Omo River Basin

On Fistula

Patients awaiting surgery at Addis Ababa Fistula Hospital

Patients awaiting surgery in crocheted shawls donated to Addis Ababa Fistula Hospital, Ethiopia

Discovering Obstetric Fistulae in Ethiopia

By Alison M. Jones and Gussie T. Baker (All rights reserved.)

Photographs by Alison M. Jones

Ruth Kennedy with recovered patients

Addis Ababa Fistula Hospital, hospital liason officer Ruth Kennedy with patients recovered from surgery.

EQUALITY FOR WOMEN is not apparent in rural Ethiopian culture. Polygamy is commonly practiced. The literacy rate is a mere 37% for females, compared to 50% for males. The average woman bears 5.3 children. In thus adding to the workforce, she establishes her worth. Baby girls are seen as potential dowry and beasts of burden meant to carry water and firewood, but receive no attention to their well-being. Jeffrey Sach’s Millennium Development Goals Report Summary warns that “children’s and women’s health in the world today [is a] catalogue [of] death, disability, and suffering.” Ethiopia’s women certainly face extraordinary challenges and hardships.

In Ethiopian communities physical labor is still assigned to women. In the Rift Valley, in the Bale Mountains and along the Omo River women carry bundles of firewood twice their size and heavy jerry cans of water for many miles. They are doubled over as they trudge across rocky mountainsides or dry, desert terrain. From the age of two, girls and women carry the heavy burdens of Africa. These women are small and thin. They resemble Ethiopia’s National Museum’s 3-foot-8-inch, 3.2 million-year-old skeleton of Lucy much more than today’s healthy American or European children. Most Ethiopian women are married to subsistence farmers or pastoralists, living in profound poverty and often on the verge of starvation. The lack of proper nutrition and clean fresh water is the cause of the Ethiopians’ small stature — not genetics.

patient awaiting surgery

Addis Ababa Fistula Hospital, patient awaiting surgery

Out of 78 million Ethiopians, an estimated 12 million face serious threats from food insecurity and famine. More than half of the country’s children under five years of age are stunted. Ethiopia has the highest rate of stunting in the world. Here, as elsewhere in Africa, the prevalence of stunting is significantly higher in rural households with no protected water source and no toilet facility. The 51% of Ethiopians who are stunted are children of illiterate, uneducated families.

While there is no significant gender difference in prevalence of malnutrition, stunting has a particularly tragic effect on childbearing women. Women in reproductive years and children are most vulnerable to malnutrition due to low dietary intakes, inequitable distribution of food within the household, improper food storage and preparation, dietary taboos, infectious diseases and lack of health care. The high nutritional costs of pregnancy and lactation further contribute to the poor nutritional status of Ethiopian women.

Stunted girls and women are subject to the horrors of obstetric fistulae when they live with poverty, famine, rudimentary health care, young pregnancy and home delivery on dirt floors. Most Americans and Europeans are unaware of this condition because it has been nonexistent in the West for almost a century. Fortunately, in Ethiopia the Addis Ababa Fistula Hospital exists to exclusively treat and cure women who have suffered the long-term, life-altering effects of fistulae caused in childbirth.

Rural Ethiopian girls traditionally receive their first water jar at age two. By age eight they are carrying loads of water, wood and grain that are much too heavy for their physical size. Despite females being assigned the beast-of-burden role, if food is short, it must go to the boys before the girls. This favoritism exacerbates the stunting of girls’ bones, particularly in the pelvic region.

In Ethiopia rural, poor and often illiterate girls are betrothed between ages of 9 and 13. Married two years later, they usually begin having babies usually by 15 years of age while their bones are still undeveloped. Rape victims may be as young as seven. Whether married or raped, most Ethiopian women have at-home deliveries under dirty conditions with no clean water.

recovering patient

Addis Ababa Fistula Hospital, patient in hospital bed recovering from surgery

The fistula damage begins early in the labor process when babies become lodged in narrow birth canals, blocked by underdeveloped pelvic bones. This obstructed labor lasts for an average of 3 to 4 days, sometimes as much as a week. During that time, repeated, futile contractions cut off blood to vaginal tissue compressed between the fetal head and the bony pelvis. This tissue becomes necrotic, sloughs off and a fistula (opening) develops between the bladder and the vagina, the rectum or both. The uterus squeezes the unborn babies to death in 95% of fistula cases. The girls are left mourning, traumatized inside and out.

These meant-to-be mothers soon realize that, rather than gaining the status of having produced a child, they are incontinent due to their fistulas. Urine and feces continually trickle down their legs causing sores and soaking their clothes. Due to the resulting stench, husbands, families and communities ostracize these victims, forbidding them from using the village well, which in most cases is their only water source. Because delivery is often on the ground, dirt often enters the uterus and thus many women die from septicemia and other gynecologic injuries. Fistulae can lead to kidney disease and even death. Many of these women drink as little as possible to avoid leakage and thus become dehydrated. Some victims of fistula choose suicide as the only escape from living as a pariah.

Outcast, abandoned and shamed women arrive at the Fistula Hospital with tragic stories. One 17-year-old girl leaked urine and feces for many months before coming to the hospital. A 23-year-old-woman’s husband divorced her after she leaked urine and feces for five years. Another woman was still limping from lingering nerve damage, despite her surgery and lengthy rehabilitation. An 8-year-old rape victim, waiting for curative surgery, was shivering with malaria as well as dealing with the handicaps of her fistula. A 50-year-old victim had been incontinent for decades.

The World Health Organization’s last estimate 16 years ago estimated more than two million women live with fistulae. In 2006 the UN said over 800,000 women have ongoing fistulae just in Nigeria, where one in 18 women die in childbirth versus one in 2,400 in Europe. The Fistula Foundation states 100,000 women and girls develop fistulae each year in the developing world. While most common in sub-Saharan Africa, fistulae are found in all developing and war-torn countries.

patient in hospital bed

Addis Ababa Fistula Hospital, patient in hospital bed.

What can prevent Obstetric Fistulae? Cesarean sections easily can; but in sub-Saharan Africa such surgery, like any medical treatment, is infrequently available. Doctors usually must travel by foot or donkey over miles of dirt paths or rotten roads, making immediate access to emergency care impossible. Complicating this need for emergency health care for these women, Ethiopia struggles with a significant brain drain of surgeons who train and then choose to work in Europe or the US.

What can cure Obstetric Fistulae? Surgery, the only cure, is simple, has a 97% success rate and costs only $300. Many doctors in Africa only charge $42 to cover their surgical supplies; but often even that cost cannot be met. Not until 1974 could fistula correctional surgery be obtained at all in Ethiopia. Today within the entire country it is only available at the Fistula Hospital in Addis. Thanks to private donors worldwide, surgery here is free.

Ethiopia’s pioneers in surgical repair of obstetric fistulae were Drs. Reginald and Catherine Hamlin, both obstetrician-gynecologists. They came to Ethiopia’s Princess Tsehal Memorial Hospital in 1959 to establish a midwives’ school. By the mid-1970’s the demand for fistula treatment became so great that the Hamlins established the Addis Ababa Fistula Hospital, specifically for girls and women with childbirth injuries. Now over 1200 free operations are done each year, averaging six per day. Unfortunately this covers only a fraction of Ethiopia’s increase of 9,000 new cases of obstetric fistulae each year. For every treated patient, there are more than 30 untreated victims.

recovering patient

Addis Ababa Fistula Hospital, patient in hospital bed recovering from surgery

Within three decades the Addis Ababa Fistula Hospital has restored the lives and hopes of over 25,000 women. The goal of the hospital is to heal and rehabilitate those suffering from childbirth and related injuries so that they can return to their communities with dignity and a sense of self-worth. The tortured path of these patients begins with the confusion of an arranged marriage, continues through post-birth pain, loss and scorn and ends with the new life they are given at the Addis Ababa Fistula Hospital.

Each new arrival is given a colorful crocheted shawl, which provides cheer and warmth. These wraps are knit by women in the UK and donated by The Hamlin-Churchill Childbirth Injuries Fund. The wards are bright, airy and clean. Nursing aides attend post-operative patients, as well as return patients pregnant again and awaiting necessary cesarean sections. Girls awaiting surgery calmly chat in the courtyards, listening, supporting and reaffirming each other. Those in recovery help out in the pharmacy, laboratory, rehabilitation rooms, schoolrooms and administrative buildings. Some learn about meal preparation, literacy training or nursing techniques so they can assist incoming patients as available. While recovering, patients are advised on how to return to their homes and find jobs within their communities.

The Addis Ababa Fistula Hospital is a model for fistula treatment, long-term care, prevention and training. Inspiring the creation of numerous centers in the developing world, this hospital has trained over 100 surgeons from the developing world. Today all medical students specializing in obstetrics and gynecology in Ethiopia are required to train for two months at the Addis Ababa Fistula Hospital.

Satellite centers are being established to help rural women with arrested labor who otherwise walk, or are drawn in carts, with babies half-born to clinics many miles away. The Addis Ababa Fistula Hospital’s U.S. Fistula Trust has paid the $450,000 cost of the centers in Bahir Dar and Harar, yet many more regional centers are needed in Ethiopia.

Ruth Kennedy

Addis Ababa Fistula Hospital, liason officer Ruth Kennedy with patient

The Addis Ababa Fistula Hospital goes beyond providing surgery by caring for 35 long-term patients who are unable to be cured completely or return home. Some are trained as nursing aids. One hundred largely-cured, but still stranded, women live in a residence near the Addis Fistula Hospital. In each of the ten houses, ten women live together as a family with a central community hall, a training center for teaching skills and literacy and a farm with cattle and chicken. Thus a home and a new sense of dignity is created for those who can never be what they were before the childbirth injury.

Ruth Kennedy, the Hospital Liason Officer, has a plaque in her office that says, “The smile that shines through the tears is worth the wait of years.” Yet at the current rate of action, it will take many decades before fistulas disappear from the third world and war-ravaged regions. Until then, to be a stunted girl or woman in an African village can be truly a terrible thing due to lack of clean delivery practices and emergency obstetric care. Left untreated, fistula victims risk abuse and violence. The two million women suffering from fistulas today are voiceless. They are young, female, poor, rural and ostracized. They are the 21st century’s lepers.

patients recovered from surgery

Addis Ababa Fistula Hospital, patients recovered from surgery.

In the Report Summary of The Millennium Development Goals, Jeffrey Sachs noted, “Indisputably, women’s poor health is connected to broader social, economic, and environmental conditions, some of which must be addressed from outside the health sector. [Support for] gender empowerment, education, water availability, hunger, and income sources can have a powerful effect on the health and survival of … women and children.”

Often poor health can be traced to a direct source — for example, dirty water directly causes infection — however some factors are less tangible. For example, a woman’s inferior status ignores her need for adequate nutrition, schooling and emergency care for obstetric complications. Many root causes must be faced by the multi-pronged international efforts following the Hamlins’ very successful first step in addressing the tragedy of obstetric fistulae.


The Addis Ababa Fistula Hospital. On line: The Fistula Foundation. Accessed November 2005.

The Medical Journal of Australia 2003. Online: De Costa, Caroline M. James Marion Sims: Some Speculations and a New Position. Accessed November 2005.

U. S. Central Intelligence Agency. Online: CIA: The World Factbook: Ethiopia. Accessed November 2005.

Girma, Woldemariam and Timotiows Genebo. Determinants of the Nutritional Status of Mothers and Children in Ethiopia. Addis Ababa, Ethiopia. Nov 2002. (Available online: Determinants of the Nutritional Status of Mothers and Children in Ethiopia. Accessed November 2005.)

Hamlin, Dr. Catherine, with John Little. The Hospital by the River: A Story of Hope. Monarch Books, 2004. Publisher: “Dr. Hamlin is the new Mother Teresa of our age.” The New York Times: “When gynecologists Catherine and Reg Hamlin left their home in Australia for Ethiopia they never dreamed that they would establish what has been heralded as one of the most incredible medical programs in the modern world. But over forty years later, the couple has operated on more than 20,000 women, most of who suffer from obstetric fistula, a debilitating childbirth injury. This is the awe-inspiring story of the life and mission of Dr. Catherine Hamlin who, with her husband Reg, established what has been heralded as one the most incredible medical programs in the modern world.”

OneByOne. Funding Care for Women with Fistula. Online: Accessed Nov. 2005.

Millennium Development Goals, Task Force Report on Maternal and Child Health. 2005. Who’s got the power? Transforming health systems for women and children. Online:
. Accessed Nov. 2005.

American Journal of Agricultural Economics (Vol. 87, Issue 2, pp 273-288), 2005. Yamano, Takashi, Harold Alderman and Luc Chritieaensen. Online: Child Growth, Shocks, and Food Aid in Rural Ethiopia. Accessed Nov. 2005.

Suellen Miller, CNM, PhD, Felicia Lester, MPH, Monique Webster, MPH, and Beth Cowan, MD. Obstetric Fistula: A Preventable Tragedy. American College of Nurse-Midwives (Vol.50. No.4 pp 286 – 294) July/August 2005.

[Posted by NWNL on March 25, 2008]