Pakistan’s Sindh Government Increases Access to Obstetric Fistula Repair Services to Comply with Orders by the High Court

Thanks to public interest litigation conceptualized by the Center for Reproductive Rights’ South Asia Reproductive Justice and Accountability Initiative (SARJAI), women in the Sindh Province of Pakistan now have access to obstetric fistula repair services in government hospitals.

On December 15, 2021, the Sindh High Court issued its final court order in the petition on obstetric fistula after the government of Sindh reported that it had made significant progress staffing government hospitals with gynecologists and establishing fistula repair centers that provide fistula repair surgeries free of cost.

Obstetric fistula is a hole that develops between the birth canal and the rectum or bladder that leads to continuous, uncontrollable flow of urine, feces or both. The primary cause is obstructed labor that is not properly addressed through timely emergency obstetric care. In Pakistan, women from low-income backgrounds face barriers to accessing quality obstetric care services and often give birth without trained birth attendants and without access to medical facilities—increasing their chances of developing obstetric fistula. It is estimated that 5,000 new cases of fistula emerge every year.

Women with fistula are often shunned by family members and community, abused or abandoned by their husbands, and left without the ability to lead normal lives. In addition to isolation and stigma, when left untreated, fistula can be fatal and carries severe physical consequences including rashes, boils, and ulcers on women’s vulva and thighs.

“For years, women have lived with this debilitating condition that could have been repaired through relatively simple surgical procedures,” said Sara Malkani, the Center’s Legal Adviser for Asia. “We’re pleased that the government of Sindh has finally acknowledged its maternal health obligations and has taken positive steps to improving the lives of women in the region.”

The case, Syed & Others v. Sindh, was the first case filed in Pakistan that sought recognition that the widespread incidence of obstetric fistula was a violation of women’s fundamental rights to dignity and life.

In February 2019, the High Court directed the government to recruit gynecologists in government hospitals and establish four fistula repair centers. Due to the failure of the government to act expeditiously, petitioners filed an application in August 2019 seeking directions to the government to implement the High Court’s orders. Subsequently, the government submitted periodic reports showing partial implementation.

In December 2021, the government submitted a report on its progress, which included plans to fill the remaining gynecologist posts in government hospitals in Sindh and fistula repair surgeries being conducted at repair centers and hospitals in Karachi. At the final hearing on December 15, 2021, the High Court acknowledged that the government had taken significant steps towards the implementation of the Court’s decision and disposed of the petition.

About Syed & Others v. Sindh

The case, Syed & Others v. Sindh, was developed with input from members of the Center’s SARJAI initiative—a network of organizations and lawyers working to advance reproductive rights established by the Center in 2012. The case was filed in the High Court of Sindh in Karachi by Malkani on behalf of the petitioners: Kiran Sohail, a survivor of obstetric fistula; Dr. Shershah Syed, a gynecologist providing fistula repair services; and Tehrik-e-Niswan, a Pakistani women’s rights organization. 

Sohail developed obstetric fistula after she gave birth in 2006 and although she repeatedly sought medical help, the doctors at government health facilities she approached lacked the training to provide treatment. She suffered with the condition for eight years, until she obtained repair surgery in 2014 at Koohi Goth Hospital—the only hospital in Karachi that provides fistula treatment free of charge.

The hospital was founded by Dr. Shershah Syed in 2005 in response to the widespread suffering caused by obstetric fistula in Pakistan.  “Every woman has a right to basic obstetric care, in case of an emergency, at her doorstep, free of charge. And it can be done,” said Syed.

The petition asserted that the widespread incidence of fistula, a preventable condition, in Sindh constituted a violation of women’s fundamental rights to life and dignity guaranteed under the Pakistan Constitution and that the violations were due to the non-implementation of maternal health policies, including the National Maternal Newborn and Child Health (NMNCH) Framework and the Sindh Health Sector Strategy. The petition also argued that Pakistan was violating its international human rights obligations to ensure women’s right to health without discrimination.

The petition requested the High Court to order the Sindh Maternal, Neonatal and Child Health Programme and the Sindh Department of Health to:

• Train and equip one gynecologist in every District hospital in Sindh to provide fistula repair surgery.
• Provide basic and comprehensive emergency obstetric (maternal) care in accordance with the NMNCH Framework.
• Ensure that community midwives are trained and deployed across Sindh in accordance with the NMNCH Framework.

The High Court responded by ordering the respondents to implement maternal health policies and report on their progress, and also formed a committee comprising government officials and experts to develop a plan for implementation. In February 2019, the Court passed a final order directing the Sindh government to establish fistula repair centers in government hospitals in four cities in Sindh and to fill vacancies in gynecologist posts in government hospitals. At the final hearing on the implementation of the High Court’s directions on December 15, 2021, the High Court acknowledged that the government has taken significant steps towards the implementation of the Court’s decision and disposed of the petition.

After Pursuing the Case for Six Years, Progress Is Made

After six years of court actions by SARJAI and orders by the High Court, at the final hearing in December the government of Sindh reported its progress to the Court, which included:

• Four fistula repair centers across the province have trained gynecologists who conduct fistula repair surgeries, free of cost. Their data showed that 34 surgeries have been conducted in these centers in 2020 and 2021.
• Two hospitals in the city of Karachi have also been equipped to provide fistula repair surgery and have provided 33 surgeries since 2020.
• It has scheduled interviews in January and February 2022 to fill the remaining vacancies for gynecologist posts in government hospitals in Sindh.

“As a result of our case, there has been very significant progress in maternal health in Sindh province in Pakistan,” said Malkani. “We will continue to work to make sure the government meets its obligations and fully implements the Court’s order so women can be guaranteed timely access to this crucial health care and be spared years of devastation caused by obstetric fistula.” 

Sheema Kermani, President of Tehrik-e-Niswan, a co-petitioner, said, “Many women in Pakistan are unable to access basic maternal health services. We are pleased that the Sindh High Court acknowledged the need to redress this grave human rights violation and that the Sindh Government has taken measures to prevent and treat a serious pregnancy-related morbidity.”

Case Fact Sheet

Case Background