Considering the poor conditions of the health sector in Sindh, civil society members filed a petition in Sindh High Court against the Sindh government. “The inspiration,” says Sara Malkani, a lawyer, “came from Indian activists who have filed fundamental rights petitions against their government to draw attention towards its failure to provide basic rights to citizens.”

The petition has been filed particularly against the Health Department of Sindh on behalf of the women suffering from obstetric fistula claiming that they are facing this misery due to lack of maternal health facilities in general and the absence of a policy for fistula treatment in particular. Represented by lawyer Malkani, the petitioners are Kiran Rohail, a fistula patient, Sheema Kirmani of Tehreek-i-Niswan and Dr Shershah Syed. Cases of several other patients have been mentioned in the petition.

WHAT IS IT?

Obstetric fistula is the most devastating and serious of all childbirth injuries and common in the world’s poorest countries including Pakistan, where too many mothers give birth without any medical help. Since obstetric fistula is an opening between the bladder and the final section of the birth canal and the large intestine, caused by prolonged obstructed labour, it leaves the woman incontinent of body wastes. It’s a condition which arises during childbirth where timely emergency obstetric care is not available. Nevertheless, the condition is treatable.

One million women worldwide suffer from this preventable condition and for many in Pakistan, being stigmatised adds to the suffering

If a woman’s labour becomes obstructed, she endures days of prolonged labour, sometimes up to five or six days. Her baby is unlikely to survive. And if the woman survives, her body is literally broken by childbirth.

Obstetric fistula is highly stigmatising, indeed, a taboo in our society. Not only do women with this condition suffer physically, they also face social isolation, discrimination and ensuing psychological pressure due to the stench and bodily discomfort. Many are abandoned by their husbands and families, and treated as though their problem is a curse or divine punishment for a wrongdoing.

The condition afflicts the poorest and the most marginalised women and girls lacking access to timely and life-saving maternal and reproductive healthcare, which is a basic human right.

KIRAN’S STORY

Thirty plus Kiran Sohail’s story is no different. During the birth of her first child in 2006, she suffered from obstetric fistula. Despite living in the booming metropolis of Karachi, an untrained midwife (dai) from her neighbourhood assisted her delivery. Soon after the birth, Sohail noticed that her bodily wastes would leak without control. Over the months, she sought treatment at private and public hospitals but doctors were unable to help her. Some told her that she needed surgery which they weren’t trained to perform. She continued to live with fistula for eight years and had five more children. Unable to perform daily chores or to go out comfortably, her daily life became a misery.

In 2014, her nephew who worked at Koohi Goth Hospital, Karachi, suggested that she opt for surgery there and in November, her surgery took place. She now lives a dignified and productive life.

NUMBERS

Dr Raheela Mohsin of Aga Khan University explains: “The prevalence of obstetric fistula in Pakistan is around one percent. However, the risk factors are lack of education, low socioeconomic background with no access to antenatal care and approach for secondary/tertiary care hospital. It also occurs among malnourished girls, and those who get married and get pregnant in teenage years.”

Dr Sajjad Ahmed Siddiqi, project manager of Pakistan National Forum on Women’s Health (PNFWH), explains that 99 percent of fistula cases take place among poor women. “The main reasons are lack of education, early marriage and stunting (short stature, which is the result of poverty and malnutrition). Of these, early marriage is the most crucial cause. Girls as young as 15 or 16 years are having babies. Since they are weak, they have higher incidence of obstructed labour resulting in fistula.” A look at the patients’ record at PNFWH (almost 2,000 patients) revealed that all women seeking surgery at the centre were poor and illiterate.

While fistula has almost been eliminated from the developed world, it continues to affect the poorest of the poor women and girls living in some of the most resource-starved regions in the world. Pakistan is one of the countries where, due to poor healthcare services, obstetric fistula has become a major challenge.

According to the Pakistan Economic Survey 2016-17, over the last 10 years the country’s health expenditure has been about 0.5 to 0.8 percent of its GDP which is far less than the World Health Organisation (WHO) benchmark of six percent of the GDP required to provide basic and life-saving health facilities. According to World Bank’s latest report, currently Pakistan’s per capita health spending is 36.2 US dollars which is, again, far below the WHO’s low-income countries benchmark of 86 dollars.

Public health activities have increased in terms of physical infrastructure and workforce and the government of Pakistan also claims that the number of doctors, dentists, nurses and Lady Health Visitors (LHVs) has increased. The ratio of doctor, dentist, nurse and hospital bed versus population has also improved. However, that still means that at present, there is only one doctor attending 997 people and one hospital bed for 1,584 people in the country.

The Maternal, Neonatal and Child Health (MNCH) Programme was launched in 2007 at Sindh. The aim was to improve women and children’s health through better service delivery and supported health systems by providing comprehensive emergency obstetric and neonatal care services and family planning services.

Talking about the lack of doctors and health facilities in Sindh, Dr Fazlullah Pechuho, the Secretary Health Sindh, says 5,400 doctors have been trained and they are being posted on domicile basis in their respective districts. He conceded that referral system is weak but blamed the doctors for not doing their job.

While the government may claim to have improved health facilities in the country, maternal death rate of 170 per 100,000 speaks of the state of the health delivery system.

It is a fact that 3,500-5,000 new cases of obstetric fistula are reported every year in Pakistan, of which about 1,500 are from Sindh. According to Dr Shershah Syed, president of Pakistan National Forum on Women’s Health (PNFWH), out of these, only 20 to 30 percent are brought to hospitals for surgery while a large number of these cases are not provided with the required intervention. Dr Pechuho considers this number small, especially as “they do survive”.

According to DHIS data, during the past three years (2015-17), 83 cases of fistulas were reported in Sindh (41 in 2015, 10 in 2016 and 32 in 2017) whereas the data for cases that underwent surgery was not available. Obstetric services are only available at secondary and tertiary level hospitals.

Dr Iqbal Hussain Chandio, Project Director Mother, Neonatal and Child Health Centres (MNCH, of which Sindh has 89) says that midwives have been trained under the mother and child health programme to assist in normal delivery and refer complicated cases to DHQs or tertiary care.

CURRENT SCENARIO IN KARACHI

While it is a general perception that fistula occurs in rural areas where health facilities are sparse and deliveries take place at the hands of dais, Dr Shershah says that even in Karachi about 60 percent of deliveries take place at home — in the city’s slums, including localities such as Neelam Colony (a slum close to Karachi’s posh Defence and Clifton areas). A dispenser present at one of the health facilities in the locality confirmed this, saying that antenatal care is available at the facility and the patients are referred to the Karachi Metropolitan Corporation (KMC) hospital, though most deliveries take place at home at the hands of dais. For the past few months, another centre had no lady doctor, nor facilities for delivery.

If such is the condition in the largest metropolis of the country, one can imagine the conditions in the smaller towns and rural areas.

While the health secretary says that Lady Health Workers (LHWs) are working to facilitate people, Shama Golani, the Assistant District Coordinator, says that a LHW is not trained to provide antenatal care. “We advise expecting mothers to go for antenatal check-up to the BHU and RHC in the locality and even give them referral slips, but we are not trained to give antenatal care or assist in delivery.” However, she says, that if matric-pass LHWs are given three-month labour-room training in delivery, the community would be much safer. “LHWs work in their own community and are there 24/7, and so assistance to these women is needed.” Some midwives have indeed been given 18-month-long training for antenatal care.

APATHY

Dr Pechuho did not feel the need to include fistula surgery in the medical course, saying that any gynaecologist can perform this surgery. However, doctors performing this surgery such as Dr Shershah and Dr Yasmin ruled out Pechuho’s claim, explaining that it is a specialised surgery and needs a specially-trained surgeon as every gynaecologist can’t perform it.

The top health officials of the Sindh government are not paying heed to this devastating issue, shifting the responsibility to non-governmental organisations (NGOs). When asked about the training of doctors, both Dr Pechuho and Dr Chandio seemed to leave it to Dr Shershah to fulfil the task. “We have trained senior doctors and now they should train others,” says the secretary health.

While it is a general perception that fistula occurs in rural areas where health facilities are sparse and deliveries take place at the hands of dais, Dr Shershah says that even in Karachi about 60 percent of deliveries take place at home — in the city’s slums.

While talking about treatment facilities, Dr Siddiqui says, “In the entire country, seven fistula centres are working. The one in Koohi Goth centre, is run under an NGO [PNFWH] while the remaining are associated with government-run hospitals, but they do not have any specific funds for the treatment of fistula patients.” As to the number of trained surgeons, Dr Siddiqi says that 19 surgeons trained by PNFMH are working in the country while there are a few more working here and there.

In 2005, the ‘End Fistula Campaign’ began in Pakistan with the collaboration of UNFPA (United Nations Population Fund) but their funding stopped in 2016. Later, the Fistula Foundation USA funded the programme in 2017 but funding for this year is not ensured.

“A few years ago, at the Jinnah Post Graduate Centre [JPMC] Karachi, a fully functional fistula ward was set up under the aegis of USAID, where fistula patients come off and on,” says Dr Seemi Jamali, the executive director of the centre. Elaborating on the status, Dr Halima Yasmin, a senior gynaecologist at JPMC, says, “Even before the centre was established, fistula surgeries were being performed at JPMC. Six to eight surgeries are performed each year, besides some 25-30 cases are dealt with to prevent fistula.” She explains that they get referred cases of obstructed labour and if timely care is given and a caesarean is done, fistula can be prevented in most cases.

Besides these, a few private hospitals are also handling fistula cases. “If a fistula case who can afford private treatment comes to the hospital, it is referred to the hospital’s Clifton campus,” Dr Urooj Malik at Dr Ziauddin Hospital, Keamari, says. “Otherwise, she is sent to the Sindh Institute of Urology & Transplantation [SIUT] where urologists deal with the case.”

Since fistula surgery costs anything between 50,000 rupees to 500,000 rupees, according to Dr Shershah, and most patients are poor, it is highly unlikely that they can afford private treatment.

WHY SUFFER FROM A CONDITION THAT IS PREVENTABLE INSTEAD OF SEEKING TREATMENT?

In most of the cases, obstetric fistula is preventable to a large extent. Experts believe it can be avoided by delaying the age of first pregnancy and timely access to obstetric care. The key to prevention of obstetric fistula is proper antenatal care. According to Dr Shershah, ensuring skilled birth att­endants at all births and emergency obstetric care for all women who deve­lop complications during delivery is a must for the prevention of fistula. Universal access to emergency obstetric care, improved access to family planning ser­vices and increased edu­­cation for girls and women are essential in­gre­dients of long-term st­­­­­­r­­a­­­tegy for the prevention of fistula.

“Obstetric fistula can only be prevented by providing good antenatal care, labour management by those who have proper training, and awareness as when and where to refer for timely operative delivery,” Dr Mohsin asserts.

Additionally, the underlying factors that contribute to women’s and girl’s marginalisation — lack of access to quality health services and education, persistent poverty, gender and socioeconomic inequality, child marriage, early pregnancy — are some of the core areas that need to be addressed. Above all, it requires political will and allocation of adequate resources to make maternal health a high priority.

The writer is a member of staff

Published in Dawn, EOS, May 13th, 2018