Behind the Scenes of “Love, Labor, Loss”

Lisa Russell

Obstetric fistula is not just a women's issue, and not just about the developing world. It is about our inability to prioritize people's lives and about legislation that restricts funding based on political battles. And it reflects a sense of complacency towards striving for social equality and progress.

"The baby is not breathing." It was one of the most disturbing statements I heard while shooting my documentary film Love, Labor, Loss in Niger just a few years ago. I had traveled to this West African country to shoot a film on obstetric fistula, a childbearing injury caused by a prolonged, obstructed labor. It was our second day of shooting and my intention was to film a successful Cesarean section, illustrating one way to prevent obstetric fistula. Unfortunately, the woman we had filmed had waited too long for the surgery. We were left filming her newborn baby as he was dying on camera.

I had decided to shoot a film on obstetric fistula in Niger for several reasons. Niger's position as the second poorest country in the world, according to the Human Development Index, translated to poor health for the general public, and in particular, for women. Niger had the highest fertility rate in sub-Saharan Africa (on average, each Nigerian women has eight children), its maternal mortality rate was 920 deaths per 100,000 births. Eighty-five percent of women delivered at home without the help of a trained provider. There were only ten OB/GYNs for the country that had a population of 11 million. Finally, the vast rural landscape, heat and lack of passable roads made traveling from the rural areas to places that had adequate emergency services for women in difficult labor nearly impossible. Given my public health background, I knew all of these conditions combined would create an atmosphere where obstetric fistula would flourish.

But perhaps the most significant reason I chose Niger had little to do with the tragic health conditions of women in Niger. I had learned of a special compound that had been formed at the Niamey National Hospital where women suffering from fistula had migrated for the previous few years from across the country, seeking help, and had formed their own special community. Here, they shared domestic responsibilities and consoled each other. At any moment, you could see women cooking, pounding kasava, braiding each other's hair, or making bracelets they would sell for small income. Despite the tragic reasons that brought them together, it was a beautiful place. Shooting a film on something as physically offensive as a woman leaking waste could lead to a type of film that victimizes women, and since my priority was to ensure that I retained the dignity of the women I was filming, this fistula compound would allow me to show that despite such adversarial conditions, lives of women living with fistula can and do go on.

Although obstetric fistula is estimated to affect over two million women worldwide, this horrible childbearing injury was relatively unknown to the general public in 2003, when I decided to make the film. Affecting primarily young, uneducated, poor women in developing countries who don't have access to emergency obstetric care, such as c-sections, during an obstructed labor, obstetric fistula leaves women childless (the woman usually delivers a stillborn), incontinent (the damage to her pelvic area from days of labor leaves her leaking waste continuously) and often socially isolated from her community (because of the unrelenting stench caused by her leaking).

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That day, we were visiting the Central Maternity Hospital in the capital, Niamey, intending to shoot interviews and b-roll of the country's most prestigious hospital that focuses primarily on women in difficult labor. When the OB/GYN first introduced us to this patient, she was lying on her side with the back of her hospital gown soaked in blood. Like many other women in Niger who encounter troubles with their pregnancy, she had spent several days traveling by foot, donkey cart and taxi to get to the hospital. "She has been here since 6 am," the doctor explained. I looked at my watch, realizing she had been waiting for over six hours. I asked why she has been waiting so long for her surgery. The doctor explained to me that women must come to the hospital with their "supplies" – meaning all the bandages, syringes, and other items needed for their surgery. This woman's family had been roaming the streets of Niamey since dawn begging for the last $20 needed so that they could trade it for another woman's supplies so the surgery could begin.

Within the next hour, the $60 worth of supplies arrived and the patient was immediately prepped for her c-section. It's obvious this poor, rural woman has never had surgery before (the c-section rate in Niamey is only 2%) and fear covered her face with every move the doctors made. The anesthesiologist waited for the surgeon's go-ahead so that he could sedate her right before the first cut is made. The surgery was quick and the baby was pulled from her abdomen in a manner of minutes. My cameraman and I were both surprised by the seemingly simplicity of the operation.

It wasn't until the child was wheeled into the post-delivery room where the nurse began CPR that I realized how critical the situation had become. The nurse began by putting a suction hose up the infant's nostrils to drain mucous while doing compressions on the baby's chest. I thought this was normal procedure until five minutes passed. I asked what was wrong. "The baby is not breathing," she said as she looked at me, keeping her confidence that all would be all right.

Finally, after about eleven or twelve long minutes after we had arrived in the room, the baby choked for air and began to cry. The nurse pulled out a mouthful of mucous and placed an oxygen mask over the baby as she began to clean up the blood. "He is going to be okay," she confidently told the camera.

When I screen and discuss my film, I don't usually tell this story. The stories people want and expect to hear about obstetric fistula are those about the large numbers of women whose lives have been destroyed by this relatively unknown condition and the numerous programs that are repairing women's fistulas and giving them a new life. They expect to hear about fistula is perpetuated by early marriages and women's voicelessness when it comes to decision making about their health care. These are all important aspects of the challenge of obstetric fistula.

But in this story, a woman, in labor, is at the country's most adequate facility and is not served because she is poor and her family lacks the resources and know-how to advocate for her life. A woman is at risk of delivering a stillborn baby because a mere $20 cannot be materialized. A doctor, capable and passionate enough to save this woman's life, waits helplessly for the supplies to arrive as he watches her wait in pain and misery. And a camera crew, ready to share a positive story about progress being made in fistula prevention and treatment in Niger, filming a near-death experience with camera equipment whose cost could cover over 100 c-sections.

This story demonstrates that obstetric fistula is not just a woman's issue, nor is it just about the developing world. It is about the economic disparity between the haves and the have-nots. It is about our inability to prioritize people's lives and about legislation that restricts funding based on political battles. And it reflects a sense of complacency towards striving for social equality and progress. The gap between rich and poor countries and between rural and urban areas continues to create conditions that make women at risk for obstetric fistula – lack of education, lack of employment, scarcity of safe motherhood services and indeed, early marriage, which is often justified by the economic security it gives the family.

Because I came to filmmaking with a public health background, I look at obstetric fistula through a human rights lens. Whenever I screen my films, therefore, I try to balance pointing out the effects that local cultural practices – such as early marriages and unattended births – can have on maternal health and mortality, with drawing attention to the legislation and policy that can hamper efforts to improve global women's health. This includes U.S. policies such as the Global Gag Rule, the $34 million withdrawal from the United Nations Population Fund, certain restrictions in PEPFAR funding, as well as our country's refusal to ratify CEDAW (the Convention on the Elimination of All Forms of Discrimination Against Women) which is considered the international bill of rights for women. If we could adhere to the ideals and promises made in the Universal Declaration of Human Rights, to the promises made at the Cairo and Beijing conferences, and could strive towards the goals outlined in the Millennium Development Goals, than maybe we can realize a future where women are not dying in pregnancy or childbirth and their newborns have a chance at a hopeful and productive life.

When I listen to the footage of that moment in the post-delivery room years ago, I can hear my voice whispering to my cameraman, "Are we really going to film a baby dying?" as the nurse's determination to save the newborn perseveres. By now, I've learned to respect that nurse's resolve and recognize sometimes you need a few "close calls" to build the internal strength and fire to keep on fighting.

LOVE, LABOR, LOSS is a Governess Films Production made possible from the support of UNFPA's Campaign to End Fistula, EngenderHealth, Women's Dignity Project, Feminist Majority Foundation, International Center for Research on Women (ICRW), Global Health Council and the One By One Project. View a clip from the film below.

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