Delivery from shame

When women arrive at the Addis Ababa Fistula Hospital, they usually reek of urine and feces. Often they have walked many miles and their husbands have abandoned them as social outcasts. Common in countries where women labor in childbirth without any medical care, fistula is an injury resulting from days, even a week, of obstructed labor. The rare woman to survive such trauma and blood loss is left with an open wound that dribbles human waste-and her child is usually dead or severely malformed.

If Ethiopians ever forget what fistula is, one woman they can thank is Dr. Catherine Hamlin, an Australian-and a Christian-who in 1975 opened the first fistula hospital in Addis Ababa with her late husband Reginald. It remains the only fistula hospital in the world.

Hamlin, 87, has spent a lifetime first developing the surgery, then sewing up otherwise "useless" women. Each woman who walks in smelling of human waste walks out of the hospital in a new dress. Reginald, who died in 1993, would call out to the repaired women, "Who is this looking so pretty and happy?"

Patients also receive a Bible and can attend Bible studies at the hospital, surrounded by lush gardens and cared for by nurses who themselves are sometimes ex-patients. The women who can't return to normal life-the ones who must live with a catheter or can't remarry-work at the hospital or move into the nearby village for fistula women, where they learn to be independent and start their own businesses: making cheese, growing vegetables, raising chickens, or tailoring clothes.

On a recent visit to Washington, Hamlin drew glances from passersby as she described the first attempts to remedy fistulas in the 19th and early 20th century, using bent spoons inserted into vaginas and silver jeweler's wire to sew up women. When a woman has prolonged, obstructed labor, "the bladder and the rectum get squashed-a piece of tissue drops out," Hamlin explained, creating a hole so the woman is incontinent. "It's not a tear, so you have to make the bladder come together so it heals. Scar tissue forms so there are all sorts of problems." Usually the baby is stillborn. "A few hours later, she says, 'I wish I had died with the baby,'" Hamlin said, describing a typical fistula patient.

A 2005 study of fistula patients in Kano, Nigeria, revealed that 67 percent of women with fistula were abandoned by their husbands. Some women develop disabilities and atrophied muscles because they lie in one position, perhaps on their sides, for weeks, months, years, hoping the hole closes and the leaking stops. Suicide rates are high among these women, Hamlin said. One patient's uncle told her that he had cut the rope as his niece was jumping from a tree. A missionary doctor once told her that fistula patients will "break your heart because you can't do much for them."

The Addis Ababa Fistula Hospital, which the Hamlins founded, has repaired fistulas in over 35,000 women. Two million women and girls around the world currently live with fistula, most in sub-Saharan Africa and Asia, according to the World Health Organization, and about 50,000 to 100,000 develop fistulas each year. The fistula problem is acute in Ethiopia because of the continued practice of child marriage, despite its illegality, so young teenagers whose bodies aren't fully formed become pregnant and terrible labor often follows. Girls who grow up with poor nutrition, too, often have smaller pelvises, which make labor and delivery difficult. And women in rural areas of Ethiopia, who have less access to healthcare, have three times as many children as women in cities.

Thanks to the Hamlins, Addis Ababa has become the global headquarters for fighting fistula: The first meeting of the International Society of Obstetric Fistula Surgeons was held there in 2008. But the country faces a major hurdle to solving fistula: "We need many more doctors," said Dr. Fekadl Ayenachew, a top Ethiopian gynecologist and surgeon with the fistula hospital. The Addis Ababa Fistula Hospital and its rural offshoots pride themselves on being staffed by Ethiopians, who know the culture, the area, and the people, and have more invested in the place. Mamitu Gashe, one of the fistula surgeons at the hospital who now trains other surgeons in fistula repair, was first a fistula patient, a peasant who became pregnant at 16. But the hospital struggles to retain Ethiopian medical personnel, though it is the top institution for training doctors in fistula repair. The doctors often leave for better pay in Western countries, chiefly the United States. Ethiopia has 170 obstetricians and gynecologists serving a population of 82 million, and only 40 of those serve rural areas, which hold 85 percent of the population.

Ayenachew is one of the few who works in a rural area of the country. "Many of my friends left Ethiopia for better pay and better life," he told me. "I had some opportunities to leave but I stayed in. I feel it's worth it to stay in. And now I have my family." Mark Bennett, the CEO of the hospital and its offshoot projects, said, "We need to find ways for people like Fekadl to stay." Ethiopia's health ministry in a recent report found that one-third of trained Ethiopian doctors had left the country in the previous decade. The ministry also found that only 5.7 percent of women giving birth in the country had help from a health professional. Still, there's good news: The maternal mortality rate in Ethiopia has been cut almost in half in the last decade.

The Ethiopian government has attempted to address the scarcity of doctors in a number of ways, some of them desperate, such as mandating that all medical schools expand their class sizes. A more effective measure, which the fistula hospital has pioneered, is training Ethiopian midwives, sending them out to care for the particularly vulnerable rural mothers. The Addis Ababa Fistula Hospital has a network of five rural fistula clinics and plans to open another 25 rural clinics within the next four years.

The Ethiopian Emperor Haile Selassie commissioned the Hamlins to open a midwifery college when they first arrived in Ethiopia in 1959, on a contract to serve at a local hospital for three years. Between developing fistula surgery, setting up a hospital, and surviving ensuing coups, communist rule, and civil war, the fistula hospital didn't open its midwifery college until 2007.

Now hospital staffers see midwives as their front-line soldiers to prevent fistula. Midwives notice the first signs of a troubled pregnancy and help to provide care or to bring the woman to a hospital. The Hamlin College of Midwives selects students from rural areas to be trained in Addis Ababa, then the new midwives return to work in their rural communities. Last year the college graduated its first class-11 midwives-and plans to graduate 25 a year going forward.

Hamlin recalled a conversation from her early days in Ethiopia between her husband and the emperor, who became a friend:

"Why do my women get this disease?" the emperor asked.

"It's nothing to do with your women. It's your roads and mountains," replied Reginald Hamlin.

"Oh, I'm so glad it's not my women," the emperor said.

The country's geography-rugged valleys and towering tabletops-coupled with poor infrastructure make a journey to the main hospital in the capital arduous. Rural roads are still bad, according to Ayenachew.

One fistula patient walked 450 kilometers (280 miles) to the hospital, Hamlin recounted in her book, The Hospital by the River. Another woman with fistula arrived with a note from a missionary doctor dated seven years previous-she said it had taken her that long to beg enough money for the bus fare to Addis Ababa. Some bus drivers won't allow fistula women on their buses because of their odor. Reginald Hamlin would drive the family's Volkswagen down to the city bus station and ask if any women were leaking urine and bring them back to the hospital. He would also pick up fistula patients outside an old hotel in the city, the only place they were allowed to camp. Now, with the hospital's reputation it doesn't need to go after patients.

Age hasn't dampened Hamlin's good spirits. When I asked how she feels physically, she joked, "I feel like I'm going to perish at any moment!" Each day she rises early, has tea, and reads her Bible. She still performs surgeries and gardens. Her voice, though shaky, is mellow and glad. Whenever she mentions a place, she lovingly sketches out its landscape with her hands. The hospital in Addis, she tells me with sweeping gestures, stands on a slope near a river, and has a garden.

This same woman can describe gory details of fistula without flinching. Some patients arrived at the hospital with their babies dead in their wombs. Hamlin recalled many times delivering a dead baby who had been decaying inside his or her mother for days, the stench causing attending nurses to vomit or faint. Hamlin didn't faint, but her sympathy and sorrow for the mothers is constant. The horrors she has witnessed over 50 years in Ethiopia can be forgotten, though, when new, healthy babies arrive, giving the staff hope that one day the fistula hospital will become simply a maternity ward.

Learning on the job

A reliable surgery to repair fistula wasn't developed until the 19th century. Hamlin and her husband drew advice from an Egyptian doctor, Pasha Naguib Mahfouz, a Coptic Christian who was one of the pioneers of fistula repair in the first half of the 20th century and helped eradicate the condition in Egypt. He sent them drawings of his surgeries. The Hamlins wrote anyone around the world who had tried fistula surgeries to get their advice, and began developing their own techniques for the difficult operation.

The Hamlins had never seen a fistula until they arrived in Ethiopia. Reginald Hamlin performed his first attempted fistula repair on a 17-year-old whose husband had abandoned her, and he succeeded. The Hamlins were working under difficult circumstances: A blood bank, so vital for surgeries, was nowhere to be found when they arrived in Ethiopia in 1959. The refrigerator at the hospital where they first started usually had one or two pints of blood in it, according to Hamlin, and they had difficulty convincing suspicious staff and able patients to give blood. That's changed over the last 50 years.