A Walk to Beautiful
Program Overview and Discussion Guide
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.
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.
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
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
relates how each
woman came to be at the hospital.
women's progress at the hospital as each undergoes treatments for her
condition, and reports on each woman's outcome.
fistula, while 100 percent preventable, is a silent epidemic because it primarily
affects poor girls and women in developing countries.
Can be used up to one year after program is recorded off the air.
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.
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.
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
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.
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
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.
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
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
What insights or inspiration did you gain from this film? What
did you learn about the film's subjects and/or about yourself?
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
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
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
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?
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?
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?
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:
What type of campaign do you want to develop? (e.g., informational,
Who will be your audience? (e.g., the general public,
politicians, health providers, press)
What information will you include about obstetric
What materials will you need? How will your materials
reach your intended audience?
How will you fund your campaign?
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
insufficient human resources
insufficient financial resources
insufficient political support for maternal health
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
affected population is unaware of treatment
affected population needs to be reintegrated into
insufficient and/or inconsistently applied laws in
cases of rape and sexual violence
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.
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
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
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.
information about fistula and efforts to treat and prevent the problem.
The Worldwide Fistula Fund
obstetric fistula and lists ways of preventing the condition.
Dignity: Seven Stories of Girls & Women with Fistula
personal stories of women and girls with fistula.
Testimony: Obstetric Fistula and Inequities in Maternal Health
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.