From Sunrise to Sunset
“In Mali, it is said that childbirth should not last longer than from sunrise to sunset.”
Obstetric fistula is a lesion that forms between the vagina and the bladder and/or the rectum following a problematic childbirth. It causes constant leakage of feces and/or urine, resulting in the social exclusion of the affected women. According to the World Health Organization (WHO), this condition affects 2 million women worldwide. In West Africa, it accounts for 3 to 4 cases per 1,000 births, but no one knows the exact number in Mali.
Primarily affecting women with low socio-economic status in rural areas where medical coverage is poor, fistula is mostly linked to the fact that women do not have access to prenatal care or cannot give birth in health centers with qualified personnel. Adolescent girls who become pregnant before reaching full physical development are the most affected.
Because of their bad odors, these women are often excluded from their communities, abandoned by their husbands, and rejected by their families, in addition to having lost the baby during childbirth in 90% of cases. Often isolated and in a state of depression, an expensive surgical operation is the only way to cure them. Many women do not know that treatment exists and do not have access to the facilities where these interventions are performed. For several years, NGOs have been implementing prevention, repair, and reintegration campaigns to cure this condition, which impacts women both medically and socially.
The eradication of obstetric fistula remains a major challenge for this country, which is facing a security and political crisis, one of the consequences of which is the weakening of public services over a large part of its territory.
Bamako, Mali – February 2022
Wandé, 26 (left) and Rokia, 22 (right), in front of their room at the Oasis center in Bamako. « My delivery was very difficult. Three days later, the illness appeared. My parents told me that it would be cured with traditional medicine » says Rokia. The young woman has been living at the center for a year. She already had four operations and is waiting for her fifth.
« During the delivery, I was so tired that I don't remember anything. I had never heard of fistula before. It was the day after the delivery that I realized there was a problem. I have been here for four months now and my husband has never come to see me. He never calls me. » Kadidjatou is 23 years old. She is from the Mopti region. She has been suffering from fistula for a year.
« This disease brings up very dark thoughts » says Mariem, 23. According to a Duke Global Health Institute study, nearly 85% of women with fistula interviewed suffered from depression. 65% had thoughts of suicide or self-destruction.
Marwa is 40 years old. Originally from Ivory Coast, she came specially to Mali to be treated in the center. « I already had six operations, one in my country and five in Mali. I thank God, because my husband supports me in this hardship. But because of my fistula, I can no longer work. »
The women live in community and can be with their children. Lessons are sometimes given in the main room of the center.
« Because of my illness, my husband divorced me. He didn't support or help me. My parents paid for my care in the beginning. Now they can't afford it. I do laundry and small jobs to earn some money. I would like to be remarried, but no one will accept me. » Djeneba, 34, has been a regular visitor to the center for eight years.
Wandé have the scars of her cesarean because of her difficult delivery two years ago. She lost her child, as 90% of women who develop fistula.
« For three days I had contractions and it was only on the fourth day that I gave birth by cesarean at the health center. The baby was dead. For a week I was unconscious, I didn't know if it was day or night » said Maïmouna, 22, from Bourem district, 100 kilometers away from Gao hospital. « When I will be recovered, I would like to be a dressmaker to support myself and be independent. In our society, if you're not married, you're a slut. » Maïmouna was married at the age of 15 and has been living at the center for four years now.
Wandé prays in her room before her surgery.
Aïssata Samassekou operates Wandé, one of the resident of the Oasis center. This operation is part of a program of the NGO Artemedis International. The operation can cost up to 300,000 CFA francs (about 450€) with transportation, accommodation and medical care.
After her sixth operation, Marwa is transported from the operating room to the urology department. She will stay there for a week in observation. If the operation is successful, she will be able to return home in Ivory Coast.
For the past six years, Awa has lived between the Oasis center and her village in the Koulikoro region. She already had five operations. « When I got sick, my husband divorced me because he said I would never get better. He married another woman. We had two children together. It's very difficult, i am often depressed. But no matter how difficult it is, I have to stay brave. »
Sitan, 19 years old (left) is from Bamako. She is waiting for her fourth operation in a year. Despite prenatal consultations at the health center, her delivery was difficult. Her baby died during birth. This was her first pregnancy. According to the Demographic Health Survey, 80% of Malian women receive prenatal care but this number varies between regions: 96% in the Bamako region, and only 23% in Kidal region, in the north of the country.
“Having children is God's will,” says Kadidjatou. Mali has a fertility rate of 6.3 children per woman. The median age for first pregnancy is 19. Early marriage is one of the factors that can cause difficult childbirth and thus possibly lead to the development of obstetric fistula.
The consulting room of Dr. Aïssata Samassekou, surgeon and head of the Oasis Center.
45 women live at the Oasis center, for more or less long stays. Often excluded from their village, being together allows them to regain confidence. « We have fun, we do everything together. It helps me to deal with my anxiety » says Maïmouna.