Obstetric fistula: Another reason CII is wrong on underage marriage

May 23, 2014

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"The CII's response is a blow to all that we have been advocating for years against early marriages," Dr Sajjad Ahmed says.
"The CII's response is a blow to all that we have been advocating for years against early marriages," Dr Sajjad Ahmed says.

Dragging the urine bag behind her, Hamida walks up slowly towards the doctor and lays down the chaddar at her feet. With tears trickling down her weather-beaten cheeks, she implores the doctors to make her healthy again.

"It's a very bad disease; a very bad one indeed. I smell all the time. It's taken a toll on my entire family," she says.

There are many like Hamida at Karachi's Koohi Goth Women's Hospital, who are being treated for an injury that occurs during childbirth called obstetric fistula.

According to the 15th State Of World's Mothers 2014, launched early this month by Save the Children, Pakistan is among the most perilous places to be a mother, ranked 147th among the 178 countries.

Among South Asian countries, Sri Lanka was the best place to be a mother at 89th position, while Pakistan scored last in the region among all neighbouring countries including Nepal (116th), Bangladesh (130th), India (137th) and Afghanistan (146th).


Also read: ‘Nearly 5,000 fistula cases surface every year in Pakistan’


An entirely preventable condition if you ask the international medical community, fistula develops during prolonged labour, when the baby's head puts pressure on the lining of the birth canal and eventually rips through the wall of the rectum and bladder, resulting in urinary or faecal incontinence.

Dr Suboohi Mehdi, a surgeon at the Koohi Goth hospital says the lethal combination of "poverty, illiteracy and socio-cultural practices" has helped the disease to spread.

Obstetric fistula is perhaps one of the most telling examples of inequitable access to maternal health care and, until recently, one of the most hidden states the United Nations Population Fund (UNFPA). On May 23, the world observes the second annual 'International Day to End Obstetric Fistula'.

In the eight years since the fistula project began in Pakistan, with the help the Pakistan National Forum on Women Health (PNFWH is a non-government organisation working for reproductive health), 12 fistula repair centres have been set up across Pakistan, all in government hospitals working under 38 trained doctors.

Unfortunately there is no fistula-specific data available for Pakistan, which indicates the official apathy surrounding the condition. But Dr Sajjad Ahmed, manager of the PNFWH's Fistula Project, estimates there can be anywhere between 4,000 and 5,000 women in the country suffering from the condition which can only be treated through reconstructive surgery.

"While we are able to treat a 500-600 women each year, we have the capacity to do approximately 2,000," said Ahmed.

The custom of early marriages in society is one of the biggest factors leading to this condition. Mehdi says,

When a mere child becomes a mother herself, what do you expect?

"Her bones are weak and the nutrition of the mother-to-be is not taken care of in this male-dominated society.

"Together, with fewer or no health facilities in their areas, the tradition of home deliveries where pregnancy-related complications cannot be diagnosed in time and traditional birth attendants unable to handle such deliveries has resulted in high maternal morbidity and even deaths."

Take Sheherbano for instance who was married off two years back to 27-year old Umaid Ali, when she was just 12. Barely a kid herself, she delivered a healthy baby boy a fortnight back in the village of Choohar Jamali, in Thatta district.

But her condition has cast a pall of gloom over the happy couple.

"She had a long and difficult labour. The dai tried to deliver the baby at home, but after four hours, gave up and we rushed her to a private hospital, in Choohar town. The midwife succeeded in saving both the baby and my wife but she was in a lot of pain for several hours. After delivery, she asked me take her to Karachi and to this hospital," Ali, a farm hand, explained.

He has taken a loan of Rs 50,000 and is worried he may run out of funds soon.

"I don't know how many days we are supposed to stay here," he wonders absently.

"It often takes a number of surgeries, over several months before they are completely dry and smell-free," says PNFWH's Ahmed.

But Ali has no idea that his wife's complication could very well be because her body may not have been ready to give birth. When he is told, this, he says with some misgiving: "It's a custom in our village that as soon as the girl reaches puberty, she should be married off. That's what her parents did," he says shrugging uncomfortably.

At that point, Sheherbano, who has all along been listening quietly, interrupts and says adamantly she would make sure that if she has a daughter, she does not go through what she did. She says,

I will wait for her to get a little older, maybe till she is 16.

"I would tell Sheherbano to put her daughter to school, this will automatically delay marriage," says Ahmed, but adds: "Given the cultural barriers, where delaying marriage may not be possible, I would tell her teach her daughter about the various contraceptive methods available to delay her pregnancy until she is at least 18."

The young couple from Thatta has no idea that last month the Sindh Assembly passed a law prohibiting child marriage.

The Child Marriage Restraint Act 2013, prohibits marriage of children below 18 and those violating the law would be penalised. Those found guilty could be sentenced to three years imprisonment and could also be fined Rs 45,000. The Sindh Assembly is the only one to have passed such a bill.

Back in 1929, a bill introduced the age of a girl for marriage to be 14 years and in 1965, it was amended to 16 years of age.

Interestingly, the Child Marriage Restraint (Amendment) Bill 2014, follows hot on the heels of the recent controversial proclamation in March 2014, by the Council of Islamic Ideology's chairperson Maulana Muhammad Khan Sherani who had said: "The laws limiting the age for both the segments of marriage are un-Islamic and needed to be rectified."


Also read: CII endorses underage marriage


Bushra Khaliq, rights activist and executive director of Women in Struggle for Empowerment (WISE)-Pakistan, the government of Sindh has full support from the country's civil society.

But it has been strongly opposed, yet again by Maulana Sherani. "Some people want to please the international community against Islamic teachings and practices," he said.

"CII's response to the amendment in the bill is a blow to all that we have been advocating for years against early marriages and their consequences. Such proclamations only confuse people who are reluctant to let go of cultural traditions which have scientifically proven to be harmful," Ahmed says.

Dismissing the CII chairman's response, Khaliq said: "Few religious scholars are in favour of early marriages; most support the amendment in the law."