By Clara Colombatto

Researchers from the Duke Global Health Institute (DGHI) are launching a study on psychological interventions for women with obstetric fistula in Tanzania this September.

A fistula develops during long obstructed labor: the fetus is stuck in the birth canal and erodes the vaginal tissue. After the traumatic labor experience and loss of the child, women return home and realize they constantly leak urine or feces. Moreover, they suffer from severe pain and are likely to develop urinary tract infections.

Women with obstetric fistula are stigmatized and ostracized by society, and spend years hiding their condition from others.

Aheyu, one of the protagonists in A Walk to Beautiful, a 2007 documentary about a group of Ethiopian women with fistula.

Aheyu, one of the protagonists in A Walk to Beautiful, a 2007 documentary about Ethiopian women with fistula.

Duke researchers conducted a series of interviews from 2010 to 2012 and found that this rejection and self-isolation leads to higher levels of depression, anxiety, and PTSD in women with obstetric fistula, even after a repair surgery.

The work is being led by Melissa Watt, DGHI assistant professor, Kathleen Sikkema, professor of psychology and neuroscience, global health, and psychiatry and behavioral sciences, graduate student Sarah Wilson, and Dr. Gileard Masenga, a surgeon at Kilimanjaro Christian Medical Center.

Wilson is doing a dissertation on the project as a member of the DGHI’s doctoral scholar program.

Based on their empirical observations, Watt and colleagues developed interventions for women receiving fistula repair surgery. The aim is to reduce shame and reframe fistula as a medical condition rather than a personal failure. If successful, the therapy could be a model for treatment of mental health issues related to fistula.

Adapting western psychological therapies in West Africa is a difficult process: “The way we do therapy in the U.S. is very individualistic, emphasizing the idea that your own thoughts are the most important thoughts, versus the thoughts of your parents or your community,” Sarah Wilson says.

But “in Tanzania, identity draws upon family and community,” Watt says. To raise awareness and acceptance of fistula, the team has previously organized workshops.

While the last U.S. hospital treating fistula patients closed its doors in 1895, more than 2 million women live with fistula worldwide as of today. In this sense, “obstetric fistula is a terrible condition and embodiment of disparities in society and health care,” Watt says.