Think Equal: obstetric fistula

Well-being is not just the absence of illness and injury.

Gender equality, with investment in gender-responsive services and infrastructure that meets the needs of women and girls, is essential for a world where all women achieve the highest possible standards of physical, mental, reproductive and sexual health throughout their lives.

As the global voice for women’s health, FIGO believes that the challenges women face – in their choices, pathologies and safety – cannot be solved in clinical isolation.

We asked Gillian Slinger, obstetric fistula activist, midwife and Senior Project Manager of FIGO’s Fistula Surgery Training Initiative about the inequity which leads to this neglected public health and human rights issue, its devastating impact, and innovations that are making a difference.

‘Think equal, build smart, innovate for change.’ What does this mean to you in the context of obstetric fistula?

In a world of unequals, the most unequal of unequals are the women and girls with obstetric fistula. They represent deep-rooted inequity on two levels: the first related to access of essential services, notably health but also education; the second, related to their socio-economic situation and opportunities.

These themes of innovation and change are really brought to life with FIGO’s Fistula Surgery Training Initiative: our work, with an incredible range of partners, focuses on directly bridging the inequality gap to reach women with obstetric fistula who are otherwise entirely left behind.

Access to public services is essential for health and wellbeing, particularly primary care: but there is often a dangerous gap between men and women, rural and urban. What is the biggest challenge you see for women with obstetric fistula when it comes to accessing public services?

Investment in women’s health is fundamentally linked to the status of women in society, and obstetric fistula is the starkest realisation of their neglect.

Women living with obstetric fistula are double victims of the gaps in access to public services. The first through lack of health services for safe delivery and emergency obstetric care – notably C-section – which leads to obstetric fistula. The second with the severe shortage of trained fistula surgeons and holistic treatment units, meaning that at present only 1 woman in 50 is able to access fistula repair services.

This is a neglected public health and human rights issue, but it falls low on the global political agenda. The obstetric fistula treatment community is passionate and dedicated, but woefully insufficient in terms of both human and financial resources.

How is FIGO’s Fistula Surgery Training Initiative working to advance gender equity when it comes to access to public services?  

Women with obstetric fistula are the living proof of high maternal mortality. The focus we are finally seeing on reduction of maternal death is critical, but maternal morbidity – physical or mental illness and disability directly related to pregnancy –  gets significantly less focus.

That’s why FIGO’s programme is critically important: by addressing one of the most devastating maternal morbidities, training more surgeons and allowing more women to access life-changing treatment, we are helping transform the lives of some of the world’s most vulnerable women from despair to action.

Some women who have had their fistulas repaired choose to put the issue behind them, returning to their communities to concentrate on rebuilding their lives with dignity. Many others are so outraged by what has happened to them, and the risk to other women, that they are empowered to become activists themselves, working to prevent their sisters suffering as they have done.

Ultimately our programme is about global health equity, empowering women to break the cycle of poverty which contributed to their fistula in the first place. We work hard to ensure that women are a key part of the solution. More than a third of our FIGO Fellows in high-need countries are female, including in Somaliland, Yemen, Afghanistan, Nigeria.

OBGYNs are on the frontline of women’s health, and change. What is the most exciting innovation you have seen when it comes to accelerating progress for gender equality in the field of obstetric fistula?

Obstetric fistula uniquely affects women – and in 94 percent of cases the long labour also tragically leads to a stillborn baby. I am inspired every day by champions of the fistula world - many of whom are women - committed to finding a solution. It’s not just OBGYNs, but also midwives, frontline health workers and of course fistula surgeons, turning adversity into a powerful movement for change.

We are not ready to celebrate. In 2013 the International Day to End Obstetric Fistula was launched by the UN, refocusing international attention and calling the world to action on an annual basis.

On a policy level, recognising how women living with obstetric fistula are really the heart of the 2030 Sustainable Development Agenda is a powerful shift in thinking. These women represent deep seated inequities, disadvantage and neglect and if we cannot find a solution for them, then Health For All will have failed, absolutely.

Can you share a story that illustrates why healthcare systems need to respond more directly to the specific healthcare needs of women and girls with obstetric fistula?

About 14 years ago I met an adolescent girl at a fistula treatment centre in Chad. Traveling with her mother across the desert, it had taken them several weeks to arrive, and she was so poor – barefoot, with nothing but a yellow shawl wrapped around her.

That, for me, was life-changing. Here was the entrenched inequity women and girls face: no access to health services, stillborn baby delivered at home, and a 15-year-old girl suffering the dire consequences of an obstetric fistula.

In memory of this special girl in yellow and in harmony with all women and girls like her round the world, I always wear a yellow flower when I speak about obstetric fistula. I’ve met women of all ages, from young girls to women in their 80s who have lived with a fistula for sixty years.

Failure after failure of the system, societal, medical, institutional, right through the life-course. It’s why, in tandem with all the crucial prevention work, FIGO is working with committed partners on this game-changing initiative: to make sure no woman with obstetric fistula is left behind.

Please don’t forget them.