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HEALTH-PAKISTAN:
Obstetric Fistula - Grim Reminder of Unmet MDGs
Zofeen Ebrahim

KARACHI, Jan 17 (IPS) - ''I wouldn't have thrown her out but would certainly have remarried,'' says Mohammad Qasim easily, sitting in a verandah at the Koohi Goth Maternity Centre in the suburbs of this southern port city.

Married for 16 years to Qasim, Najma Bibi bore him eight children. Three of them died, the last from obstructed labour that called for surgical intervention to reapir obstetric fistula. Najma cannot thank her doctors enough, for they saved her marriage.

When complications arose during labour, the dai or traditional birth attendant (TBA) gave up and asked Qasim to take Najma to a doctor. "We didn't have money for an operation (Caesarean section) so I went to my relatives to borrow some,'' said Qasim. Najma waited in pain and by the time the fees were arranged she had delivered a dead baby and developed a fistula.

An entirely preventable and treatable condition, fistula is caused by prolonged labour. As the baby's head presses against the lining of the birth canal, it perforates the wall of the rectum and bladder leaving the mother unable to control her excretory functions.

The unrestricted flow of urine and faecal matter then leads to immense psychological trauma and social ostracism. The victim also becomes prone infections and crippling nerve damage.

According to United Nations Population Fund (UNFPA), nearly two million women -- a vast majority in sub-Saharan Africa and parts of South Asia -- suffer from this devastating injury. A major challenge for health care professionals is that each year that number is increasing by over 50,000 to 100,000. Yet, true prevalence remains underreported and is a stark indication of the low priority given to women's health on national health agendas.

But for a global effort, in line with the Millennium Development Goal (MDG) of reducing maternal mortality by three-quarters by 2015, there is a need to develop specific fistula repair programmes that can be integrated into women's right to health.

What is tragic, however, is that fistula can be avoided by stopping child marriages, delaying the age of first pregnancy, by cessation of harmful traditional practices, and by timely access to good emergency obstetric care (EmOC).

Sakina was married before she reached adolescence and moved by her mother-in-law to her husband's bedroom as soon as she began menstruating. Three pregnancies followed of which two ended in miscarriages. Sakina, now 20, talks of how she became incontinent after the first pregnancy. ‘'I went to the village pir (spiritual healer) and got better. But by the third pregnancy, it got worse. Unable to take care of me, my husband sent me to my mother's house. Taking pity on my condition, my brother brought me here."

Availing the free time on her hands, Sakina, who has been at the maternity centre for three months, has been attending adult literacy classes. "I can write my name now," she says proudly.

But the important lesson that she and her mother-in-law have learnt during her stay is that early marriages are to be avoided. "But our knowing this is of little help as decision on marriage, when and to whom, is taken by our menfolk. You should teach them," says her mother-in-law.

Dr Shershah Syed, a leading gynaecologist and founder of the Pakistan Forum on Women's Health, a non-government organisation working for women's reproductive health, laments that there is "no place for such women (with fistula) in Pakistan's national health policy". Syed learnt the technique of repairing fistulas at the Addis Ababa Fistula Hospital over a decade ago and has since been running free fistula repair camps in the remote areas of Pakistan.

Of Pakistan's 145 million people, 33 million are women in the reproductive age. And every 20 minutes, a woman loses her life while giving birth in the country. The UNFPA estimates maternal mortality ratio in Pakistan to be 533 per 100,000 live births.

Of the women who survive, many suffer illnesses, injuries and disabilities that plague them for the rest of their lives. "We keep forgetting those who did not die but wish they had," says 86- year-old Imtiaz Taj Kamal, secretary general of the National Commission for Maternal and Neonatal Health (NCMNH).

In Pakistan, 80 percent of births take place at home, usually with the assistance of TBAs, says Dr Sadiqua Jafarey, president of the NCMNH and professor of Obstetrics and Gynecology at the Ziauddin Medical University. "A TBA will not be able to recognise many complications."

Bleeding particularly after child birth, conditions related to high blood pressure (fits or convulsions due to high blood pressure, infection (sepsis) after childbirth, prolonged labour and abortion, particularly abortion induced by TBAs, are some of the complications. "The underlying contributory causes are poverty, illiteracy, low status of women and non-availability of emergency obstetric care in case of complications," says Kamal.

In 2006, the UNFPA launched its first-ever national campaign to end fistula in Pakistan, putting in one million US dollars for three years. This is part of its global campaign in over 30 countries of South Asia, Africa and the Arab region in a bid to eradicate this disability.

Seven regional centres -- at Karachi, Islamabad, Multan, Quetta, Larkana, Lahore and Peshawar -- have been set up where surgeries to repair fistula are carried out free of charge. Awareness raising meetings are also organised in the community and the mosque imams, local medical persons and media are involved to help in the endeavour. "But it works best by word of mouth, when a satisfied woman goes home and tells others about her recovery more come in," says Dr Ayesha Haq, one of the doctors at the maternity centre which, since March 2006, has sent 80 beaming women home. "Many of the women I see everyday have tragic stories to tell of how being rejected by their families,'' says Haq.

Just the smile on their faces is rewarding enough for Haq. Operating on fistula patients requires expertise but 95 percent of cases are repairable, she says.

Cultural taboos are the foremost hindrance in getting the women to come to the centre. ''Although we provide free transport, many women are unwilling to venture so far. It's a long process and may take months for the patient to get well completely -- from a month to even six months where multiple injuries need to be closed."

Secondly, says Haq, the women cannot believe they can get well and that it would not cost them anything. ''Many have gone for treatment to TBAs, quacks and even spiritual healers and spent a fortune -- and they have become resigned to their fate. They are also scared of being operated upon.''

Another problem is that there are taboos against women living away from home for extended periods. ‘'Knowing this we extend our hospitality to one female attendant. Often the husband also comes along saying that the community does not accept the idea of a woman living away in a strange place, even if accompanied by a close female relative.''

"The UNFPA provides theatre equipment, patient transportation, surgery cost, medicines and food. When the woman leaves the centre, to celebrate the start of a new chapter in her life, she is sent home dressed up in a new set of clothes," says Haq. In its first year, this support project will end in 2008, but Haq is not overly worried. ‘'We will continue running it as smoothly as it is now being run. We have friends who, I am sure, will extend us their support."




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