Rukia (in the foreground) recovers after a successful fistula operation at Malalai Maternity Hospital in Kabul (August 2014). Credit: Karlos Zurutuza/IPS

By Karlos Zurutuza
KABUL, Sep 2 2014 (IPS)

“The smell of faeces and urine isolates them completely. Their husbands abandon them and they become stigmatised forever” – Dr Pashtoon Kohistani barely needs two lines to sum up the drama of those women affected by obstetric fistula.

Alongside the health centre in Badakhshan – 290 km northeast of Kabul – Malalai Maternity Hospital is the only health centre in Afghanistan with a section devoted to coping with a disease that is seemingly endemic to the most disadvantaged members of the population: women, young, poor and illiterate.

“Given that a caesarean birth is not an option for most Afghan women, the child dies inside them while they try to give birth. They end up tearing their vagina and urethra,” Dr Kohistani told IPS. “Urinary, and sometimes faecal incontinence too, is the most immediate effect,” added the surgeon as she strolled through the hospital corridors where only women wait to be seen by a doctor, or just come to visit a sick relative.“Pressure mounts on them from every side, even from their mothers-in-law. They have to hear things such as `I had five children without ever seeing a doctor´. Many of these poor girls end up committing suicide” – Dr Nazifah Hamra

They are of practically all ages. Some show obvious signs of pain while others look almost relaxed. In fact, they are in one of the very few places in Afghanistan where the total lack of male presence allows them to uncover their hair, take off their burka and even roll up their sleeves to beat the heat.

According to Nazifah Hamra, head of Malalai´s Fistula Department, “malnutrition is one of the key factors behind this problem. You have to bear in mind that women from remote rural areas in Afghanistan always eat after the men. Girls often don´t get enough milk and essential nutrients for their growth. And add to it that they only get to see a doctor when they marry, and usually at a very early age.”

Dr Hamra told IPS that she attends an average of 4-5 patients suffering from a fistula at any one time. Rukia is one of the two recovering in an eight-bed ward on the hospital´s second floor.

“I was 15 when I got married and 17 when I got pregnant,” recalls the 26-year-old woman from a small village in the province of Balkh, 320 km northwest of Kabul.

“When I was about to give birth, I had a terrible pain but the road to Kabul was cut so I was finally taken to Bamiyan, 150 km east of Kabul.”

Sitting on the bed carefully in order not to obstruct the catheter that still evacuates the remaining urine, Rukia tells IPS that her son died in her womb. An unskilled medical staff only made things worse.

“What the doctors did to her is difficult to believe. She was brutally mutilated,” said Dr Hamra, adding that medical negligence was “still painful common currency” in Afghanistan.

In a 2013 report on the risks of child marriage in Afghanistan, Human Rights Watch claims that children born as a result of child marriages also suffer increased health risks, and that there is a higher death rate among children born to Afghan mothers under the age of 20 than those born to older mothers.

Brad Adams, Asia Director at Human Rights Watch, called on Afghan officials to end the harm being caused by child marriage. “The damage to young mothers, their children and Afghan society as a whole is incalculable,” Adams stressed.

Rukia´s husband left to marry another woman so she had no other choice but to move back to her parents´ house, where she has lived for the last nine years. But even more painful than her ordeal and the defection of her husband, she says, is the fact that she will never be a mother.

Dr Hamra knows Rukia´s story in detail, as well as those of many others in her situation. “Pressure mounts on them from every side, even from their mothers-in-law,” she told IPS. “They have to hear things such as `I had five children without ever seeing a doctor´. Many of these poor girls end up committing suicide.” However, preferring to look towards the future, she said that Rukia will do well after the operation.

“From now on she´ll be able to enjoy a completely normal life again,” stressed the surgeon, who also wanted to express her gratitude to the UN Population Fund (UNFPA) which “seeks to guarantee the right of every woman, man and child to enjoy a life of health and equal opportunity.”

Annette Sachs Robertson, UNFPA representative in Afghanistan, briefed IPS on the organisation´s action in the country:

“We started working in 2007, in close collaboration with the Afghan Ministry of Public Health. We train surgeons and we provide Malalai with the necessary equipment and medical supplies. Thanks to this initiative, over 435 patients have been treated and rehabilitated at Malalai Maternity Hospital and we have plans to extend the programmes to Jalabad, Mazar and Herat provinces,” explained Robertson, a PhD graduate in biology and biomedical sciences from the University of Harvard.

“You hardly ever see these cases in developed countries,” she added.

According to a 2011 report on obstetric fistula in six provinces of Afghanistan conducted by the country’s Social and Health Development Programme (SHPD), “the prevalence of obstetric fistula is estimated to be 4 cases per 1000 (0.4 percent) women in the reproductive age group. 91.7 percent of women with confirmed cases of obstetric fistula cannot read and write while 72.7 percent of fistula patients reported that their husbands are illiterate.”

“Twenty-five percent of women with fistula reported that they were younger than 16 years old and 67 percent reported they were 16 to 20 years old when they had got married. Seventeen percent of women with fistula reported that they were younger than 16 years old when they had their first delivery. Twenty-five percent of women with fistula reported that they developed the fistula after their first delivery, while 64 percent reported prolonged labour.”

Meanwhile, thanks to yet another successful operation, Najiba, a 32-year-old from Baghlan – 220 km north of Kabul – will soon be back home after suffering from a fistula over the last 14 years.

Born in a remote rural village, she was married at 17 and lost her first son a year later, after three days of labour. Despite the fistula problem, she was not abandoned by her husband and, today, they have six children.

“I was only too lucky that my husband heard on the radio about this hospital,” explains Najiba, with a broad smile hardly ever seen among those affected.

(Edited by Phil Harris)

Naz Bibi is awaiting treatment for fistula at the Koohi Goth Women’s Hospital in Pakistan. Credit: Zofeen Ebrahim/IPS

By Zofeen Ebrahim
KARACHI, Jun 17 2014 (IPS)

The word on the street was that if there were one place on earth that could treat Mohammad Lalu’s wife, it would be the Koohi Goth Women’s Hospital in Pakistan’s port city of Karachi.

The 50-year-old stone crusher hailing from the remote village of Dera Bugti in the southwest Balochistan province had spent 30 years searching for a facility that would treat his wife, Naz Bibi, who suffers from obstetric fistula.

Sitting upright on a plastic sheet draped over one of the hospital beds, Bibi told IPS, “It took us two days of non-stop travel to get here and we spent 12,000 rupees (roughly 120 dollars) on the bus fare alone.”

It is a princely sum for a family of extremely modest means, in a country where the average income is less than 1,200 dollars a year. But for Lalu and his wife, the expenditure will be worth it if it can cure Bibi of her terrible affliction.

“Obstructed labour is especially common among young, physically immature women giving birth for the first time.” – United Nations Population Fund (UNFPA)
While virtually unheard of in the developed world, obstetric fistula is still common in many Asian and African countries: the World Health Organisation (WHO) estimates that it affects nearly three million women annually.

While country-specific data is harder to find, local experts suggest that anywhere from 4,000 to 5,000 women in Pakistan are suffering from fistula.

Caused by prolonged or stressful labour, the condition arises when the baby’s head puts undue pressure on the lining of the woman’s birth canal, eventually ripping through the wall of the rectum or bladder and resulting in urinary or faecal incontinence.

Medial professionals say young women, whose bodies have not yet matured enough to endure the birthing process, are most vulnerable, as well as those who lack adequate nutrition or live too far away from modern healthcare facilities.

Because fistula causes a woman to lose control over her bodily functions, there is a huge stigma around the condition. Those afflicted by it often smell bed, and are sequestered away from their communities and families, forced to suffer in silence.

This is particularly traumatic for young mothers, who end up spending the better parts of their lives having little to no contact with the outside world.

Lalu told IPS that Bibi’s trouble started soon after she delivered a stillborn baby boy when she was just a teenager during her first marriage.

“I am her second husband,” he said. “Her parents married her to me after her husband left her, but did not disclose she was suffering from this dreadful problem.”

Unlike many other husbands, Lalu did not turn away from his new wife; instead, he has gone to great lengths to find her the necessary treatment. This hasn’t been easy, since fistula can only be managed through reconstructive surgery, which is cost-prohibitive for thousands of women.

Koohi Goth is one of 12 centres set up under the United Nations Population Fund’s (UNFPA) Fistula Project that offers the service for free.

Now in its eighth year, and assisted by the Pakistan National Forum on Women’s Health (PNFWH), it has trained 38 doctors to carry out the surgery. These numbers, experts say, pale in comparison to the scale of Pakistan’s maternal health crisis.

‘100 percent preventable’

According to the country’s latest Demographic and Health Survey, 276 women out of every 100,000 die during childbirth.

“All these deaths are 100 percent preventable if we can provide quality of care and stop child marriages,” Dr. Sajjad Ahmed, head of the Fistula Project in Pakistan, told IPS.

He believes that delaying the age at which a woman experiences her first pregnancy would be a huge step forward in preventing conditions like fistula.

According to the UNFPA, “For both physiological and social reasons, mothers aged 15-19 are twice as likely to die of childbirth than those in their 20s. Obstructed labour is especially common among young, physically immature women giving birth for the first time.”

But changing the mindset that sees nothing wrong with the idea of a child bride will not be easily accomplished, especially in rural Pakistan.

Dr. Suboohi Mehdi (Surgeon at Koohi Goth Hospital, Karachi) on Fistula Cases from IPS News on Vimeo.

Thirteen-year-old Shahbano, hailing from the village of Sanghar in Pakistan’s Sindh province, occupies the bed next to Bibi. She tells IPS she was married at 11 and developed fistula three weeks ago, during prolonged labour involving her first child.

Luckily, both Shahbano and her baby son survived the ordeal, but she must now hope that her surgery goes well, so she is not afflicted by incontinence for the rest of her life.

“In our culture, when a girl first begins to menstruate, her parents are obliged to marry her off,” Shahbano’s husband, Abid Hussain, told IPS.

Neither he nor his teenage wife had any idea that the Sindh provincial assembly passed the Child Marriage Restraint Act last month, prohibiting the marriage of children under 18 years of age. Violation of the bill could earn offenders a three-year prison term or a 450-dollar fine.

In 1929, the official marriage age stood at 14 years, and in 1965 the law changed, making it illegal to marry anyone under the age of 16. Today, Sindh is the only province to have recognised 18 as the bare minimum age for marriage – a decision that has elicited vehement opposition from religious groups.

Maulana Muhammad Khan Sherani, chairman of the Council of Islamic Ideology, which acts as an unofficial parliamentary advisor, said in reference to the amendment: “Some people want to please the international community [by going] against Islamic teachings and practices.”

“Such proclamations act as a spanner in our fight against early marriage and early pregnancy,” Ahmed asserted.

He says if he could give girls like Shahbano one piece of advice it would be to educate their children, especially their daughters.

“It will take a generation to put things right, but education will automatically bring about a cultural change, which could delay marriages. I see that as the only way to eradicate this condition,” he stressed.

Currently, the country only has the capacity to handle 2,000 cases of fistula, but doctors end up treating just 500 to 600 women a year.

Ahmed says this is largely due to the fact that people do not know the condition is preventable or treatable, and so avoid seeking out medical assistance. Many women live in rural areas without access to televisions, radios or cell phones, making it hard to spread awareness.

To circumvent the problem, hospitals have mobilised ‘lady health workers’ – women who go door-to-door in remote areas delivering information on sexual reproductive health and rights.

“We have a huge brigade of almost 100,000 lady health workers,” Ahmed said. Although they cover just 60 percent of the country, they act as a bridge between rural populations and urban-based care providers.

Perhaps these sustained efforts will enable Pakistan to see the day when conditions like fistula are nothing but a distant memory.

(END)

Teen mothers give birth to 81 out of every 1,000 children in Nepal. Credit: Mallika Aryal/IPS

By Mallika Aryal
CHAMPI, Nepal, Jul 11 2013 (IPS)

Radhika Thapa was just 16 years old when she married a 21-year-old boy three years ago. Now, she is expecting a baby and is well into the last months of her pregnancy. This is not the first time she has been with child – her first two pregnancies ended in miscarriages.

“The first time I conceived I was just 16, I didn’t know much about having babies, nobody told me what to do,” Thapa tells IPS in between assisting customers at the vegetable store she runs with her husband in the small town of Champi, some 12 km from Nepal’s capital, Kathmandu.

"When girls get pregnant their education stops, which means a lack of employment opportunities and poverty." -- Bhogedra Raj Dotel
“The second time I wasn’t ready either, but my husband wanted a baby so I gave in,” she admitted.

After the second miscarriage, Thapa’s doctors urged her to wait a few years before trying again, but she was under immense pressure from her in-laws, who threatened to “find another woman for her husband if she kept losing her babies”.

What might seem like a horror story to some has become an accepted state of affairs in Nepal, the country with the highest child marriage rate in the world.

On average, two out of five girls are married before their 18^th birthday. The legal age for marriage in Nepal is 18 years with parental consent, and 20 without, a law that is seldom observed, least of all in rural parts of the country.

Studies show that child marriages occur most frequently among the least educated, poorest girls living out in the countryside.

According to the 2011 Nepal Demographic and Health Survey (NDHS), 17 percent of married adolescent girls between 15 and 19 years are either pregnant or are mothers already. In fact, research shows that adolescent mothers give birth to 81 out of every 1,000 children in Nepal.

The survey also shows that 86 percent of married adolescents do not use any form of contraception, meaning that few girls are able to space their births.

Disturbed by trends in countries like Nepal, the UNFPA spotlighted teen pregnancy as the theme for this year’s World Population Day, observed annually on Jul. 11.

“Globally there are 16 million girls aged 15-19 who give birth each year – they never had the opportunity to plan their pregnancy. It is a developmental issue that goes beyond health,” Vallese stressed.

In reality, teen pregnancy can be a matter of life and death. Adolescent girls under the age of 15 are up to five times more likely to die during childbirth than women in their 20s.

The number one cause of death among girls aged 15-19 relates to complications in childbirth. Young mothers are at a high risk of suffering from complications such as obstetric fistula and uterine prolapse.

Furthermore, “the first child born to a mother aged 12-20 is at greater risk of being stunted or underweight, suffering from anaemia or even of dying before the age of five,” says Vallese.

Less visible, but equally troubling, is the host of social complications that teen mothers must navigate.

“When girls get pregnant their education stops, which means a lack of employment opportunities and poverty,” says Bhogedra Raj Dotel of the government’s family planning and adolescent sexual reproductive health division.

According to the UNFPA, 37 percent of married adolescent girls are not working and 76 percent of those who are employed are not paid in cash or kind for the work they do.

Menuka Bista, 35, is a local female community health volunteer in Champi, assisting about 55 households in her area. Bista has been advising Thapa, to ensure that the girl has a safe pregnancy.

“Radhika (Thapa) is educated, she knows she needs to go to the doctor and eat nutritious food for her baby to be safe, but she doesn’t make decisions about her body: her husband and in-laws do,” Bista told IPS.

This observation finds echo in research carried out by various experts: according to Dotel, husbands and in-laws make all the major decisions about a woman’s reproductive health, from what hospital she visits to where she will deliver her child.

For this reason, Vallese believes it is important to train husbands and family members on reproductive health and rights.

Another problem, experts say, is that almost all national policies have been designed with the assumption that adolescent pregnancies affect only married women, with little acknowledgement of the fact that unmarried teenaged girls also engage in sexual activities, said Vallese.

The penetration of the Internet and mobile phones into every aspect of daily life, coupled with a massive wave of migration of young rural men into urban areas, has created “a significant teenage population that engages in pre-martial sex,” she stressed.

Whether the teenaged girls are married or unmarried, sex education plays a major role in decreasing the number of pregnancies.

Sex education is a part of the national school curriculum from Grade 6 upwards, but teachers are not trained, and are uncomfortable talking about it. When the subject comes up in a classroom, most teachers simply skip that chapter, or defer to a health worker to explain the process of reproduction.

“There’s a general (perception) that teaching about sexual health makes girls promiscuous, but we have found it to be exactly the opposite,” says Shova KC, chair of a local cooperative that works with women in Champi.

Public health experts, meanwhile, have criticised the government for not implementing existing policies that could spare thousands of young girls from the trauma of complicated pregnancies so early on in life.

For instance, “more than 500 youth friendly service centers have been set up but progress is about more than just ticking boxes,” UNFPA Assistant Representative Latika Maskey Pradhan, told IPS.

In the future, she said, advocates must keep a close eye not only on how policies are designed but also on how they are implemented.