Vandana Tripathi on Healing Women and Healthy Mothers

Vandana Tripathi is deputy director of Fistula Care Plus, a project of the United States Agency for International Development (USAID) and managed by global women’s health organization EngenderHealth. Fistula is a type of hole or rupture in the birth canal, caused in a variety of ways, that can lead to debilitating long-term chronic health problems. Education, prevention, and care of fistula conditions are a top healthcare priority in developing nations.

What led you to focus on fistula prevention and treatment?

From the first moment I learned what public health is, I was drawn to maternal health. If public health is the nexus of medicine and social justice, maternal health is where gender equity, human rights, and public health all collide. No one should die giving life–certainly not from preventable causes. Only women face this risk, and almost every maternal death can be prevented.

Even though there has been tremendous progress in reducing maternal deaths around the world, I’m convinced that a substantial number of the maternal deaths we have averted become maternal morbidities–in other words, women who survive but experience severe complications, and may be left with devastating childbirth injuries and no access to care and treatment. Fistula is one of the most severe things that can happen to a woman giving birth without killing her. A woman with obstetric fistula has usually lost her baby during labor, and now she has a condition that can severely affect her physical and mental health, her ability to work, her most intimate relationships, and her ability to participate in her community.

In addition to this human aspect, I wanted to work on fistula because it’s an incredibly crystallized sentinel indicator of how well a health system is functioning. So many things have to go wrong for a woman to be left with an obstetric fistula–but so many things have to go right for that same woman to access fistula repair. I’m a researcher, a measurement person, and fistula is a powerful measure of whether and how health systems and communities are caring for pregnant women. I also like the optimism of working on fistula services, of building the capacity to provide quality surgical care in low-resource settings and supporting the tremendously skilled and hard-working providers who dedicate their lives to delivering this care.

What has surprised you as you’ve traveled the world for your work?

I have had the extraordinary privilege of traveling to more than 30 countries, in Africa, Asia, Latin America, and Europe. Over the years, my work has introduced me to an incredible range of people working to help communities become healthier and stronger, like nurse/midwives (and Irish nuns!) delivering maternal health care in semi-nomadic communities in rural Kenya; Zapatista-identified Mayan advocates working to improve food security in Chiapas, Mexico; peer educators coping with the HIV/AIDS crisis among street youth in St. Petersburg, Russia; and doctors and therapists providing free forensic exams to torture survivors seeking asylum right here in New York.

But, everywhere I’ve been, I’ve been energized, inspired, and constantly schooled by the educators, volunteers, providers, and advocates who take on the public health challenges they see around them. Communities know what works–how to change harmful social norms, the practical things that can make it easier for families to seek health services, and the assets that already exist in their own villages and neighborhoods that we can amplify to improve health and wellbeing.  

When I arrived in the United States as a kid who only spoke Hindi, I felt like no one knew anything about my culture here–our food, our clothes, our music, our religion. Everything was “weird” or, at best, exotic. Things have changed so much in the past decade, in terms of our visibility in American culture, but the 1980s were rough!

So, on a personal level, as an Indian immigrant, one of the things that surprised me (in a wonderful way) was to see how my culture of origin has been shaped by and has had influences on so many others around the world. Looking at a Romany newspaper promoting community health in Bucharest and realizing that I could understand half the words because they were the same in Hindi. Seeing so many words I recognized on Swahili signs in Kenya from the mixed Hindi/Urdu language I grew up speaking, and realizing that Arabic shaped languages around the world just as much as Latin did. And of course, chatting with taxi drivers from South America to Russia about the Bollywood movies they grew up watching!

What currently in-practice approaches for fistula prevention have been most effective in your view?

Fistula connects to so many of the issues that affect women’s ability to live healthy lives and to fulfill their human potential. Evidence from our programs and research shows us that the women who are most vulnerable to poverty, to social exclusion, and to gender-based violence are also most vulnerable to experiencing fistula. So, obviously at a very basic level, preventing fistula is about valuing the lives of girls and women–their ability to stay in school, to avoid early marriage and early childbearing, and to have access to family planning services if they want to delay or space their pregnancies.

But fistula prevention is also about the fundamentals of care during pregnancy and childbirth, like making sure that families and communities support women to have a plan for getting to a health facility when labor starts. And making sure that women have access to midwives who can monitor labor and recognize quickly if labor is prolonged or delayed. And also making sure that, if a woman does experience prolonged or obstructed labor, she gets timely, appropriate, good quality care.

The director of my project often says that obstructed labor is the “invisible complication”–the woman isn’t bleeding out as in hemorrhage, and she isn’t seizing as in eclampsia. She might be suffering tremendously. But in an overwhelmed labor ward in a low-resource setting, perhaps with multiple women in each bed, with not enough midwives or nurses, she may be invisible. And she might literally labor for 24 hours or more in that facility before she gets the cesarean section or other care she needs to save her and her baby. So fistula prevention isn’t just about getting a woman to a health facility–it’s about strengthening those facilities, so they have the people, equipment, and supplies they need to actually provide good care.

Are there any promising avenues of research or theory regarding new ways or applications to prevent and treat fistulas?

One of the things I’m excited about is fulfilling the potential of non-surgical fistula prevention and treatment. Catheterization after prolonged and obstructed labor may help prevent fistula formation, and it can even repair some proportion of fistula cases–especially those which have occurred recently and meet other clinical criteria. Anytime you can prevent unnecessary surgery, it’s a win, in terms of reducing the risks and burdens on women. So, we’re working in our project to raise awareness among clinicians about this, document current practices and gaps, and help standardize training in non-surgical fistula prevention and treatment. We want to see this approach expanded, so that non-surgical care is always part of our arsenal against fistula.

What other areas of medicine and healthcare interest you professionally?

Quality of care is really important to me. We’ve spent years telling women in poorer countries to go deliver in health facilities. And they’re doing it! Facility births have gone up dramatically in low-resource settings. But we have more and more evidence that care quality is just not good enough in many facilities.

In my project, we’re seeing that more and more fistula cases may actually be iatrogenic in origin–in other words, caused by mistakes during cesarean section or other health procedures. Of course, mistakes can happen anywhere, including the best hospitals in the U.S., but this also reflects the fact that so much childbirth care is happening in facilities without enough staff, training, equipment, or supplies. And that’s just a terrible outcome, especially in a setting where that woman may not be able to ever access fistula repair.

We owe it to women to help health systems provide real quality of care–so that if a woman in, say, rural Congo, has spent all the money she has to get to a hospital in labor, she actually gets the interventions that can make her delivery safe, and that emergencies can be handled quickly and properly.

In public health, we often talk about social and behavior change in communities. How can we encourage communities to adopt behaviors that promote health? But health systems are communities too, and we need to figure out ways to help providers change behaviors–for example, to do the simple things in labor and delivery care that don’t necessarily cost any money, but that ensure danger signs are spotted early, and can help protect mothers and newborn, especially in that crucial hour right after delivery. Something as simple as skin-to-skin contact, just putting a newborn on the mother’s body immediately, can save lives in settings where incubators are few and far between, and protecting the baby’s warmth is essential to survival. But studies show us that many of these no-cost practices aren’t performed very often. So I’m really interested in understanding the drivers of better quality care, and of course, in making sure that we’re actually measuring care quality, instead of assuming that providing a training or some new equipment, is adequate for changing practices.

What would you like to accomplish personally in the next ten years?

I want to continue to support changes in how communities and health systems care for and support pregnant women, so that childbirth can become safer and women have the opportunity to fulfill their goals for their lives and their families’ lives. I want to make sure we keep talking about quality of care. My colleagues often talk about “too much and too little”–there are countries, even hospitals, in the places I work, where one woman might get an inappropriate cesarean section that leaves her with a fistula, and one woman might die because her danger signs weren’t recognized or managed in time. I want to work towards leveling this, so that women and newborns are getting care that isn’t too much or too little, but just right.

I also want to be part of changing how childbirth happens here at home. So many of my friends have been utterly disempowered by their delivery experiences. They haven’t felt listened to, or felt railroaded into interventions and procedures they didn’t understand, request, or want. I’ve had my own experience of this, waving around clinical review articles while hooked up to a drip in triage, trying to point out that I didn’t need to be rushed into labor induction based on one potentially negative ultrasound scan. And I was fortunate enough to have the ability to download, read, and wave around those articles and a wonderful obstetrician who listened to me when I called her!

We’re seeing birthing centers closing in New York and women choosing to deliver at home because they don’t feel they can avoid an over-medicalized experience in a hospital. That shouldn’t have to be the only choice! We have “too much too soon, too little too late” here, too. There are hospitals with cesarean sections rates going through the roof, and yet we have such high maternal mortality compared to other high-income countries. The number of maternal deaths among African-American women in our country is a travesty. There is a lot that we can see in common between what’s happening in global maternal health and what’s happening here in the U.S. So, I hope I can bring some of these lessons we’ve learned in global health back home, too.

On a very personal level, I have two boys – they’re 4 and 6 years old. In 10 years, they’ll be teenagers, and I hope I’ll have helped them become confident in themselves and caring towards others, so that they don’t feel like there’s only one way they can be strong young men. Basically, if they are empathetic and love to read, I’ll feel good about my accomplishments!

What has been your experience as an Indian-American professional woman in your field?

In college, when I was taking all those pre-medical courses that seemed to have little to do with being a healthcare provider (organic chemistry!), I happened to take a class on the burden of disease in developing countries–things like cholera and malaria. And it was a lightning bolt.

I realized that public health was a much better fit for the things that excited me and that I was good at. But it was such an unknown path. Indian-Americans became doctors! My parents asked at one point if I was going to just hand out condoms.

I don’t think I could have described a career in public health at that time, and certainly no one in my community had gone that route that I knew of. And now, of course, there are so many amazing Indian-American women who are leaders in this discipline. So, it’s been really nice, over my 20+ years in this field, to see us represented more and more in this profession that I do think is, as I said earlier, fundamentally about social justice.

Growing up in the Bay Area and then East Tennessee, I was very aware of how being an immigrant, bringing a religion and other values that might seem strange to the mainstream culture, affected how I grew up. I think this experience helps with critical thinking. I never took for granted that things had to be done just one way, because I was constantly negotiating very different ways of doing things, very strongly held but very divergent belief systems.

I think Indian Americans, like many other communities in the U.S., by necessity learn how to think across multiple frameworks, ways of communicating, and values. And we definitely also learn code switching! Ultimately, I think this has been a strength working in global health, and public health generally, where we are always working across languages, cultures, and power structures, and where we are always collaborating. Nothing in public health has ever been the accomplishment of just one person!