Fistula survivors gathered with Bonnie Ruder at Terrewode shortly before her departure from Soroti in March. (Photo courtesy of Bonnie Ruder)

Bonnie Ruder, a midwife in Eugene and an Oregon State master’s student in public health and anthropology, had gone to Uganda to learn about a traumatic condition known as obstetric fistula. It arises when labor is prolonged and the constant pressure of the baby on the birth canal causes tissue to die and a hole to open between it and the colon or urethra. Globally, about 2 to 3 million women suffer with the condition and the heartbreaking social isolation it causes. In Uganda alone, about 140,000 women live their days unable to control persistent leakage of urine or fecal matter, and about 1,900 new cases arise there annually. (See Birth Knowledge, an October, 2011, Terra story about Ruder’s research.)

During her time in Uganda, Ruder worked in a regional hospital in the town of Soroti. She interviewed 17 fistula survivors in their homes and in the offices of Terrewode, a nearby women’s health organization. She wanted to know what they had experienced and how they understood the causes of fistula. This summer, she is analyzing the information for her master’s thesis in OSU’s Reproductive Health Lab, but her eventual goal is to assist Terrewode in educating and treating women and reducing the number of new cases.

“It was eye opening,” she says. “I heard their stories about trying to get to a hospital (to give birth), and once they got to the hospital, being ignored for days. They said that the doctors checked on them and just kept saying it wasn’t time. When it finally became ‘time,’ the baby could be dead, and they would rush the women into surgery. The women would be told their baby was dead, that there was nothing the doctor could do, and they would be sent home.”

It was common, Ruder adds, for a woman to be told nothing about what it meant to live with a fistula or how it could be treated. “Sometimes the health-care people would say ‘come back,’ but if she is really poor, how is she supposed to come back? In the meantime, her husband would leave her, and she would be pushed further into poverty to the point where she won’t be able to come back.”

Meanwhile, a potential source of help has been outlawed by the government, she adds. The majority of rural women still give birth at home with the help of a family member or traditional birth attendant. About 60 percent of Uganda’s births occur in this fashion, but in 2010, the government made birth attendants illegal. “They’re really trying to import the Western way of birth without the resources to do it. It doesn’t feel locally appropriate,” she says.

Policy Not Enforced

Fortunately for women who still rely on birth attendants, it’s a cosmetic policy, adds Ruder. Enforcement is nonexistent. Still, what little support birth attendants had received from non-profit organizations has declined, and women have a harder time getting access to attendants’ services.

At the same time, the hospital birthing system is badly overworked. So-called free beds are available, but to use them, patients must bring all their own food and supplies and have a relative or friend bring them any drugs they might need. To get timely help from a doctor or a midwife requires a “tip,” which is usually out of reach of the very poor.

While she was in Soroti, Ruder worked with Terrewode to identify women with fistulas and to get them treated. “If fistula victims can get to town, Terrewode will take them to the hospital and give them all the supplies they need and check on them daily. They’ll tip the doctor to move them up higher on the list of people in line for surgery. And when the surgery is done and women are ready to go home, they also give them bus fare,” says Ruder.

Although she returned to Oregon in March, Ruder continues to assist Terrewode by writing grant proposals. The group is educating a network of women who can promote sound birthing skills and identify fistula sufferers in need of help.

Oregon State’s relationship with Terrewode continued through the efforts of another master’s student in public health, Lauren Baur from Pennsylvania. In July, Baur followed in Ruder’s footsteps and went to Soroti to assist Terrewode. See a video about Baur’s experience below.

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For more information about education abroad opportunities for OSU students, contact the International Degree & Education Abroad (IDEA) office at 541-737-3006.

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.

OSU master's student Bonnie Ruder, left, used her midwifery skills with Haitian women after the 2010 earthquake. (Photo courtesy of Bonnie Ruder)

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.

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Ruder interviewed 17 fistula survivors in Soroti and working in the regional hospital. See a June 2012 story about her experience.