Introduction

Chronic health problems. Social isolation. Economic exclusion. The consequences of obstetric fistula are devastating, life-altering—and almost completely avoidable.  

A serious childbirth injury, obstetric fistula develops due to prolonged, obstructed labor. It’s largely preventable with quality maternal care and fully treatable via surgery. And yet today it affects roughly half a million women, mostly in the Global South.  

Pakistani lawyer Sara Malkani knew things could be different for the 5,000 women developing the condition each year in Pakistan. She saw this suffering for what it was: the outcome of an under resourced health system, not of childbirth itself. This meant change would have to begin with the law.  

Sara had picked her career for this very reason. “Growing up in Pakistan I was inspired by the work of women lawyers and activists challenging regressive laws and social customs in the country,” she says. “I studied law because I believed it was a force for social and political change.”  

All around her she saw evidence of a reproductive health crisis. “As I became aware of the high rates of maternal deaths, as well as poor access to comprehensive sexual education, contraception and abortion in Pakistan and across South Asia,” she says, “I realized the importance of advocating for reproductive rights.” In 2014, Sara joined the Center’s South Asia and Reproductive Justice and Accountability Initiative (SARJAI). Working with the Asia Program, she began to develop a legal strategy that would hold the Pakistani government responsible for this crisis—and force it to address the issue of reproductive care head on.

Work in progress

Work in progress

A year later, Sara filed a lawsuit on behalf of Kiran Sohail and Dr. Shershah Syed in the High Court of Sindh, Pakistan’s second most populous province.  

Kiran, a Pakistani mother of six, had developed obstetric fistula after giving birth at home. She had lived with the condition—which occurs when a hole develops between the birth canal and the rectum or bladder, leading to the continuous, uncontrollable flow of urine, feces, or both—for almost a decade.  

Though Kiran continuously sought surgery, doctors at the government hospitals where she could afford care weren’t trained to provide it. After eight years she finally received treatment at a hospital founded by Dr. Syed, the only local facility offering it for free.  

Sara based her case around the argument that the government had an obligation to prevent and treat obstetric fistula—and its failure was a violation of the right to dignity and life. It was the first time the Pakistani courts had been asked to recognize reproductive care as both a constitutional and a human right. The outcome would set an important precedent.   

As the case went on, the Court gave orders directing the Sindh health department to improve its maternal health facilities and expand access to fistula repair treatment. Its final order in 2019 tasked the government with establishing four fistula repair centers and filling vacant gynecology posts across the province. The Center monitored progress, and at its request the Court stepped in once more to enforce the requests.  

By December 2021 Sindh had met all its obligations, even equipping two additional hospitals to provide treatment. “Over the years, it was gratifying to see our persistence rewarded through positive interim court orders and the gradual implementation of these by the government,” says Sara. “It reinforced the realization that litigation can be an effective tool to hold the government accountable.” 

Worth the fight

Worth the fight

As of 2024, the United Nations Population Fund reports significant improvements in Pakistan’s treatment of obstetric fistula cases. Mobile clinics offer surgery free of charge, and community health workers are tasked with spreading awareness and providing referrals.  

But the problem is far from solved. Most women suffering from the condition live in impoverished, isolated areas where care is still difficult to access. And many birth attendants don’t have the training to prevent it from developing in the first place.  

Other serious barriers to reproductive rights persist across the country: Recent data shows that two in three Pakistani women don’t make their own decisions about their reproductive health.  

Rather than discourage her, this keeps Sara going. “Without legally enforceable rights, many women and girls will remain deprived and marginalized,” she says. “Even though working with the law and legal institutions can be tiresome and sometimes futile, we should not give up on them.” 

She’s learned, she says, “that any gain for the rights of the marginalized is hard-won and fragile.” When she’s in need of hope, she looks to the people around her: “Working with a community of activists and survivors keeps me motivated and energized.”