By DENISE GRADY


DODOMA, Tanzania - Lying side by side on a narrow bed, talking and giggling and poking each other with skinny elbows, they looked like any pair of teenage girls trading jokes and secrets.

But the bed was in a crowded hospital ward, and between the moments of laughter, Sarah Jonas, 18, and Mwanaidi Swalehe, 17, had an inescapable air of sadness. Pregnant at 16, both had given birth in 2007 after labor that lasted for days. Their babies had died, and the prolonged labor had inflicted a dreadful injury on the mothers: an internal wound called a fistula, which left them incontinent and soaked in urine.

In January at the regional hospital in Dodoma, they awaited expert surgeons who would try to repair the damage. For each, two previous, painful operations by other doctors had failed.

“It will be great if the doctors succeed,”Ms.Jonas said softly in Swahili, through an interpreter.

Along with about 20 other girls and women ranging in age from teens to 50s, Ms.Jonas and Ms.Swalehe had taken long bus rides from their villages to this hot, dusty city for operations paid for by a charitable group, Amref, the African Medical and Research Foundation.

The foundation had brought in two surgeons who would operate and teach doctors and nurses from different parts of Tanzania how to repair fistulas and care for patients afterward.“This is a vulnerable population,”said one of the experts, Dr.Gileard Masenga, from the Kilimanjaro Christian Medical Center in Moshi, Tanzania.“These women are suffering.”

The mission - to do 20 operations in four days - illustrates the challenges of providing medical care in one of the world’s poorest countries, with a shortage of doctors and nurses, sweltering heat, limited equipment, unreliable electricity, a scant blood supply and two patients at a time in one operating room - patients with an array of injuries, from easily fixable to dauntingly complex.

The women filled most of Ward 2, a long, one-story building with a cement floor and two rows of closely spaced beds against opposite walls. All had suffered from obstructed labor, meaning that their babies were too big or in the wrong position to pass through the birth canal. If prolonged, obstructed labor often kills the baby, which may then soften enough to fit through the pelvis, so that the mother delivers a corpse.

Obstructed labor can kill the mother, too, or crush her bladder, uterus and vagina between her pelvic bones and the baby’s skull. The injured tissue dies, leaving a fistula: a hole that lets urine stream out constantly through the vagina. In some cases, the rectum is damaged and stool leaks out.

One of the most striking things about the women in Ward 2 was how small they were. Many stood barely 150 centimeters, with slight frames and narrow hips, which may have contributed to their problems.

Speaking to doctors and nurses in a classroom at the hospital, Dr.Jeffrey P. Wilkinson, an expert on fistula repair from Duke University in North Carolina, noted that women with fistulas frequently became outcasts because of the odor. Since July, Dr.Wilkinson has been working at the Kilimanjaro Christian Medical Center, which is collaborating with Duke on a women’s health project.

“I’ve met countless fistula patients who have been thrown off the bus,”he said.“Or their family tells them to leave, or builds a separate hut.”

Fistulas are a scourge of the poor, affecting two million women and girls, mostly in sub-Saharan Africa and Asia - those who cannot get a Caesarean section or other medical help in time. Long neglected, fistulas have gained increasing attention in recent years, and nonprofit groups, hospitals and governments have created programs, like the one in Dodoma, to provide the surgery.

Cure rates of 90 percent or more are widely cited, but, Dr.Wilkinson said,“That’s not a realistic number.”

It may be true that the holes are closed in 90 percent of patients, but even so, women with extensive damage and scarring do not always regain the nerve and muscle control needed to stay dry, Dr.Wilkinson said.

Ideally, fistulas should be prevented, but prevention lags far behind treatment. Worldwide, there are still 100,000 new cases a year, and most experts think it will take decades to eliminate fistulas in Africa, even though they were wiped out in developed countries a century ago. Their continuing presence is a sign that medical care for pregnant women is desperately inadequate.

“Fistula is the thing to follow,”Dr.Wilkinson said.“If you find patients with fistula, you’ll also find that mothers and babies are dying right and left.”








Injuries from obstructed labor during childbirth can leave the mother incontinent, and often an outcast. Jeneth Mangele, 30, received spinal anesthesia for her fistula repair at the Dodoma Regional Center in Tanzania.