Layla A. Al-Jailani
Yemen

Nouria strolls across the kitchen, making lunch for her family as she does every day. Her stride is slightly wobbly, but any observer would think this was a healthy young woman. What they do not see, however, is the hidden anguish, pain, and shame that tears at her body and eats through her soul. We expect the ill to be visibly unwell. The pain should be drawn on their faces. They ought to pant when walking across the room or grimace when they move. Yet that is not always the case. Some conditions, such as obstetrical fistula, are well-hidden because of shame and embarrassment.

Obstetrical fistula occurs after prolonged, obstructed labor. When a woman should be celebrating the birth of her child, these women are, instead, devastated. Their babies usually have perished, and they are now plagued with incontinence of urine, stool, or both. These women hide their condition in shame, afraid of what the future holds.

In the developed world, obstetrical fistula is rare if not obsolete. In the developing world, however, it is not uncommon at all. Nouria is one of the women who came from the periphery of Yemen, seeking relief from the morbidity that has tainted her existence.

Nouria was a newlywed at the age of fourteen. Soon after her wedding, she developed morning sickness and discovered she was pregnant. It was a moment of ecstasy for the entire family. She lived in a small village in Yemen and since the nearest medical center was twelve hours away, she intended to deliver at home like the rest of the women in her village. However, her labor did not go as planned. The baby was in a transverse position, making a normal vaginal delivery impossible. Oblivious, the family tried a home birth for over forty-eight hours. When all attempts failed, they took the ailing mother on the twelve-hour journey to the nearest city. She was a thread away from death. The medical staff immediately performed a Cesarian section to deliver the now-dead baby. The trauma of delivery left her with two obstetrical fistulas. Unable to hold urine or stool, her husband refused to accept her back into his home. She moved back into her parents’ house with the intention of returning to the hospital to repair her condition. It took five years to gather enough money to make that dream come true.

She hoped that the doctors would be able to alleviate her suffering. Unfortunately, it was too late and her condition too complex: her bladder and rectum had been destroyed during the delivery. The doctors were unable to help her, so Nouria must now live with an obstetrical fistula for the rest of her life.

It took Nouria five years to reach out for help. Others do not know their condition can be fixed, so they endure at home helplessly. These women suffer in silence; only those closest to them know the anguish they experience.

Not only do these women lose their babies, but they lose their dignity, as well. Many of the affected women have been divorced by their husbands. With downcast heads and tears in their eyes, they return to their parents’ homes. Now bearing the weight of the label “divorcee,” they are shunned by society. The neighbors whisper and taunt as they walk by. These women are left to fend for themselves, feeling helpless and guilty because of a condition that is out of their control. They have no choice but to isolate themselves from the outside world, afraid that they may smell or embarrassed of the diaper they now must wear. They live in fear that one day someone might discover the illness they keep secret.

For some women, the burden is too much to carry. The eyes that gleamed so brightly dim. They forget how to smile. Some conclude that death is more merciful than the condition that has taken over their lives. These are young, beautiful women, standing on the cusp of their adult lives.

They have so much they could share, but in a moment of despair they take their own lives, depriving their families, their communities, and the world of their special personality and talents.

Many factors play a part in the incidence and prevalence of obstetrical fistula, but the main two factors are poverty and ignorance. Village women are often married young, sometimes as young as ten or eleven years old. They do not understand the importance of antenatal care or the possible consequences of home births. The family brings a traditional healer or old woman to deliver the baby, but when the labor lasts for days and the baby is still not born, these young women are too disempowered to make their own decisions. The decision is left in the hands of a mother-in-law who proclaims, “All of us had a normal birth, you should too!”

Many of these women are only brought to the hospital when on the verge of death, exhausted and covered in sweat. No longer is the problem solely an obstructed labor. She is handed over to medical professionals in a state of shock with multiple genital tears and a ruptured uterus.

The families live in villages on mountain tops far away from any health care facility. They do not have access to medical staff that can bring them through the challenges of childbirth. With no roads leading to the nearest city and no cars to carry them to a medical center, they are left with no choice than to deliver their babies at home and hope for the best.

Stories like Nouria’s are not a rarity. Obstetrical fistula is widespread in Yemen. The exact number of victims is unknown. Unaware that relief is possible, they hide away, scared of what people would think if they ever found out. Medicine is a scale with two hands. One is the medical staff, equipment, and training. Yet the other side, which is just as important, is often overlooked: community awareness and knowledge of the causes and treatments of illness, which provides the foundation for a healthy society.