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Emma’s benni cake and the battle to contain obstetric Fistula in Sierra Leone

By Osman Benk Sankoh

50-year-old Emma, a petty trader, comes to the Aberdeen Women’s Center (AWC) not far from the cosy beaches of Lumley in the West end of Freetown daily to sell her wares.


Wrapped in transparent plastic bags and placed on a tray, the 50-year-old sells ‘benni cake’ (produced from sesame seeds) to the medical staff, who are familiar with her.

To Emma, the AWC- the only fistula repair service facility that provides free surgical treatment for women suffering from obstetric fistula, is not only a regular selling point. In August 2008, she was among the first patients to undergo surgery for obstetric fistula at the Centre. It is a medical condition in which a hole develops in the birth canal due to childbirth.


Following successful surgery, Emma was grateful to the AWC staff who helped her recover and gain a new life. As well as keeping the Centre fed her delicious benni cake, Emma brings her grandchildren for check-ups at the Outpatients Clinic.


Emma is lucky to be alive in a country rated poor in terms of healthcare and where the exact magnitude of obstetric fistula has not yet been satisfactorily determined. Today, her hard toil enables her to make a modest profit and care for her family.


UNFPA’s Country Representative in Sierra Leone, Dr Kim Eva Dickson, says anecdotal evidence from initial modelling studies estimates a prevalence of nearly 2,500 women and girls living with obstetric fistula in the country. UNFPA is working with the Ministry of Health and other stakeholders to conduct studies to determine the prevalence.


According to Programmes Manager at the AWC, Alexandra Rigby, from March 2005 to May 2018, 4,048 fistula patients have undergone surgery at the Centre. “The oldest was 66 years, and the youngest was 4 (a rape victim). Most of our patients have fistula due to prolonged, obstructed labour, but we treat children whose fistula is the result of violent rape,” she said to Hidden Voices.


Addressing obstetric fistula is a key part of UNFPA’s efforts to contribute to the three transformative results of the agency’s strategic plan. The UN’s reproductive health and rights agency works to ensure all women and girls can realize their rights to health and dignity at all times.


According to the Country Representative: “UNFPA supports a three-pronged strategy to obstetric fistula management” as part of the global campaign to end the ailment. These approaches are prevention, treatment, and rehabilitation.


On prevention, Dr Dickson said: “UNFPA supports community sensitization and awareness creation on the need to prevent harmful practices such as child marriage, given that most brides are young girls whose bodies are not yet matured enough for pregnancy and delivery. We mobilize communities to encourage skilled attendance at births so that skilled midwives properly manage incidences of obstructed labour. If complications occur, we also support the linkage of these patients by referral for the provision of emergency obstetric and newborn care (EmONC) services such as caesarian sections. In this regard, UNFPA is supporting the training of midwives to provide skilled attendance at births and Surgical Assistant community health officers (SACHOs) and Nurse Anesthetists to support EmONC services.”


The Rep said UNFPA also supports the Aberdeen Women’s Centre to provide treatment for 200 obstetric fistula clients annually. And on rehabilitation: “UNFPA supports Haikal an NGO providing rehabilitation and social reintegration services to fistula clients after they have had fistula surgery and been discharged from AWC.”


A typical day at the AWC starts with a morning Devotion at 8:15 am, and then the Ward Round, where the doctor and nurses check the patients. After the Ward Round, any patients scheduled for surgery that day are prepared and sent to the theatre. Aftercare is also delivered for the surgery patients.


For Rigby, “If we don’t have any surgeries planned, the fistula patients go to the classroom for health education and skills training.” She says noon is lunchtime, and in the afternoon, patients have a sit bath with lukewarm water and salt to maintain their hygiene. Medication is given out at 2:00 pm. At 5:00 pm, the patients eat; at 6:00 pm, the nurses do their vitals and give out any further medication needed.


The Programme Manager says they get funding from Freedom from Fistula, a UK-registered charity supported by The Gloag Foundation. Notwithstanding, their challenges include language barriers, funding, and depression.


From UNFPA’s perspective, child marriage, teenage pregnancy and inadequate numbers and quality of skilled birth attendants are some of the most significant barriers to ending fistula in the country. To address these, Dr Dickson urges the Government: “to continue to invest in training quality midwives and improve their working conditions.”


Outside of Freetown, AWC offers mobile money to its fistula patients to get transport to and from the hospital. “We will also reimburse transport costs if they do not have mobile money. We conduct Screening Trips across all districts and bring patients back in our ambulance, as well as advertise our free services on local radio stations around Sierra Leone,” Rigby states.


By the end of the year, the AWC hopes to have performed 250 surgeries. For UNFPA, obstetric fistula is not a disease. It is the consequence of a lack of access to appropriate skilled care. As she continues to sell her cake to eke out a livelihood, Emma says she is eternally grateful to the selfless services of personnel at AWC who has restored her dignity.

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