Two University of Chicago surgeons help restore normal lives to women living with terrible childbirth complications.
By Danielle Shapiro
Photography by Danielle Shapiro
The good news came in stages for physicians Scott Eggener and Gregory Bales on their final morning volunteering at Panzi Hospital in the war-torn eastern Democratic Republic of the Congo. As the schedule went up on the surgical ward’s white board, Eggener noticed three sling procedures were planned for the day. “That’s what you want to see,” said the Chicago assistant professor of surgery and urologic oncology. “They’re doing it on their own.”
Eggener was talking about Panzi’s medical director, gynecologist Denis Mukwege, and his staff, who’d learned how to perform the sling surgery only days earlier. Eggener and Bales had spent a week at Panzi, giving operations to women with terrible incontinence while teaching Mukwege and his staff to perform the procedures. In the sling operation, physicians use abdominal-wall tissue to tighten the urethra and control urine flow.
The second bit of good news came as Eggener and Bales, a Chicago associate professor of surgery who specializes in female urology, incontinence, and pelvic-floor reconstruction, made their final rounds checking in on some of their 15 patients. From their hospital beds, the women greeted the two Americans with broad, shy smiles and watched intently as the doctors talked over cases with Mukwege. All were sore and moved gingerly, but most were upbeat. The reason? They were dry. For some it was the first time in decades.
“She even feels like she has to go a little bit,” Mukwege said of Maria Mapendo, 30, who’d suffered a fistula, a tear between her bladder and vagina, during childbirth 15 years earlier. In cases like Mapendo’s, patients don’t feel an urge to pee, because any urine in the bladder immediately pours out. Even with previous surgery to close the tear, she’d been leaking.
Thrilled, the doctors exchanged congratulations with a fist bump.
During their visit to the approximately 300-bed hospital in Bukavu, a cramped and impoverished town bustling on the south shore of Lake Kivu, every woman the two surgeons saw had a fistula. Some also suffered from stress incontinence. Mukwege is one of the few gynecologists in the region who performs fistula repairs—he did 300 in 2008—but 10 percent of his patients have such severe tears, he cannot help them. He wanted the expertise of urologists.
Usually, fistulas result from obstructed labor. The condition renders women unable to control their urine and, if the rectum is affected, feces as well. United Nations Population Fund estimates suggest that more than 2 million women in the developing world live with untreated fistulas, and 50,000 to 100,000 new cases occur every year. In areas with high rates of maternal mortality, like the Congo, there may be two or three fistulas for every 1,000 pregnancies.
Young and small women are at particular risk because their pelvises may be too narrow to fit a fetus. Most babies born to mothers with fistulas die before they emerge from the womb. Afterward the women endure constant leaking and odor. Husbands often expel them from their homes, families and communities may shun them, and survival becomes a struggle. If the pregnancy resulted from rape, a war tactic used in epidemic proportions in the Congo, the woman may be doubly stigmatized. “It’s hard to imagine the level of poverty and genital destruction,” said Eggener, noting that most American urologists will never see so many patients with such complex problems. “It’s the equivalent of a little bomb going off in that area.”
Eggener had been on medical missions to developing countries before, but the trip was a first for Bales. It was organized by a San Francisco pediatrician who found out about the lack of care for the most severe fistulas and recruited Eggener. He then recruited Bales. Private funding financed the trip.
According to the International Monetary Fund, seven in ten Congolese live in poverty. Access to medical care is scarce, especially for those in villages hours or days away from modern hospitals like Panzi. Pregnant women face increased dangers. A 2008 Save the Children report said that one in 13 Congolese women risked death in childbirth.
For those who survive, the complications can be dire. Fistulas are among the most debilitating, though women may also suffer infections, genital prolapse, and infertility. Some of Eggener and Bales’s patients had already undergone as many as six previous surgeries to repair their incontinence. True to the statistics, several became pregnant after being raped, and almost all bore children who were already dead.
For Mukwege, the hospital’s medical director, the Chicago physicians’ week at Panzi was a success. He’d been waiting two years for urologists to visit his hospital and was thrilled to learn the new procedures. “To have these women here is a burden for me,” he said, explaining that many of his hundreds of patients remain at the hospital for years because they have nowhere else to go. They become like family, their struggles his struggles, especially when his medical skills fail them. “You feel relieved to have others who can share the burden.”
For Eggener and Bales, the success was more measured—they’d hoped to help even more women than they did. They had planned primarily to perform and teach a lengthier, more complicated procedure called a urinary diversion (and had brought three suitcases of donated supplies for the purpose). If a woman’s fistula is too large and cannot be fixed, her best option is a urinary diversion, which reroutes urine away from a damaged bladder into an external bag attached to the abdomen. But only two women consented to that surgery. Instead the doctors ended up mostly doing slings, best for patients who’ve had a successful fistula repair but still experience leaking because their urethral sphincters don’t function properly.
Bales believed communication difficulties may have contributed to the women’s resistance. Neither he nor Eggener speak French, let alone Kiswahili or Mashi. Mukwege and others translated, but the situation was not ideal. “Scott and I come from an area where we could offer so much,” said Bales. “My frustration today was how little the patients understood what we could do for them.”
Working with international colleagues under unfamiliar, low-resource conditions proved another hurdle. On the first day Eggener was often reduced to one-word exchanges: “Speculum? Lidocaine? Catheter?” The operating room lacked air conditioning or ventilation, and soon Eggener’s wavy black hair stuck to his forehead. Both men left the OR in sweat-stained scrubs. Women sedated with only regional anesthetic—a simpler option—moved at inopportune moments. The electricity shut off several times, once leaving Eggener in the pitch black with his patient’s abdomen open.
Recovery from the surgeries takes from several days to several weeks. About one month after their visit, Bales reported that both women with urinary diversions and half of the sling patients remained totally continent, while 25 percent of sling patients saw “dramatic improvement”—a good outcome, he said, given the cases’ complexity.
For sling patient Chibanvunya Tracilla, the results were transformative. At 38, she was dry for the first time in 23 years. “I feel better and worth the same as other people,” she said, recalling how even children in her community had insulted her because of her condition. “I will no longer be neglected,” she added. “This is over now.”