Ending Obstetric Fistula: A Journey of Hope and Resilience with Bonnie Ruder

I think one of the most important things about fistula is that it is completely preventable and treatable. So this is a solvable problem. We used to have this problem here in the US and now we don't.  – Bonnie Ruder

In this powerful new On Health episode, I’m joined by Bonnie Ruder, co-founder and Executive Director of Terrewode Women's Fund. Bonnie is a dedicated medical anthropologist and licensed home birth midwife with over 20 years of experience. She works tirelessly to end obstetric fistula and other childbirth injuries in Uganda. Her work combines a deep commitment to women's health with a focus on sustainable, community-based solutions.

In This Episode We Explore: 

• Definition and causes of obstetric fistula – and why this should never happen to any woman, anywhere in the world 
• The nefarious history of obstetric fistula surgery on enslaved women in the United States
• The medical, personal and social impacts of fistula on women's lives — and their incredible resilience
• Bonnie's journey from home birth midwife to fistula activist
• Holistic treatment approaches: medical care, social reintegration, and economic empowerment
• Efforts to prevent fistula through better access to maternal healthcare and the role of traditional birth attendants in fistula prevention

I hope you’ll join me in supporting the Terrewode Women's Fund. Donations can be made through their website, terrewodewomensfund.org. Even small contributions can make a significant impact, providing essential medical care and support to women in need.

The resilience and strength of these women are incredible. Their stories inspire us to keep fighting for better maternal health care.” – Bonnie Ruder

Transcript

Aviva: Welcome everyone to today's On Health episode. We're going to be confronting a fairly heart-wrenching challenge that's under-discussed but faced by women worldwide, particularly in many African nations. This is the devastating condition of obstetric fistula. I have seen women who have come from countries where they have had fistulas and minimal opportunity for repair, and the impact on women's lives is devastating. I first saw the impactful film “Walk to Beautiful,” which I highly encourage everyone to watch, when it aired in 2007, and I was utterly jaw-dropped by the stark realities it presented. This condition is often caused by prolonged obstructed labor without access to timely medical intervention and affects over 2 million women worldwide. It leads not only to chronic infections and incontinence, but those in turn lead to medical issues that women live with, like odor resulting from urinary and fecal incontinence, ulcers on their genitals, their buttocks, and their legs.

But also, and perhaps even more devastating—I can't speak for these women, but certainly my guest today will be able to represent what's really happening—is this deep level of shame and devastating social and cultural ostracization. So my guest today, Bonnie Ruder, will join me to explore the personal stories of resilience and the ongoing battle, if you will—and I don't use that word lightly because I tend to stay away from military language—but it really is such a challenge against obstetric fistula and the triumphs and enduring struggles of these really courageous women. Bonnie is a medical anthropologist, a licensed home birth midwife with over 20 years of experience, the mom of two boys and two stepdaughters, and she's the co-founder and executive director of Terrewode Women's Fund, a US-based nonprofit whose mission is to end obstetric fistula and other childbirth injuries in Uganda through long-term partnerships in the local community and through NGOs and other agencies in the region by supporting holistic treatment and access to safe childbirth education and services.

And I just want to say that as so many aspects of my life have unfolded, whether it's my online community or my teaching or my medical practice, I didn't expect the deep level of women's relationships and friendships that would come into my life through the On Health podcast. And one of those is with a woman named Julie Kay. I've interviewed Julie, and she is an incredible reproductive justice attorney, and now she's brought Bonnie into my life and into the On Health community. And Bonnie, I'm just so grateful for you and delighted to have a sister midwife here to talk with today. So thank you for joining me.

Bonnie: Oh, thank you. I'm actually so grateful to talk to you. I've followed you for years. When I was training to be a midwife, I read your books, and then I followed your journey as you became an MD and started writing about women's health and thyroid. So it's really an honor to be here.

Aviva: Oh my gosh. Well, thank you for saying that. It's funny, people think, “Oh, you get to a point in your life, and you're there.” But I feel like I'm always evolving, and it's really nice to hear. It's a reminder for me to also just like, “Oh, keep owning the legacy and doing what I'm doing too.”

Bonnie: Yeah, definitely. It's beautiful.

Aviva: Oh, thank you. So tell us first how and why you became a home birth midwife since you just shared that that was an early part of your journey.

Bonnie: Actually, after my undergraduate, I went and volunteered in Zimbabwe for a year, and I worked with a women's organization there and an amazing woman. Her name was Emma Mge, and she was out in the commercial farms. This was in the nineties in Zimbabwe. And we were setting up women's clubs and helping women, teaching them about HIV and also income-generating skills. But one of the things I kept hearing from women was when they were really remote on these farms, the struggles with their childbirth. So when I came back to the US, I took a detour. I think I was going to go into international development. Instead, I got my hands on “Spiritual Midwifery,” and I changed course completely and went to midwifery school. I thought that home birth midwifery was the right path for me. I knew someday I wanted to return to Africa and work, and I wanted something low-tech, high-touch, as I say it.

Aviva: You have to have. I worked for a month doing maternity care, and then you end up doing—I did pediatrics as a family doctor at the time. That was part of what I did as part of my residency in Haiti. I was easily able to acclimate to the environment whereas some of the OBs and family docs down there who had not had home birth midwifery experience didn't know what to do without an ultrasound or a fetal monitor. We have a different set of skills that are really important in the field.

Bonnie: Yes. So that was my path. And then I practiced for years here in Oregon and had my own family before I later returned to school for medical anthropology and dove into obstetric fistula work.

Aviva: And what was it about—there are so many things in maternal health and women's health that we can find. There's no shortage. It could be HIV. It could be—I mean, there's a million things. What was it specifically that first got your attention on fistula work and made you say, “This is where I want to put my time, my energy, my love, my knowledge”?

Bonnie: I think one of the most important things about fistula is that it is completely preventable and treatable. So this is a solvable problem. We used to have this problem here in the US, and now we don't. For most people I have to completely explain what fistula is when I first tell them about my work. And that is a tribute to the great maternity care. I mean, there are problems with our maternity care system here in the US, but women are not suffering from obstetric fistulas. So we know that this shouldn't be happening in this day and age anywhere in the world. And the fact that there are so many women in Uganda where I work—over a hundred thousand women are estimated to be suffering from fistula, and that just shouldn't be the case. So devoting myself and my work to a problem that we can fix was really appealing. And then also just the suffering that occurs with fistula. It's heartbreaking. And I guess I wanted to do something for these women.

Aviva: To your point that so many women here have never even heard of a fistula, and they were like, “What is that?” Let's break it down. Can you explain exactly what it is, what causes it, and what happens?

Bonnie: Well, it's a devastating childbirth injury that occurs from prolonged obstructed labor. The baby's head is actually compressing during that long labor, compressing the soft tissues in the mom's birth canal. And so these labors can go on from two to—I've heard of women who have labored for six days. During that time, that tissue that is compressed between the baby's head and the pelvic rim of the mom loses all blood supply. Once the baby is finally born, that tissue sloughs away, leaving a hole between either the bladder and the vagina, the rectum and the vagina, or both sometimes. Through that hole, there's continuous leaking of urine and/or feces. Sadly, this is a very difficult labor on the mom, but also the baby. In 90% of the cases, the baby dies during and is born stillbirth. So it's such a trauma for these women.

Aviva: You mentioned prolonged labors and obstructed labors, and certainly many women listening will have had the experience of the one or two or three-day labor that felt like it was never-ending, and maybe things resolved. Maybe there was pelvic rocking or rebozo use or an epidural or a forceps or vacuum extraction or C-section, but it was resolved. What is it in these other settings that is leading to these prolonged labors without any resolution?

Bonnie: That's true, especially as midwives. We're a little more comfortable with longer labors, but in these cases, a lot of the women who experience fistula are actually quite young and might have experienced a lot of malnutrition growing up. So their pelvis might not be fully developed and ready. We've had girls as young as 12 years old in the hospital with fistula. Uganda itself has one of the highest rates of teenage pregnancy in the world globally. So the smaller pelvis and not being fully prepared for pregnancy is one of the contributing factors. The other is just the poor maternal healthcare that's available to them. They aren't going to have people helping them switch positions and move and change. And then when they finally do need a C-section, that also isn't available to them. They have a really low C-section rate in Uganda, especially in the rural areas where women suffer from fistula. So when a problem is recognized, and they realize they need a C-section and this care, often the doctor isn't at the hospital, there isn't blood at the hospital, the oxygen and all the things you need for a successful cesarean delivery are not available to these women.

Aviva: What about traditional birth attendants and their ability to help with these longer labors? We know that here in the US, as midwives, we do always have the option to get medical care, but we also have things that we know can resolve these prolonged labors, like baby's head position. Obviously, we're not usually midwifing 12 and 14-year-olds at home, so that's a whole different story.

Bonnie: One of my first research projects in Uganda was with traditional birth attendants, and it was so fascinating and interesting to sit down and talk with them. In Uganda in 2010, traditional birth attendants were outlawed, and this was part of the government's efforts to get more women to deliver with trained healthcare providers in health facilities. Today, most women do deliver in health facilities, the majority of women. There are still home deliveries, of course, but I'd say because of the outlaw and also just the lack of investment, the traditional birth attendants in Uganda have not received a lot of training. Often, someone who's called a traditional birth attendant in Uganda is just the woman in the village who's had the most babies. In terms of having knowledge passed down over generations, so much of that has been disrupted. It was disrupted by colonialism, it was disrupted by war and political upheaval in Uganda. So that kind of tradition where women had this knowledge passed down and would know what to do in terms of prolonged obstructed labor, it doesn't exist in Uganda the way one would hope.

Aviva: I saw that quite a bit in Haiti as well. In fact, a lot of the local midwives were actually men, and many of them had cataracts and were arthritic. It was very interesting and kind of transformative of my somewhat romanticized beliefs, actually. One of the biggest problems we saw there, which I'm imagining is a very big issue in Uganda, was just the lack of transportation. Also, lack of access to medical facilities in communities, but then also no resources to get a woman who was even a half-hour or an hour away. A lot of these women would walk. We would actually note when women came to the hospital how far up their legs the mud went, especially if they had ruptured membranes. We could see from the fluid leaking and just dirt from the roads accumulating higher and higher up their legs depending on how far they had walked. Is that also an issue in Uganda, just ruralness and lack of access to transportation to get to places in long labors?

Bonnie: Absolutely. It is a huge problem. I did a maternal health assessment in Uganda in this region in the eastern region, and the district hospital, which is supposed to be where women are referred to from these health facilities when they need a C-section, the ambulance was sitting there with no air in the tires, no gas in the tank. Women live really far out. And then also during the rainy season, the roads can be impassable. It's a huge problem, the transportation. Sometimes women are delayed in getting money for the ambulance to take them to the regional referral hospital where there might be another delay before the doctor's there. They on their own will need to raise the money, their family, to put fuel in the ambulance to get them to the main hospital.

Aviva: Bonnie, I'm curious, with the really young age of girls becoming mothers, is that teenagers in relationships with other teenagers, or is this a country where there's more of a child-bride situation happening, or both? Or is there sexual assault resulting in pregnancies?

Bonnie: All three, absolutely. That young 12-year-old case was sexual assault, and I have seen very young brides, girls married off, especially if their parents have died, then family members will arrange a marriage for them. And then also teenage pregnancy in relation with other teenagers. That's a little older though.

Aviva: I shared just in my intro a little bit of some of the devastating impact – but I think it's really important to bring this to life – I just remember watching “Walk to Beautiful,” which was set in Ethiopia, and the walk was to the hospital. That was—it was an allegory of the journey, just women forced to live on the edges of town in huts that they had put together themselves. The odors as a risk for attracting animals. I mean, just so many layers upon layers of isolation, often their children becoming kind of outcasts if they were living with the mothers. It's so dire. And I wonder if you can bring to life some of why this issue is so important. I mean, the sheer numbers of women going through this, but what are they really going through?

Bonnie: It is dire. You're absolutely right. It's heartbreaking. So often the women themselves don't understand why they're leaking, and also their families in the community don't understand. I've talked to many women who were sent home from the hospital, realized they're leaking, and were told, “Oh, it'll clear up in a few days.” So then they go home, and it's not clearing up. They'll try multiple ways to get treatment, but they don't really understand. They're not given a diagnosis, which I think in itself is a tragedy. But then because of the odor, and they're living in villages in huts without running water, there's no laundry. Soap's expensive. So they often are built a solitary hut on the edge of the property and live on their own away from the family. They don't eat with the family, which women talk about all the time how hard that was for them to spend all this time alone. It's a very lonely disease. And I think all of us, we've experienced loneliness at some times, but every day, people just don't want to be near them. In Uganda, many of the women are divorced or abandoned by their husbands, and they're sent back to their parents or their family. If they did have children, in Uganda, the children are part—it's more of a patriarchal line, and they stay with the father and the father's family. So then they're also separated from their older children, which as you can imagine, they've just lost a baby and suffered this horrible injury, and now they're separated from their husband and their children.

Aviva: These are countries where women are often dependent on being married for survival, for shelter, for food.

Bonnie: Absolutely. And their ability to produce children. That's what they're valued for, sadly.

Aviva: I think for me, the scene in “Walk to Beautiful” that was the most poignant for me in some ways, there was a woman who was getting on a bus to go to the fistula repair clinic. When we talk about urine leaking and we talk about feces leaking, there is no control over it coming out. So this woman was sitting on the bus with just a puddle of urine trickling down her legs and puddling at her feet. Of course, nobody wanted to sit next to her, and her shame was so apparent. But this is also, as in so many countries, it's not just lack of access to sanitary products, it's lack of access to adult diapers, anything to contain. So women end up using old rags. Can you talk a little bit about the complexities of this? Because I really want women who are listening to us to really understand we're not talking about jumping on your trampoline and leaking a little pee. This is like zero control of urine containment or stool containment.

Bonnie: You're completely right. The women, they don't have access to any sanitary products to hide the leaking, but then that also creates a lot of odor. All that cloth up against their skin creates sores. And then at night when they're sleeping, their mattress gets wet. So they'll have a grass mattress, and that gets wet with urine or feces, and they just have to live that way day in and day out. It's a very isolating, embarrassing—they're full of shame. Most of the women consider suicide at some point. That was one of the really tragic things I discovered in doing the research. When I sat down with these women and heard their stories, they just didn't want to go on living. It was that bad. It destroyed their lives.

Aviva: Are women finding each other and talking with each other? Did they realize they're not alone?

Bonnie: No. Many of these women are really isolated because it's not that prevalent of a disease. So they might be the only woman in their village who is suffering from this. This is one of the beautiful things about the hospital is that once the patients are all there together, the women, that alone is healing for them. To find out that they weren't alone, that this wasn't their fault, that there are other women who have been suffering from this, and that sisterhood just develops in the hospital. You can see their face, everything about them becomes lighter. They're like, “Oh, this wasn't my fault.” They're sharing stories and helping each other heal from the pain. It's really quite beautiful, that realization that they're not alone.

Aviva: So tell us about Terrewode. What does it mean? How did you found it? What is it doing? What are the obstacles? Tell us all the things. It's incredible.

Bonnie: Terrewode was founded in Uganda in 1999 by Alice Emasu, and she is just a powerhouse and a true visionary. For years, she put together an amazing team of women, and for years, they were working on helping women access treatment in local government hospitals. Those were mainly done through fistula surgical camps. So it'd be like a two-week camp where they would do radio ads and some outreach, and a bunch of women would show up to get surgery. But over the years, they realized, one, women were waiting for care way too long because these camps were held so sporadically, and two, the quality of care in these camps; it's just not an injury that can be healed that quickly. A lot of times there are complications, and women need more additional care, and that wasn't available in these camps. The women weren't treated with the nurturing care that Alice and her team thought they should be. So their dream became to create their own hospital, similar to the Hamlin Hospital in Ethiopia. I worked with Alice in Uganda in 2011 and 2012. I moved there for a winter with my family, my two young boys. They were eight and eleven, and we totally bought into this dream. It really changed the course of my life. I came back to the US, and within a few years, I founded Terrewode Women's Fund. We are the US-based nonprofit, and our mission is to support Terrewode in their work to end fistula in Uganda. We are long-term partners, and we stand in solidarity with Terrewode in fighting fistula in Uganda.

Aviva: What are the stages of repairing fistula that women go through? And it's not just the repair but this reintegration, and how does their community welcome them back after they've been ostracized for so long?

Bonnie: One of the good things about fistula is that it is treatable. With surgery, about 90% of women can be successfully repaired, and their continence completely restored. So that is amazing, and that is one of the things that we work so hard to make sure women have access to the surgical care. But the other part is healing from the trauma of therapy. Terrewode, all the years that they were working to help women access treatment in the public hospitals, they started realizing that treatment alone, the women were still ostracized often in their community, and they also still carried this heavy burden of shame. I think in the US, we've learned so much more recently about trauma and how it affects us. So I think we can all imagine what the impact of this is on women. 

They developed a holistic reintegration program. This is a two-week program, and they provide individual counseling, group counseling. They provide education. For some women, this is really when they learn why they suffered from the fistula and how it can be prevented. They become safe motherhood advocates, and they learn all—they're educated on safe motherhood. They also get legal rights, so they return to their community as advocates for improved maternal health. The last part is the economic empowerment. They teach microfinance skills and help them form savings clubs, but they also do income-generating skills training. These women, they have been so impoverished by fistula and just pushed really deep into poverty. So when they return to their communities, now they have a skill, and they can start their own business and just really feel empowered and start their new life with their fistula healed. It's really like a transformation. They return, and they have their dignity back, and they're empowered and confident again. So that's a really beautiful part of the healing journey.

Aviva: That's incredible. I'm so curious, for women who have been more aggressively shunned by a now-former husband or parents, are these women able to return home and not hold onto anger? I'm not exactly even sure what the emotion would be, but are they able to feel part of their families again? Or is there just a lingering, “Hey, I was in need, and you totally rejected me, and now I need a different community and a different place and way to be”?

Bonnie: I would say there's some of both, but I would say in most cases, they are able to repair the family. Terrewode will bring the family and the husband actually to the hospital, or they'll all go to the community and do counseling. I'm amazed at how forgiving these women are and how much they can just move on with their life. It's something I've learned. I've learned so much from these women—their resiliency. It's stunning to me, what they've endured, and then how they can sit there and laugh and smile with me and just be grateful for the small things in life. It's been a true learning and beautiful lesson for me, the forgiveness. But then there are some families that—gender-based violence also is a part of fistula. There are some times when Terrewode and the women realize it's not safe to return to that community or to that marriage. We will help them relocate somewhere else where they might have a sister or an auntie or someone. Another beautiful thing about the hospital is that they employ caretakers at the hospital who were former fistula survivors. These are women who either live nearby the hospital or, for whatever reason, couldn't return to their community. So now they're employed, and they actually get to be part of helping other women heal from fistula.

Aviva: That's so beautiful. And who are the healthcare workers that are providing the surgical support?

Bonnie: We have three Ugandan doctors who are at different levels of training. There's a quite intensive training program for fistula surgeons, and Terrewode hires all local clinicians from Uganda. One of the things about Uganda that's unique is there's 40 local languages, I think actually over 40 local languages. One of the things that Alice and her team do is they hire nurses who can speak many languages. They try to get people speaking all the different languages, so there's always a translator when women from very remote areas come in. Someone can communicate to her in her language, which is also really comforting to the women to have everything explained in their local language.

Aviva: One of the things that we hear about, and I certainly talk about in the US, is the overuse of cesarean section as a major risk factor for maternal health. Then we have places like Uganda or where I worked in Haiti, and I think you've worked in Haiti too?

Bonnie: Yes.

Aviva: So the conditions there, another deeply medically under-resourced country. The World Health Organization is actually pretty clear on this, right? There's a range of 15 to 19% C-section access being the sweet spot. When we go over 19%, it actually has diminishing returns for mom and baby as a dyad, which we have here in the US with rates as high as—well, an average of 34%. But then you mentioned Uganda, just a complete lack of access to C-sections, or significant lack, especially in rural areas. I'm so curious for you as a midwife who has worked in Uganda and in Haiti and in the US, what are some of the parallels and the differences that you see in these contexts? Any kind of universal lessons about how we think about birth, why birth isn't safer for mothers everywhere, and what we can do to make birth safer both in these over- and under-resourced? A big question. So you take it where you want to go.

Bonnie: I think one of the things that's been on my mind a lot lately is just the lack—it's reproductive justice. In Uganda, mothers and children, there's so much talk about how they're valued, but then when you see where's the money to care for these women in the hospital, where's the maternal healthcare? It's just not there. So that's a reproductive justice issue. Here in the US, we are seeing that. So it's women's ability to make choices for themselves, but also the Black maternal health crisis here in the US. I mean, that's just stunning, and that shouldn't be happening. I listened to your wonderful interview with Sharon Malone in April, and she was talking about Michelle Browder and her work in Alabama with Anarcha Lucy and Betsy and those statues. Those women, actually, they were slave women who had obstetric fistula. The surgical experiments they were doing without anesthesia, it was fistula. So these are longstanding problems that have occurred here in the US, and then we continue not to invest. In the US, if there was a true investment in maternity and reproductive justice here, there'd be paid maternity leave. You have a baby, you should have some time off to take care of that baby and bond with that baby. So we don't see the investment here in the US and the prioritization, and we also don't see it in places like Uganda and many countries in the world, sadly.

Aviva: And I should clarify too that even though we do have a rampant overuse of C-section and other obstetric interventions in this country, and that's really so profit-driven, we have entire states in this country, in what is called the Black Belt—Alabama, Georgia, Mississippi, etc.—where there are hundreds of counties combined that have zero maternal health, no hospital, no family physician who's doing obstetrics. So we do have these incredible—there's a term that Leah Penniman of Soul Fire Farm first introduced me to, which is rather than saying food deserts, we say food apartheid. I've started using the term, and I don't know if anyone else is using the term, but it slipped out recently, and I've now started to say medical apartheid. We do have medical apartheid in the United States, which isn't entirely dissimilar. I mean, the disparities of the levels of poverty in a place like Haiti or Uganda are unique and specific, but we have significant poverty and significant lack of access to care here. And it's very racialized and very biased.

Bonnie: Yeah, I mean, it's shocking and it's shameful.

Aviva: It is shameful. I heard the—I'm not going to name names, but I was at a meeting, and I heard the president of one of this country's major hospital systems say that the maternal morbidity and mortality rates in the United States should be the most shameful thing we recognize about American healthcare and about our culture in general. This was so profound.

Bonnie: Yeah, I agree 100%.

Aviva: Yeah.

Bonnie: I co-founded Terrewode Women's Fund in 2014, and our first goal was to help Alice and her team raise money for a dedicated fistula hospital in Uganda. I'm happy to say we were successful, and the hospital opened in 2019. It's a beautiful facility in Eastern Uganda. This year, this last year, 2023, we celebrated a thousand patients treated—so a thousand women and girls whose lives have been completely transformed and restored and their dignity restored. It's an amazing hospital with holistic, patient-centered care. I talked about the sisterhood that develops, but also the Terrewode team, they put the women and girls they treat at the center of all their decisions. It's such an amazing healing space. They also have the first and only physical therapy program for women suffering from fistula and pelvic floor disorders. So yeah, it's pretty amazing, and we're very proud of this hospital.

Aviva: And how does it stay funded now?

Bonnie: So that's where we come in here in the US. Raising money in Uganda is really hard, and this is part of the reason I started a nonprofit here in the US. I believe this issue is so important, and I know that when I tell people about it here in the US, they also want to help. So we fundraise here in the US and raise awareness, and then we practice trust philanthropy with Terrewode, where we are very trusting, transparent partners in supporting them in their work. That's how all the funding—none of the patient care is completely free of charge, and so everything from the transportation, the meals, the surgical care, the reintegration program, the patients don't have to pay for any of that care. It's all supported by donations from here in the US and also from a few other places around the world.

Aviva: Is this your full-time work now?

Bonnie: Yeah, it is my full-time work now. It is.

Aviva: Is it a team of you, or do you have a team?

Bonnie: It's a team of me. I have a very active board. I have a few consultants, and we've been really successful the last few years though, so we're hoping to grow. So it might not always be a team of just me.

Aviva: For those who are listening who would want to get involved in helping to support your work, how could they do that?

Bonnie: We have a website, terrewodewomensfund.org, and on there, we have a lot of ways to get involved. You can sign up for our newsletter. You can fill out a form to get in touch and volunteer. And then most importantly, I'd say, you can donate. The full cost for surgery is $1,200. So a lot of people donate monthly, and some of them who can afford it donate $100 a month, and in a year, they support a full cost of a surgery for a woman or girl. One of our board members pointed out that that's less than the cost of a latte each day. So that's kind of amazing. But we have people give—I’d say most of our donors give small amounts, and that really supports the work. You can look on our LinkedIn and our YouTube. We have some videos also of the work and patients that we've worked with in Uganda, so that's another place that they can find us. Did I already say Facebook and Instagram?

Aviva: We'll make sure to put all the information in the show notes so that everyone can find you and find Terrewode Women's Fund. Can you also just tell us for those people who are like, “I'm feeling like doing something right this second, and I don't have a minute to go to show notes,” what can they do if they're just like, “I want to donate right now”?

Bonnie: Go right to our website, terrewodewomensfund.org, and there's a donate button right on that homepage. That would be wonderful.

Aviva: So it's T-E-R-R-E-W-O-D-E?

Bonnie: Yes, that's exactly right, terrewodewomensfund.org.

Aviva: Bonnie, we've talked so much about this really devastating problem, and even though I know you said it's rare in the sense that it may be only one woman in her village, but actually, cumulatively, it's not rare. It's really significant. Clearly, you and I know as midwives, as women, prevention is always the goal, not just repair. In fact, if we could do more prevention, that would be incredible on every level. So what are the efforts that are being done, and what can be done, especially in these rural communities, to prevent fistula?

Bonnie: Yeah, prevention is the key. If we don't prevent fistula, this hospital is going to be running for years repairing fistula. Actually, we're in a very exciting time for Terrewode Women's Community Hospital. We are starting to plan for phase two of the hospital, which is a maternal center of excellence. So it'll be a full maternity hospital that starts with high-quality prenatal care all the way through postpartum and, importantly, really high-quality and timely C-sections for women that need it. The other wonderful thing about phase two, this Terrewode Maternity, will be that we are envisioning it as a training center. So we want to bring up the quality of care in the whole region and bring in clinicians from some of these rural health facilities and kind of upskill them, provide them additional training and some simulation training. So the idea is not just to create one high-quality maternity center but to bring up the level of care and show what can be done in terms of providing excellent care in Uganda.

Aviva: Amazing. Thank you.

Aviva: I'm really just so grateful you're doing this work and really excited to hear how it evolves over time and just to look at those fistula numbers going down. I mean, this sounds like it has the potential to be incredibly impactful. Bonnie, you have followed your inner voice and created a path that is not the average traveled path. You became a home birth midwife. You reinvented yourself with medical anthropology as an add-on when you felt like you wanted and were inspired to know more. You went to Uganda. I'm so curious—two things: What is it that allows you or inspires you to have that confidence in your inner voice and follow that? And then there's a question I ask all my guests, which is, if you could tell your younger self anything, how old would she be, and what would you tell her? So kind of the amalgamation of that—you're following your inner voice, how do you know to do that?

Bonnie: I have written on my board here in my office, “How can I be of most service in the world?” And that is kind of my guiding light in life. I really want to be of service and help create a better, healthier world for people. So that's my north star. And then my younger self—you're right, my path has not been straightforward, and I think I would tell her that that's going to be okay. It's going to work out. It's going to be curvy. You're not going to always know where you're going, but you're going to meet fellow travelers who want to join you on this path, and it will ultimately be beautiful.

Aviva: Well, I'm with you on service being the north star. I have a beautiful—I'll pick it up for when we have video—but it's a beautiful gift that was given to me, and it's just kind of like the New York symbol with the “I love New York,” but it says “give” with the heart for the V.

Bonnie: Oh, I love that.

Aviva: I keep this right front and center on my desk. Service and following a path, kind of carving our own path in a way, is something we both share in common. I see the light and shine in your face from the give-back that the work gives you.

Bonnie: Absolutely.

Aviva: So thank you for that. Everyone, this has been a journey into perhaps a topic that you have never heard of before, and I hope it's been expansive. I hope that in hearing Bonnie's story, if there's something close to your heart that you're also inspired to give into or be part of or serve, that you trust that. There's a beautiful quote by Rumi. It's one of my favorite quotes, and that is, “Whatever you're seeking is also seeking you.” So trust in that inspiration. It may not be that you have to move to a foreign country and change your whole life or go back to school, but there may be small, local ways that you feel like there's something you want to contribute to. We don't use this podcast per se as a fundraiser, but we do often have folks on who are creating incredible things and incredible change in the world, and they're bootstrapping it and can use our support. I know that we will be contributing to Terrewode, and we welcome and invite you to go to the website. If you can, if it's one latte a day's worth or more, it's a cause worthy of contributing to because a small amount really can change women's lives. I truly believe that when we change one woman's life, the ripple effect is exponential and uncountable. So thank you all for being here. Thank you, Bonnie, again, for being with me and for doing all that you do.

Bonnie: Thank you so much for having me.

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