Fistula and the loss of dignity

Though a serious health problem, fistula should be addressed as a matter of human rights and social justice.

Involuntary leakage of urine is not something anyone would want but for thousands of women, fistula is a harsh reality.

Fistula is a medical condition caused when a woman endures prolonged obstructed labour, sometimes for days, without timely medical intervention. Due to obstructed labour, the pressure of the baby’s head against the woman’s pelvis can cause extensive tissue damage. In most cases the baby dies and the woman is left with a fistula (passageway) between her vagina and bladder and/or vagina and rectum, resulting in incontinence of urine and/or faeces. Fistula is more common in developing countries, especially in rural areas where most women give birth at home, at the most attended by midwives or dais.

Women living with fistula suffer both medical and social consequences. In addition to incontinence, the medical consequences of fistula include frequent bladder infections, painful genital ulcerations, kidney failure and infertility. At the same time they are often blamed for their condition due to the misperceptions about the causes of birth complications, abandoned by their husbands because of the constant leaking of urine and faeces, ostracised by their families and communities and forced to suffer in isolation.

According to Dr Shershah Syed approximately 5,000 cases of fistula occur every year in Pakistan. It is more prevalent in rural areas and city slums because of poverty, lack of awareness and absence of emergency obstetric care which is the right of every woman. The problem is aggravated by unskilled health providers and negligent health professionals who do not fulfil their duty with responsibility. Unfortunately, of the thousands of fistula cases that occur in Pakistan every year at present only 1,000 cases are been treated with corrective surgery every year. One such lucky person is 18-year-old Razia Bibi, a resident of Rahim Yar Khan, who developed a fistula after giving birth to a stillborn baby after 18-hour long obstructed labour. Her husband had passed away two months ago and she lived with her father-in-law and three sisters and had no way to seek healthcare at any nearby rural health centre (RHC). She was weak and in pain and after three days she noted that she had no control over urine and stool. Fortunately, she got some information about the free fistula treatment at Koohi Goth Women Hospital, Karachi, and somehow managed to reach there. After initial preparation and correction of her anaemia and nutritional status her Colostomy was performed. She is still in the hospital for next operation of Colostomy reversal. As she has no home she will remain at Koohi Goth Woman Hospital for the next three months. Hopefully, after repair and reversal of colostomy she will be able to lead a normal life. All the expenses of her treatment, stay and travel are being borne through UNFPA’s Fistula Project.

Yet another story is that of Sehar who lives in Thimka, a small town near Jalalpur Jatta near Gujrat. During her third pregnancy at age 25 years, she developed this problem. She already had two children but had never visited any hospital or healthcare centre, because there was no such facility in her village and she didn’t have resources to go to the hospital away from her village. The women in the village do not seek antenatal care and deliver at home with the assistance of a senior lady of the house or the community. While delivering her third child Sehar remained in labour for two days. She was tired, exhausted and wanted to die as the pain was unbearable. The local Trained Birth Attendant (TBA) was called who gave her some herbal drugs and injections with the help of which she was able to deliver the baby. But after the delivery she started leaking urine; she went to a local doctor to Gujrat where she was diagnosed as a case of fistula and was referred to Lady Walington Hospital, Lahore, for free fistula treatment. She was successfully treated and is expected to be able to have a normal life in her village.

Though a serious health problem, fistula should be addressed as a matter of human rights and social justice. It is unfortunate that thousands of women suffer unnecessarily because of a condition that is not only treatable but also preventable to a large extent. Fistula can be repaired by a simple surgical procedure which does not need any special technology or extensive expenditure, thus restoring health, hope and a sense of dignity of women living with this devastating condition.

Experts believe that the ultimate goal should be prevention. For this there is a need to draw attention to the links between fistula and poverty, inequality, gender disparity and poor education, as all these combine to put the women at greater risk. An important step would be to delay the age of first pregnancy and provide timely access to obstetric care. There is also a need to provide basic health care and train more competent staff on safe motherhood and emergency obstetrical care.

As preventive measures will take time to bear fruit, treatment is needed for those women who experience a fistula. Pakistan government and Pakistan National Forum for Women’s Health with the support of UNFPA have set up seven clinics and six referral centres in major cities of the country which offer free treatment as well as free food and travel for patients and their attendants who are unable to meet these expenses.