjan from the western town of Man to receive treatment for obstetric fistula, one of the most serious injuries of childbearing.

“Since the birth of my child, my genital organ hasn’t gone back to normal,” she explained to the doctor. “Because of an infection, I have a constant discharge and I give off a bad smell that prevents me from going out in public. Help me, I’m suffering!” she pleaded.

She’s lucky she sought care as early as she did. “When the condition is several months old, treatment becomes difficult,” said Mariam Touré, a doctor at the hospital’s urology department, which is currently treating 20 fistula patients.

Gba is one of an increasing number of Ivorian women presenting with obstetric fistula, a hole in the vagina or rectum caused by a difficult labour.

According to the UN Population Fund (UNFPA), the conflict that has gripped Côte d’Ivoire since 2002 is a major cause of reproductive health problems in the country. Almost half of the health structures in the central, northern and western zones of the country have been pillaged or destroyed, UNFPA said, leading to fewer prenatal consultations, fewer hospital treatments and more unassisted births.

Humiliating disease

Obstetric fistula can be caused by female circumcision and abortions that are poorly executed. More commonly, the injury occurs among women who have a narrow or underdeveloped pelvis that blocks a baby’s passage through the uterus during birth.
During prolonged labour, the unborn child presses tightly in the birth canal, cutting off blood flow to the tissues of the vagina and bladder. The tissues rot away, leaving a hole through which urine and faeces flow uncontrollably.

“It’s a humiliating disease for a woman,” said Habibou Kané, 34, one of 10 or so other women waiting to see a doctor at Treichville hospital, in a room where most patients sat with their head between their knees. “Not only are we physically rotting away, but because of the effects of the disease, we are abandoned by our husbands and sometimes our families,” she said.

A 2006 assessment by the Ivorian Ministry of Public Health found that women with the disease perceived it to be equivalent to death. In the eyes of the victims, “it’s a dirty and disgraceful disease that is more serious than AIDS,” the report said.

Fatou Dramé, 23, did not realize she had contracted fistula after her labour. “We tried all the traditional treatments without success. My parents started treating me like a witch. My husband took a new wife. I became a burden and I left the house,” she told IRIN.

Dramé was married very young, and suspects the removal of her clitoris caused the fistula. “But I couldn’t talk about it in front of the family because religious beliefs are stronger than you think,” she said.

More cases in former conflict areas

There are cases of obstetric fistula in Abidjan in the south, but the west of the country is by far the most affected area.

According to the Ivorian health authorities, the general hospital in Man admitted 116 new cases of fistula between August 2006 and April 2007, after Médecins Sans Frontières (MSF) - Belgium began giving logistical support for fistula treatment at the hospital. About 100 other women are awaiting treatment.

This compares unfavourably with a Ministry of Public Health assessment that found just 209 cases in the previous decade, 1995-2005.

The increase is likely due to a combination of factors, according to Kate Ramsey, coordinator of the UNFPA’s Campaign to End Fistula.

Destabilisation in the country has likely diminished access to the care needed to prevent fistula. Most of the patients at Man hospital came from areas formerly under control of the rebels, the Forces Nouvelles de Côte d'Ivoire. But Ramsey said the increase could also be due to the fact that care is now available to some women for the first time.

“More and more women are coming forward, so we’re realising that the numbers are greater than expected,” Ramsey said. The practice of female circumcision, still ingrained in many African cultures, is also a factor. Patients come from as far as Mali, Sierra Leone and Guinea to seek fistula treatment in Côte d’Ivoire.

Expensive treatment

There is no official tally of the number of women suffering from fistula in Côte d’Ivoire, but experts say as the country’s health infrastructure rebuilds, hospitals will be bombarded by cases of the disease since the health system has been dysfunctional for five years.

Still, at a cost of up to 500,000 CFA francs (about US$1,000), the treatment for obstetric fistula is not available to all patients, the majority of whom live in poverty.

“We can’t even find enough to eat. I don’t know if it will be possible to find that amount of money for the treatment,” Gba said. “It’s true our lives depend on it and we have to do as much as we can, but a little help wouldn’t be so bad.”

The treatment is effective in 85 percent of cases, according to Touré, the Treichville doctor. “But patients tell us that other women who don’t have the means to treat themselves have difficulty handling the social isolation, and eventually die neglected,” she said.

“Of all the health problems today, fistulas are the forgotten ones,” said former Minister of the Rights of Women and the Family Constance Yaï, now coordinator of the Programme national de lutte contre les pratiques traditionnelles affectant la santé (PNPLS - a national program fighting against traditional practices that affect health). “We have no situation as bad as that of these women,” Yaï told IRIN.

Hope

Because of the departure of MSF - Belgium, which ended its work at Man hospital in early July, the UN Population Fund has decided to step in. On 11 July, it signed an agreement with health officials in Côte d’Ivoire to build a fistula treatment centre in Man. The UNFPA has already amassed the funds and work is scheduled to begin in August.

The project will in part improve facilities for fistula patients, which for now consist of makeshift structures as hospital rooms. “For the UNFPA, it’s dramatic to see these women lying directly on the ground under flimsy shelters,” Philippe Delanne, UNFPA’s representative in Abidjan said as the agreement was signed. “With this centre, we think we will be able to help these many destitute women.”