In May, the United Nations Population Fund (UNFPA) marks both the International Day of the Midwife (May 5) and the International Day to End Obstetric Fistula (May 23). UNFPA’s Regional Director for Asia-Pacific Yoriko Yasukawa explains how these issues are linked to each other and ultimately to the health and well being of entire nations.

When Zainab’s* labour contractions began in the remote Afghan mountain village of Balakoh, her desperate family fashioned a stretcher out of her wooden bed, hoisted her up on their shoulders and carried her for hours across rough terrain to the nearest childbirth facility. Safia, the midwife at the UNFPA-supported Qaramat Family Health House, discovered the anemic and malnourished woman was carrying not one child, but four -- with two of the babies in unsafe birthing positions. Delivering the quadruplets safely, without potentially horrific physical harm to the mother-to-be, would be a challenge Safia had never faced before.

Thousands of miles away, a similar lack of access to family planning services and skilled birth attendants had long compromised the well-being of pregnant women and new mothers in remote villages scattered amid densely forested areas in Lao People’s Democratic Republic. 20-year-old Du, barely an adult herself but already a mother of two young sons in the village of Labangkhok, near the border with Viet Nam, wanted to prevent further pregnancy for a while, to safeguard her own health and take time to nurture her children.

In between these two places lies a remarkable facility in Dhaka, to which dozens of women from across Bangladesh – 21-year-old Nasima Nizamuddin among them - have made a pilgrimage in an effort to regain their lives and their dignity, after having undergone surgeries to repair bodies literally torn during unsafe childbirth, resulting in obstetric fistula, a hole in the birth canal caused by prolonged, obstructed labour.   

An obstetric fistula not only causes frequent pain and infections, it leaves women with chronic incontinence, with urine and feces leaking from the body.  Survivors often find themselves ostracized and abandoned by their families and communities, unable to work and move freely in society. However, the condition is almost entirely preventable, and its persistence is a violation of human rights.

This was Nasima’s story too. She developed fistula during the birth of her son. Her husband left them soon after.  Treated for her condition at one of the nine hospitals in Dhaka that performs reparative surgery for fistula, Nasima eventually came to the UNFPA-supported Fistula Patients Training and Rehabilitation Centre – the only one of its kind in Bangladesh - to heal.  Efforts to treat the condition are gaining ground in Bangladesh and elsewhere, but rehabilitation efforts are equally important.  Nasima eventually left the centre with newfound confidence, determined to rebuild her life and take care of her child.

Emergency obstetric care has essentially eliminated obstetric fistula in affluent countries. But it continues to affect the most marginalized and impoverished women.

Each year, 50,000 to 100,000 women worldwide are affected by obstetric fistula.  An estimated 2 million women, the vast majority in Asia-Pacific and sub-Saharan Africa, are living with the condition.   The simple and devastating reason why far too many die or suffer fistula as a result of childbirth are a lack of basic health services – especially those of a midwife or skilled birth attendant. 

This is why UNFPA works with government and civil society partners to establish and strengthen crucial midwifery programmes that create an indispensable section of the health work force to save lives and prevent needless suffering from fistula and other injuries related to childbirth.  There is still a long way to go to reach this goal.  In South Asia, for example, only 51% of women giving birth have access to skilled birth attendants. To bridge this enormous gap, governments must invest much more in health services, especially in sexual and reproductive health. On average, South Asian countries only spend just over 4% of their GDP on health, whereas richer countries (members of the Organisation for Economic Cooperation and Development – OECD) invest nearly 13% on average.

An expectant mother receives a check up at the Qaramat Family Health House in Afghanistan's central highlands. ©UNFPA Afghanistan 

But creating cadres of midwives and skilled birth attendants to help women deliver safely, as well as providing essential childbirth, post-delivery and affordable fistula treatment services, must go hand-in-hand with several key actions.

Governments must ensure comprehensive sexuality education to help all young persons learn early on in their lives to make responsible and happy choices about sex, love and marriage that are respectful and caring of their partners and of themselves. Governments must guarantee family planning services and contraception for all who need them, including young people and regardless of whether or not they are married.

And governments, in partnership with civil society, must end child marriage – a prevalent practice in so many countries -- for once and for all.  Children should not be giving birth to children, which not only endangers the health and safety of underage mothers and their newborns, but endangers the very ability of girls and women – and indeed entire nations -- to achieve their full potential.  

Ultimately, ending the crippling scourge of obstetric fistula and guaranteeing safe childbirth and post-natal care is linked to a country’s ability to fulfill the Sustainable Development Goals that underpin the 2030 Agenda, whose pledge is to ensure a life of dignity for all people, achieving gender equality and “leaving no one behind.”

For Du and other women in many of the hardest to reach places in Lao, that pledge is becoming a reality with the recent arrival of midwifery and family planning services in her village, created under the government’s National Skilled Birth Attendance Development plan, supported by UNFPA.  Du and her husband now use contraceptives to plan their family better, and if and when they have another child, Du will be supported by a skilled birth attendant to ensure safe delivery.    

Back in the Afghan mountaintop village of Balakoh, what could have ended in tragedy has had a happy ending. It took a nerve-wracking hour, but Safia helped Zainab deliver all her quadruplets safely – preventing fistula or other injuries, an accomplishment the midwife is justifiably proud of.

But for each such story that has a happy ending, many more do not.

We must persevere until every woman and girl has access to the family planning, preventive care and safe delivery services she needs in an environment free of harmful practices like child marriage.

We must persevere until every single woman and girl living with fistula has been treated.

We must persevere until every fistula survivor is welcomed back into her community and receives the support services she needs to rebuild her life, reclaim her dignity, and restore her hope and dreams for the future.