Madagascar and the Issue of Obstetric Fistula

Edward Flynn CSSp

In late October, along with five others, I visited Madagascar. The five others were a social work lecturer from Canada, a Swiss human rights trainer, and three representatives of the World Council of Churches (WCC) from Geneva / New York. We were there to explore the obstetric fistula situation and to engage with personnel from several of Madagascar’s many Christian churches and with doctors and surgeons, midwives, NGOs, and UN agencies.

Perfect storm

The absence of emergency obstetric care facilities and poor road/transport infrastructure in rural areas of Madagascar, where women live in poverty, makes for a perfect storm. In general, surgical standards are low, and many women with fistulae suffer several surgeries without ever having a positive outcome. Oversight of all fistula operations to reduce the suffering endured by women is urgently needed.

With a limited repair capacity, the existing backlog of some 50,000 cases in the country is rising annually by over 500. The need for qualified surgeons to perform complex operations makes the situation desperate.

At current rates, a hundred years of repair operations would not eliminate the problem. Hence the necessity of a strong prevention policy, strategy, and program. Daily consistent care by many midwives and doctors in rural areas means that assistance is now beginning to reach those most in need of emergency obstetric services. Having visited hospitals and villages in three locations distant from the capital, what was most striking was the gap between urban and rural situations which are separated by distance, language, and facilities. This gap must be addressed if preventing obstetric fistula is ever to be realized.

Women living in poverty in rural areas, the absence of emergency obstetric care facilities, poor road infrastructure, and no transport mean many delays in getting pregnant patients to the care required.

High Prevalence of Fistula Cases

With an annual rate of new cases between 1,500 and 4,000, the capacity of the repair facilities leaves a shortfall of at least 500 a year. There is also an existing backlog of an estimated 50,000 cases in the country. The lack of adequately qualified surgeons to perform complex operations makes the situation desperate.

A hundred years of work repair operations would not eliminate the problem at existing annual rates. Hence the necessity for a firm prevention policy, strategy, and program.

With high poverty levels, a large proportion of the population living in rural areas, poor roads, and scarce health facilities, Madagascar has many conditions supporting an increasing number of women living with obstetric fistula.

Add in the growing number of teenage pregnancies and underage marriages, and you have the perfect storm for fistulae. And so far, we haven’t even mentioned inequality.

There are at least ten health facilities around this large island where repair operations are performed. The capacity of all these centers is still unable to cope with the 3,000 new cases a year. The cities of Madagascar have facilities that ensure the safe birth of children. The villages don’t. That is why we work on the prevention of obstetric fistula.

Madagascar is a forgotten country

Living from hand to mouth, the lack of reserves, little foreign investment, and large numbers without work are some of the factors preventing any improvement in the situation of people experiencing poverty. Survival occupies the minds of people experiencing poverty and leaves them unable to give much attention to the future.

Weak national infrastructure and the lack of regulatory bodies in the health and education sectors mean those far from administrative centers receive few services. In the country’s south, some walk five hours to access a health clinic with no midwife. And then face the same return journey home. Little wonder that there are deaths along the way.

Madagascar is one of the poorest countries in the world. It has 80% of its population living on less than €2 a day. Gross Domestic Product per person is estimated to be about €530. Forty-seven percent (47%) of the children of this, the fourth largest island in our world, are malnourished. And according to the 2019 Human Development Index, Madagascar ranks 164th out of 189 countries.