How Health Systems Hurt Women. Review of Fistula Politics by Alison Heller, Rutgers University Press (2018).

Medical anthropology has come a long way from its initial focus on the interpretive dimensions of health  and sickness. The Medical Anthropology series from Rutgers University Press provides a showcase for contemporary explorations of lives lived through the intersection of everyday practices, transnational health systems and global inequalities.

Fistula Politics. Birthing Injuries and the Quest for Continence in Niger  by Alison Heller  is an ethnographic account of the experiences of women left incontinent by injuries they sustained through giving birth  in the West African country of Niger,  and of the clinics and humanitarian organizations which make claims to save them. The book, based on extended fieldwork and life history interviews,  strives to show how ordinary women’s lives are changed by obstetric fistula while   confronting the stereotypes of abject social exclusion commonly circulated in the emotive marketing of Western development agencies.

The book’s main strength is showing  how different  women are affected by the  injuries  they sustain  through prolonged labor  which often  results in the death of the child.  Its most revealing insight, essential for those seeking to improve maternal health in low income settings, is the contribution of role strong local support networks in  determining  how far the  effects of  injuries acquired during  delivery  lead to social withdrawal  and marginalization.  Heller’s  detailed  ethnography explores how pre-existing vulnerabilities,  of which the most significant was the loss of a  woman’s own mother,  predispose some unfortunate women to extreme social isolation. Whether they had previously borne surviving children,  or were first or second wives,  were also likely to affect women’s abilities to sustain their social selves as they strive to manage their incontinence.

Shame, seclusion and reduced social interactions did, however, characterize the lives of most women affected by obstetric fistula, provoking an ongoing, frequently unsuccessful, quest for treatment.  Occasional fistula repair clinics, the majority supported by  foreign, mainly US funded, humanitarian  organizations, operate within an inadequate and overstretched health system slanted towards the priorities of  better off urban residents. Niger’s health system cannot meet the  needs  of  women living in remote rural locations whose birthing injuries are caused,  in large part,  by delays in the referral hierarchy.  Rural women’s first point of contact  with  maternity services  are understaffed health centers far from  the  sites  of obstetric capability where complex births could be more safely managed.

Selection for fistula  repair  surgery  is a lottery based on the likelihood that intervention will be successful  and the availability of  skilled medical personnel whose flying visits are financed through international philanthropy.  Those not selected wait, sometimes for years at a time, in the hope that they can access future treatment.  Because the system favors those whose fistulas appear amenable to simple surgical procedures,  women requiring more extensive operations are either left untreated or receive ineffective  treatment. Many such women, desperate to regain continence, subject themselves to repeat, often unsuccessful, operations.

This sensitive and compassionate book shows how the prevalence of fistula  in low income countries in Sub Saharan Africa today cannot be understood as an unfortunate consequence of female reproductive processes.  The high incidence of fistula in Niger is socially and politically produced through  ineffective maternity services  and the transnational philanthropic initiatives which prioritize surgical repair for a small number of women over the repair of the fractured health system.

Fifty years of neo-liberal polices and a thoughtful reflection on  the persistent colonial  rationalities  which  inform the  representation of the problem and its technical surgical fixes promoted  through philanthro-capitalist humanitarianism  are  invoked explain the current state of the health system in Niger and the orientation of  interventions directed at  helping women with fistula across  sub Saharan Africa. These  points are important. But  these institutional  factors are accentuated by, and co-produce, a culture of acceptance of poor reproductive care, high incidence of still birth and staggering rates of  maternal mortality  which is enacted through the health seeking behavior of mothers and the practices of  clinic staff.  The book’s concluding chapter rightly argues that  changing these expectations and the politics which creates them must be the starting point for more effective health interventions.

Why women’s reproductive health is so little valued within a socio-political milieu  where reproduction is paramount is left largely unexplored in a book which is at pains to distance itself from  the  explanatory tropes of cultural practice and failures of  local knowledge conventionally  invoked by Western aid agencies.  Nevertheless, the reference point of Western humanitarianism and its strategies of representation provides an entry point for wider debates about humanitarian philanthropy,  health systems and human rights.  A recommended read for scholars and practitioners in global public health, international development and medical anthropology.