Kabul, Afghanistan – With 2,000 babies delivered each month, the Malalai Maternity Hospital in Kabul buzzes with a joyous kind of bedlam.
Clipboard-wielding nurses power walk through the hallways. New mothers coo at tiny newborns. Every so often, a woman in labour is rushed through the throng towards the delivery room.
Writes Danielle Moylan – @danielle_jenni a freelancer writing living in Kabul
Over the entrance a sign reads: Fistula Clinic.
Inside, 44-year-old Kobra, who has beautiful, strong features worn by years of tough rural living, sits on a bed covered with a plastic sheet.
“I have thought to myself every night,” she says, stretching her hands out, palms up, “why did this happen to me?”
Explained in medical terms, fistula, as dealt with at Malalai Hospital, is a hole between the vagina and the bladder or rectum, or sometimes both. It is often, but not always, obstetric – the result of a difficult, lengthy childbirth. There are many other causes too, including trauma from sexual assault and prolonged infections.
It has been all but eliminated in developed countries. When it does occur, it can nearly always be cured by inexpensive, uncomplicated surgery.
But in countries such as Afghanistan, it is destroying thousands of women’s lives.
A woman with fistula suffers chronic incontinence. She constantly leaks urine or faeces through her vagina, forcing her into a never-ending, futile battle to stay clean, made all the more difficult for the many without ready access to clean water. Some endure burns on their legs from acid in the urine.
But above all, fistula’s greatest impact is psychological. The chronic incontinence emits a foul smell, bringing the woman intense, constant shame.
Kobra has had fistula for seven years. She has iatrogenic fistula from a botched hysterectomy.
She counts herself lucky to have a supportive family, but has not held her young children in her arms for years: she’s afraid they’ll recoil from her – her clothes are often soiled and wet.
Her poverty has only exacerbated the toll of her fistula. With incontinence, she is unemployable. Her husband earns only a small daily labourer’s wage – just enough to cover the basics for a family of seven, but not for a modicum of comfort.
Unable to afford incontinence pads, she would make three trips to the bathroom every night, but would still soak her sheets. “I would wake up ashamed,” Kobra says.
“Ninety percent of the fistula cases I see are because of poverty,” says Dr Nafiza, the chief surgeon at the Malalai fistula clinic. Malalai is Afghanistan’s only public hospital providing fistula surgery. For those who can afford it, there are a few private clinics providing treatment for fistula.
Afghanistan’s limited access to healthcare, lack of skilled birth attendants such as midwives, and poor education create a perfect storm for fistula, Nafiza explains.
Other factors are cultural: Women in Afghanistan are often deprived of choice in family planning and even their own healthcare.
Early marriage is another problem.
Despite laws banning marriage under the age of 16, many Afghan girls are married in their early teens, often before their pelvises are fully developed to cope with childbirth.