Source: All Africa
PREGNANCY is supposed to be a life fulfilling event which results in a healthy baby and a proud mother.

But sadly this is not always the case, especially if they are poor, illiterate and live in rural areas, far from health posts.

According to the latest statistics, Zambia has a maternal mortality rate of 591 per 100,000 live births.

In a series of stories, the Times will explore maternal mortality in Zambia and the efforts being made to ensure that women do not suffer harm or die through child birth.

The most common and devastating type of genital fistula is obstetric fistula, a hole in the birth canal usually caused by prolonged obstructed labour.

It is a totally preventable complication of labour which can be avoided by delaying the age of first pregnancy, stopping harmful traditional practices, and timely access to obstetric care.

It results in nearly all cases in the death of the baby and leaves the woman suffering from health problems, including chronic incontinence, shame and social segregation.

Namasiku Kamuya lived with the debilitating burden of obstetric fistula for six years, when her rectum ruptured during the delivery of her first baby.

No amount of antibiotics could cure the uncontrolled leaking of urine and faecal matter, nor the stench she emitted.

Living in the remote village of Kulatembo in Southern Province, 21-year-old Kamuya said access to health care is almost impossible, so throughout her pregnancy she was attended to by a traditional birth attendant (TBA).

Kamuya represents many economically disadvantaged young women in rural areas, who are not able to make appropriate birth choices such as where to deliver and what type of birth to opt for.

These women, whose birth choices are determined by relatives, often end up being attended to by TBA's, who lack the necessary skill to determine or identify possible complications that could lead to difficult child birth.

University Teaching Hospital (UTH) managing director, Lackson Kasonka, a gynecologist said poverty is a major underlying factor which explains the increased numbers of women suffering from fistula.

"This condition mainly affects young women, who are voiceless and their child birth choices are dictated to them by their immediate family members, and because of this, many of the child births cases are difficult births, resulting in fistula, due to unskilled domestic conditions under which these women give birth," he said.

Dr Kasonka said 66 per cent of child births are still attended to by unskilled TBAs and this has contributed to the incidences of fistula.

He cited Luapula Province as having the most cases, probably because of its proximity to neighbouring Democratic Republic of Congo (DRC) which lacks health care services.

Explaining how TBA's do more harm than good in child birth, Dr Kasonka said traditionally, these women's main focus is on achieving a delivery, whether the baby or mother survives.

The more pregnancies they achieved, the greater their reputation and of course there was always the monetary benefit - a chicken, a goat, chitenge or actual cash.

This, Dr Kasonka said is a great motivation. "As medical personnel we have a credo that the sun should never rise and set on a woman in labour. But midwives will leave a woman in labour for days just so that they can deliver a baby dead or alive and safeguard their reputation."

TBAs are prone to administering herbs to enhance labour without knowing the effects of prolonged (obstructed) labour.

The baby would have long died due to pressure and suffocation and is then expelled out of the birth canal forcefully, causing rapture of either the bladder or rectum, and in some extreme cases, both.

The forceful expulsion of the baby is done without consideration of what in medical terms is referred to as the 'push factor' or passage (birth canal) is adequate or not.

Dr Kasonka, said as much as the job carried out by TBA's was complementary to the country's health care system; they (TBA's) did not have the necessary skill and capacity to pre-determine difficult labour cases, which resulted in complications such as fistula.

The age at which women give birth pre disposes them to fistula. Some girls get pregnant in their early teens, when their bodies are not ready for child birth which causes pressure on their narrow and undeveloped pelvis.

This is true for a 15-year-old Given Nabulanda who developed fistula after a three day labour for her first child.

Living in a remote village in the Luapula Province, Nabulanda said she went into labour while at a fishing camp and a TBA was called.

Her bladder was so badly ruptured that she had to have three operations.

"The nurses have told me that my pelvis was to small and I should have had a caesarean but when I was delivering the TBA told me to continue pushing and even started slapping me."

The loss of their baby and the resultant fistula is the beginning of a life of stigma and discrimination, being abandoned by husbands and family, because of the inability to control the passing of urine and stool.

The stench is overwhelming and many women are moved into separate quarters where they are left to their own devises.

While fistula is not fatal, it causes other conditions like depression and infections which could become fatal.

Fistula can only be reversed by cosmetic surgery, which entails placing back the tissues, which may have been displaced due to the rapture of either the rectum or the bladder.

While the solutions appear simple, women face many hurdles in seeing treatment. First is the lack of access to information.

Kamuya said her younger sister heard about fistula operations on radio Liseli. Nabulanda said she heard about it through a neighbour who was visiting from Lusaka. Both say it was pure chance that they were able to access treatment.

There is also a lack of trained physicians trained in fistula repair. In Zambia, Dr Kasonka is the single most qualified fistula surgeon and is training a group of doctors to perform the surgery.

There is also not a standard training manual until last month when UNFPA launched its manual, for healthcare providers from low-and middle-income countries involved in the prevention and management of fistula.

Its purpose is to enable dedicated physicians to acquire the knowledge, skills and professionalism needed to prevent obstetric fistulae and provide proper surgical, medical and psychosocial care to women who have incurred fistulae, whether during childbirth or because of inflicted trauma.

Dr Kasonka the country's only obstetric and gynecologist who specialises in surgical operations to reverse the effects of fistula said it is important for women who have experienced fistula repairs to ensure that their next pregnancy is delivered in a health institution, as chances of requiring a caesarian section may be higher.

He is training a team of doctors to assist in the operations who have been going around the country, to the provincial hospitals where he operates on an average of 40 women per week.

"The response to these operation we carry out in different parts of the country have been mixed because most them believe there is little or nothing that can be done to correct their situation, while others who are optimists, would come in numbers to get some help.

But even those who doubt that anything can be done, still come in large numbers, just to see if their beliefs can be proven wrong," he said. 

• Zambia