But not every patient at the hospital is as elated as Baksh this Sunday. On a bed beside her lies Noorjahan, who has travelled from Jacobabad in search of treatment. She fails to receive any going away gifts.
Koohi Goth Maternity Home is one of seven medical facilities where free surgical treatment for fistula is provided under the United Nations Population Fund’s (UNFPA) Campaign to End Fistula. The project has treated 2,300 patients so far.
Unfortunately for fistula patients, though, the UN project is ending in December and doctors are unsure whether they will be able to lead the campaign without the UN assistance. “We are far from achieving our target because most fistula cases have not even been identified as yet,” says Dr Faaria Ahsan, programme officer of the UNFPA’s Reproductive Health and Fistula project in Islamabad.
“The tragedy is that we don’t even have rough estimates of the number of patients as most are shy of coming forward and are often ostracised by their families.”
Causes of fistula
Sunday is the day all fistula patients at Koohi Goth Maternity Home look forward to. It is the day patients undergo operations, are examined and those who have recovered are sent home. The hospital, located on the outskirts of Karachi, has been providing free treatment to women suffering from one of the most devastating aftermaths of childbirth: fistula.
An entirely preventable condition, obstetric fistula is an abnormal opening in the birth canal that results in chronic leakage of urine and/or faeces. The condition develops when prolonged labour presses the unborn child’s head against the mother’s birth canal, causing the soft tissues around her pelvic bones to compress. This creates an opening between the vagina and urinary bladder and/or rectum, leaving the woman unable to control her excretory functions.
Other causes are poorly performed abortions or caesarian sections. This is known as iatrogenic fistula and its rate currently stands at 30 per cent in Pakistan, says Dr Shershah Syed, a senior obstetrician who has been treating fistula patients at the Koohi Goth hospital for eight years.
The living dead
Noorjahan is one such patient. Her husband abandoned her a few days after she returned from the hospital following their first child’s death from obstructed labour. “I had barely forgotten the pain of giving birth to a stillborn child when my husband told me to leave his house. He said he wanted another wife,” wept the 32-year-old who has been living with her brother and mother for the past 12 years.
“He said it was hard for him to stay around me because of my condition.”
The unrestricted flow of urine often leads to immense psychological trauma and social ostracism, not to mention infections, explains Dr Ahsan.
For four years Noorjahan visited her neighbourhood clinic where the doctors said her condition was ‘normal’ and continued to prescribe medicines that did not help. She later sought the help of a medical facility in Quetta where she underwent two operations but still could not be cured. Finally, her doctor there recommended Koohi Goth Maternity Home where she has been told that multiple surgeries would be needed before she can lead a normal life. Doctors add that most cases require multiple surgeries.
“My neighbours say I am cursed and this is a punishment,” says Noorjahan. “I know it’s not true, but it hurts.”
“The pain and loneliness associated with fistula is compounded by a sense of shame and humiliation,” says Dr Sajjad Ahmed who is also affiliated with the UN project in Karachi. Nurses say some patients at the hospital are too embarrassed to leave their beds and walk around in the ward.
“It is because of this stigma that most victims – who belong to poor families – are still hidden from the public eye.”
As a result, many women don’t approach doctors even when they develop rashes and infections, exacerbating the pain they are living with.
But Dr Ahsan feels that a solution might exist in the shape of lady health workers. “Since they know their community well, and women with fistula are easily identifiable, they can be major agents of change,” says the doctor. “The success rate of fistula surgery is 90 per cent, but we first need to identify the patients.”
However, for that to happen, commitment from the government is necessary. “Our health policies rarely focus on the real health issues of the country,” she asserts.
Even if all fistula patients are identified, it would take more than 60 years to clear the backlog, says Dr Ahsan. According to a recent UNFPA estimate, every year there are 4,000 to 6,000 new cases of obstetric fistula, of which only 390 are treated.
The question of resources
Lack of resources at public hospitals only compounds the problem. Fistula patients need to be admitted for at least 21 days and no public hospital is willing to spare a bed for that long. However, at the Koohi Goth Hospital, fistula patients not only have a dedicated ward, their commuting, food and other costs are also borne by the hospital. Moreover, the pair of new clothes that are gifted to patients who have been cured are supposed to symbolise a new beginning.
Doctors say fistula can easily be avoided by discouraging early marriages and delaying the age of first pregnancy.
Access to emergency obstetric care is also the need of the hour, they add.
“This is something only the government can do,” says Dr Shershah. “We require at least 100,000 trained midwives to avoid deaths and diseases related to childbirth.”
Doctors working with UNFPA also aim to integrate the fistula project in the reproductive health and safe motherhood programmes, but require government support. “Considering the burden of fistula patients in Pakistan, the government should integrate fistula treatment in the national health policy,” says Dr Faaria. With the UN project ending, the need for government intervention is greater than ever.
Published in The Express Tribune, July 30th, 2010.
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