Kelly on Heller, 'Fistula Politics: Birthing Injuries and the Quest for Continence in Niger'

Alison Heller
Chau J. Kelly

Alison Heller. Fistula Politics: Birthing Injuries and the Quest for Continence in Niger. Medical Anthropology Series. New Brunswick: Rutgers University Press, 2018. 270 pp. $34.95 (paper), ISBN 978-1-978800-36-6; $120.00 (cloth), ISBN 978-1-978800-37-3. 

Reviewed by Chau J. Kelly (University of North Florida) Published on H-Sci-Med-Tech (May, 2022) Commissioned by Penelope K. Hardy (University of Wisconsin-La Crosse)

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Alison Heller’s Fistula Politics: Birthing Injuries and the Quest for Continence in Niger provides a nuanced ethnographic study of how obstetric fistula (a traumatic birthing injury brought on by prolonged obstructed labor, which causes vesicovaginal and/or rectovaginal incontinence) affects the lives of Nigérien women and their households. Heller focuses on the women “whose lives have been transformed” by fistula “to illuminate many larger questions about power, biomedicine, stigma, resilience, care, kinship, commodification, and representation within the context of illness and treatment-seeking” (p. 4). This detailed book illustrates the complexities of biomedicine and Nigériens’ interactions with it through a singular medical intervention that Western media outlets claim is cheap, easy, and highly successful.

Fistula Politics makes a critical intervention in the study of fistula as part of a larger medico-political framework in Muslim West Africa. Unlike the sensationalistic articles about fistula in major media outlets over the years, Heller takes a nuanced approach that rejects simplistic victim/abuser narratives.[1] Heller interviewed one hundred women at four different fistula centers and two types of spaces (three urban centers in Niamey and one rural facility in Danja, Maradi State) to amass significant evidence that is both qualitative and quantitative. Nigérien women form the core of Heller’s work with their personal experiences with fistula, revealing the range of experiences that fistula and urinary incontinence creates for women, who range in age from fifteen to seventy years old and who developed the condition at different points in their reproductive lives. Contrary to the prevailing media and narratives from nongovernmental organizations (NGOs), the women developed fistula ranging from their first to their twelfth pregnancy and the average time that women lived with the condition before meeting Heller was seven years. While some women regained continence through surgical intervention, many remained “wet” for years as they waited for their next surgery in the hopes that another procedure will resolve the leaking. In the process, Heller uncovers the resiliency of the women and the problems with deploying biomedicine as an incomplete practice without adequate funding or training.

Heller organizes the book into three parts, each dealing with specific elements of how birth injury and incontinence altered Nigérien women’s lives. Each part of the book begins with a woman’s story, which helps the reader to gain deeper understanding of how women navigate their condition. Part 1 gives ethnographically rich details of the women, their birthing experience, and the ways they and their families understand their injury. Heller starts chapter 2 by directly challenging the common claim that women with fistula are stigmatized and rejected by their husbands and community. While fistula certainly changed women’s lives, how well women weathered this crisis also depended on their relationships with their husbands and family before the injury. The fistula exacerbated existing tensions and conflicts, pushing already precarious women out of familial security. But women with living mothers and stable marriages before the injury suffered little social stigma and verbal abuse, though their self-perception deteriorated. Some women also managed to conceal their condition, though this took a heavy emotional toll and the potential of outing their condition caused distress. In chapter 3, Heller examines how fistula directly affected women’s marriages; whether they remain married, divorced, or in some liminal state depended on a variety of factors. The type of marriage also played a significant role, whether forced, familial, or love matches, with familial marriages proving the most stable. Nigérien women with fistula had fewer children than those without injuries; accordingly, “66 percent of pregnancies among the 100 women with fistula ended in a still birth” (p. 84). The presence of co-wives increased the likelihood of conflict and abandonment as women lost status in their households.

In part 2, Heller turns to the clinical spaces to examine how biomedicine relates to birthing and fistula repair. For chapter 4, Heller reveals Nigérien cultural ideals around childbirth, which expect women to labor quietly and without complaint, oftentimes for days. Women lack the means to decide for themselves whether to go to the health center, transportation is limited, and once there, women endure further delays in care or experience abuse at the hands of midwives who attempt “abdominal expression” with disastrous results (p. 112). The social and material consequences of waiting inform chapter 5, wherein women with fistulas spend months, sometimes longer, lingering at fistula centers in the hopes that the next surgery will resolve their condition. Unlike the popular narratives from NGOs, not every fistula surgery is successful and easily resolved. Women wait and travel to different fistula centers in search of treatment because their hopes for cure are “sustained by faith in biomedicine,” while the state “allow[s] fistula organizations to profit from women’s subordination” (p. 124).

For the last section, Heller dismantles the humanitarian marketplace and the use of fixed narratives by NGOs of young female victimhood for fundraising campaigns that simultaneously vilify and erase African men. Chapter 6 addresses the ways that biomedical practice and humanitarian tropes are translated and distributed for public consumption. Heller admits this was shocking even as she returned from her initial foray into the field, wherein her preliminary findings contradicted the dominant narratives of crisis and lost innocence. Donors and media want simple narratives, images with pretty faces and positive outcomes, which chapter 7 reveals sometimes cost women their privacy, plunging their domestic and private affairs into the wider community. Many women with fistula manage to conceal their condition from everyone other than their husbands and mothers, but NGOs demand photos, videos, and other expressions of gratitude, which find their way into the public purview. This brings me to my one criticism of an otherwise phenomenal book: though Heller takes great care to obscure the women's identities, including over two dozen photos of these same women feels problematic, even though it is highly unlikely the images will circulate in Niger. The images confound the larger point that Heller is making about media representation of vulnerable women. In the final chapter, Heller offers some recommendations for changes, most significantly, improvements at the most basic level of the health system in terms of preventive labor and delivery care for rural women who suffer the most from fistula.

Heller’s ethnography, Fistula Politics, is a welcome addition to ethnographic studies of fistula, biomedicine, and the body.[2] Her recommendations for changes are well thought out and rooted in plausible action; however, overcoming the NGO trap and political inertia are likely to prove extremely challenging, particularly given the limited investment in training regimens for midwives. The book is eye-opening and makes a clear case that fistula is a complex medical condition, which also suggests that more complex types of interventions are needed. Most notably, fistula is best prevented through better training and greater investment in basic health services, particularly in the delivery of care for birthing women to prevent traumatic injury and fistula.


[1]. See, for example, Nicholas D. Kristof, “Alone and Ashamed,” New York Times, May 15, 2003; Nicholas D. Kristof, “New Life for the Pariahs,” New York Times, October 13, 2009; and “Inside the Fistula Hospital,”, 2005,

[2]. Anita Hannig, Beyond Surgery: Injury, Healing, and Religion at an Ethiopian Hospital (Chicago: University of Chicago Press, 2017); Julie Livingston, Improvising Medicine: An African Oncology War in an Emerging Cancer Epidemic (Durham, NC: Duke University Press, 2012); and Kathryn Linn Geurts, Culture and the Senses: Bodily Ways of Knowing in an African Community (Berkeley: University of California Press, 2003).

Citation: Chau J. Kelly. Review of Heller, Alison, Fistula Politics: Birthing Injuries and the Quest for Continence in Niger. H-Sci-Med-Tech, H-Net Reviews. May, 2022. URL:

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