Preventing Obstetric Fistula for all Women, Everywhere

Reflections on a visit to Malawi – the Warm Heart of Africa

by Edward Flynn CSSp

“You can miss it on a map. On a continent of a big sky, big game, big challenges, the little country of Malawi (Flames) – less than half the size of the UK – is an unassuming place. But within its borders, it embodies the greatest contradictions of our time: poverty and generosity. Urgency and serenity. Despair and hope (Bono 2006).”

Between 6 – 31 October 2025 myself, Ms Dannette Haley (ICRC Geneva) and Mrs Eirene Carson (a midwife working in NHS Cambridge), visited Malawi in south-east Africa. A key reason for visiting Malawi was that more than 70 percent of its population is rural. Given that the greatest number of women and girls living with or at risk of living with obstetric fistula live in rural areas, our focus was to learn and understand some of the realities and challenges of obstetric fistula and explore ways in which to prevent it. Visits and conversations during the time focused on:

Listen and learn about the situation and the various challenges faced in Malawi in relation to obstetric fistula
Provide a background to the work of the SafeBirth4all coalition in Ireland including raising awareness of the human rights dimensions of obstetric fistula at the Human Rights Council in Geneva and share experiences of visits to other countries, including Angola and Madagascar
Share information about good practices observed in other countries and resources, such as the Guide for Churches on the Prevention of Obstetric Fistula
Meet with a variety of relevant individuals, church groups, medical, local and international NGOs and government personnel to raise awareness about obstetric fistula
Raise awareness about the importance of the prevention of obstetric fistula.

In 2006 Anne Conroy wrote, “[t]he struggle for food and survival dominates life in Malawi”. This remains true today. It was the dry season during our visit and food is in short supply in many parts of Malawi. The rains to accompany seed planting, were yet to come and this landlocked country is dependent on rainfall for its crops and harvest. Many items are imported from neighbouring countries, and discussions are ongoing about the importation of maize from Zambia. There are few products that are exported from this isolated country. Food shortages, hunger months, malnutrition and food insecurity are a regular part of everyday realities for the people of Malawi.

Public transport, a critical and essential facility for most Malawians, is one example of the struggle to survive: on September 28th a bus ticket from Lilongwe to Mzuzu cost 25,000 kwacha (€13). Ten days later, on October 8th the same ticket cost 65,000 kwacha (€34). The price of petrol rose from 2,700 (€1.40) to 3,500 (€1.8) kwacha per litre overnight on the 1st of October (front page headlines on The Nation that day). During this time €1 = 1, 920 kwacha, however, the unofficial exchange rate is more than twice that amount. This resulted in price hikes for most goods and services, especially food items, which is devastating for those with limited resources. This has a particular impact on women from rural areas in affording transport to and from ante and post-natal support services.

Reflections on the key visits while in Malawi

Among the visits made during the first week, the most informative was to the Bwaile Fistula Centre in downtown Lilongwe. We were informed that there is a backlog in the country of 15,000 obstetric fistula cases that are on the waiting list for repair surgery. With 1,800 new cases each year and a capacity for 900 repair operations per year, the backlog will continue to grow. We were told about one woman who had waited 28 years for her fistula repair operation. During our visit, we learned that there are many cases of fistula in towns along the shore of Lake Malawi – Nkhotakota, Salima and Mangochi. The small stature of the women in this area is considered a contributory factor. Difficulties with arranging transport prevented us from visiting the area.

About 15 years ago, a decision was made by the government of Malawi to prevent Traditional Birth Attendants (TBAs) from supervising home births. The directive was that all births were to be attended by qualified midwives in a hospital. Expectant mothers would have to pay a fine (to the village chief and to the hospital) if they failed to go to hospital for their delivery. On the face of it, this seems like a good decision. However, some 80% of fistulas in the country now occur in hospital settings, which is averse to the expected or desired outcome. The necessary quality infrastructure and qualified personnel have not yet been put in place to avoid this reality.

For this and many other reasons prevention is essential.

While in Lilongwe, we also visited the Archbishop of Lilongwe, Rev George Tambala O’Carm, who was very welcoming when we visited him at the end of our first week. From the members of other church related groups and individuals we met, there was general appreciation that we were paying attention to this difficult and hidden reality. Some we spoke with had not realised that obstetric fistula is such a debilitating condition. Since our visit I have heard that a couple of church groups have committed to have further conversations about the issue, and at one academic institution they intend to include the topic as part of a practical theology course.

Other visits between October 11 – 26

For the next two weeks Mrs Eirene Carson (a midwife working in the NHS in Cambridge) and I travelled north to Mzuzu, south to Balaka, Zomba and Blantyre to visit hospitals, health centres and church leaders. In Balaka we stayed at the Spiritan student house where we prayed with the community at the grave of Fr. Anthony O’Boyle, an Irish Spiritan who died in Balaka in 2001.May he rest in peace. We arrived in Balaka on the 19th of October, which was the 24th anniversary of the date of his burial.

During the final week of the visit, I had follow-up meetings with church personnel and doctors to share our experiences from around the country.

On the last day of my visit, I had a conversation with an individual from the Ministry of Health who gave me hope that there are people in Malawi who are deeply concerned with improving the lives of women who, up to now have been forgotten.

Reflection:

As I write, I am reminded of the title of a book I read many years ago – “Don’t push the river, it flows by itself” by Fritz Pearls. It seems appropriate in this situation. Going to Malawi, I was full of plans to visit many places and meet many people. When I got there, I discovered the pace of life was much different and I had to adjust to it. While I was hoping for a more positive response from certain individuals, I was surprised to receive an encouraging and affirmative response from unexpected quarters. That is one of the wonderful aspects of this work – you never know from whom or from where you will meet people who are genuinely interested in responding to the need to promote prevention.

Given the dispersion of the population, there is a great need to develop a community-based prevention approaches to ending the experience of obstetric fistula. I think the development of a model for prevention in a community setting could be a worthwhile contribution to make.

A word of thanks to the Medical Missionaries of Mary (MMM) community in Lilongwe and Fr. Frank Taylor SPS (St Patrick’s Missionary Society) for their support and hospitality during our visit to Malawi.

Summary of site visits and meetings

Bwaila Fistula Centre in Lilongwe (LLW) with Dr Margaret Moyo, Ms Monica – a nurse at the centre and a former fistula patient; Dr. Ennet Chipunga, the current surgeon at the Bwaila Centre

A day visit to Kasina – a rural village Health Centre run by the MMM sisters, facilitated by Fr Frank Taylor

Christian Health Association of Malawi – a joint project of all churches

Visit to offices of UNFPA with members from the World Council of Churches (WCC)

Met with the Archbishop of LLW Rev George Tabale

At the end of Sunday Eucharist in the local catholic parish we were given an opportunity to introduce ourselves to the congregation and to give a brief presentation about the work of the Coalition and the reason for visiting Malawi

The Assistant to the Catholic Bishop, Fr Isaac John Katumbi and Ms Theodora – the head of Health services in the Diocese

St John’s Hospital Mzuzu: Dr. Jessie (Obs/Gyn), Mr. Crispin, matron, Dr Thom, clinical director of Mzuzu Central Hospital (district level) and Dr. Eugenie (Obs/Gyn)

The offices of Wells for Zoe – an NGO working on water, forestry, education farming and health – and with staff who administer the work and go on outreach to rural and remote health centres.

Ms Anne Conroy an independent consultant on policy who has lived in Malawi for 30 years and has worked for various government institutions and ministries

Balaka staying with a Spiritan student community and had an opportunity to share with the community about the work of the coalition

Travelled to Zomba: met with Anglican ministers in Domasi; Director of the District Hospital in Zomba; leaders of the Baptist Church in Zomba

Blantyre: met with the moderator and assistant of the Presbyterian church; Health Director Ms Vivian and the Vicar General and the head of development services in the Catholic Diocese of Blantyre; Ms Gertrude – head of the Theological College in Zomba

Malawi Human Rights Commission

General secretary of the Malawi Council of Churches (MCC) – Rev Kenneth Alemekezeke Phiri invited Dr. Mwai of the WCC to make a presentation on obstetric fistula for 30 minutes at the AGM of the MCC in February 2026

Zoom meeting with Mr Hans Katengeza from the Ministry of Health