Comment: Fertility control crucial for all women

In the days before the vote, I was struck by the anti-abortion lobby's energy and its continuing ability to set the terms of the agenda despite considerable public disagreement with their position. I wondered, not for the first time, why anti-abortion campaigners, if they are indeed "pro-life", don't campaign for legislation to oblige the state to resuscitate late foetuses if there is potential for viability. This would not deny women the right to end late pregnancies, but would oblige them to accept that if a viable foetus left their body, it would be the sole responsibility of the state, with a duty to protect its interests as a separate human being.

I can only assume anti-abortionists don't campaign for this because the real issue is not the "life of the child" but a desire to control women's fertility. Leaders of the religious right, who set the agenda on this issue, have no place for women's rights. They know that without control over their bodies, women have little real chance of equality.

It is true that in the US and Europe women have gained some control over their fertility, although it remains constantly under threat.

However, in other respects, even in the West, women continue to have far less control over their bodies than men, with only limited ability to prevent domestic violence, sexual exploitation and rape.

In many developing countries the situation is far worse for there are many women have no control at all.

Too often young girls, weakened by malnutrition and exhausted by heavy work, walk for miles to collect water or fuel. Many are forced into early marriage, in some cases well before their bodies have fully developed. Thereafter they are at risk of domestic violence and rape.

Without access to contraception or abortion, they give birth in agony and many lose their children.

Those who attempt illegal abortion, often die.

As Kate Hawkins, of Sussex University's Institute of Development Studies, said this week: "Every eight minutes a woman dies in the developing world due to unsafe abortion in countries where termination of pregnancy is illegal or safe services are unavailable." She points out that throughout the world "at least 13% of maternal deaths are due to unsafe abortion".

Regrettably, there is no very vocal lobby to end these maternal deaths or the deaths of, or injuries to, mothers and children resulting from childbirth in unsafe conditions.

Many churches pray for an end to abortion but few for an end to infant or maternal injury or death.

One of the common causes of child deaths and maternal injury is obstructed labour in conditions where caesarean sections are not available or unaffordable. Deaths and injuries often occur. Where mothers do not die, a result is often obstetric fistula - a dreadful complication which in the West was eradicated in the late 19th century, but in developing countries continues to blight the lives of millions of women. It is most prevalent in sub- Saharan Africa and Asia.

Fistulas develop over many days of obstructed labour, when the pressure of the baby's head against the mother's pelvis cuts off blood supply to surrounding tissues, which necrotise and rot away.

The dead tissue falls away and the woman is left with a hole between her vagina and her bladder (called a vesicovaginal fistula) and sometimes between her vagina and rectum (rectovaginal fistula). This results in permanent incontinence of urine and, in 20% of cases, faeces as well.

A majority of women who develop fistulae deliver dead babies and are subsequently abandoned by their husbands and ostracised by their communities, both because of their inability to have children and their foul smell.

It is estimated that in Ethiopia there are some 100,000 women suffering with untreated fistulae. The World Health Organisation estimates that approximately two million women worldwide have untreated fistulae and that each year around 100,000 develop the condition.

Fewer than six in ten women in developing countries give birth with a trained professional. In Ethiopia, it is one in ten. When complications arise, as they do in approximately 15% of all births - not least because of the incidence of female genital mutilation - there is no one available to help the woman.

The experience of Berhane, a 15- year-old Ethiopian girl, is typical.

Berhane was pregnant with her first child. She squatted for days on the mud floor of her husband's hut with no one to care for her but her mother-in-law. In agonising pain she was unable to cry out for fear it would disturb his husband's sleep.

By the third day she was sure her baby was dead. It was not until the sixth day that she delivered her tiny dead baby.

She cried herself to sleep and awoke to find her bed soaked in foul-smelling urine. Despite her efforts to keep clean, her husband left her, her family disowned her and the villagers shunned her.

According to pioneering Australian obstetrician Dr Catherine Hamlin, the root causes of fistula are poverty and the low status of women and girls which, among other factors, cause malnutrition, small stature and stunted growth.

She said: "Poverty is the basic factor. The girl child is the last one to be fed in the family. She has to look after the old people first, the men, then her husband and/or her brothers. She is the last person to be of any importance in the family . . .

the girl."

But fistula is both preventable and treatable. Dr Hamlin, who with her late husband Reginald cofounded the Addis Ababa Fistula Hospital in Ethiopia, has been has been successfully treating women and girls with fistulae without charge for almost 50 years. Berhane was one of them. The Hamlins came to Ethiopia in 1959 and found a country with virtually no services for expectant mothers and none for treatment of obstetric fistulae.

When they arrived they had never even seen one.

Reginald and Catherine quickly began to learn everything they could about obstetric fistula and perfected a surgical technique to mend the injuries. In 1974 they set up the Fistula Hospital. Over the years it has treated more than 30,000 women.

Many patients are very young and others have suffered for decades. Many have walked for hundreds of miles to reach the hospital, enduring great hardship and humiliation as they travel. Though some are helped by their families, they are unable to use public transport because their smell is so offensive. Some have experienced years of social ostracism.

The hospital can successfully treat over 90% of the fistula cases it receives. Of those who are successfully treated, many go back to their families. Some are able to give birth and are offered caesarean sections if they return to the hospital.

Some choose never to return home, remaining at the hospital where they receive an education and, in some cases, are trained as nurses. One remarkable former sufferer is now able to perform the operation which saved her.

Sometimes the injuries from the obstructed labour are so extreme that the patient can never be completely cured. They may require ongoing medical care and can never return to their villages. They too are offered employment in the hospital.

Catherine Hamlin, now well into her 80s, still operates and has raised funds to set up several other hospitals.

She has ensured that the issue of obstetric fistulae is securely on the UN agenda and has received numerous awards and accolades, including nomination for a Nobel Peace Prize.

Despite increasing fame, Hamlin's priorities remain the same.

She tells of a father who had sold his only ox to travel many miles with his daughter so she could be treated. She asked him how he would manage on the farm without an ox and he replied: "I don't mind.

I want my daughter to be cured."

A few days later some visitors to the hospital heard his story and collected enough money to buy him two oxen. The daughter, who had serious injuries and will probably never be able to marry again, now works as a nursing aide in the hospital.

To support the hospital contact Ethiopiaid on 0207 2019981.

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