Tanzanian women hit by vaginal fistula

pix:Béatrice de Géa for The New York Times

DODOMA, Tanzania — Lying side by side on a narrow bed, talking and giggling and poking each other with skinny elbows, they looked like any pair of teenage girls trading jokes and secrets.

But the bed was in a crowded hospital ward, and between the moments of laughter, Sarah Jonas, 18, and Mwanaidi Swalehe, 17, had an inescapable air of sadness. Pregnant at 16, both had given birth in 2007 after labor that lasted for days. Their babies had died, and the prolonged labor had inflicted a dreadful injury on the mothers: an internal wound called a fistula, which left them incontinent and soaked in urine.

Last month at the regional hospital in Dodoma, they awaited expert surgeons who would try to repair the damage. For each, two previous, painful operations by other doctors had failed.

“It will be great if the doctors succeed,” Ms. Jonas said softly in Swahili, through an interpreter.

Along with about 20 other girls and women ranging in age from teens to 50s, Ms. Jonas and Ms. Swalehe had taken long bus rides from their villages to this hot, dusty city for operations paid for by a charitable group, Amref, the African Medical and Research Foundation.

The foundation had brought in two surgeons who would operate and teach doctors and nurses from different parts of Tanzania how to repair fistulas and care for patients afterward.

“This is a vulnerable population,” said one of the experts, Dr. Gileard Masenga, from the Kilimanjaro Christian Medical Center in Moshi, Tanzania. “These women are suffering.”

The mission — to do 20 operations in four days — illustrates the challenges of providing medical care in one of the world’s poorest countries, with a shortage of doctors and nurses, sweltering heat, limited equipment, unreliable electricity, a scant blood supply and two patients at a time in one operating room — patients with an array of injuries, from easily fixable to dauntingly complex.

The women filled most of Ward 2, a long, one-story building with a cement floor and two rows of closely spaced beds against opposite walls. All had suffered from obstructed labor, meaning that their babies were too big or in the wrong position to pass through the birth canal. If prolonged, obstructed labor often kills the baby, which may then soften enough to fit through the pelvis, so that the mother delivers a corpse.

Obstructed labor can kill the mother, too, or crush her bladder, uterus and vagina between her pelvic bones and the baby’s skull. The injured tissue dies, leaving a fistula: a hole that lets urine stream out constantly through the vagina. In some cases, the rectum is damaged and stool leaks out. Some women also have nerve damage in the legs.

One of the most striking things about the women in Ward 2 was how small they were. Many stood barely five feet tall, with slight frames and narrow hips, which may have contributed to their problems. Girls not fully grown, or women stunted by malnutrition, often have small pelvises that make them prone to obstructed labor.

The women wore kangas, bolts of cloth wrapped into skirts, in bright prints that stood out against the ward’s drab, chipping paint. Under the skirts, some had kangas bunched between their legs to absorb urine.

Not even a curtain separated the beds. An occasional hot breeze blew in through the screened windows. Flies buzzed, and a cat with one kitten loitered in the doorway. Outside, kangas that had been washed by patients or their families were draped over bushes and clotheslines and patches of grass, drying in the sun.

Speaking to doctors and nurses in a classroom at the hospital, Dr. Jeffrey P. Wilkinson, an expert on fistula repair from Duke University, noted that women with fistulas frequently became outcasts because of the odor. Since July, Dr. Wilkinson has been working at the Kilimanjaro Christian Medical Center, which is collaborating with Duke on a women’s health project.

“I’ve met countless fistula patients who have been thrown off the bus,” he said. “Or their family tells them to leave, or builds a separate hut.”

For the women in Ward 2, the visiting doctors held out the best hope of regaining a normal life.

Fistulas are a scourge of the poor, affecting two million women and girls, mostly in sub-Saharan Africa and Asia — those who cannot get a Caesarean section or other medical help in time. Long neglected, fistulas have gained increasing attention in recent years, and nonprofit groups, hospitals and governments have created programs, like the one in Dodoma, to provide the surgery.

Cure rates of 90 percent or more are widely cited, but, Dr. Wilkinson said, “That’s not a realistic number.”