HOLD ON A MINUTE Episode 2: Ending Obstetric Fistula

Jingle Intro 

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Host- Introduction 

00:00:04:04

Hello! You are listening to “Hold on a Minute!”, a podcast by UNFPA Asia and the Pacific. This podcast series presents inspiring and powerful stories on the sexual and reproductive health and rights of women across the Asia-Pacific region.

00:00:21:08

I am Chaowarat Yongjiranon or Poupée, your host. On this episode we address one of the most painful and damaging injuries suffered by women during childbirth called obstetric fistula.  

 

00:00:34:24

Obstetric fistula occurs when a woman suffers a prolonged and obstructed labor without access to timely and quality maternal health care. The result is a hole between the birth canal and bladder and/or rectum. This condition leaves the woman leaking urine, faeces, or both, resulting in lifelong physical and emotional trauma. Women may suffer chronic medical problems, depression, social isolation, and deepening poverty.   

 

00:01:05:23

In today’s episode, we will hear from experts to understand the reasons behind Obstetric Fistula, and what we can do to end this tragic condition. But first, let’s listen to the story of Ayesha.

 

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Story of Ayesha

STORY SCRIPT

 

00:01:20:17

My name is Ayesha. I live with my husband’s family in his village surrounded by beautiful mountains. 

 

00:01:29:00

But when I was pregnant with my first child, I could not visit the doctor or a midwife because it was difficult and too expensive to travel. 

 

00:01:39:04

One day, I started to get labour pains. I was in so much pain that I could not move [dramatic voice]. My husband brought the traditional birth attendant from the village to help me deliver the baby. 

 

00:01:51:02

It was a difficult, painful, and long labour which lasted for four days. Despite the complications, the traditional birth attendant didn’t call for professional medical help.

 

00:02:03:04

Finally, my baby was stillborn. I was still in a lot of pain. I also started to leak urine which I could not control, because of the injury I got during childbirth. [sad voice]

 

00:02:14:12

I felt embarrassed and ashamed. People in my village avoided me or made fun of me. I never felt clean. [sad voice]

 

00:02:22:10

My husband and I did not give up though. We kept asking around to find out who can help me. After two years, we heard about a hospital in the big city that helps women like me get surgeries for free. [uplifting/hopeful voice]

 

00:02:36:02

My relatives and in-laws helped us collect money so my husband and I can travel to the city. 

 

00:02:42:03

I was finally able to see a professional doctor at the hospital. The doctor said that my condition was not easy to treat. One surgery was not enough, so I had to go through multiple surgeries, which took three years. It was a tough process, and I had to be really patient. 

 

00:03:00:01

Thankfully, the midwife who worked at the hospital became like a sister to me. She supported me and encouraged me to stay strong. 

 

00:03:08:18

Finally, after five surgeries, I am fully healed, and so happy to return to my normal life.   [happy/ cheerful voice]

 

00:03:15:07

I was lucky because I was able to find a hospital which offered help for free. Without their help, I would have continued to live in shame and fear.

 

00:03:24:02

I am sure there are many women with the same condition who continue to suffer, because they don’t know they can get treatment.

 

00:03:31:04

As a fistula survivor, I now spend time speaking to the women in our village about what happened to me. I tell them to visit a trained midwife during their pregnancy and delivery so they avoid what happened to me. 

 

00:03:44:12

I don’t want any woman to go through the same pain which I had to endure.

 

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00:03:50:06

Third Voice - Hold on a minute, the story doesn’t always end like this for every woman suffering Obstetric Fistula. 

 

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Host - Interview 

 

00:03:55:03

Despite the traumatic experience of Ayesha, her story is one of hope because she was eventually able to find and receive treatment and care. But she should not have had to endure this painful condition in the first place, and sadly, Ayesha is not the only woman who had to suffer obstetric fistula.  It is estimated that half a million women and girls are living with this condition.  Today we are honored to hear from two experts working to improve maternal health, and eradicate obstetric fistula. 

 

00:04:29:08

We have with us, Dr. Shershah Syed, a prominent physician and surgeon from Pakistan and a Fellow of the Royal College of Obstetrics and Gynecology in the UK.  Dr. Syed has worked passionately as an advocate for women’s rights and maternal health at both national and international levels.  He was the President of the Society of Obstetricians and Gynecologists of Pakistan from 2007 to 2010 and is currently the President of the International Society of Fistula Surgeons and also the Pakistan National Forum on Women’s Health. 

 

00:05:07:07

Also with us is Catherine Breen Kamkong, the UNFPA Asia-Pacific Regional Advisor on Sexual and Reproductive Health and Rights.  Catherine leads UNFPA’s work in the Asia and the Pacific region for maternal and reproductive health and midwifery.  Before her current role, Catherine also worked for UNFPA in countries across the region, such as Thailand, Cambodia, and Nepal. Prior to joining UNFPA, she worked with international NGOs in India, Thailand, and Myanmar. 

 

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EXPERT Q&A Conversation

 

00:05:39:23

HOST

Imagine how much stress and how much of a traumatic situation it was for her during  her pregnancy. Can you tell us a little bit more about her story? Catherine?

 

00:05:53:11

CATHERINE  

Yes. So Ayesha's story is really it's a very painful reminder for all of us, of these women that are probably some of the most forgotten and the most left behind in countries all over the world. Ayesha story is typical of women who suffer this painful and really life altering injury from the simple and natural act of giving birth.

 

00:06:17:02

CATHERINE 

So, Ayesha, she was living in a remote part of the country and. And that's something that's quite characteristic. We see that women who experience fistula, they are often living in the most remote parts of countries where it's really difficult to access care. And she was also unable to afford care. I think in the story we heard that they didn't have the money for her to even attend antenatal classes or the classes to help her prepare for the birth and stay healthy during her pregnancy.

 

00:06:47:19

CATHERINE 

And I think also Ayesha’s story is painful as we can see that there's just this level of neglect. I mean, being in prolonged labor for so many days without anybody prioritizing her care, nobody prioritizing her access to this emergency care. It's really you know, it's one of neglect. And the other thing I think that's really sad about her story and it's very characteristic of women with.. living with fistula is the loss of her baby.

 

00:07:19:00

CATHERINE 

Can you imagine? I mean, if we pause and think about it, you've gone through this long and painful labor and you end up with this horrendous, lifelong injury, but you've also lost that baby that you've carried. For however many months. And so all of these pains combined make living very, very hard. And I think that story of Ayesha is one that very sadly is repeated time and time again in many of the countries.

 

00:07:45:23

HOST

Catherine, exactly what I think a lot of us are thinking when we hear about her story, because in today's world, with the technology that we have, it's sad to know that this is not just the only case. Dr. Shershaah, you have been in this field for so long. I'm sure you've seen so many stories similar to this.

 

00:08:06:15

HOST

Can you, is there, a specific story that you've come across that you know you'd like to share with us and who in your thoughts are the most likely to suffer from fistula during childbirth and why?

 

00:08:19:19

DR. SHERSHAH 

Well, you are very right. Thank you very much for giving me this chance to talk about our very unfortunate patients and only those who are fortunate are able to reach our hospital where we can treat 99% of them. The bad thing is that majority of these patients are living in the remote areas in the mountains that they don't know, even that there is a hospital, 

 

00:08:44:17

DR. SHERSHAH 

where services are available where they can be treated freely. So one of the example I want to give you, one of our patients. She comes from Rahim  Yar Khan, which is a small city about 400 miles from Karachi. She was born blind and but she got married at the age of 14 years. And after just a few months after that marriage, she became pregnant.

 

00:09:15:01

DR. SHERSHAH 

And then she was six months pregnant. Her husband died because of an accident. And after that, it was a big problem because she was thrown out from her husband's house. In fact, they lost her, that she brought the bad things to our home that our son died. But anyway, she ended up with her mother. And her mother was an illiterate woman.

 

00:09:40:03

DR. SHERSHAH 

And she organized a TBA, a Traditional Birth Attendant to deliver [the baby]. She was in labor for three days. After three days, she delivered a dead fetus and she developed RVF and VVF, Vesicovaginal fistula and Rectovaginal Fistula . And then she had no idea where to go because her mother was angry most of the time because she was passing urine and stool at home.

 

00:10:09:11

DR. SHERSHAH 

So she found out after knowing many people that there's a hospital in Karachi where she can be treated freely. So she decided to come to Karachi. She traveled 400 miles in three days, not just because it is very far. It is because no bus will take her. After a few miles, they will throw her out because she's smelling.

 

00:10:36:02

DR. SHERSHAH 

And the other passengers are saying that this is very bad. Anyway, she came to Karachi and from Karachi Station, she traveled to our hospital and she was admitted in our hospital. Then she had to be admitted six months because she needed four operations with colostomy in everything. After that, she was treated fully and everything was fine.

 

00:11:03:02

DR. SHERSHAH 

So she used to tell us that when she was blind and she was blind, people liked to help her because she's blind. But when she had this fistula, nobody liked to help her. Actually, everyone was hating her. So she told me it's better to be blind than having a fistula. So this patient was an example that she can get treatment and she's fine.

 

00:11:29:16

DR. SHERSHAH 

Same as another patient, from Baluchistan, from the very far remote village. She was in labor for three, four days, actually. Then she delivered a baby, with the same problem, for two years. She had no place to go. After some time, they came to know about this hospital. So she started a journey on a small stretcher.

 

00:11:54:10

DR. SHERSHAH 

And they brought her to the big city for that. And she came to our hospital. Same. She was treated for four months. She was recovered.

 

00:12:05:10

HOST

Doctor, I think you're going to probably answer what I was going to ask in terms of, I mean, I just had to say something because, 3 to 4 days of labor, that's quite a big situation there. And it seems as if there's different aspects that we have to think about. The aspect of the culture aspect where she was married at 14 years old and the aspect that, you know, she didn't have the facility or the experts to help her during her pregnancy.

 

00:12:35:09

HOST

What are the factors that are in play with the cause in this ongoing situation?

 

00:12:41:20

DR. SHERSHAH 

Very good question. I gave the example of these two cases because in both cases, first of all, she got married at a very young age, both of them, at 14 and 14 and a half, that they were kids and they got married and they got married with men who are illiterate and they have no idea about family planning or not getting pregnant once you are in this situation.

 

00:13:09:08

DR. SHERSHAH 

And then the worst thing was, in that village, in both of their villages, they have no help as far as basic obstetrical care is concerned. So they have no midwives. They only have traditional birth attendants (TBAs). And they have no idea about family planning or the normal delivery, etc., etc.. So then when both of them went into labor,

 

00:13:30:14

DR. SHERSHAH 

They have no place to go, because there's no BHU or RHC, basic health unit or rural health center. So they were in the care of a TBA. The TBA has no idea.  TBA’s work is that it will happen. It will take two days, three  days, four days. So there was no obstetrical care. And once she was in labor and there was a delay of 24 hours, she should be transferred to a tertiary care center where a cesarean section can be performed, but the tertiary care center is far from their places.

 

00:14:04:05

DR. SHERSHAH 

So then she delivered and after delivery in both cases it took more than two years for them to leave their village and come to the hospital where they can be treated. So it's basically poverty and illiteracy.

 

00:14:18:12

So and the third thing, which is really important, the absence of emergency obstetric care, when there's no emergency obstetric care, what can you do?

 

00:14:28:17

DR. SHERSHAH 

And before the emergency obstetric care, both of these girls should have been seen by qualified, competent midwife who can refer them, who can diagnose the problem- what's wrong. And patients will go into obstructed labor, especially the fistula. A properly trained midwife will recognize this condition from the very beginning and they will send the patient to the obstetric care hospital. So these are the major things.

 

00:14:56:04

DR. SHERSHAH 

Now, if you are talking about ending fistula by 2030, so what is the conclusion from these two cases and many cases in different parts of the world? The conclusion is if these  girls were seen by competent, confident, skilled midwife, the midwife can book them. Midwife can decide when the delivery is imminent. And is it possible for them to do the delivery or is it good to shift the patient to tertiary center or secondary care center where they can have cesarean section and there will be no fistula. So this is the story.

 

00:15:34:08

HOST 

Very, very extreme cases from what I'm hearing from your side. Now when we take a look at other regions, the Asia Pacific specifically, there has been the prevalence of the fistula condition. But how common is it, Catherine? Because, you know, when you talk about the Asia - Pacific region, it's quite a big range of different socio-economic situations that we're talking about.

 

00:15:58:23

HOST 

How prevalent is it?

 

00:16:00:21

CATHERINE 

So it's quite hard to actually quantify the prevalence of obstetric fistula because, as Dr. Shershah explained, it's often a very hidden illness and condition. Women that are living with the fistula hidden in mountainous areas, in their villages, and in their homes. And they're not coming out, so they're not counted. So it is quite hard for us to really quantify.

 

00:16:29:00

CATHERINE 

But they say that there has to be at least a half a million cases of obstetric fistula in the world and in our region, particularly Afghanistan, Bangladesh, Pakistan and India. These are the countries where we are seeing more cases of obstetric fistula. And some of the reasons for that are also the fact that women are still delivering, having significant number of the deliveries at home.

 

00:16:56:01

CATHERINE 

They're not coming to health facilities to deliver their babies. So this really is Dr. Shershah explained, really contributes to the burden of obstetric fistula.

 

00:17:08:24

HOST

You know, when we're taking a look at the situation in the case studies that we've talked about so far in our podcast, there's so many signs or so many factors that come into play in contributing to the prevalence of obstetric fistula. So when we talk about the prevention of it, Dr. Shershah, what are the main factors that should be considered by lawmakers in our communities to prevent this?

 

00:17:36:07

DR. SHERSHAH 

Number one, child marriage should be stopped. This is a cultural thing, this is a traditional thing. And for that they need to be educated. The village should be educated, the people should be educated. So let's suppose there's a girl who is under-age and she got married. So there should be somebody like a midwife who can advise them for the family planning, even if they get married in the younger age group.

 

00:18:02:11

DR. SHERSHAH 

But if there is somebody who can advise, they can advise for family planning. And despite family planning, she become pregnant. That there’s somebody who is a  midwife should book her for a proper basic antenatal care. And once she's under the care of this midwife, she'll make sure that this patient will not go into labor in the center if she feels that she has abnormal pelvis and the chances that she will go into obstructed labor.

 

00:18:34:10

DR. SHERSHAH 

So this patient should be referred to secondary or tertiary medical center. There she can have a normal delivery or cesarean section and if she's delivered by [the care of] a competent obstetrician gynecologist or midwife, then there very little chance that she will get a fistula. So this is very simple thing in all the cases, basically education and eradication of poverty. 

 

00:19:00:04

Fistula is a disease of poor people who are living in slums. Who are living in a rural area where no help is available. And that is the dilemma.

 

00:19:12:05

HOST

And Dr. Shershah, a good point in terms of the importance of the role of midwives, something that we've talked about extensively, Catherine, in our previous episode about how it's so important to support midwives to, you know, and it's not just about increasing the numbers, but the quality of education and training that goes into midwives. When you take specifically the role of midwives, how can they protect women from this painful injury?

 

00:19:42:03

CATHERINE

Midwives are really key to stopping any new cases of fistula. Midwives, they provide care to women during their pregnancy and during their births, and they really play this critical role. As Dr. Shershah has explained in identifying, caring for women during her pregnancy, but also identifying whether she's at risk and referring her early. Midwives work in partnership with obstetricians.

 

00:20:09:11

CATHERINE

And we, you know, our focus is on that woman and her care. And it's both of our priority to make sure that she has a healthy pregnancy, birth and an outcome of a healthy baby. So midwives are critical in this role of caring for all women, even in the most remote parts of countries where obstetricians are unable to go.

 

00:20:33:12

CATHERINE

The other thing is that women really care holistically for women during that their pregnancy, birth,  and after their births as well. So women, midwives, are likely to know which women have fistula. And as Dr. Shershah explained, like actually talking to the women about the fact that there is care available, that there are champion, wonderful fistula surgeons, in some of in some countries who will be able to do surgery and repair this condition for women.

 

00:21:11:03

CATHERINE

So midwives play a big role in that, in identifying women that are suffering with it with an obstetric fistula and getting her the care that she really needs. And the other thing that I think is really important role of a midwife with fistula is that they can provide some of that psychological support and care. Because when a woman has gone through a very traumatic labor and birth, she is likely to be quite traumatized and the midwife is able to provide that sensitive, close care to the woman and to listen to her and hear from her if she would like to have other children after that fistula is repaired.

 

00:21:49:19

CATHERINE

To support her in that and build her confidence in that, or alternatively to help her with family planning and helping her make those choices of not to have a baby if it's going to be risky for her life and something that she, you know, she also doesn't want. So midwives really play this crucial role of being with all women, including with women that have obstetric fistula.

 

00:22:17:12

HOST

When you take a look at the bigger picture, obviously, you know, we it's so crucial to support and to build that ecosystem for midwives to thrive and to access those, you know, far reaching areas where, these cases are unfortunately, you know, great in number. So when we take a look at the UNFPA and what it is doing to prevent obstetric fistula from happening, how is UNFPA treating it? How is UNFPA supporting hospitals? 

 

00:22:50:24

CATHERINE

So UNFPA places huge priority in midwifery, strengthening the quality of midwifery education, because we know that if we train competent midwives, confident, competent midwives, and then that they are out there deployed into these health facilities and centers and mentored and supported, that we're not going to be having these bad outcomes like obstetric fistula for women.

 

00:23:20:04

CATHERINE

So one of our huge, huge efforts is on strengthening the quality of midwifery education and trying to realize a dream that every village, every woman has access to a midwife for her pregnancy and her birth. The other thing that UNFPA does is supporting the training of obstetric fistula surgeons. Dr. Shershah is the absolute expert and should talk to this, but it's really important.

 

00:23:49:24

CATHERINE

UNFPA places importance on training obstetric fistula surgeons, not huge numbers of them, but on quality on a few qualified, passionate, competent fistula surgeons who can operate in centers of excellence. So we support that in a number of countries in our region and also the equipping of some of the hospitals with some of the key equipment and things that they need to actually do the repairs.

 

00:24:17:18

CATHERINE

But I would say that there's a huge amount more that UNFPA could do, and our only limit is our funding.

 

00:24:26:04

HOST

Catherine, actually, you have been with Dr. Shershah at his hospital. And so, you know, I would like to ask Dr. Shershah about the situation on the ground in Pakistan. Obviously, we don't see everything with what's been going on in the world. So it's definitely interesting and it would be a great insight for us for our podcast to know more about what you're doing on your side to prevent obstetric fistula, Dr. Shershah?

 

00:24:56:06

DR. SHERSHAH 

Thank you. Just before telling you about what I'm doing in the hospital, we must remember that whenever you have maternal deaths, with every maternal death you are going to have about 15 to 20 complications. And out of this, 15 to 20 complications, if you have one hundred maternal death, then you have 1500 complications.

 

00:25:19:09

DR. SHERSHAH 

And out of these 1500 complications, maybe you will have some fistula also. So any country which is having a high maternal mortality rate, then they are having fistula which is not in front of us. So like in Pakistan, there's estimation that we are having about 4 to 5000 new fistula formation in our country and with all our centers, with the efforts of UNFPA,

 

00:25:42:05

DR. SHERSHAH 

And I'm really thankful to UNFPA for last many, many years. They are supporting us and many, many organizations in the world to help women in need. So when you have this, all these facilities, so we are not repairing more than 2000 to 2500 fistula every year despite all our efforts. So whatever we are repairing, we should continue repairing those fistula.

 

00:26:07:14

DR. SHERSHAH 

But at the same time we must close the factory of the fistula formation and that factory will only be closed by the trained competent, confident, a skilled midwife who can help those women. In Pakistan, we have more than 85,000 villages and we in Pakistan Medical Association and Society of Obstetrics and Gynecology, they all demand the government that we actually need, at least we need 200,000 competent midwives so they can work  in these villages.

 

00:26:43:03

DR. SHERSHAH 

They can shift the patient to the basic health unit. They can go with the patient to tertiary care center or RHC, Rural Health Center, where the patient can have caesarean section when it is required and then the fistula can be prevented. 

 

00:27:00:00

DR. SHERSHAH 

In the women's hospital, what we do, we produce 140 very competent midwives every year. Then every year we do more than 30 competency based workshops, CBT, and most of these workshops are sponsored by UNFPA and some other organizations and these midwives come from all over the country and they stay in our hospital from six weeks to 12 weeks, and we overhaul them.

 

00:27:29:13

DR. SHERSHAH 

We changed their attitude, we train them, they attend the labor room, and they become a very competent and confident midwife. 

 

00:27:37:10

HOST

Well, you know, there are other factors as well in terms of things that we can't control. You know, there are things such as disasters that happen. 

 

00:27:49:00

HOST

When you are challenged with disasters that you can't control, you know, for example, in the Asia and Pacific area, how is the situation, Catherine, Do you see increased cases of fistula in humanitarian situations?

 

00:28:04:19

CATHERINE 

Yes. So Asia and the Pacific is very prone to natural disasters. And we have seen also political crises, we could say so in countries like Afghanistan, where women are really restricted in being able to seek care during their pregnancy and birth, it's highly likely that we are going to be seeing increased cases of fistula, of obstructed labor, where a woman didn't get the care that she needed.

 

00:28:35:04

CATHERINE 

We also know that in other countries in the Asia-Pacific region that experienced natural disasters, as the health facilities are destroyed, the roads are broken and transport isn't available. So this really limits women's ability to access care. And this is exactly the type of situation that contributes to women suffering a fistula because she hasn't been able to seek care.

 

00:29:03:01

CATHERINE 

She's probably experienced a prolonged labor at home without the care that she needs. And it's highly likely that we've got many cases of fistula in these situations. Now, the thing is that we try to find out about those. We try to do some education of midwives in these different countries to be able to identify, notify and refer.

 

00:29:26:22

CATHERINE 

But I think one of the things that we have to just do better is ensuring that when these, we know that these sort of natural disasters are going to take place frequently and we need to be prepared for that and we need to be prepared to have midwives and effective referral systems ready to go when disasters happen so that women are not alone during their pregnancy and birth and that they receive the care that they need so that they don't end up with these horrific injuries in childbirth.

 

00:29:58:06

HOST

Now, you know, throughout our conversation, we've talked about a very serious situation that is still sadly ongoing. There are a lot of points to consider, but at the end of our podcast, we really do want to send a significant, important message to our listeners. So Dr. Shershah, can you give us any final thoughts on how we can end this painful illness?

 

00:30:23:09

DR. SHERSHAH 

So my message is very simple and message towards the policymakers of different countries, especially like Pakistan. If they want to end fistula till 2030, they have to do massive investment in the midwife, number one. And then we give this massive investment in the midwife, we hope that this midwife will not only work as a midwife, but also to work as a community developer or the community supporting a staff.

 

00:30:57:04

DR. SHERSHAH 

And it is the most, easiest and most cheapest way to prevent maternal death and prevent, prevent fistula. 

 

00:31:05:24

HOST

Catherine. You know, coming from a perspective that has been working in the Asia Pacific region, what are your final thoughts about how we can end this painful illness?

 

00:31:16:04

Catherine 

So for me, ending obstetric fistula is a problem that has a solution and that is something that's very powerful because there's many problems in our world that don't have the solution. And this problem has a solution. And we've talked in this in this podcast together about what those solutions are. So midwifery, investing in midwives, investing in quality education of midwives and deployment and supporting midwives really across all countries.

 

00:31:48:17

Catherine 

This is the big, big first step for us in, in preventing and ending obstetric fistula. And the second area that I still feel is so important is that every woman that's living with a fistula that we reach her, that we find her and that we treat her, it feels like it's something that's manageable and something that we should be able to do in our lifetime.

 

00:32:10:05

HOST

Catherine, Dr. Shershah, listening to you has made me emotional. It has. It is because it's so it's as we said it, it can be solved. We just need to make the right moves. Thank you so much for your work, Dr. Shershah. Thank you so much for joining us here on our program. We look forward to hearing from you and Catherine as well in terms of how your work will proceed and continue on with the fight.

 

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00:32:40:07

 

Thank you also to our listeners for joining us today. For more insightful episodes of “Hold on a Minute!” by UNFPA Asia- Pacific, follow our podcast pages on Spotify, Facebook, YouTube, and Apple Podcast.  Just search for UNFPA “Hold on a minute”.  

 

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