The New Nation - Internet Edition

Arifa As Alam

Asma Begum was married off when she was only 14. She became pregnant in no time. Despite all the odds, Asma began dreaming of her unborn child. But that was not to be.

During delivery, Asma faced serious complications. Her life was at stake. So, the doctor preferred cesarian section to save her life. Though she survived, her vaginal passage, urinary bladder and rectum merged together. As a result, Asma lost control over urination and defecation. Urine and stool used to flow continuously. And her husband abandoned her to make the matter even worse.

Prof Sayeba Akter of Bangabandhu Medical University says Asma has developed fistula. Due to malnutrition, early marriage and prolonged labour, her baby got stuck in her vaginal passage, with the bone of urinary bladder and rectum in such a way that her doctors were compelled to resort to cesarian section. As a result, her vaginal passage, urinary bladder and rectum got merged making her a fistula patient.

Prof Sayeba says if the delivery is obstructed due to any other reason other than contraction of the uterus or if the labour lasts more than 12 hours, the baby's head can be trapped in the tip of uterus. At that time, the urinary bladder and rectum remain under pressure due to the baby's position. And due to the pressure, blood circulation in these limbs is hindered and the rot begins there. Within a few days, there develops a hole and this problem is called delivery-related fistula.

She further says, "If there is any abnormal connection between the urinary bladder and vaginal passage, it is called Vesicovaginal Fistula (VVF), while the abnormal connection between rectum and vaginal passage is called Rectovaginal Fistula (RVF)." According to the UNFPA, there are now about 2 million under-18 mothers in the developing world. Being isolated and insulted, these young women are leading a dreadful life -- both physically and mentally. The UNFPA says the vaginas of young girls are small compared to the shape of an unborn baby. On many occasions, babies are dangerously positioned inside. As a result, during delivery, holes are found in vaginal passage and urinary bladder or rectum or in both places.

Currently, there are many like Asma who are affected by various pre- and postdelivery-related diseases. Among the diseases, childbirth-related fistula has taken a dangerous turn in Bangladesh and other developing countries. According to UNICEF, the outbreak of the disease is widespread in the poor countries of Asia and Arab and Sub-Saharan Africa.

A UNFPA-assisted survey conducted in Bangladesh in 2003 shows the number of women affected by fistula is 1.69 in 1000. According to this calculation, there are more than 70,000 fistula-affected women in the country. Most of these women live in poor, rural and remote areas where acceptable maternity care is not available. According to UNICEF, the mortality risk of l5-year-old pregnant girls is five times higher than those of 20-year-old women and above. And the risk of being affected by fistula is very high among under-aged pregnant girls. Engender Health Bangladesh, an international NGO, is working with assistance from the UNFPA for eradicating delivery-related fistula. SM Shahidullah, the person responsible for implementing the fistula programme, says women get affected mainly due to delayed delivery, obstructed delivery, lack of education, malnutrition, early marriage, pregnancy at early age, lack of emergency maternity care, absence of skilled midwives, lack of knowledge about prolonged or obstructed labour and lack of training among health personnel. Besides, one can get affected as a result of operation during delayed or obstructed delivery. He also says generally village women are affected by fistula. The low standard of living, early marriage, constant pressure to go for having children, ignorance about pregnancy, negligence to healthcare before and after delivery, conservativeness, confidence in conventional treatment, reluctance in delivery in hospital, unwillingness to be treated by male doctors, reluctance to transfer pregnant women to hospital, transportation problem, lack of money etc may cause this embarrassing disease.

Prof Sayeba says many people do not talk to others about the disease due to ignorance or out of shyness. Then again many people even do not know if there is any treatment for it. As a result, they continue to suffer from fistula though it is curable. According to the UNFPA, 90 percent of the patients get cured through operation. It costs about US$ 300 for the treatment and care afterwards. After five surgeries, Asma is now fully well and she is now a mother of a lovely child born through operation after her second marriage.

SM Shahidullah says National Fistula Centre was set up in 2003 in the Dhaka Medical College Hospital. At non-government level, fistula treatment and care is available at Memorial Christian Hospital, Cox's Bazar, Mirzapur Kumudini Hospital and Lamb Hospital, Dinajpur.

Statistics from the National Fistula Centre shows the number of patients visiting the centre is gradually increasing. But the number of beds has not increased. There are only 13 beds in the Dhaka Medical College Hospital for fistula patients, which is somewhat inadequate. Allocation needs to be increased. Besides, there is a need for more centres for treatment and care. To save women from the severity of the disease, service will have to be made available for the patients, says SM Shahidullah. New arrivals are not free from the dreadfulness of the disease. Due to obstructed delivery, there may be problems in children's bones. Even they may die. But subject to a little bit of awareness, one can escape from this disease. There is a need for ensuring emergency maternity care during pregnancy.

He also says, "The expectant mothers need to be taken to hospitals or clinic for delivery. If not possible, there will have to be arrangement of a skilled midwife at home. Emergency transport has to be arranged. There should be separate savings for any emergency during delivery."

Prof Sayeba says being aware is more important than to be affected by any disease. The main objective of the care during pregnancy is to detect probable complications and be prepared accordingly. If care during pregnancy can be ensured, the number of fistula-affected women will reduce significantly. And to do that, awareness among women is a must.

She also says there are some misgivings about the disease. Many think if anyone is affected by fistula she will not be able to be mother again. Many husbands believe normal sexual relationship is destroyed due to it. There is no possibility of either of it if treated in time.

The important thing is only mass awareness can address all the problems relating to fistula.