Imagine being in labor for five days, with your only means of transport to a hospital for emergency delivery a three-day trip by donkey. In rural Africa, such an experience is common and often ends in despair: the baby emerges dead and the woman suffers severe birthing trauma.

A recent Stanford-led gynecological surgery mission to the east African nation Eritrea repaired the physical damage ensuing from nearly 40 prolonged labors such as these. The Stanford surgical mission stemmed from a trip made last year by Mary Lake Polan, MD, PhD, chair of the Department of Obstetrics and Gynecology, who traveled to Eritrea to document women’s health conditions there.

Amreen Husain (left) and Joelle Osias (second from left) were part of a group of Stanford gynecologists who joined staff at the Mekane Hiwet Hospital in Asmara, Eritrea, to treat women for injuries from lengthy labors. PHOTO: COURTESY OF MARY LAKE POLAN

During a labor that goes on for several days, the pressure of the fetus’ head against the pelvis can cut off the blood supply to the area, killing the tissue. This condition, called a fistula, leaves a hole between the bladder and the vagina or — more rarely — between the rectum and the vagina. As a result, women with fistulas constantly leak urine from their vaginas and in some cases stool. The women smell bad and they soil their clothes and surroundings, and develop painful rashes and infections.

In nations like the United States, fistulas are rare. But in the developing world, the rate of fistula is estimated to be 350 per 100,000 deliveries, Polan said. She noted several factors that likely lead to higher rates: malnutrition and stunted growth increase the likelihood of obstructed labor, cultural practices lead to early marriages and early pregnancies, and health care is extremely limited. "The condition usually leads to ostracism and poverty," said Polan.

She organized a surgical mission to Mekane Hiwet Hospital in Eritrea’s capital city Asmara. Gynecologists volunteered for the trip and medical device manufacturer Nellcor, founded by former Stanford anesthesiologist Bill New, MD, donated equipment to monitor the respiratory status of surgery patients. Pharmaceutical and device companies including C.R. Bard Inc., CooperSurgical Inc., Cook Urological, Boston Scientific Microvasive Urologic and Ethicon Corp., as well as others, donated over $40,000 of equipment and medicines including catheters, sutures and antibiotics.

The surgical team, consisting of Amreen Husain, MD, ob/gyn assistant professor; staff gynecologists Carol Glowacki, MD, and Joelle Osias, MD; and Johns Hopkins University fistula surgeon Clifford Wheeless, MD, arrived in Asmara Sept. 20. Polan coordinated the team’s visit and continued to gather data on Eritrea’s fistula problem.

The team members’ expertise was in demand. When they arrived for work at the Asmara hospital, 20 patients were already waiting. Two days later, the hospital’s staff had to start turning women away. The team repaired 37 fistulas before returning home on Oct. 9. The women who came for treatment often learned about the program through radio ads.

"These woman have a difficult time working, going out in public and just keeping themselves clean," said Glowacki. "Their husbands usually divorce them. Sometimes they are kicked out of their family home and beg on the streets."

Team members said the experience was exhilarating despite the daunting scope of the fistula problem. "It was amazing to me how courageous the women were," said Husain. "Some came alone, traveling for three or four days, to be operated on by these doctors who were foreign. And the doctors there were phenomenal too. They were willing to do types of cases they had never seen or done before."

The patients expressed extraordinary gratitude. "They’d pat their hands over their hearts to show their thanks. They’d hold your hand, kiss your hand. They were incredible," said Glowacki.

Only a few fistula hospitals exist in the world, most in Africa, but all are nearly impossible for Eritrean women to reach. One center, the Addis Ababa Fistula Hospital, is just over the border in Ethiopia but is off limits to Eritreans because of fighting between the two nations.

The Stanford team hopes to work with Eritrean officials and health-care workers to establish a fistula center at the Mekane Hiwet Hospital. Already on this trip they began working toward that goal. The Eritrean staff observed the surgeries and are prepared to take on more complex cases on their own.

"It was very gratifying that we could be a catalyst to help these women overcome a devastating problem," said Osias. "And it was affirming that we could provide training to the local physicians, empowering them to solve the problem. I have the hope that we will transcend our own usefulness and help set up something that will be there long after we’re gone."

Contributions to women’s health care in Eritrea may be made through Polan. For information, contact her via e-mail at polan@stanford.edu.