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.

For more information, visit www.lovelaborloss.com.


Analysis Human Rights

El Salvador Bill Would Put Those Found Guilty of Abortion Behind Bars for 30 to 50 Years

Kathy Bougher

Under El Salvador’s current law, when women are accused of abortion, prosecutors can—but do not always—increase the charges to aggravated homicide, thereby increasing their prison sentence. This new bill, advocates say, would heighten the likelihood that those charged with abortion will spend decades behind bars.

Abortion has been illegal under all circumstances in El Salvador since 1997, with a penalty of two to eight years in prison. Now, the right-wing ARENA Party has introduced a bill that would increase that penalty to a prison sentence of 30 to 50 years—the same as aggravated homicide.

The bill also lengthens the prison time for physicians who perform abortions to 30 to 50 years and establishes jail terms—of one to three years and six months to two years, respectively—for persons who sell or publicize abortion-causing substances.

The bill’s major sponsor, Rep. Ricardo Andrés Velásquez Parker, explained in a television interview on July 11 that this was simply an administrative matter and “shouldn’t need any further discussion.”

Since the Salvadoran Constitution recognizes “the human being from the moment of conception,” he said, it “is necessary to align the Criminal Code with this principle, and substitute the current penalty for abortion, which is two to eight years in prison, with that of aggravated homicide.”

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The bill has yet to be discussed in the Salvadoran legislature; if it were to pass, it would still have to go to the president for his signature. It could also be referred to committee, and potentially left to die.

Under El Salvador’s current law, when women are accused of abortion, prosecutors can—but do not always—increase the charges to aggravated homicide, thereby increasing their prison sentence. This new bill, advocates say, would worsen the criminalization of women, continue to take away options, and heighten the likelihood that those charged with abortion will spend decades behind bars.

In recent years, local feminist groups have drawn attention to “Las 17 and More,” a group of Salvadoran women who have been incarcerated with prison terms of up to 40 years after obstetrical emergencies. In 2014, the Agrupación Ciudadana por la Despenalización del Aborto (Citizen Group for the Decriminalization of Abortion) submitted requests for pardons for 17 of the women. Each case wound its way through the legislature and other branches of government; in the end, only one woman received a pardon. Earlier this year, however, a May 2016 court decision overturned the conviction of another one of the women, Maria Teresa Rivera, vacating her 40-year sentence.

Velásquez Parker noted in his July 11 interview that he had not reviewed any of those cases. To do so was not “within his purview” and those cases have been “subjective and philosophical,” he claimed. “I am dealing with Salvadoran constitutional law.”

During a protest outside of the legislature last Thursday, Morena Herrera, president of the Agrupación, addressed Velásquez Parker directly, saying that his bill demonstrated an ignorance of the realities faced by women and girls in El Salvador and demanding its revocation.

“How is it possible that you do not know that last week the United Nations presented a report that shows that in our country a girl or an adolescent gives birth every 20 minutes? You should be obligated to know this. You get paid to know about this,” Herrera told him. Herrera was referring to the United Nations Population Fund and the Salvadoran Ministry of Health’s report, “Map of Pregnancies Among Girls and Adolescents in El Salvador 2015,” which also revealed that 30 percent of all births in the country were by girls ages 10 to 19.

“You say that you know nothing about women unjustly incarcerated, yet we presented to this legislature a group of requests for pardons. With what you earn, you as legislators were obligated to read and know about those,” Herrera continued, speaking about Las 17. “We are not going to discuss this proposal that you have. It is undiscussable. We demand that the ARENA party withdraw this proposed legislation.”

As part of its campaign of resistance to the proposed law, the Agrupación produced and distributed numerous videos with messages such as “They Don’t Represent Me,” which shows the names and faces of the 21 legislators who signed on to the ARENA proposal. Another video, subtitled in English, asks, “30 to 50 Years in Prison?

International groups have also joined in resisting the bill. In a pronouncement shared with legislators, the Agrupación, and the public, the Latin American and Caribbean Committee for the Defense of the Rights of Women (CLADEM) reminded the Salvadoran government of it international commitments and obligations:

[The] United Nations has recognized on repeated occasions that the total criminalization of abortion is a form of torture, that abortion is a human right when carried out with certain assumptions, and it also recommends completely decriminalizing abortion in our region.

The United Nations Committee on Economic, Social, and Cultural Rights reiterated to the Salvadoran government its concern about the persistence of the total prohibition on abortion … [and] expressly requested that it revise its legislation.

The Committee established in March 2016 that the criminalization of abortion and any obstacles to access to abortion are discriminatory and constitute violations of women’s right to health. Given that El Salvador has ratified [the International Covenant on Economic, Social and Cultural Rights], the country has an obligation to comply with its provisions.

Amnesty International, meanwhile, described the proposal as “scandalous.” Erika Guevara-Rosas, Amnesty International’s Americas director, emphasized in a statement on the organization’s website, “Parliamentarians in El Salvador are playing a very dangerous game with the lives of millions of women. Banning life-saving abortions in all circumstances is atrocious but seeking to raise jail terms for women who seek an abortion or those who provide support is simply despicable.”

“Instead of continuing to criminalize women, authorities in El Salvador must repeal the outdated anti-abortion law once and for all,” Guevara-Rosas continued.

In the United States, Rep. Norma J. Torres (D-CA) and Rep. Debbie Wasserman Schultz (D-FL) issued a press release on July 19 condemning the proposal in El Salvador. Rep. Torres wrote, “It is terrifying to consider that, if this law passed, a Salvadoran woman who has a miscarriage could go to prison for decades or a woman who is raped and decides to undergo an abortion could be jailed for longer than the man who raped her.”

ARENA’s bill follows a campaign from May orchestrated by the right-wing Fundación Sí a la Vida (Right to Life Foundation) of El Salvador, “El Derecho a la Vida No Se Debate,” or “The Right to Life Is Not Up for Debate,” featuring misleading photos of fetuses and promoting adoption as an alternative to abortion.

The Agrupacion countered with a series of ads and vignettes that have also been applied to the fight against the bill, “The Health and Life of Women Are Well Worth a Debate.”

bien vale un debate-la salud de las mujeres

Mariana Moisa, media coordinator for the Agrupación, told Rewire that the widespread reaction to Velásquez Parker’s proposal indicates some shift in public perception around reproductive rights in the country.

“The public image around abortion is changing. These kinds of ideas and proposals don’t go through the system as easily as they once did. It used to be that a person in power made a couple of phone calls and poof—it was taken care of. Now, people see that Velásquez Parker’s insistence that his proposal doesn’t need any debate is undemocratic. People know that women are in prison because of these laws, and the public is asking more questions,” Moisa said.

At this point, it’s not certain whether ARENA, in coalition with other parties, has the votes to pass the bill, but it is clearly within the realm of possibility. As Sara Garcia, coordinator of the Agrupación, told Rewire, “We know this misogynist proposal has generated serious anger and indignation, and we are working with other groups to pressure the legislature. More and more groups are participating with declarations, images, and videos and a clear call to withdraw the proposal. Stopping this proposed law is what is most important at this point. Then we also have to expose what happens in El Salvador with the criminalization of women.”

Even though there has been extensive exposure of what activists see as the grave problems with such a law, Garcia said, “The risk is still very real that it could pass.”

Culture & Conversation Human Rights

Let’s Stop Conflating Self-Care and Actual Care

Katie Klabusich

It's time for a shift in the use of “self-care” that creates space for actual care apart from the extra kindnesses and important, small indulgences that may be part of our self-care rituals, depending on our ability to access such activities.

As a chronically ill, chronically poor person, I have feelings about when, why, and how the phrase “self-care” is invoked. When International Self-Care Day came to my attention, I realized that while I laud the effort to prevent some of the 16 million people the World Health Organization reports die prematurely every year from noncommunicable diseases, the American notion of self-care—ironically—needs some work.

I propose a shift in the use of “self-care” that creates space for actual care apart from the extra kindnesses and important, small indulgences that may be part of our self-care rituals, depending on our ability to access such activities. How we think about what constitutes vital versus optional care affects whether/when we do those things we should for our health and well-being. Some of what we have come to designate as self-care—getting sufficient sleep, treating chronic illness, allowing ourselves needed sick days—shouldn’t be seen as optional; our culture should prioritize these things rather than praising us when we scrape by without them.

International Self-Care Day began in China, and it has spread over the past few years to include other countries and an effort seeking official recognition at the United Nations of July 24 (get it? 7/24: 24 hours a day, 7 days a week) as an important advocacy day. The online academic journal SelfCare calls its namesake “a very broad concept” that by definition varies from person to person.

“Self-care means different things to different people: to the person with a headache it might mean a buying a tablet, but to the person with a chronic illness it can mean every element of self-management that takes place outside the doctor’s office,” according to SelfCare. “[I]n the broadest sense of the term, self-care is a philosophy that transcends national boundaries and the healthcare systems which they contain.”

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In short, self-care was never intended to be the health version of duct tape—a way to patch ourselves up when we’re in pieces from the outrageous demands of our work-centric society. It’s supposed to be part of our preventive care plan alongside working out, eating right, getting enough sleep, and/or other activities that are important for our personalized needs.

The notion of self-care has gotten a recent visibility boost as those of us who work in human rights and/or are activists encourage each other publicly to recharge. Most of the people I know who remind themselves and those in our movements to take time off do so to combat the productivity anxiety embedded in our work. We’re underpaid and overworked, but still feel guilty taking a break or, worse, spending money on ourselves when it could go to something movement- or bill-related.

The guilt is intensified by our capitalist system having infected the self-care philosophy, much as it seems to have infected everything else. Our bootstrap, do-it-yourself culture demands we work to the point of exhaustion—some of us because it’s the only way to almost make ends meet and others because putting work/career first is expected and applauded. Our previous president called it “uniquely American” that someone at his Omaha, Nebraska, event promoting “reform” of (aka cuts to) Social Security worked three jobs.

“Uniquely American, isn’t it?” he said. “I mean, that is fantastic that you’re doing that. (Applause.) Get any sleep? (Laughter.)”

The audience was applauding working hours that are disastrous for health and well-being, laughing at sleep as though our bodies don’t require it to function properly. Bush actually nailed it: Throughout our country, we hold Who Worked the Most Hours This Week competitions and attempt to one-up the people at the coffee shop, bar, gym, or book club with what we accomplished. We have reached a point where we consider getting more than five or six hours of sleep a night to be “self-care” even though it should simply be part of regular care.

Most of us know intuitively that, in general, we don’t take good enough care of ourselves on a day-to-day basis. This isn’t something that just happened; it’s a function of our work culture. Don’t let the statistic that we work on average 34.4 hours per week fool you—that includes people working part time by choice or necessity, which distorts the reality for those of us who work full time. (Full time is defined by the Internal Revenue Service as 30 or more hours per week.) Gallup’s annual Work and Education Survey conducted in 2014 found that 39 percent of us work 50 or more hours per week. Only 8 percent of us on average work less than 40 hours per week. Millennials are projected to enjoy a lifetime of multiple jobs or a full-time job with one or more side hustles via the “gig economy.”

Despite worker productivity skyrocketing during the past 40 years, we don’t work fewer hours or make more money once cost of living is factored in. As Gillian White outlined at the Atlantic last year, despite politicians and “job creators” blaming financial crises for wage stagnation, it’s more about priorities:

Though productivity (defined as the output of goods and services per hours worked) grew by about 74 percent between 1973 and 2013, compensation for workers grew at a much slower rate of only 9 percent during the same time period, according to data from the Economic Policy Institute.

It’s no wonder we don’t sleep. The Centers for Disease Control and Prevention (CDC) has been sounding the alarm for some time. The American Academy of Sleep Medicine and the Sleep Research Society recommend people between 18 and 60 years old get seven or more hours sleep each night “to promote optimal health and well-being.” The CDC website has an entire section under the heading “Insufficient Sleep Is a Public Health Problem,” outlining statistics and negative outcomes from our inability to find time to tend to this most basic need.

We also don’t get to the doctor when we should for preventive care. Roughly half of us, according to the CDC, never visit a primary care or family physician for an annual check-up. We go in when we are sick, but not to have screenings and discuss a basic wellness plan. And rarely do those of us who do go tell our doctors about all of our symptoms.

I recently had my first really wonderful check-up with a new primary care physician who made a point of asking about all the “little things” leading her to encourage me to consider further diagnosis for fibromyalgia. I started crying in her office, relieved that someone had finally listened and at the idea that my headaches, difficulty sleeping, recovering from illness, exhaustion, and pain might have an actual source.

Considering our deeply-ingrained priority problems, it’s no wonder that when I post on social media that I’ve taken a sick day—a concept I’ve struggled with after 20 years of working multiple jobs, often more than 80 hours a week trying to make ends meet—people applaud me for “doing self-care.” Calling my sick day “self-care” tells me that the commenter sees my post-traumatic stress disorder or depression as something I could work through if I so chose, amplifying the stigma I’m pushing back on by owning that a mental illness is an appropriate reason to take off work. And it’s not the commenter’s fault; the notion that working constantly is a virtue is so pervasive, it affects all of us.

Things in addition to sick days and sleep that I’ve had to learn are not engaging in self-care: going to the doctor, eating, taking my meds, going to therapy, turning off my computer after a 12-hour day, drinking enough water, writing, and traveling for work. Because it’s so important, I’m going to say it separately: Preventive health care—Pap smears, check-ups, cancer screenings, follow-ups—is not self-care. We do extras and nice things for ourselves to prevent burnout, not as bandaids to put ourselves back together when we break down. You can’t bandaid over skipping doctors appointments, not sleeping, and working your body until it’s a breath away from collapsing. If you’re already at that point, you need straight-up care.

Plenty of activities are self-care! My absolutely not comprehensive personal list includes: brunch with friends, adult coloring (especially the swear word books and glitter pens), soy wax with essential oils, painting my toenails, reading a book that’s not for review, a glass of wine with dinner, ice cream, spending time outside, last-minute dinner with my boyfriend, the puzzle app on my iPad, Netflix, participating in Caturday, and alone time.

My someday self-care wish list includes things like vacation, concerts, the theater, regular massages, visiting my nieces, decent wine, the occasional dinner out, and so very, very many books. A lot of what constitutes self-care is rather expensive (think weekly pedicures, spa days, and hobbies with gear and/or outfit requirements)—which leads to the privilege of getting to call any part of one’s routine self-care in the first place.

It would serve us well to consciously add an intersectional view to our enthusiasm for self-care when encouraging others to engage in activities that may be out of reach financially, may disregard disability, or may not be right for them for a variety of other reasons, including compounded oppression and violence, which affects women of color differently.

Over the past year I’ve noticed a spike in articles on how much of the emotional labor burden women carry—at the Toast, the Atlantic, Slate, the Guardian, and the Huffington Post. This category of labor disproportionately affects women of color. As Minaa B described at the Huffington Post last month:

I hear the term self-care a lot and often it is defined as practicing yoga, journaling, speaking positive affirmations and meditation. I agree that those are successful and inspiring forms of self-care, but what we often don’t hear people talking about is self-care at the intersection of race and trauma, social justice and most importantly, the unawareness of repressed emotional issues that make us victims of our past.

The often-quoted Audre Lorde wrote in A Burst of Light: “Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare.”

While her words ring true for me, they are certainly more weighted and applicable for those who don’t share my white and cisgender privilege. As covered at Ravishly, the Feminist Wire, Blavity, the Root, and the Crunk Feminist Collective recently, self-care for Black women will always have different expressions and roots than for white women.

But as we continue to talk about self-care, we need to be clear about the difference between self-care and actual care and work to bring the necessities of life within reach for everyone. Actual care should not have to be optional. It should be a priority in our culture so that it can be a priority in all our lives.