His Maternal Instinct

By Nicholas D. Kristof, The New York Times

Dr Syed with Ashrafi Akbar. Nicholas D. Kristof (The NYT)

She is an illiterate woman from the tribal areas of Pakistan who almost died in childbirth a year after marrying at the age of 12. She suffered a horrific injury during labor called a fistula that left her incontinent and smelly, and for the next 13 years she was confined to her house — never stepping outside for shame at the way she was leaking wastes.

He is a famous Pakistani ob-gyn who was educated in Ireland. After spending eight years there, he returned with plans to set up a fertility clinic for rich patients and zip around in a Mercedes-Benz. But he was so shattered by the sight of women dying unnecessarily in childbirth that he decided to devote his career instead to helping impoverished women like her.

So they met in one of the hospitals established by the doctor, Shershah Syed, and he has been helping the young woman, Ashrafi Akbar. She is scheduled to undergo a final repair of her fistula in that hospital today.

People in the West are properly outraged by Taliban oppression of women in parts of Pakistan. But some of the greatest suffering of women here isn’t political or religious. It comes simply from the inattention to maternal health care.

Here in Pakistan, a woman dies every 35 minutes because of problems from pregnancy or childbirth, according to United Nations figures.

The underlying reason is that maternal health has never been a priority globally, either to poor countries or to foreign aid donors like the United States. The only exceptions are Britain and Norway, and I hope the Obama administration will back them up.

In this part of Pakistan, Sindh Province, there is a saying that goes: If your cow dies, that is a tragedy; if your wife dies, you can always get another.

“This is simpler than an atomic bomb,” Dr. Shershah said, speaking of improving maternal health in Pakistan. “We have an atomic bomb, but we haven’t done this because the government isn’t interested. The day the government decides it doesn’t want maternal deaths, we will have no more mothers dying.”

Ashrafi’s case was typical: She tried to deliver at home with the help of an untrained birth attendant. But her pelvis wasn’t big enough to accommodate the baby’s head, so four exhausting days of labor produced nothing.

Finally, the family took Ashrafi to a clinic, and the baby was delivered dead. Then she found that she was dribbling urine and stool through her vagina. She smelled, and the salts in her urine left sores on her thighs.

Ashrafi had heard that doctors in Karachi might be able to cure her, and she asked if someone could take her. Instead, Ashrafi’s husband divorced her. Embarrassed and humiliated, Ashrafi fell into a deep depression. She locked herself up in her parents’ home and refused to see anyone.

Thirteen years passed. Ashrafi says she didn’t leave the house once. I asked her, and a cousin of hers whom I reached by telephone, how she spent her days. The answer: sewing, caring for her sick mother — and crying.

Finally, she prevailed upon her brothers to take her to Karachi, where she was examined by Dr. Shershah. At 56, he is one of his country’s best-known doctors and is president of the Society of Obstetricians and Gynecologists of Pakistan. But three times he has been pushed out of his job, he said, for saying that resources would be better spent on education and health than on atomic weapons or F-16s.

With government support nine years ago, Dr. Shershah started a top-level maternity wing in a public hospital in Orangi, an impoverished Karachi neighborhood that by some reckonings is the largest slum in the world. The hospital now handles 6,500 deliveries a year — yes, 6,500 — and accepts women from hundreds of miles away. Several years ago, a half-dead woman came from Baluchistan Province — by camel.

In addition, Dr. Shershah is hitting up friends to try to build a new maternity hospital on the grounds of a former madrassa on the edge of Karachi. So far, he has built a wing to repair fistulas free of charge and to train midwives. He says that in five years or so, as the money trickles in, the hospital will be complete. (Friends in America have set up a tax-deductible charity, National Health Forum. For more information, please go to my blog, www.nytimes.com/ontheground.)

In addition to his regular work, Dr. Shershah repairs fistulas there every Sunday, and that is how he encountered Ashrafi. Her case turned out to require a series of operations because of the long wait. But after six months of surgeries, she should be repaired and ready to go home by the end of this month.

Already, the nurses say, she is different from the shy, morose young woman who arrived. Now she smiles and sometimes laughs, and she spends her days outside in the hospital courtyard, bathing in the sunlight that she missed for 13 years.

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