FROM Kharan district in Balochistan, Sameera is around 20 years old and has three children. During her fourth delivery, at home with a dai, her labour continued for two days.
Eventually she made it to hospital where she finally delivered another day later — a stillborn baby. Back at home she noticed an almost constant and uncontrollable urine discharge.
The shame of it sent her into exile to her mother’s home for a year until she sought help at the fistula repair centre at Koohi Goth Hospital in Karachi.
Obstetric fistula is one of the most devastating injuries to occur during childbirth. It is a hole that forms between the birth canal and bladder that leads to continuous, uncontrollable flow of urine and sometimes faeces. The main direct cause of obstetric fistula is prolonged, obstructed labour during childbirth. Of all the pregnancy-related health complications, obstetric fistula is perhaps the most tragic. It causes not only physical discomfort but also deep psychological and emotional trauma. Women with uncontrolled urine flow are often shunned by their families and communities, condemned to lead isolated lives as outcasts.
Approximately 3,500 women in Pakistan develop fistula every year according to estimates by the United Nations Population Fund. May 23 marked the International Day to End Obstetric Fistula, a condition that affects an estimated two million women worldwide. This occasion is an opportunity to remind our government of its unmet promises to protect and promote the rights of women to healthy pregnancy and childbirth.
Obstetric fistula is an appalling condition in every way.
Obstetric fistula is an appalling condition in every way. It is entirely preventable. It afflicts the poorest women in our country, usually those living in remote areas, due to the lack of affordable, accessible and quality maternal health services. It is caused by social practices harmful to women and girls: those who marry as children are more likely to experience obstructed labour because their bodies are not ready for motherhood. Fistula is also more likely to occur in women without access to family planning methods that allow them to limit and space their pregnancies.
Finally, obstetric fistula can be prevented if doctors manage an obstructed labour with timely caesarean section.
However, caesarean section performed by an unskilled and negligent surgeon may lead to what is referred to as iatrogenic fistula. Unfortunately, there are many cases of iatrogenic fistulas also in Pakistan due to the lack of skilled and qualified gynaecologists.
Although fistula can be cured through a relatively simple surgery, many women are forced to live with this condition for years due to the lack of awareness that it is curable and no access to affordable treatment. Most government hospitals are unable to provide fistula treatment. Koohi Goth Hospital is the most well-known charitable facility offering free repair of fistula in Karachi. Liaquat University Hospital in Jamshoro and Shaikh Zaid Women’s Hospital in Hyderabad are two government hospitals that do fistula repair.
The fact that obstetric fistulas persist as a problem for women in Pakistan illustrates the dire state of maternal health in this country. Roughly one maternal death occurs every 20 minutes. If you are a woman of reproductive age in Pakistan, the biggest risk to your life is posed by pregnancy.
However, if you were to judge Pakistan’s devotion to maternal health by the number of its international and local commitments, policies and programmes, you could be forgiven for believing that maternal health is a top priority for our government. In 2005, Pakistan adopted the UN Millennium Development Goals, which includes the goal to reduce maternal deaths to 140 per 100,000 live births by 2015. The federal government adopted a comprehensive policy addressing all aspects of maternal health in 2006. The National Framework on Maternal Newborn and Child Health 2006 set out a detailed scheme for the provision of maternal healthcare at primary, secondary and district-level government hospitals. (At that time the maternal mortality ratio was 276 per 100,000 live births.)
In 2010, with the devolution of healthcare to the provinces, implementation of the national framework fell on the provincial health departments. Yet the schemes and policies set forth in this framework are not mirrored on the ground.
Pakistan will not meet its MDG targets for maternal health in any province, even though nationally the MMR is coming down. (WHO estimates put the figure currently at 170 per 100,000 lives births.)
Obstetric fistula like many maternal morbidities, can be prevented if the government decides to keep its promises to ensure the right to reproductive health. Women with obstetric fistula cannot lead a life of health and dignity, which is their right under our Constitution. A woman should not imperil her right to live a healthy, productive and dignified life simply because she becomes pregnant.
Sara Malkani is a lawyer based in Karachi. Ayesha Khan is with the Collective for Social Science Research.
Published in Dawn, May 24th, 2015