How USAID cuts could undermine battle against fistula in Malawi

• USAID cuts hit health services in aid-dependent Malawi
• Progress on maternal health, including fistula, threatened
• Donors, including UNFPA, support lone fistula clinic

LILONGWE, Malawi - Alinafe Lloyd's life could have been so different.

After suffering an obstetric fistula during the birth of her second child, she could have been left permanently damaged, incontinent and even cast out from her community.

But instead, the 31-year-old mother is standing in front of a hot stove in Kukawundu village outside Malawi's capital Lilongwe, excited about the scones she is cooking and will serve in the tea room she runs with her husband, Damston.

After losing her baby during a complicated labour in 2017 and suffering a fistula - a small hole between the birth canal and the bladder or rectum - Lloyd was able to get reconstructive surgery in the only specialised treatment centre in Malawi.

Recuperating from the labour, "I discovered I was leaking urine," Lloyd said. "Then they explained to me the problem was fistula, but it is something that could be fixed."

The 35-bed Bwaila Fistula Care Centre in Lilongwe offers surgery, rehabilitation and community reintegration programmes and is supported by the United Nations' sexual and reproductive health agency UNFPA and the Freedom from Fistula Foundation.

But now programmes to treat fistula and other maternal health conditions are under threat in Malawi and elsewhere because of global aid cuts, including President Donald Trump's decision to gut the U.S. Agency for International Development.

UNFPA said in April that 43 grants worth about $330 million in total aid funding had been affected.

The grants included funds for critical maternal health care, protection from violence, rape treatment and other life-saving  care in more than 25 crisis-stricken countries and territories.

"Women in crisis zones will be forced to give birth without medicines, midwives or equipment, putting their lives and their babies' lives in jeopardy," UNFPA's Executive Director Natalia Kanem said when the cuts were announced.

In Malawi, one of the poorest countries in the world and one of the hardest-hit by droughts and floods caused by climate change, the aid cuts have slammed critical sectors including health care, education and humanitarian relief, according to a July report by the Non-Governmental Regulatory Authority (NGORA), a government body that regulates NGOs in the country.

"Many NGOs were forced to scale down activities, lay off staff, suspend service delivery, and, in some cases, shut down entire programs," according to the report.   
  

Richard Delate, UNFPA's acting representative in Malawi, described the funding situation as "fluid."

"We have seen a lot of donors, obviously, the (U.S. government) being the most prominent, where there have been big reductions in funding and very rough reductions in funding," he said to reporters in July.

"So that has resulted in governments having to really pivot and think through how they respond," he said, adding that initiatives like UNFPA's Maternal and Newborn Health Fund would seek to draw in new funds.

"But I don't think we will ever be able to fill the full gaps left behind by the U.S. government withdrawal," Delate said. 

Progress 'sliding back'

Obstetric fistula is often the result of prolonged or difficult labour, and most of the half million women suffering from the condition live in the Global South, according to the United Nations. Around 90% of the women who develop a fistula also lose the baby.

Women with untreated fistula are often shunned because of the smells caused by leaking urine and faeces. This can lead to depression and worsen poverty.

A fistula can usually be repaired with reconstructive surgery, but often women do not know treatment is available or cannot afford to travel to specialist clinics.

UNFPA says the keys to ending fistula include ensuring that all women have access to skilled birth attendants and emergency obstetric care as well as family planning.

These are precisely the services being hit by global aid cuts.

Margaret Moyo, country director at Freedom from Fistula Foundation, said the organisation would like to open other clinics in Malawi but is now more worried about survival.

"You never know for how long (the donors) will be here ... so sustainability is very key and the government is working towards that," she said. 

She said funds to pay for women to travel to the clinic were drying up as well due to aid cuts.

Malawi's Health Secretary Samson Mndolo said the government was assessing the situation and hoping to avoid "sliding back" on progress already made. 

"We as a country will prioritise and see how we can help fill the gaps ... because this will help us reduce a lot of potential complications downstream," he said.

At the care centre, women are trained in skills to help them become self-sufficient when they leave, which is how Lloyd learned about opening her own tea room.

This is especially important for younger women - teenagers are particularly prone to obstetric fistula.

"Young women who experience fistula experience high degrees of social stigma due to a number of things, including body odours, even the fact that they've had a teen pregnancy," Delate said.

"Supporting those women is a way of also restoring their dignity and self-worth, and I don't think one can ever measure that in financial terms," he said.

At the Bwaila centre, Lilian James, who travelled some 200 km (125 miles)from the Balaka district to undergo fistula surgery, is now sewing reusable menstrual pads, a skill she learned in her rehabilitation.

James received a sewing machine as well as a solar panel as part of her rehabilitation, allowing her to run a small business charging people's phones, which provides money for her to buy goats and chickens.

Her newly found self-sufficiency allows her to turn to helping others, she added.

"I was stigmatised before but now ... I do volunteer work both in the church and the community," she said.

UNFPA facilitated travel for this reporting.

(Reporting by Charles Pensulo. Editing by Clar Ni Chonghaile and Ellen Wulfhorst.)