I came to Pakistan with the desire to photograph the women of this country and learn about fistula and maternal health-related issues here.
Coming from a developed country, I know that I have skilled medical care at my disposal if anything were to happen to me. Pakistan presents a completely different situation. For women here, pregnancy too often results in death—typically from preventable causes.
Obstetric fistula—a painful and usually ostracizing condition that can result from prolong obstructed labor and cause incontinence, infections and even paralysis—occurs most frequently among poor, vulnerable women in developing countries. In Pakistan, fistula is a common reality for those who lack access to adequate medical care.
Pakistan’s leading fistula expert, Dr. Shershah Syed, remarked: “This is a wealthy country, yet women and babies are not receiving the care they need.”
Gender discrimination is pervasive, expressing itself in myriad ways. In many families, a baby boy is still preferable to a girl, a woman’s right to choose her partner is habitually denied, and some girls are forbidden from attending school.
Early marriage is commonplace, and many girls become pregnant when they are more vulnerable to complications. Family planning and contraceptives are not prioritized, and there is intense social pressure to become pregnant soon after marriage. Early and closely spaced pregnancies heighten the risk of developing debilitating conditions like fistula or dying during pregnancy and childbirth.
According to national statistics, roughly one out of every 89 women in Pakistan dies of maternal causes, and 1 out of 11 children born in the country die before their fifth birthday. The maternal mortality ratio in rural areas is almost twice that of urban areas. More than half of women in the country give birth without professional help, relying instead on traditional birth attendants, called dais, or family members.
Dr. Shershah took me to the Qatar hospital in Orangi Town, one of the most impoverished neighbourhoods in Karachi. The bumpy road alone made me wonder how ambulances could ever get to the hospital in time in an emergency.
The doctor was scheduled to perform a fistula repair operation. The 17-year-old girl was in the waiting room, ready to enter the operating theatre. She came from Chaman, a town in Baluchistan, close to the southern border with Afghanistan. Married at the age of 15, she quickly became pregnant. After two days of obstructed labour, the family decided to bring her to a private hospital where they had to pay 75,000 Pakistani rupees (approximately $900 dollars) for a Caesarean section.
Her father and brother made about 80 rupees (approximately $1 dollar) a day and the operation left the family with a huge debt. Due to the delay in access to care, the baby died and the young would-be mother developed fistula.
Having heard about Dr. Shershah, the girl’s family packed up and travelled to Karachi. The husband didn’t come along. Since he was not being supportive, divorce was most likely in her future. Desperate after travelling and searching for the doctor, the family finally found him after six weeks. They were extremely relieved: help was on its way.
While the doctor performed the fistula repair, a baby boy was born by Caesarean section in the operating theatre next door. This woman and baby were lucky to receive proper care at a hospital.
After the fistula operation, the girl from Chaman was immediately dressed and taken to her bed. She was surrounded by her relatives, who anxiously waited to hear how the surgery had gone. The ward was filled with women who had just given birth or had a fistula repair operation; everyone wanted to show me their babies and have their picture taken.
After seeing lots of happy mothers and babies in the recovery room, it was a shock to see a stillborn baby in the labour room just minutes later. I asked about the cause of death and if they would perform an autopsy. But the nurse told me that the cause of death for stillborns was usually filled out as ‘unknown.’
Health care should be a priority, and more skilled doctors, nurses and midwives need to be trained. I decided to pay a visit to the School of Nursing and Midwifery at the hospital and later on went to the nurses and midwives graduation ceremony at the Koohi Goth Women’s Hospital.
The school aims to develop well-informed and trained staff who can teach others within the health-care system, thereby improving national nursing and midwifery standards. The graduation ceremony was the closing point of a 30-week course with women from different parts of the country.
They will return to their respective villages and cities and teach others what they have learned in the course, spreading their knowledge.
The next day I visited the fistula ward at Koohi Goth. With UNFPA support, this hospital performs free repair surgeries and provides the necessary care for women living with fistula.
At the time of my visit, 13 patients were waiting for or recovering from surgery. These women were of all ages and from different parts of the country.
There are many medical and social consequences to living with fistula: physical and emotional isolation; abandonment and divorce; shame and estrangement from the community. Fistula patients are often subjected to major psychological trauma. Finding ways to help such patients reintegrate into their social networks is an important part of their treatment.
One young woman from Multan was scheduled to go home later that week. But her return will most likely be difficult, and reintegration into her community will take time. At 24, she had endured more hardship than most women experience in a lifetime.
She was married very young and immediately became pregnant. The delivery went badly and after days of obstructed labour and a stillborn baby, she ended up with fistula. Not understanding her condition, her husband divorced her.
She needed lengthy treatment, including reconstructive surgery. However, not fully aware of her condition, she didn’t seek treatment and married a second time. The second husband also divorced her because she could not have intercourse nor bear children. She was left on her own again.
However, the young woman finally received the reconstructive surgery she needed, and was to return to her village soon.
Poverty is an underlying cause of fistula. Here in Pakistan, it is a widespread problem. On every street corner, mothers with babies tap on car windows and ask for money. Children try to wash the windshields for a coin or two.
Girls are usually seen as an economic burden and married or traded between families. The girl becomes dependent on her in-laws, and men of the household make all of the important decisions.
The living conditions that I witnessed in the Lines slum, in the heart of the city, are difficult; hard-working people worry every single day about the future, uncertain if they will have enough food to feed their children.
I ended my visit in Karachi on a happy note from Dr. Shershah. He introduced me to a 26-year-old woman named Shamim. She was ready to leave the hospital after a successful fistula repair.
Married at the age of 16, she became pregnant the following year. As in many cases I’ve seen and heard about during my visit to Pakistan, the labour was difficult, lasted for days and the dai that assisted her didn’t refer her to a hospital to have a Caesarean section. She delivered a stillborn baby and developed fistula.
She had two other pregnancies over the following two years, but she miscarried. Shamim decided to go to a gynaecologist in search of help and was referred to Dr. Shershah to be treated. Her husband was supportive and, after treatment, they adopted a baby girl.
The family reunion in their home in Korangi was a joyous one. The women of the family surrounded her and listened as Shamim told her saga—her baby girl hugged and kissed her.
Shamin’s story gave me hope that other women living with fistula might also have a chance at recovery.
Watch the slideshow.
Reported by Wendy Marijnissen.