The life-changing surgery that gives women back their dignity and their health

So many inspiring women who dedicate their lives to helping other women are not as well-known as they should be. It was at the home of one of those women that I first heard about Dr. Catherine Hamlin and her decades of loving work to help Ethiopian women suffering from obstetric fistula.

Dr Catherine Hamlin at the Hamlin Fistula Hospital, Ethiopia 2009. Photo: Lucy Horodny, AusAID. Wikimedia Commons.

Living in North America, I had never heard about this problem. But Edna Adan Ismail knew it all too well. She saw it often in her hospital in Hargeisa, Somaliland, where I was staying while doing research a decade ago. (Edna is a force of nature and one of my heroes.)

The television program we were watching told the stories of rural women who, suffering from fistula, had to live in huts away from their families because they always smelled of urine, of the difficult  journey of one woman to get help from a unique hospital in Addis Ababa – and of the surgery that gave her back her life.

Watching that program, I could understand why a colleague had told the Hamlins back in 1959 that the fistula patients “will break your hearts”. The two Australians had come to Ethiopia on a three year contract with the Ethiopian government to work as obstetrician-gynaecologists and set up a midwifery school in Addis Ababa, and they had never seen a case of obstetric fistula before.

In 1994, Dr. Catherine Hamlin explained it crisply and succinctly to a visiting American. “Dear, a fistula is a hole between an internal organ and the outside world that shouldn’t exist. And in the case of all the women here, the cause is unrelieved obstructed labor, the hole is between the bladder, vagina, and sometimes the rectum, leaving a woman incontinent. Surgery is their only hope.” Often their babies were still born, after agonizing labour often lasting several days.

The condition leaves women trapped in a life of pain, shame and isolation, often abandoned and shunned by husbands and families. Most think they are the only ones who suffer from the condition. And yet it is almost entirely preventable, and can often be repaired with a single life-changing surgery.

Surgeons from around the world come to Hamlin Fistula Ethiopia to learn best-practice fistula-repair surgery, pioneered by the Hamlins in their first years in Addis Ababa. That was an amazing achievement, because the Hamlins had never seen an obstetric fistula case before they arrived there from Australia in 1959, expecting to stay only a few years.

But the plight of the fistula patients touched their hearts. They sought out long-forgotten medical textbooks from Europe to develop treatment techniques for fistula, which has been largely eradicated with C-section deliveries in “first world” countries. They refined the surgical technique to close obstetric fistula injuries while treating a broad range of obstetric cases at Princess Tsehai Memorial Hospital in Addis. They operated on 300 patients in their first three years, and as news spread, many more patients came seeking treatment.

In 1962, the Hamlins built a hostel in the hospital grounds, using donations from overseas, and then worked for more than a decade to establish a specialized fistula hospital, founding the Addis Ababa Fistula Hospital (now Hamlin Fistula Ethiopia) in 1974. It was the only medical centre in the world at that time dedicated exclusively to obstetric fistula repair. Dr, Reg Hamlin worked at the hospital until his death in 1993. Dr. Catherine Hamlin continued the work, treating more than 45,000 women, before she had to retire. She lived in her apartment on the hospital grounds until her death in March 2020, being cared for by Mamitu, a former fistula patient she treated more than a half century ago, who has stayed at the hospital, and even trained to perform surgery. (The hospital has now treated more than 60,000 women.)

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She was twice nominated for the Nobel Peace Prize and in 2009, the year she turned 95, she was awarded the Right Livelihood Award, often called the ‘alternative Nobel Peace Prize, for “restoring the health, hope and dignity of thousands of Africa’s poorest women.” In 2012, she was given Ethiopian honorary citizenship.

Even after she was no longer doing surgeries herself, she continued her advocacy work at the national and  international levels. Even, in 2004, on Oprah. This matters, because the hospital is supported by an international community of people and donors who want to eradicate fistula. No woman is charged for her surgery.

The Oprah Winfrey Show, watched by 49 million Americans and millions more across the globe (I watched it in Edna’s apartment in Hargeisa), offered a huge pulpit from which Dr. Hamlin could share her dream of eradicating obstetric fistula forever. It is something few of Oprah’s US audience would have been familiar with, because modern obstetrical care largely ended it in the US and Europe in the 20th century. But it remains prevalent in sub-Saharan Africa and Asia – the World Health Organization estimates that approximately two million women have untreated obstetric fistula.

“These women have suffered more than any woman should be called upon to endure,” Dr. Hamlin said. “To meet only one is to be profoundly moved, and calls forth the utmost compassion that the human heart is capable of feeling.”

In countries like Ethiopia, where more than 70% of births take place without a doctor or nurse present, midwives in remote areas can be the difference between life and death for women and babies. Dr. Hamlin, believing the key to eradicating fistula lay in prevention,  established the Hamlin College of Midwives in 2007.

To date, 190 Hamlin Midwives have graduated with a Bachelor of Science (Midwifery), and have delivered over 70,000 babies in the past three years alone. Graduates are deployed for a minimum of four years to one of the 50 Hamlin-supported midwifery clinics near their hometown. These clinics have had a remarkable impact – new cases of fistula drop to almost zero in nearby villages when a Hamlin midwife arrives at a clinic.

A key is that their local knowledge and ability to speak the local language means they have the cultural sensitivity to dispel misconceptions about seeking medical help on issues affecting women’s health, as well as the training and practical experience to help women.

From July 2020 to June 2021, a record-breaking 1,567 surgeries were performed at Hamlin, which has six treatment centres around the country. But Hamlin knows that there are still an estimated 31,000 women living with devastating fistula injuries in Ethiopia, and its Patient Identification Program is systematically finding them and connecting them to ltreatment. 

The stigma associated with obstetric fistula means that many women cannot return to their communities and few have an income that allows them to live independently, so Dr Hamlin founded Desta Mender (‘Joy Village’) in 2002 as a recovery centre for long-term fistula patients. It reflected her philosophy of treating the whole woman, not just the fistula.

The rehabilitation and reintegration centre helps women learn skills to be reintegrated back into their community. Now it has created a new Women’s Empowerment Program, a three-month residency where women learn leadership and communications training, learn how to create and run small businesses, and receive vocational training. Training is provided by Holleta College, with support from Women’s Hope International. Two cohorts of women had completed the training by September 2021, and a third will start soon.

The United Nations aims to end obstetric fistula by 2030, but during this year’s International Day to End Obstetric Fistula (May 23), advocates warned that the pandemic will affect that goal. While fistula can largely be avoided by delaying the age of first pregnancy, ceasing harmful traditional practices, and providing timely access to obstetric care, overburdened health systems can mean that fistula repairs are deemed non-urgent, and in economically perilous times, the number of child marriages could increase as daughters are more likely to be married off.