Review of Fistula Politics: Birthing Injuries and the Quest for Continence in Niger. Alison Heller, New Brunswick, NJ: Rutgers University Press, 2019, 250 pp.

Reviewed Book

Fistula Politics: Birthing Injuries and the Quest for Continence in Niger. Alison Heller, New Brunswick, NJ: Rutgers University Press, 2019, 250 pp.

Every year, an estimated 50,000 to 100,000 women around the world develop obstetric fistula, a birthing complication that causes fecal and/or urinary incontinence through the vagina following prolonged labor. Obstetric fistula is entirely preventable through timely access to appropriate obstetric care. In 2003, the United Nations Population Fund and its partners launched the Global Campaign to End Fistula. Active in over 50 countries in Africa, Asia, and parts of the Middle East, the campaign works to prevent fistula from happening and to treat and rehabilitate women when it does.

In Fistula Politics, Alison Heller draws on ethnographic research with fistula survivors in four treatment centers in Niger to challenge dominant media, donor, and NGO narratives about the causes and consequences of fistula and solutions for this condition. According to these narratives, young girls and women who develop fistula are innocent victims of patriarchal “African cultures” that force them into early marriage and childbearing. Once these young women develop fistula and become incontinent, they are cast aside by their husbands and replaced with a new spouse or divorced entirely and ejected from the family home. The stigma of fistula-related incontinence may further isolate women from important family and community networks, leaving them financially destitute and with little social support. Fistula survivors have been dubbed by some advocates as “the new lepers,” drawing parallels with the ostracization experienced by carriers of this infectious disease, who were held in quarantine, often against their will, during European colonial rule. Fortunately, surgical repair, estimated at a mere $300 to $400, can relieve women of their affliction, thereby transforming their lives through bodily restoration and reintegration into society. Rehabilitation services provide further assistance by training women with income generation skills such as sewing.

Through close attention to the conjugal stories and reproductive experiences of 100 Nigerien women with fistula, Heller casts doubt on each of these overly simplistic narratives. Among the most prominent Western donor and media explanations of the primary causes of obstetric fistula is the familiar trope of the sexual pathology of “African cultures,” and African men in particular as sexual predators of young girls. Readers are likely familiar with this trope in shaping popular explanations of the practice of female genital cutting. In this narrative, Africa exists as a barbaric place in which men exercise sexual and reproductive control over innocent girls by maiming them and depriving them of sexual pleasure.

Similarly, in the Western imagination, “African cultural practices” that promote early marriage and excessive childbearing are considered among the primary underlying causes of obstetric fistula. Heller shows how such narratives belie the diversity of women’s conjugal, sexual, and reproductive experiences. For example, early marriage does not immediately lead to sexual activity in Niger. Women who marry young often continue to live with their parents until they are ready to engage in sexual relationships with their husbands. Fistula occurs throughout women’s reproductive lives, across a wide range of ages and number of deliveries. By blaming pathological African cultures for fistula, these narratives fail to identify failures within public health systems, amplified by decades of structural adjustment policies, that expose women to barely accessible, low-quality obstetric care.

Another narrative suggests that fistula is an all-encompassing identity that destroys women’s social relationships, leaving them abandoned and living alone in “huts” at the fringes of their communities. While recognizing the devastating power of fistula stigma to disrupt women’s lives and relationships, Heller shows how fistula ultimately does not define women’s sense of self and relationships with others. On the contrary, many of the women in her study maintained family and social relationships while living with fistula. Some managed to successfully conceal their condition from friends, neighbors, family members, and even husbands. Ironically, Heller illustrates how fistula advocacy in the form of televised events during which fistula survivors share their success stories and receive gifts of soap and cloth (sometimes printed with the words “obstetric fistula”) can disrupt the careful corporeal and social work women perform to conceal their condition. While fistula surgery is framed as a negligible cost to potential givers in the West, the threat of being “outed” during such advocacy activities, or even while awaiting surgery at a treatment center, can cost women dearly.

A third advocacy narrative relates to the capacity of surgery and rehabilitation services to physically and socially transform fistula survivors. According to global fistula advocates, an estimated 90% of women who undergo fistula repair surgery are cured of incontinence. In contrast, Heller’s study suggests that for many women, fistula surgery is an incredibly long and ultimately disappointing process. Among the women she interviewed who actually received surgery, less than half (36%) were completely cured of incontinence, or left the hospital permanently “dry.” Most of these women (64%) continued to experience incontinence after surgery. Since the procedures tended to be performed by specialists from large cities or by foreigners during surgical trips, women waited for operations for months and sometimes even years. Many needed more than one operation. For the private and public entities that received external donor funds to house and rehabilitate women as they awaited surgery, these long periods represented lucrative opportunities. In other words, Heller shows not only that fistula surgery may be less successful than we are led to believe, but also that in settings like Niger, with staggering levels of income inequality, fistula aid may incentivize practices that lengthen women’s waiting periods for surgeries. While women did not pay for room and board at these centers or for the operation itself, they struggled to salvage relationships with spouses, families, and friends during these protracted absences. Some preferred to return home “still leaking” rather than continue to wait, seemingly interminably, for an operation that might not make them “dry.”

Heller’s book is an important contribution to the anthropology of global health. She frames fistula surgery as a “magic bullet” that does little to address structural inequalities that leave rural women vulnerable. Additionally, she illustrates how women are further exploited by a humanitarian aid market that capitalizes on gendered and racialized forms of human suffering. In a field of critical global health studies frequently dominated by research on infectious disease, Heller’s book offers an important focus on maternal and reproductive health. Despite the global community’s enthusiastic embrace of discourses and programs related to safe motherhood, Heller shows how, for too many Nigerien women, quality obstetric care remains out of reach.

Fistula Politics is a highly readable, teachable, and beautifully illustrated monograph that is grounded in careful empirical observation. The book is elegantly organized and could be taught in undergraduate and graduate courses in medical anthropology or sociology, global health, human reproduction, gender studies, human rights, or research methods.

Although Heller expertly traces the micro/macro politics of fistula, the book would have benefited from greater consideration of “meso-level” actors and institutions such as health workers and health facilities. While Heller recognizes how global policies such as structural adjustment have crippled health systems in developing countries like Niger, more insight is needed on what it means for health workers to provide obstetric care in under-equipped and under-staffed facilities and with limited training. Without careful attention to the structural circumstances in which health workers deliver services, we run the risk of adding yet another conveniently reductionist narrative to the list of explanations for the causes of fistula: the “incompetent African health worker.”