As a midwife in Eugene, Ore., Bonnie Ruder has overseen more than 150 successful homebirths. When she leaves for Uganda with her family in November, she will be investigating circumstances when things don’t go so well.
At Oregon State University, Ruder is pursuing master’s degrees in medical anthropology and in international public health. In Uganda she will combine these disciplines by studying cultural attitudes toward obstetric fistulas, a medical condition that affects 2 to 3 million women worldwide, mostly in developing countries. Fistulas result in incontinence and social isolation for women if left untreated.
“The roots of the problem are complex,” says Ruder. “Training traditional birth attendants would help. But there are deep cultural traditions at work.”
Fistulas can occur when any unnatural passageway opens up between two organs in the body. During childbirth, especially with girls whose bodies have not fully developed, prolonged pressure by the baby can damage the lining of the birth canal, leading to an opening between the vagina and the urinary tract or the rectum.
In collaboration with Terrewode, a nonprofit organization in Uganda, Ruder will interview birth attendants and fistula sufferers about their understanding of causes and preventive measures. As a member of OSU’s Reproductive Health Laboratory, her ultimate goal is to improve maternal health care for women in developing countries as well as the United States.
Ruder will work in the eastern Ugandan city of Soroti until the end of March, 2012, but it won’t be her first trip to Africa. In 1995, after receiving a bachelor’s degree in political science at the University of Arizona, she volunteered with a nonprofit group in Zimbabwe, the Kunzwana Woman’s Association, working with women on commercial farms and in mining communities. “Living conditions on the farms were terrible and tragic,” she says.
That experience inspired her to move to Oregon and become educated in homebirth as a midwife. In June 2010, following the March earthquake in Haiti, Ruder volunteered for three weeks with Mother Health International in a birth center about two hours from the capital, Port-au-Prince.
“The Haitian women were amazing,” she says. “They were so happy and appreciative of the care.” Many would ride a motorbike from the mountainous countryside to the center to give birth. Because they often had other children at home, they would clutch the newborn in their arms a few hours later as they sped away for the jarring ride home. “It was not our ideal post-partum picture,” says Ruder.
On her way back to Oregon from Haiti, Ruder met Dr. Lewis Wall, a medical anthropologist and obstetrician at Washington University in St. Louis, who established the Worldwide Fistula Fund to serve women in developing countries. While at the university, Ruder also met Alice Emasu, a Ugandan woman and coordinator for Terrewode, an organization in Soroti whose aim is to empower women and support families.
With a $50,000 grant from the The Fistula Foundation, Emasu is addressing some of the cultural factors that lead to childbirth-related fistulas such as poor nutrition, lack of adequate medical care and child marriage. The organization will increase advocacy for treatment, prevention and social integration of fistula patients. Ruder’s ethnographic research will provide a better understanding of how Ugandan women and birth attendants view fistulas.
She explains that from a biomedical perspective, the condition is caused by “obstetrically obstructed labor,” but if local people don’t share that understanding, solutions to the problem may not be effective.
“I’ll ask women who have suffered from the fistula what they think caused it and what they think could prevent it. I’ll also ask those same questions of traditional birth attendants,” says Ruder. With Terrewode, she will evaluate her findings in light of existing approaches to preventing fistulas through education. In the long run, she adds, educating girls and empowering women may be the most effective public health option.
Ruder will travel to Soroti with her husband Eric and two children, Lucas, 8, and Soren, 11. Terrewode is not supporting her work financially, so she is raising funds to help pay for expenses for travel, translation and other activities.
Ruder interviewed 17 fistula survivors in Soroti and working in the regional hospital. See a June 2012 story about her experience.