Kabul, Afghanistan – As the country continues to face an unprecedented crisis that has greatly impacted on its health system, health facilities are striving to ensure that reproductive health services remain accessible to women, including those suffering from obstetric fistula.

These women include Aisha*, a 35-year-old mother of three from Ghazni province, who has had five expensive but unsuccessful surgeries to repair her fistula. Since having the fistula 12 years ago, Aisha lived in shame and was despised even by her own family.

Obstetric fistula is a traumatic childbirth injury among women caused by a hole between the birth canal and bladder or rectum that causes uncontrollable urinary incontinence or feces leak. Women who have obstetric fistula often suffer from stigma and their lives are defined by lifelong physical and emotional trauma.

Aisha refused to remain in such a situation but the crisis that befell Afghanistan since the Taliban took over in August 2021 drove the majority of the population into poverty. Having no money to spend for another surgery, she traveled to Kabul to avail of the free fistula repair surgery at the Malalai Maternity Hospital. Today, Aisha is on her way to recovery from her sixth surgery and hopes that it will be her last.

The Malalai Maternity Hospital is one of the three government hospitals in Afghanistan that have obstetric fistula wards established through the support of UNFPA. The two others are Herat Regional Hospital in the western region and Jalalabad Regional Hospital in the east. UNFPA also supported training for doctors to ensure the hospitals have the capacity to manage simple and complicated fistula repair surgeries, as well as for midwives to care for fistula patients. UNFPA likewise provided medicines for the wards.

Another mother, Haadiya*, 50, also turned to Malalai Maternity Hospital for her second fistula surgery. “I paid AFN 50,000 (about $700) for my first surgery in a private hospital but after a couple of months, I had the problem again,” she said. “It’s my second surgery and I’m hoping to fully heal this time.”

According to the 2015 Afghanistan Demographic and Health Survey, 3%-4% of Afghan women experienced symptoms of obstetric fistula but more than half of them did not seek treatment. With the high cost of surgery, many women are forced to live with the pain and shame.

Dr. Nazifa Hamrah, head of the Malalai Maternity Hospital fistula ward, noted that the number of women seeking fistula treatment in the hospital has increased after August 2021 and attributed it to the current crisis.

“The economic challenges and lack of medical services are driving women to seek medical care in public health facilities, including for fistula treatment,” she said. “About 20 to 25 patients go under surgery every month. It was lower before August 2021.” The ward has four physicians and five midwives.

The widespread poverty that is a consequence of the humanitarian emergency in Afghanistan is expected to impact efforts to address obstetric fistula as health services are interrupted in many areas. Other factors include the expected increase in child and early marriage linked to poverty.

“Obstetric fistula predominantly affects women who lack access to quality maternal health care, those who marry early, have frequent childbearing, general poor health and are living in poverty,” explained Dr. Abdul Malik Faize, Reproductive Health Programme Officer at UNFPA Afghanistan. Lack of access to antenatal and emergency obstetric care, and contraception for birth spacing exacerbate the situation.

There is a need to focus on strengthening access of women to skilled birth attendants, maternal health care, building the capacity of health professionals on prevention of obstetric fistula, case finding, and training of more surgeons to perform obstetric fistula surgeries.

“We need to work with partners to put in place a comprehensive package of fistula care that promotes both physical and psychosocial recovery and awareness activities targeting and mobilizing health workers and influential community members,” Dr. Faize said.

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*Fistula survivors’ names changed to protect their privacy.