Ayesha Khan's presentation on 'A Public Interest Litigation Case to Address Obstetric Fistula in Sindhat' at a Consultation on Maternal Health Petition hosted by the Collective for Social Science Research on 30 November 2018.
The World Economic Forum placed Pakistan as the second worst country on gender equality in its Global Gender Gap index released in 2017 at 143 out of 144. Bangladesh, ranked at 47, is the only country in the region to have made the top 50. The index notes country’s widening the gender gap over the decade as it ranked 112 out 115 in the year 2006. In the 2017 index, Pakistan only beats Yemen and the war-torn Syria ranks ahead of Pakistan. In 2015, maternal mortality ratio for Pakistan was 178 deaths per 100,000 live births. Between 1996 and 2015, maternal mortality ratio of Pakistan was declining at a moderating rate to shrink from 353 deaths per 100,000 live births in 1996 to 178 deaths per 100,000 live births in 2015. The World Data Atlas
[At the time of petition the MMR in Sindh was 350 per 100,000 live births.]
Causes of fistula: inadequate ante-natal care, lack of family planning services, skilled birth attendants, lack of emergency obstetric facilities, weak post-partum care. However it is an entirely preventable conditions, and if the policies of the Sindh government were implemented in full then it would be sufficiently addressed.
Dawn 27 Jan 2018: The media was informed that maternal mortality in Balochistan was 765 in 2013 as per an international survey, the highest in four provinces of Pakistan, followed by 311 in Sindh, 272 in Khyber Pakhtunkhwa and 227 in Punjab while overall maternal mortality rate was 276, which was highly alarming for the whole world. However, Dr Midhat said with dedicated efforts and interventions by those international organisations, maternal mortality had brought down to such a large extent in Sindh during last five years.
Pak Constitution Article 9: fundamental right to life, interpreted by SC Pak to include all such amenities and facilities which a person born in a free country is entitled to enjoy. [failure to provide care and treatment to petitioner for 8 years during which she suffered.] Pak Constitution Article 14: right to dignity
Principles of Policy in Articles 29, 34 35 and 38 of Constitution require that the government prevent incidence of fistula and ensure accessible and affordable treatment of fistula is available to all women in Sindh. In addition to violating Pakistani laws, said the petition, the state also failed to honour the international covenants it has ratified, such as the International Covenant for Economic Social and Cultural Rights (ICESR). Article 12(1 and 2) of this recognises the right of everyone to enjoy the “highest attainable” physical and mental well-being with specific provisions for the reduction of stillbirth-rate and infant mortality.
Pakistan has also ratified the UN Committee on Economic Social and Cultural Rights providing for “family planning, pre- and post-natal care, emergency obstetric services and access to information, as well as to resources necessary to act on that information.” Article 12 (2) of CEDAW, ratified by Pakistan, does provide for elimination of “discrimination against women in the field of healthcare in order to ensure, on a basis of equality of men and women, access to healthcare services, including those related to family planning.”
In a similar Indian case in the province of Uttar Pradesh, the judge recently ordered that all medical staff vacancies be filled, action plan to ensure medical care delivered to poor, financial audit of hospitals and medical colleges, and govt officials should use govt health care facilities. No funds for medical care be unutilized or unspent.
Petitioners Tehrik-e-Niswan: advocacy and awareness building measures to raise awareness amongst the public about the issue, is a petitioner in the public interest to bring to the courts attention matter of public importance concerning enforcement of public rights. Kiran Sohail: 30 year old petitioner living in Malir, who developed obstetric fistula in 2006 during birth of first child, attended to by an untrained midwife, subsequently no doctors in government run facilities in Karachi’s maternity homes could treat her fistula, which persisted despite births of more children and 8 years, until she was finally treated at Koohi Goth Hospital. Petition seeks recognition of the violation of her fundamental rights. Respondent: Govt of Sindh National Maternal Newborn and Child Health Framework adopted in 2006, which is committed to provision of comprehensive maternal and newborn child health services at district level, including 24 hours comprehensive emergency obstetric care, training and deployment of community midwives, provision of comprehensive family planning services. and Sindh Health Sector strategy of 2012. Which has similarly beneficial goals.
On May 19 2016, a division bench of the Sindh High Court led by Chief Justice Sajjad Ali Shah called on the parties to suggest names for the formation of a committee for the implementation of maternal health policies for the prevention and treatment of obstetric fistula. On June 2 2016, the Sindh Health Department informed the Sindh High Court that an internal Working Group has been established to address the implementation of maternal health policies and insisted that another committee is not required; however, the petitioners proposed names of independent maternal health experts and advocates required to ensure the accountability of the Working Group.
Petition in Sindh Court: A Public Interest Litigation Case to Address Obstetric Fistula in Sindh
Petition in Sindh High
A Public Interest Litigation Case to Address Obstetric
Fistula in Sindh
Global Gender Gap index 143 out of 144 (2017)
Maternal mortality ratio
Pakistan: 178 deaths/100,000 live births (2015)
Sindh: 350, since reduced
Pakistan: 4-5,000/ yr
Sindh: 1,000 – 1,500/ yr
Human rights basis of petition
Constitution of Pakistan
Article 9: right to life
Article 14: right to dignity
Principles of Policy (Articles 29, 34, 35 & 38)
International Covenant for Economic, Social and
Cultural Rights (ICESR), Article 12: rights to ‘highest
attainable” standard of physical and mental well-being
UN Committee on Economic, Social and Cultural Rights
providing for full range of RH services.
CEDAW (Article 12) to eliminate discrimination in field of
Human rights instruments and law
• A potential model for PIL in other provinces.
• Path-breaking initiative for maternal health
recognition within fundamental rights.
• Legal remedies serve to support actors within
government and generate adequate political will.
Progress of Case
Dr Shershah Syed, Tehrik-e-Niswan, Kiran Sohail vs.
Sindh Health Department and MNCH Sindh Program
Advocacy and support generated by interactions with
stake-holders, press reports, CSSR support, and
Benefits of full verdict vs. orders from judge