B!RTH Blog: Gillian Slinger RM, Senior Project Manager, FIGO

What are the main birth inequalities that you’ve seen through your work?

For me, the starkest inequality is because of geographic divide. With few exceptions, where you are born entirely determines your opportunities, your life chances, your rights and your access to essential services such as healthcare and education.

Health inequalities is something I studied a lot when I was a student at LSTM, but after working for many years as a midwife in very well-resourced hospitals in the UK and Switzerland, it was nonetheless quite a shock – no matter how experienced I was in my own job – to be working in less fortunate countries where the health system and infrastructure were radically different.

I’ve been a midwife and trainer in Mali, Chad, Democratic Republic of Congo and Sierra Leone, often in very challenging environments and remote places. In these circumstances, it’s the women and girls who suffer the greatest inequalities. And in a world of ‘unequals’, the most unequal of all the unequals are the women and girls with obstetric fistula.

What single action or change would make the largest contribution to women surviving and thriving?

There’s an infamous quote from Professor Mahmoud Fathalla, an OBGYN and Past President of FIGO (International Federation of Gynecology and Obstetrics), that goes, “Mothers are not dying because of diseases we cannot prevent or treat. They are still dying because societies have yet to make the decision that their lives are worth saving.”

So I would say that improving women’s and maternal health, including prevention and treatment of often much neglected obstetric fistula, is about political will and funding.

In the current global climate, addressing maternal mortality and morbidity is held to be a global priority yet inexplicably there’s reduced funding available for maternal health issues. This means a radical reduction in funds for fistula treatment.

Still, we are seeing a growing momentum to advocate for women’s rights including sexual and reproductive health and rights. Women can be the agents for change, something I have seen repeatedly amongst the women who get treatment for their obstetric fistula.

They arrive in such dire circumstances and, thanks to a skilled fistula surgeon and care team, often leave to become fistula champions, speaking out to help prevent fistula and assist other affected women in their own communities. They desperately do not want any other woman to suffer as they have done.

Why is fistula the huge global health problem that it is?

Obstetric fistula is a neglected public health and human rights issue that inevitably occurs in the least privileged, most underserved countries in the world. National authorities, with the best will in the world, are faced with so many huge challenges – childhood malnutrition, infectious diseases, water and sanitation problems – that women with fistula fall right to the bottom of their priority list.

Due to a global shortage of trained fistula surgeons, we currently estimate that only 1 in 50 women with obstetric fistula has access to treatment. Tragically, the condition affects an estimated two million women in 60 low-resource countries, with up to 100,000 additional women developing a fistula every year.

When I was at UNFPA we put the United Nations International Day to End Obstetric Fistula in place. This was not done as a celebration – but rather calling the world to action to help raise awareness and support for women with obstetric fistula.

What is required to end obstetric fistula globally?

To end obstetric fistula, we must make sure there is no slowing in the work to improve maternal and newborn health, including prevention of obstetric fistula – more safe delivery services, skilled health personnel (including midwives and OBGYNs), and emergency obstetric care. We need more investment in staffing requirements and not just people on the ground, infrastructure improvements as well.

In parallel, efforts must be accelerated to provide much needed treatment for all women with obstetric fistula, including scaling up training programmes, raising awareness and mobilising support, both in high-burden countries, and with the global community. We urgently need more trained, skilled fistula surgeons in order to treat the backlog of women with the condition.

Our FIGO Fistula Surgery Training Initiative aims to train enough surgeons to permanently eradicate obstetric fistula. With partners, FIGO developed the world’s first Global Competency-based Fistula Surgery Training Manual, and we support multi-disciplinary team training for life-transforming care.

As part of this work, I feel very strongly that there’s an ethical and human rights perspective missing from the conversation, which is prevention of a subsequent fistula. If a woman who has had a fistula repair becomes pregnant again and has another catastrophic obstructed labour, if she can’t get the elective C-section she needs, she’ll be at high risk of having another stillborn baby and another terrible fistula injury, even more complicated than the first, or even losing her life.

Our work is not just about repairing the fistula, but about safeguarding repaired women to ensure positive outcomes for the mother and her new-born in all future pregnancies.

How important is shining a light on fistula to ensure that prevention and treatment are a priority?

Absolutely essential. Unless there is a substantial change, most of these 2 million women will die in old age with their fistula still untreated, after decades of suffering and neglect.

It is totally unacceptable that we are still only able to help one in 50 women with fistula. It is outrageous that they get a fistula in the first place, and that for all the action on Universal Health Coverage and the 2030 Agenda for Sustainable Development, without significant change, those currently left furthest behind will remain so.

With funding and focus shifts, there is a general consensus in the fistula treatment world that women with the condition are fading into the background of the global agenda. However, with many other fistula allies, I will shout from the rooftops to prevent this happening, you’ll see me!

I have become a completely different person, as a result of being a student at LSTM. Liverpool launched my career into a whole different arena, and I cannot possibly think of working on anything else while I know these women continue to be neglected.

Gillian Slinger (@FistulaGillian) is Senior Project Manager of the FIGO (@FIGOHQ) Fistula Surgery Training Initiative, which aims to train enough surgeons to permanently eradicate this neglected public health and human rights issue.