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A Walk to Beautiful

Program Overview and Discussion Guide  Print this Teacher's Guide (PDF, 8 pages)

Note: This program offers a dramatic look at the lives of women in Ethiopia, with stories told in their own voices. The program contains sensitive material about teen pregnancy, stillbirths, incontinence, and sexual coercion that—while integral to this powerful story—may be upsetting for some students. Please preview the program to determine its appropriateness for your students.

NOVA follows three Ethiopian women on their journey to find a cure for injuries they sustained during childbirth that have left them incontinent and shunned by their husbands and the communities in which they live.

The program:

• introduces 25-year-old Ayehu, who developed obstetric fistula after a weeklong labor resulted in a stillbirth.

• explains what obstetric fistula is—a condition that occurs during childbirth, in which tissue between the vagina and the bladder (and/or rectum) dies, leaving a hole and leading to incontinence.

• notes that fistula can happen to young women who grow up without proper nourishment—or whose limited calories are spent in manual labor—so that they are physically too small to have a healthy pregnancy and are unable to deliver a full-term baby.

• raises the subject of arranged marriages and child brides.

• follows the story of three women—Ayehu, Almaz, and Wubete—as they journey from their remote villages to the Addis Ababa Fistula Hospital to seek a cure for their injuries.

• relates how each woman came to be at the hospital.

• tracks the women's progress at the hospital as each undergoes treatments for her condition, and reports on each woman's outcome.

• notes that fistula, while 100 percent preventable, is a silent epidemic because it primarily affects poor girls and women in developing countries.

Taping Rights
Can be used up to one year after program is recorded off the air.

Background
Obstetric fistula is a severe medical condition in which, during childbirth, a fistula (or hole) develops between a woman's bladder and vagina and/or rectum and vagina. If a woman with prolonged obstructed labor does not receive medical care in time, the blood supply to the tissues of the vagina and the bladder (and/or rectum) is cut off. The tissue dies and rots away, leaving a fistula, which can result in permanent incontinence of urine (and/or feces). Left untreated, fistula can also lead to chronic medical problems, including ulcerations, kidney disease, and nerve damage in the legs. In addition, women with obstetric fistula have a high rate of infertility. Obstructed labor occurs in about 5 percent of all deliveries worldwide and happens when the baby cannot pass through the birth canal without medical assistance, either because the baby is too large or the birth canal is too narrow.

An obstetric fistula can be closed with surgery. When a skilled surgeon performs the surgery and the patient receives competent after-care treatment, she has a good chance of returning to a normal life with full control of her body functions. The Addis Ababa Fistula Hospital in Ethiopia has a 93 percent success rate with surgeries performed to close the fistula. However, because the structures that enable urinary control can also be damaged during obstructed labor, 10 to 30 percent of women whose fistulas have been successfully closed still cannot control their urination.

Obstetric fistula occurs primarily among impoverished women in developing countries, particularly those living far from medical services. Although no one knows for sure how many new fistulas occur each year, it is generally estimated that 50,000 to 100,000 women develop obstetric fistulas annually and that more than 2 million women currently live with fistula injuries. The majority of those suffering from obstetric fistula live in Africa and parts of Asia. The same women face additional health risks during pregnancy or childbirth. Each year more than half a million women die due to pregnancy- and childbirth-related causes; in addition, approximately 10 million women experience short- or long-term injuries, including obstetric fistula. Although the world's first fistula hospital, in the late 1800s, stood at the present site of the Waldorf Astoria Hotel in New York, obstetric fistula has been essentially eliminated in the United States.

Currently, the global capacity for treating women living with fistula is estimated at 10,000 women per year. The average cost of fistula treatment at the Addis Ababa Fistula Hospital—including surgery and postoperative care—is $450, well beyond the reach of most women with the condition. Thus, many patients receive the treatment free of charge through funding by organizations and private donors.

Along with the medical issues, women living with fistula experience a number of social stigmas as well. Poverty, early marriage, and lack of education place women at a severe disadvantage and are obstacles to their ability to advocate for their own health and well-being. Many women who develop fistulas are abandoned by their husbands and close family members, ostracized by their communities, and forced to live an isolated existence because of odor, perceptions of uncleanliness, mistaken assumptions that sexually transmitted infections are present, and, in many cases, the inability to have children. Women living with fistula are often blamed by others for their condition under the misconception that the fistula occurred as a punishment for some wrongdoing. As a result, in addition to medical care, many women need emotional support to help them return to their communities.

Obstetric fistulas, other childbirth-related conditions and injuries, and maternal death can all be prevented by ensuring that every woman has a skilled health provider with her at delivery as well as access to emergency obstetrical care in the case of complications. Prenatal care visits are important to help women plan for the birth. Family planning, including spacing of at least two years between births, also helps prevent the occurrence of fistula. In addition, efforts to promote the education of young women and to discourage early marriage could make a difference.

However, many countries have severe shortages in the number of doctors, nurses, and midwives who can assist women during childbirth. Availability of and access to medical facilities that have the trained staff and specialized surgical equipment needed for cesarean births are very limited in certain parts of the world, and many women who suffer from obstetric fistula live in remote rural areas and lack the means for transport to facilities where they could receive help.

A host of factors influence a woman's ability—or her decision—to seek emergency care. A primary obstacle is lack of awareness about potential complications during delivery and what to do should complications arise. Other factors that come into play include a general fear and mistrust of hospitals and healthcare workers, a lack of facilities and trained staff nearby, an inability to afford health care, and cultural preferences for home delivery.

Guidelines for Facilitating a Discussion
This guide was developed to provide a framework for engaging students in a discussion of the issues surrounding obstetric fistula. Below are some suggestions to help you facilitate an open and engaging discussion, followed by some activities you can do with students to further explore the program's topics.

• If possible, preview the program in its entirety. This will serve to ground you in the content and give you time to process your own ideas before you lead a discussion.

• Review both the Background section and the Discussion Questions beforehand. Consult the Links and Articles section for additional information.

• The Discussion Questions have been grouped into three categories: general starter questions, which probe for viewers' thoughts and impressions of the film; fistula questions, which focus on the medical condition; and social, cultural, and policy issue questions, which ask viewers to discuss some of the more sensitive and/or controversial aspects of the film.

• Prior to students' viewing of the film, consider conducting a brief discussion to introduce some of the themes the program covers. Review societal expectations for adolescence, marriage, gender roles, and life opportunities. Encourage students to take notes during the film for later discussion.

• Keep in mind that the program features issues that may be volatile. Discussions could include such topics as childbirth injuries, child marriage, sexual coercion and/or rape, gender roles, discrimination, and women's rights. When the subject involves cultural and social differences, it is important to be sensitive to differing viewpoints.

Discussion Questions

General Starter Questions

To get the discussion started, consider posing one or more general questions about the film, such as:

• What is your initial impression of the film? Did anything in this film surprise you? If so, what? Why was it surprising?

• If a friend were to ask you what this film is about, what would you say?

• If you could ask anyone in the film a single question, who would you choose, and what would you ask?

• Why do you think the filmmakers made this program? What were they hoping to accomplish?

• Why do you suppose the film is titled "A Walk to Beautiful"?

• What insights or inspiration did you gain from this film? What did you learn about the film's subjects and/or about yourself?

Fistula Questions

• What is obstetric fistula? How and why does it occur?

• What are some of the physical consequences of fistula? What are some of the psychosocial consequences?

• What regions of the world have the highest rates of fistula? How widespread is the problem? Why is this so?

• Can obstetric fistula be treated? If so, how? Are there any risks associated with the treatment?

• How can obstetric fistulas be prevented?

Social, Cultural, and Policy Issue Questions

• What are the characteristics of the lives of the women profiled in the film? What do the women have in common? How are they different?

• In addition to the physical ramifications, how has having fistula affected Ayehu and the other women who come to the hospital for help?

• Both Ayehu and Wubete express that death would be preferable to living with fistula. Why do you think they might feel this way?

• Compare attitudes toward marriage, childbearing, and gender roles that you see in the film with attitudes toward marriage, childbearing, and gender roles in the United States. What are some of the attitudes you see in the program regarding women? What are some similarities and differences between the attitudes that appear in the program and those in the United States? In your view, what accounts for the similarities and differences?

• What are some of the factors that contribute to the disproportionate number of fistula patients among young, poor, often illiterate women in remote areas?

• Dr. Catherine Hamlin, who opened the Addis Ababa Fistula Hospital in 1974, states that "These women [fistula patients] are not welcome in a general hospital." Based on what you've seen in the film, for what reasons might regular hospitals in Ethiopia and other countries turn away fistula patients?

• How do the hospitals and health-care workers featured in the film seek to help fistula patients? Are these strategies sensitive to community traditions? Should they be?

• Hospital staff members try to encourage the women in their care to talk about what happened to them. What is the value of having people listen to their stories? What is the power of serving as a witness to the stories that the hospital patients tell?

• During most of the 20th century, obstetric fistula was largely missing from the international global health agenda. What are some possible reasons why this problem was ignored? How can increased awareness help fistula patients? What more needs to be done?

Activities

1. The efforts of organizations to address the problems relating to obstetric fistula focus on three main areas: treatment, prevention, and rehabilitation. Separate the class into groups to research what is being done in each of these areas. After students have completed their research, have each group present its findings. Which area seems to be having the most success? Why? Which area seems to be the weakest? Why? What else might be done to help eliminate obstetric fistula?

2. There are many African and Asian countries that need resources to help identify, treat, and follow up with women who live with fistula. One way to increase awareness of the problem and generate funding for fistula prevention and treatment services is to develop an advocacy campaign, which may involve components such as letters, print materials, and/or videos. Organize students into groups and have each group create its own campaign, using the following questions as guidelines:

   1. What type of campaign do you want to develop? (e.g., informational, fundraising, awareness)

   2. Who will be your audience? (e.g., the general public, politicians, health providers, press)

   3. What information will you include about obstetric fistula?

   4. What materials will you need? How will your materials reach your intended audience?

   5. How will you fund your campaign?

3. The following is a list* of some of the problems faced by organizations and healthcare providers trying to treat and prevent fistula. Display the list and work with students as a class to determine if these problems would be considered legal, political, clinical, psychosocial, and/or cultural. What are some possible actions that could be taken in each case?

   • insufficient medical facilities and/or trained providers

   • insufficient human resources

   • insufficient financial resources

   • insufficient political support for maternal health issues

   • lack of access to quality care, including lack of transport to facilities that can provide emergency obstetric care

   • affected population is unaware of the extent of the problem (i.e., women affected by fistula don't realize it is a common condition)

   • affected population is unaware of treatment possibilities

   • affected population needs to be reintegrated into the community

   • insufficient and/or inconsistently applied laws in cases of rape and sexual violence

   • gender inequalities

   • malnutrition

   • lack of general education

   • childhood marriage and teen pregnancy

   • conflicting health priorities, such as malaria, HIV/AIDS, and child health

   * List drawn in part from "Traumatic Gynecologic Fistula: A Consequence of Sexual Violence in Conflict Settings," published May 2006.

4. While the effects of fistula can be devastating for women living with the condition, obstetric fistula is only one of many maternal health issues that women in developing countries face worldwide. In 2000, the United Nations established eight measurable goals designed to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. Give students the following list of these goals, now known as the Millennium Development Goals. As a class, discuss the goals and consider what role, if any, each plays in ensuring maternal health:

   • Eradicate extreme poverty and hunger
   • Achieve universal primary education
   • Promote gender equity and empower women
   • Reduce child mortality
   • Improve maternal health
   • Combat HIV/AIDS, malaria, and other diseases
   • Ensure environmental sustainability
   • Create a global partnership for development

   Organize students into eight groups and assign each group one of the goals. Have each group use the The Millennium Development Goals Report 2007 at www.un.org/millenniumgoals/pdf/mdg2007.pdf and the Millennium Development Goals: 2007 Progress Chart at www.un.org/millenniumgoals/docs/MDG_Report_2007_Progress_Chart_en.pdf to analyze the progress being made on its goal and report to the class. Then, as a class, analyze which goals have shown the most and least gains, and why that might be.

   Again as a class, brainstorm possible action steps that group members could take right now in the effort to achieve some of the Millennium goals that have made the least progress. Discuss students' suggestions. What kinds of steps make the most sense when the task is to combat problems that are geographically far away?

Links & Articles

Web Sites

Campaign to End Fistula
www.endfistula.org
Provides information about the global Campaign to End Fistula, along with information on efforts for treatment, prevention, and rehabilitation. Includes video segments that examine the effects of fistula in greater detail.

Fistula Foundation
www.fistulafoundation.org
Features information about fistula and efforts to treat and prevent the problem.

The Worldwide Fistula Fund
worldwidefistulafund.org
Describes obstetric fistula and lists ways of preventing the condition.

Articles

Faces of Dignity: Seven Stories of Girls & Women with Fistula
www.womensdignity.org/Face_of_Dignity.pdf
Examines seven personal stories of women and girls with fistula.

Living Testimony: Obstetric Fistula and Inequities in Maternal Health
www.unfpa.org/upload/lib_pub_file/746_filename_living_fistula_eng.pdf
Highlights social, cultural, and economic dimensions of obstetric fistula by presenting key findings of country-level needs assessments conducted in twenty-nine countries in Africa, Asia, and the Arab States from 2003 to 2006.