Nepal's 'poor woman's problem': how obstetric fistula blights lives

http://www.theguardian.com/global-development/2015/jan/26/nepal-obstetric-fistula-women

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Anita Rai does not look like a woman who has just been successfully cured of her fistula – one of the most debilitating, but least known, health issues affecting women in Nepal. Her face wears an expression of exhaustion and resignation. In a small hotel room in the eastern city of Dharan, she sits on a bed staring into space as her husband puts their belongings into a bag.

“We have a long journey back,” Anita says. “A full three days from here to my village of Pathekha. Two days on a bus, and then a day walking.” That was how long it took for her to get to a hospital after her miscarriage two years ago. “The travel is very difficult, and most people avoid it.” It’s why she had a home birth, like most women in her village.

“I was so young. I did not even realise I was in labour.” Her voice cracks slightly. “There was no one to help me, to tell me what to expect or do.” Her husband remains quiet and stares out of the window. “It wasn’t my fault. I didn’t realise those were labour pains. I thought I was ill, and I just waited.”

The prolonged labour led to further complications and left her with a severe obstetric fistula – a hole between the vagina and the rectum or bladder, which leaves a woman incontinent. Though exact numbers are hard to come by, it is estimated that hundreds of women in Nepal’s rural hinterlands are afflicted with this condition because of inadequate maternal care, underage pregnancy, or prolonged or obstructed labour. Its consequences are crippling as it leaves them unable to control their bodily functions or perform even the most basic tasks. Most live with it for years, finding themselves shunned by their families and the community, and forced to isolate themselves. Some, like Anita, are left crippled and weak, unable to work or live normal lives.

“It broke my heart,” says Anita’s husband. “We were days from happiness. A child – our dream. But instead we found months of illness and suffering.” Anita picks up her bags and leaves the room. “She hasn’t been the same since,” he says.

“This is a poor woman’s problem,” says Dr Mohan Chandra Regmi as he conducts his morning rounds in the immaculately clean maternity ward at the BP Koirala Institute of Health Sciences (BPKIHS) in Dharan. The ward is filled with young mothers from across the region, and some even from cities in India. The institute has developed an excellent reputation for maternity care, and in particular the treatment of obstetric fistula.

A patient, Mohan says, is “typically a woman who doesn’t get proper antenatal care, who was married very young, and who doesn’t have proper education, who doesn’t know where to go. She hasn’t been to any hospital or health centre, and she tries delivering at home. She ends up having labour for several days, after which quite often she can develop obstetric fistula.”

The BPKIHS is one of three facilities in Nepal that are certified to provide care for fistula patients, a neglected problem until a few years ago. “We expect a backlog of between 5,000 to 10,000 existing cases across the country, with several hundred new cases being added every year,” Mohan says.

Stigma and geography – women having to travel a long way to a health centre – are the main reasons that prevent many from seeking assistance.

“We need more facilities, more doctors, and more educational programmes in rural areas,” Mohan says as he walks round the maternity wards. “In Nepal, about two-thirds of women still deliver outside a health facility.” By the age of 20 some women have already delivered three or four children, but a woman’s body isn’t fully developed until she is 18-20, he says. “Research shows that girls who have teenage pregnancies are more likely to have complications, more likely even to have maternal death.”

Susan Lama, head nurse in the operating theatre, says more community awareness is needed. “We have our own programmess here at BPKIHS. We go to different villages and conduct outreach clinics and educate health workers. We have educational documentaries, and brochures.”

Mohan says a nationwide programme is needed to address this issue. Last year, the Nepalese government finally allocated funds for the eradication of fistula, after almost four years’ campaigning by international organisations such as the UN population fund, UNFPA, to make it a national priority.

Beena Kathayat, a 46-year-old woman from Khotang district, has lived with fistula for more than 26 years and undergone five surgeries to resolve it. In the process she lost not only her husband and her family, but also her links to her community.

“It changed everything,” Beena says from her home in Dharan’s Ammar Basti slum. “I lost everything.” The operations helped, but could not solve the problem. “There isn’t much that they can do for me now,” she adds with resignation. “But I try to help other women, and warn them about the dangers.”

As she says this, a young woman enters the room and introduces herself as Radhika. “Radhika has been living with me – I gave her a home when we met at the fistula ward. She has no family, and now I am hers and she is mine.” Radhika was married at 12, and became pregnant when she was 16. Her body could not handle the prolonged labour; the local health worker had misdiagnosed her condition and she developed fistula after the stillbirth of the baby. “I have undergone four operations,” she says. “I am a lot better now.”