In Yemen and around the world, obstetric fistula strikes the most vulnerable women

UNFPA (22.05.2020) – – Five years ago, Marwa* was a child bride living in the port city of Al Hudaydah. “I was almost 17 years old, and happy with my new life. I was a new bride and I got pregnant fast. I thought life was smiling at me,” she told UNFPA. She had no idea how quickly life would turn upside down.


Like many other women and girls in Yemen, she gave birth at home. But her labour was obstructed – a potentially fatal complication. Eventually, she delivered a healthy baby boy, but suffered a traumatic injury in the process – an obstetric fistula.


“I had sudden diarrhoea and faeces coming out of my birth canal,” she said. “I started to ask myself, why was this happening? I could not comprehend it.”


An obstetric fistula is a hole between the birth canal and bladder and/or rectum. It occurs during prolonged, obstructed labour without access to timely, high-quality medical treatment. The injury can cause chronic pain and infections, social rejection and deepening poverty.


This was Marwa’s fate: A month after her baby was born, her husband divorced her. “I had become what he described as ‘ruined’,” she said.


The most vulnerable women


This traumatic birth injury affects the world’s most vulnerable women – those living in extreme poverty, without access to timely emergency care. Child brides are particularly vulnerable; childbearing in adolescence can increase vulnerability to obstetric fistula. Those with malnutrition and poor health also face heightened risks.


Hundreds of thousands of women are living with obstetric fistula today. The persistence of this condition is a sign of global social injustice and inequity.


And it could be worsening.


Today, as the world battles the COVID-19 pandemic, health systems risk being overstretched. Transportation barriers, movement restrictions, rising costs and other effects of the pandemic are making it harder for labouring women to reach safe delivery services. “The absence of timely medical treatment will likely spur a dramatic increase in obstetric fistula,” said Dr. Natalia Kanem, UNFPA’s Executive Director.


On 23 May, as the world observes the International Day to End Obstetric Fistula, UNFPA is sounding the alarm that the sexual and reproductive health needs of women and girls could be undermined. These services – including access to maternity care and safe delivery care – must be recognized as essential and life-saving.

Under the shadow of war


Marwa’s fistula was only the start of her troubles. Conflict had erupted in Yemen, throwing communities into poverty and hobbling the country’s health system.


“They told me to be patient and accept my fate… I was told that my life is over,” Marwa said, crying over the memory of that time. “I felt so sorry for myself, my youth and my newborn baby who would grow up without a father. I felt my whole life had been taken away from me. What did I do to deserve such fate? I asked that myself repeatedly.”


Marwa spent as much time and money as she could searching for a cure. “It was useless. I knocked on many doors,” she said.


Finally, she visited a midwife named Na’ama, who had received training from a UNFPA-funded programme. “She was my last resort and my only hope.”


By chance, Na’ama had taken a course on preventing and identifying obstetric fistula, and she knew just where Marwa could get care.


Na’ama contacted the National Midwives Association, which runs a UNFPA-supported fistula treatment programme. Marwa was put on a waiting list.


“One day they called me and asked me to travel to Sana’a within a week.”


The fistula programme covered all her travel expenses. She was even able to bring her sister to look after the baby, and a male cousin; women often require a male guardian to travel within the country.


Marwa underwent a successful treatment surgery at Al Thawra Hospital.


Now, she says her life has been transformed. “I forgot all the pain I had gone through. I just felt joy and happiness,” she said.


Support needed


UNFPA has supported the establishment of three fistula units across the country. Between 2018 and 2019, more than 100 fistula surgeries were successfully treated free of charge.


But today, Yemen’s health system is on the verge of collapse. Humanitarian funding for programmes in Yemen has dried up, even as the country grapples with the arrival of the COVID-19 pandemic. Hundreds of reproductive health facilities have closer or are set to close in the coming weeks.


A pledging conference is scheduled to take place, virtually, on 2 June.


*Name changed to protect privacy

World Bank: Tanzania loan should promote all girls’ education

New Q&A on discrimination against pregnant students, young mothers.


HRW (24.04.2020) – – The World Bank should work with the Tanzanian government to ensure that all pregnant girls and adolescent mothers can attend public schools, Human Rights Watch said in a question and answer document released today. The World Bank should not disburse the initial tranches of an education 19901990 loan to Tanzania planned for 2021 until the government guarantees equal access to free and compulsory primary education and equal access to secondary education for all girls.


On March 31, 2020, the World Bank’s Board of Executive Directors approved a US$500 million loan to Tanzania for its secondary education program. In doing so, the World Bank ignored a government policy, supported by President John Magufuli, which prevents pregnant students and adolescent mothers from attending the country’s regular public schools. The World Bank has issued inaccurate information that dismisses the existence of this policy and disregarded the findings of nongovernmental groups that have documented the harm it causes.


“The World Bank, Tanzania’s largest multilateral donor, is in a great position to help ensure that every girl in Tanzania gets education without discrimination,” said Agnes Odhiambo, senior women’s rights researcher at Human Rights Watch. “The World Bank should ensure that its investments improve, not undermine, the human rights of all Tanzanian girls.”


In approving the loan, the World Bank did not address the concerns about the ban, leaving questions about its commitment to work to end this policy, Human Rights Watch said.


On April 6, Tanzania’s Ministry of Education, Science, and Technology issued a statement about the World Bank loan and said that its Secondary Education Quality Improvement Program (SEQUIP) would be carried out “without discrimination and shall include girls who drop out of school for various reasons, including pregnancy.” However, the ministry did not state that pregnant girls could return to regular public schools.


SEQUIP allows girls to study in so-called “alternative education pathways,” or parallel education centers, which the World Bank has characterized as a viable secondary school alternative. But the program faces challenges around low quality of education and access even for those who were trying get into them and is fee-based.


The Tanzania government should immediately end the school ban. President Magufuli should publicly retract his destructive comments against allowing pregnant girls to stay in school and direct his government to adopt a human rights-compliant policy to support all pregnant girls to go to school.


The World Bank should ensure that pregnant girls and adolescent mothers are not forced to choose a parallel, inferior education system. They should ensure that every girl is included in the formal education system. Girls should have the option to attend public primary and secondary schools or alternative learning pathways such as SEQUIP, if they choose, when they have been out of school for long periods.


“By approving this loan, the World Bank has endorsed inadequate measures, such as inferior parallel education options, that discriminate against girls and support abusive government policies,” Odhiambo said. “The World Bank should examine the evidence and listen to the many voices saying that while it is important to expand secondary education in Tanzania, it should not be at the expense of girls’ futures.”