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The Future IOWD Strives to Create in Rwanda


At Kibagabaga Hospital in Kigali, Rwanda, 125 women with chronic obstetric fistula camp in tents on the grounds and hope for the surgery that could transform their lives. They have come from across the country in response to radio announcements, community health worker outreach and cell phone calls announcing the arrival of the U.S. surgery team from the International Organization for Women and Development (IOWD). Most travel alone by bus, others must bring along young children and babies. They wait with expectation and anxiety, and tend to the constant washing and drying of cloth, a necessity of their condition.

Obstetric fistula is the result of a prolonged or obstructed labor when the wall between the bladder and the vagina is damaged due to lack of adequate blood flow to the area. A connection, or fistula, develops that allows urine to seep into the vagina which now will constantly leak urine. A fistula can also occur between the rectum and vagina with similar consequences. The condition has severe social and economic repercussions for these women who are shunned by their community and often abandoned by their husbands.

The IOWD team has been performing fistula repair surgery at Kibagabaga three times a year for the past four-and-a-half years. The process is well-established and the team is integrated within the local health care system and with Rwandan staff. After hugs and catching up, the surgery team sets to work to prepare the exam and OR rooms. Screening begins immediately with Rwandan medical students interviewing the women and collecting medical histories. Each woman is then examined internally to determine the source and cause of leakage, and whether they are a candidate for surgery or if additional tests are necessary before that decision can be made.

Some of the women are returning for exams following surgery performed during the previous IOWD visit several months earlier. Some do not have a fistula and will be treated for other conditions that cause incontinence. Others are told to return for surgery during IOWD’s next visit. And each morning a handful of women will be given the devastating news that their fistula is inoperable. The medical team and local staff deliver the news in a careful, respectful way to ensure there is no misunderstanding and to assure the women that the diagnosis is a carefully considered and informed conclusion.

During their two-week visit, IOWD performed 55 surgical procedures. As the week progresses, the tents fill with women who have had successful surgery. The contrast from the mood in the tents prior to surgery could not be greater. The women are exuberant and grateful. They will remain on site and under care for their recovery, and will be examined again when IOWD returns in four months. All expressed a desire to be reunited with their husbands, family and community. Their condition had separated them from homes, work and loved ones. Many have suffered this way a decade or more.

Esperance, age 55, from the western province of Rutsiro, lived with fistula for 20 years. She thought she was the only one with this problem and did not understand its cause. Her husband left her and her children did not want to be near her. She was ebullient in her thanks to the medical team and staff, spoke of all she now could do, and said she would tell other women about preventing fistula and that it can be treated.

During the first week, IOWD and Imaculee, a midwife and educator at Kibagabaga, present a talk on prenatal care and fistula prevention. A flip chart includes anatomy illustrations which are of great interest to some of the women. The meeting is also an opportunity for the women to share stories of what they have endured and express frustration that proper care was not available to them in their rural community health centers. The social and emotional aspects of their stay at the hospital are therapeutic as well.

While the IOWD team seeks to help as many women as possible, their primary mission is to expand the capabilities and skills of local health care staff and enhance the facility’s capacity to handle patients. All their work is done side by side with the hospital’s staff – from surgeons and physicians to nurses, midwives and medical students. During this trip, collaboration took place launching a model hand sanitation program, two research projects between U.S. and Rwandan medical students, the introduction of a new anesthesia machine and associated training and maintenance, daily seminars by surgeons and the distribution of a surgery training video.

Each surgery requires several anesthesia medications, antibiotics, numerous instruments, specialized sutures and needles, and an untold amount of sterile gauze, gloves, gowns and other medical consumables often taken for granted in this country. “The team literally could not operate without product donations from AmeriCares,” says Barbara Margolies, founder of IOWD. For one trip alone, the value of the antibiotics required equals about one fifth of the organization’s annual budget. Anesthesia donated by AmeriCares includes both general anesthetic agents and muscle relaxants. The IOWD team of 28 medical professionals donates their time and transportation costs, and solicit product donations necessary to conduct the mission. AmeriCares has supported 25 trips by IOWD to Niger and Rwanda.

The commitment and passion of Margolies and the IOWD team to offer women free obstetric fistula surgery is tireless and matched by the care with which they seek to enable local health workers to do the same. With repeat visits three times a year, the bonds are strong. The professional relationships extend beyond the duration of the trips and progress can be seen with each visit. Next summer Rwandan medical students have been invited to study in the U.S. They are the future that IOWD strives to create.

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