This story was supported by the Pulitzer Center
 
For more than a year now, three Liberian doctors have been far from home, hunched over operating tables at the St. Paul’s Hospital Millennium Medical College in Addis Ababa, Ethiopia, learning surgical procedures that most hospitals in their country cannot perform.
 
The doctors, Dr. Issatu S. Komara-Keita, Dr. Alexander F. Willicor, and Dr. Numeine Ernest Enders, are undergoing two years of advanced fellowship training in urogynecology and pelvic floor reconstruction, a surgical specialty that treats the bladder, reproductive system, and rectum, including pelvic floor disorders.  
 
Their studies are part of an effort by the Government of Liberia, the Economic Community of West African States (ECOWAS), and the United Nations Population Fund (UNFPA) to reduce the country’s dependence on foreign surgeons to tackle the growing number of fistula cases, one of the world’s most devastating childbirth injuries. 
 
ECOWAS provided US$245,000.   
“Based on the Minister of Health’s request to UNFPA and the ECOWAS Gender Office, both institutions agreed to sponsor the doctors. UNFPA sponsored one doctor, while the others are being supported through funds provided by the ECOWAS Gender Office in Dakar, Senegal,” Dr. Nowaih Gorpu-Dolo Dennis, Fistula Focus Person at the Ministry of Health, said in an email.
 
In Liberia, the lives of fistula survivors are marred by high costs for treatment and a lack of trained surgeons, forcing many to rely on foreign visiting doctors who provide annual treatment. The country has only three urologists—Dr. Ayun Cassell III, Dr. Lavela B. Kortimai, and Dr. Solomane Konneh—all based at the John F. Kennedy Medical Center's (JFK) urology clinic. 
 
Dr. Ayun K. Cassell III, a consultant urologist at the John F. Kennedy Medical Hospital, said these hurdles have left many women waiting months for free surgeries provided by foreign doctors or even years, worsening their condition by the time help comes.
 
“We have three urologists; we are hoping that we'll have more urologists, and we have doctors who have been sent out for studies,” said Dr. Cassell, who is also the head of the Liberia Medical and Dental Council.
 
The ongoing initiative, he said, will strengthen surgical services, improve continuity of care, and create opportunities for mentorship and knowledge transfer, helping Liberia build a permanent pool of fistula specialists capable of providing sustained treatment across the country.
 
The hidden burden of fistula in Liberia
Across the country, the Ministry of Health estimates that about 100 women develop obstetric fistula every year in Liberia, although health experts say the true number may be significantly higher than reported. The condition, which is one of the most serious childbirth-related injuries affecting women in low-resource settings, develops after a woman experiences prolonged obstructed labor, often lasting several days, without access to emergency medical intervention, such as a cesarean section. 

During prolonged labor, pressure from the baby’s head can damage surrounding tissues, creating an abnormal opening between the birth canal and the bladder or rectum and leading to uncontrollable, continuous leakage of urine or feces, or both. While the physical injury can often be repaired through surgery, the main drawbacks for survivors are rejection by spouses and the stigma associated with the condition. 
 
For survivors in rural areas, the challenges are unending. They must travel to Monrovia whenever a free campaign treatment is announced on the radio. This journey is costly, forcing them to endure terrible roads, sleepless nights, and hours sitting on motorbikes. Sometimes, before they even arrive, the campaign has ended.
 
A 2024 LIGISL gender policy brief, drawing on the country's 2022 population and housing census, found that women aged 15 and older had experienced fistula, with the proportion rising to 1% in rural areas compared with 0.8% in towns and cities. Similarly, the country’s health strategy, citing a 2018 national assessment, found that health facilities had only 56% of the general capacity needed to provide services, including emergency obstetric care.
 
According to the WHO, Liberia has made gains in improving the quality of healthcare services, but the country’s maternal mortality ratio is still among the highest in the world due to limited access to quality obstetric care. A 2022 study in BMC Pregnancy and Childbirth found that 78% of recorded births in Liberia occurred in facilities that did not meet the basic emergency-readiness standard. 
 
Dr. Tarmay K. Yekeh-Saa, deputy director for the Family Health Unit at the Ministry of Health, noted that when the Ministry conducts surveys to determine the ages and backgrounds of women affected by fistula, it often finds that many of them are young, with young people accounting for nearly two-thirds of the women affected.
 
Dr. Saa, who is an Obstetrician and Gynecologist (OBGYN), said that while the cost of fistula surgery remains out of reach for many women, the greater problem with the country’s fistula program has been the limited number of surgeons with the specialized skills needed to repair fistula.
 
“For the last five to seven years in Liberia, we really don't have the surgeons that are able to correct it,” Dr. Yekeh-Saa said in remarks earlier this year at a World Fistula Day event (May 22) held at the Ministry of Health. “Based on whenever we run a campaign, the number of persons that come forth; we believe that approximately 100 persons every year is [are] affected in Liberia.”
 
A survivor's burden
For decades, women suffering from obstetric fistula have had to wait months, sometimes years, for visiting international surgical teams to repair their injuries. These campaigns have been associated with high rates of relapse and the breakdown of surgical scars.
 
Beyond the return of the three doctors, the Ministry of Health intends to train a cohort of OB/GYNs and urogynecologists assigned to various health facilities in Liberia.
 
With support from UNFPA, the ministry has also integrated obstetric fistula into the Health Management Information System (HMIS), as it has done with maternal mortality.
 
“This will upgrade fistula as one of the key indicators for maternal care,” Dr. Dennis said. “This will follow the creation of the first specialized fistula treatment unit in Liberia and the development of the National Obstetric Fistula Strategy.”
 
Woseh Gobeh-Weah, a UNFPA sexual and reproductive health specialist, said surgical equipment and medical supplies have been donated to John F. Kennedy Hospital to complement the doctors’ work when they return.
 
"So the idea is that once they return, the operating theater will have the requisite equipment and supplies for them to start repairing cases,” she said. 
 
Ms. Weah noted that, as part of UNFPA’s support to the government, investments will be made in obstetric fistula treatment, including the training of more doctors, and midwives.
 
UNFPA’s support for Liberia’s fistula response predates the current fellowship program. For more than 15 years, with US$3.5 million in funding from Zonta International, the agency has funded the Ministry of Health-led Liberia Fistula Project, which combined prevention with free treatment, rehabilitation, and social reintegration. 
 
By 2017, UNFPA reported that the project had treated more than 1,500 fistula survivors and provided rehabilitation support to more than 400. At the Fistula Rehabilitation and Reintegration Center in Phebe, Bong County, survivors received counseling, life skills education, and training in income-generating activities. More recently, UNFPA’s support has focused on placing fistula care within national policy and routine health services.
 
“This is again another attempt for UNFPA to train specialized surgeons," Ms. Weah said, highlighting the agency’s past work in training nurses and surgeons, including Dr. John Mulbah, Liberia and West Africa renowned fistula surgeon who once led the country’s postwar fistula program. He was recalled from this position in 2018. 
 
Dr. Keita, an OBGYN and the lone female among the three trainees, has seen firsthand the lived experiences of women suffering from fistula. 
 
She hopes their return will bring a solution to one of the most pressing challenges that has crippled fistula treatment in the country.
 
“This opportunity represents not only my personal and professional growth but also a commitment to improving the lives of women and girls suffering from pelvic floor disorders,” Dr. Komara-Keita said during a WhatsApp interview from Ethiopia.
 
As a child during the civil war, she began her education at a refugee school in Guinea before moving to Ghana for secondary school. She later returned to earn her undergraduate degree in biology and chemistry from African Methodist Episcopal Zion University (AMEZU), eventually graduating from the A.M. Dogliotti College of Medicine in 2016.
 
The return of Dr. Komara-Keita and her colleagues is precious to thirty-two-year-old Pauline, who has been battling fistula for three years without repair, despite incurring high medical costs in her quest for a solution.
 
Like many other survivors, Pauline went into labor expecting to become a mother within hours but lost her baby and developed obstetric fistula after prolonged labor.
 
“My child died, and then I have to wear Pampers like a baby. Two times more pain,” she says. “When I was discharged, no one informed me that I had developed a fistula.”
 
“Left with constant daily leakages, I go from one hospital to hospital seeking answers, using income from my cassava farm and financial support from family members, but I have found no relief,” she noted. 
 
Experts say Pauline’s battle for treatment is a glaring example of the challenge survivors has been facing. Many hospitals and clinics in Liberia do not have the treatment facilities and surgeons needed to detect and treat fistulas, leaving countless women waiting for treatment for a condition that is treatable and preventable.
 
According to Dr. Philderald Pratt, secretary-general of the Liberia College of Physicians and Surgeons (LCPS), addressing this crisis requires strengthening the country’s local medical workforce. LCPS was established in 2012 with just four core faculties: Internal Medicine, Pediatrics, General Surgery, and  OBGYN. It has since expanded to 10 faculties aimed at producing homegrown specialists.
 
To date, he says the college has trained 25 OBGYN who are distributed across Liberia. While all OBGYNs trained through the program receive basic preparation to handle simple fistula cases, complex cases require advanced specialists, such as urologists and urogynecologists.
 
In the past, Liberia’s fistula response relied heavily on periodic surgical campaigns supported by international partners like UNFPA and local institutions like St. Joseph Catholic Hospital. While these outreach efforts provided care, Dr. Pratt notes that once visiting specialists leave after a campaign, local health facilities often lack the resident workforce required for long-term follow-up care or to manage complex postoperative complications.
 
Nearly all doctors entering LCPS are Ministry of Health employees bound by service contracts. Upon graduation, they are redeployed by the government. Although LCPS has succeeded in ensuring that every county now has at least one medical specialist, a complete multidisciplinary team of specialists in every county remains an unfulfilled goal.
 
“Even if you have six, and all six are based in Monrovia, only those who can reach the capital will be able to access services,” Dr. Pratt noted. “The idea is to ensure services are distributed regionally so women in rural areas don’t have to travel all the way to Monrovia for care.”

The Economic Community of West African States (ECOWAS) has committed US$245,000 to support surgeries and reintegration for obstetric fistula—a childbirth injury that creates a hole between a woman's vagina and or rectum.

Benedict Roberts, head of the ECOWAS National Office in Liberia, said women experiencing urine and stool leakage due to obstetric fistula will be identified, treated, and receive livelihood training such as tailoring, pastry making, cosmetology, and soap-making that prepares them for reintegration back into their communities.
“When they finish, we give them a small financial package along with the skills they learn to start as their own empowerment,” he said.

Obstetric fistula is a global health issue, with poorer countries being mostly affected. According to the United Nations, an estimated half a million women and girls are living with the condition, with thousands of new cases occurring each year. Most of these are in Asia and Sub-Saharan Africa.

Victims face severe stigma, neglect, and abandonment from their families and communities, leading to trauma and significant psychological impacts on their mental and social well-being. The constant leakage of urine or feces results in severe infections and chronic pain. The malodor associated with fistula makes it extremely difficult for these women to work or participate in social activities, further exacerbating their poverty and social isolation.

In Liberia, the leading risk factors are common, including teenage pregnancy, lack of proper obstetric care, low-skilled birth attendants, and rape. Underdevelopment, rebuilding from the 14-year conflict, and the Ebola crisis have created a critical gap in the country's healthcare system, according to the World Health Organization (WHO).

The fistula treatment and rehabilitation center at Phebe Hospital in Suakoko, Bong County, which was supported with aUS$3.5 million grant from Zonta International through UNFPA, is currently closed due to a lack of funding. Once a beacon for women suffering from obstetric fistula, women were allowed to stay in the dorm and trained in basic skills until full recovery. 

Ruth Walker, Ministry of Health (MOH), Fistula Coordinator, said since the UNFPA support halted in 2018, there has been no fistula care in Liberia, and the government is patiently waiting for ECOWAS to start the project. 

Finance is not the only hurdle to fistula care in Liberia—data is another issue. The Health Management Information System (HMIS) at the Ministry of Health has no record of fistula indicators, surgeries conducted, or the victims, says Walker. 

However, she said a technical working group was established with the support of UNFPA to create the fistula element in the HMIS, which will serve as fistula indicators. 
In an email, Calixte Hessou, UNFPA Programme Specialist, said the indicators were from the UNFPA metadata on maternal health, adding that UNFPA is also supporting the training of physicians as urogynecologists with an emphasis on obstetric fistula.

While the Ministry of Health is awaiting the commencement of the ECOWAS project, Dignity Liberia, an NGO dedicated to restoring hope to women with fistula and their communities through education, healing, and prevention, has constructed a maternal waiting home for 'at-risk pregnant women' in Goyah's Town, Todee District, rural Montserrado County.
Kathi Gutierrez, President at Dignity: Liberia, said the patient could be a woman who previously had a fistula. It can be a woman who is having her first child and is too young to have a baby. It can be someone who has developed gestational diabetes and high blood pressure. 

“If you are pregnant and having a normal pregnancy, you would still be welcome to stay at home, but we are trying to identify the women who are high-risk and would not do well in a village setting,” Gutierrez said. “However, she noted that only women who register as regular patients, attend at least three prenatal visits to monitor their pregnancy, and closely detect risk factors will be eligible to stay at home. Each time they visit the clinic, they will be required to bring a cup of rice, which will be used to prepare meals for them during their stay at home after the 28th week of pregnancy.

“If a pregnant woman in labor shows up at the home and is not one of our patients, we will not receive her,” Gutierrez said. “She will have to go to the hospital. We can call an ambulance for her, but she will be responsible for paying.”
"According to what is necessary, there will be certain tests that they will need to pay. Also, we will collect $20 before delivery to pay for their delivery. Currently, there will be no deliveries at the Maternity Waiting Home. However, patients will be transferred to CH Rennie Hospital in Kakata, Margibi County, for delivery.”

In 2025, Dignity: Liberia will begin the process of building an adjoining women’s clinic. Once the clinic is completed, all deliveries will be done on-site. “We will have resident doctors on call who will be able to handle C-sections.”

Obstetric fistula and other reproductive health conditions are mentioned in the draft revised Public Health Law that is before the Liberian Senate. If passed, the Ministry of Health will adopt regulations to ensure access to quality and acceptable sexual and reproductive health and family planning services, information, and education.

​​By David A. Yates and Simeon S Wiakanty

Obstetric fistula impacts about 1,200 Liberian women annually. It is a severe tear between a woman's birth canal and her bladder or her rectum, typically resulting from obstructed labor or from sexual assault. On average, Liberian fistula patients are seventeen years old and have had their fistula for five years. Without prevention or treatment of fistulas, they can expect lifelong suffering from physical pain, social shame, and chronic symptoms such as incontinence. 
The host Partner for this humanitarian project is the Rotary Club of Monrovia. The Rotary Club of Loveland, CO is the primary international partner. Dignity:Liberia board member and Rotarian, Becky Mueller Huner, R.N., is scheduled to speak at the Georgetown, TX Rotary Club about this project at its December Meeting. 
DIGNITY:LIBERIADignity:Liberia is a nonprofit, 501c3 organization with ten years of experience providing maternal care, specifically the prevention and treatment of obstetric fistula. Its board members either grew up in Liberia or have developed close ties to the country as adults. Dignity:Liberia is also a registered Liberian NGO. The organization partners with the local medical and business communities, and those working closest with fistula survivors. Dignity:Liberia's fundraising campaign, The Big Push, also continues.
Dignity:Liberia
Kathi Gutierrez
Founder, President and Executive Director
(816) 217-8751
348877@email4pr.com
https://www.dignityliberia.org