Anita Rai does not look like a woman who has just been successfully cured
of her fistula – one of the most debilitating, but least known, health issues affecting
women in Nepal. Her face wears an expression of exhaustion and resignation. In a
small hotel room in the eastern city of Dharan, she sits on a bed staring into space
as her husband puts their belongings into a bag.
“We have a long journey back,” Anita says. “A full three days from here to my village
of Pathekha. Two days on a bus, and then a day walking.” That was how long it took
for her to get to a hospital after her miscarriage two years ago. “The travel is very
difficult, and most people avoid it.” It’s why she had a home birth, like most women
in her village.
“I was so young. I did not even realise I was in labour.” Her voice cracks slightly.
“There was no one to help me, to tell me what
to expect or do.” Her husband remains quiet and
stares out of the window. “It wasn’t my fault. I
didn’t realise those were labour pains. I thought
I was ill, and I just waited.”
The prolonged labour led to further complica-
tions and left her with a severe obstetric fistu-
la – a hole between the vagina and the rectum
or bladder, which leaves a woman incontinent.
Though exact numbers are hard to come by, it
is estimated that hundreds of women in Nepal’s
rural hinterlands are afflicted with this condition
because of inadequate maternal care, underage
pregnancy, or prolonged or obstructed labour.
Its consequences are crippling as it leaves them
unable to control their bodily functions or per-
form even the most basic tasks. Most live
with it for years, finding themselves shunned
by their families and the community, and
forced to isolate themselves. Some, like Ani-
ta, are left crippled and weak, unable to work
or live normal lives.
“It broke my heart,” says Anita’s husband.
“We were days from happiness. A child – our dream. But instead we found months
of illness and suffering.” Anita picks up her bags and leaves the room. “She hasn’t
been the same since,” he says.
“This is a poor woman’s problem,” says Dr. Mohan Chandra Regmi as he conducts
his morning rounds in the immaculately clean maternity ward at the B.P. Koirala In-
stitute of Health Sciences (BPKIHS) in Dharan. The ward is filled with young moth-
ers from across the region, and some even from cities in India. The institute has de-
veloped an excellent reputation for maternity care, and in particular the treatment
of obstetric fistula.
A patient, Mohan says, is “typically a woman who doesn’t get proper antenatal
care, who was married very young, and who doesn’t have proper education, who
doesn’t know where to go. She hasn’t been to any hospital or health centre, and
she tries delivering at home. She ends up having labour for several days, after which
The BPKIHS is one of three facilities in Nepal that are certified to provide care for
fistula patients, a neglected problem until a few years ago. “We expect a backlog
of between 5,000 to 10,000 existing cases across the country, with several hundred
new cases being added every year,” Mohan says.
Pregnant women in rural Nepal would benefit from better education and maternal
healthcare. Stigma and geography – women having to travel a long way to a health
centre – are the main reasons that prevent many from seeking assistance.“We need
more facilities, more doctors, and more educational programmes in rural areas,”
Mohan says as he walks round the maternity wards. “In Nepal, about two-thirds of
women still deliver outside a health facility.” By the age of 20 some women have
"Stigma and geography – women having to
travel a long way to a health centre – are the main
reasons that prevent many from seeking assistance"
already delivered three or four children, but a
woman’s body isn’t fully developed until she is
18-20, he says. “Research shows that girls who
have teenage pregnancies are more likely to have
complications, more likely even to have maternal
Susan Lama, head nurse in the operating theatre,
says more community awareness is needed. “We
have our own programmess here at BPKIHS. We
go to different villages and conduct outreach clin-
ics and educate health workers. We have educa-
tional documentaries, and brochures.”
Mohan says a nationwide programme is needed
to address this issue. Last year, the Nepalese gov-
ernment finally allocated funds for the eradica-
tion of fistula, after almost four years’ campaign-
ing by international organisations such as
the UN population fund, UNFPA, to make
it a national priority.
Beena Kathayat, a 46-year-old woman
from Khotang district, has lived with fistu-
la for more than 26 years and undergone
five surgeries to resolve it. In the process
she lost not only her husband and her family, but also her links to her community.
“It changed everything,” Beena says from her home in Dharan’s Ammar Basti slum.
“I lost everything.” The operations helped, but could not solve the problem. “There
isn’t much that they can do for me now,” she adds with resignation. “But I try to help
other women, and warn them about the dangers.”
As she says this, a young woman enters the room and introduces herself as Radhika.
“Radhika has been living with me – I gave her a home when we met at the fistula
ward. She has no family, and now I am hers and she is mine.” Radhika was married
at 12, and became pregnant when she was 16. Her body could not handle the pro-
longed labour; the local health worker had misdiagnosed her condition and she de-
veloped fistula after the stillbirth of the baby. “I have undergone four operations,”
she says. “I am a lot better now.”
Extract from TheGuardian.com