Eva had a different story. We interviewed Eva 14 months after she was treated for a fistula. She suffered a fistula after her first pregnancy at the age of 18. She started labour in the dispensary and on the third day she was taken to the hospital, where she delivered a dead baby. She noticed she was leaking, and so a catheter was inserted and she was sent home. She stayed with the catheter for 2 months, before she was referred to a hospital for fistula repair. She is completely cured, and is now 6 months pregnant. She said she was happy with her husband and hoped to have ten children.
There is currently no follow-up of fistula patients in Tanzania, and fistula surgeons explained that they could only hope that the women were doing well after treatment. The experience during reintegration is influenced by the time and success of treatment. About one-third of the women we interviewed said they were not completely dry after treatment. They either still had a fistula or some stress incontinence. Successful reintegration, however, goes beyond the physical condition of incontinence. Societal factors and support networks play an important role as well.
When Flora returned home after treatment, her mother-in-law put pressure on her to sleep with her husband. She refused and returned to her mother. When we asked her about remarrying, she said ‘if a man approaches me, I will refuse. I will tell him that I don’t want to be destroyed any more’. Flora’s mother helped her through the process of acquiring treatment, because of which they are now left poorer than before. She said ‘The cultivation season passed, my mother did not cultivate, so currently we do not have food, we are buying food’. She added ‘I dream to have money then my mind can settle’. Another respondent, Stella, who is now cured and has a supportive husband, talked about their plans before her fistula. ‘… After selling this harvest, some would be for food and with the remaining we wanted to buy iron sheets (for the roof of their house) … but when I got the problem, that money was used to send me to witchdoctor’s ... that witchdoctor required a lot of money ... one goat and 20 000 shillings (£8)’. They were now struggling to recover the assets lost in acquiring health care.
For a woman in Tanzania, the ability to bear a child is tightly connected with self-worth. The women who already had children often did not want more, but those who did not really felt the loss. When we asked Gloria, who had gone through three marriages with a fistula and several miscarriages, what pained her the most, she said ‘only having no child. It hurts me so much. If I had a child, I would not feel the pain as much’. She added ‘I am not worried about becoming pregnant even if I get fistula, provided I have a child, I will not care.’ Some women conceived children even with fistulae, some of whom were outside of wedlock.
Fistulae impact the physical, social, economical and psychological life of women in Tanzania and all these aspects need to be accounted for when assessing successful reintegration. It is also important to realise how difficult it is to carry out home follow-up visits for these women. There were days when we drove on unpaved, bumpy roads for eight hours, searching for one woman. Some villages were not accessible by car and we had to hike for hours. Understanding the environmental context that these women come from gives perspective on the inaccessibility to emergency obstetric care and why the women that we interviewed are, in fact, the fortunate ones. Awareness is increasing and women are getting treatment sooner. I believe there is hope, a hope to move beyond incontinence.
Julia Irani, Master’s student in International Health, University of Bergen’s Centre for International Health, Norway