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Obstetric Fistula

Obstetric fistula is one of the most serious and tragic childbirth injuries. A hole between the birth canal and bladder and/or rectum, which is caused by prolonged, obstructed labour without access to timely, high-quality medical treatment. It leaves women leaking urine, faeces or both, and often leads to chronic medical problems, depression, social isolation and deepening poverty. Each year, 50,000 - 100,000 women and girls in low and middle income countries, including in the Arab states region develop fistula, and it’s estimated that 2 million women and girls are in need of fistula repairs. Yet fistula is almost entirely preventable. Its persistence is a sign of global inequality and an indication that health and social systems are failing to protect the health and human rights of the poorest and most vulnerable women and girls.

As the leader of the global Campaign to End Fistula, UNFPA provides strategic vision, technical guidance and support, medical supplies, training and capacity building, as well as funds for fistula prevention, treatment, and social reintegration and advocacy programmes. UNFPA also strengthens sexual and reproductive health care, including timely and quality emergency obstetric services to prevent fistula from occurring in the first place.

How it happens

Without emergency intervention, obstructed labour can last for days, resulting in death or severe disability of the woman. The obstruction can cut off blood supply to tissues in the woman’s pelvis. When the dead tissue falls away, she is left with a hole – a fistula, in medical terms – in the birth canal. Tragically, there is a strong association between fistula and stillbirth, with research indicating that approximately 90%t of women who develop obstetric fistula, delivered a stillborn baby.

Obstetric fistula has been virtually eliminated in high-income countries through the availability of timely, high-quality medical treatment for prolonged and obstructed labour – namely, a Caesarean section. Today, obstetric fistula occurs mostly among the poorest and most marginalized women and girls, especially those living far from medical services and those for whom services are not accessible, affordable or acceptable. Childbearing in adolescent girls before the pelvis is fully developed, as well as twin pregnancy, breech position of the baby, malnutrition, severe female genital mutilation and cutting, small stature and generally poor health conditions are among the physiological factors contributing to obstructed labour. However, any woman may experience obstructed labour, including older women who have already had babies.

Consequences for women

Left untreated, obstetric fistula causes chronic incontinence and can lead to a range of other physical ailments, including frequent infections, kidney disease, painful sores and infertility. The physical injuries can also lead to social isolation and psychological harm: Women and girls with fistula are often unable to work, and many are abandoned by their husbands and families, and ostracized by their communities, driving them further into poverty and vulnerability. The continued occurrence of obstetric fistula is a human rights violation, reflecting the marginalization of those affected and the failure of health systems to meet their needs. Their isolation means they often go unnoticed by policymakers, and little action is taken to address or prevent their condition. As a result, women and girls suffer needlessly, often for years, with no hope in sight.

Treatment, reintegration and follow-up

Reconstructive surgery can usually repair a fistula. Unfortunately, the women and girls affected by this injury often do not know that treatment is possible, cannot afford it or cannot reach the facilities where it is available. There is also a shortage of highly trained and skilled surgeons to perform the repairs. Tragically, only a fraction of the estimated 2 million women and girls in need for fistula treatment actually receive it. At the current rate of progress, many women and girls living with fistula today could die before ever being treated. Through its Supplies Programme, UNFPA has increased the number of women and adolescent girls using modern contraception by 17.9 million since 2012. Contraceptives provided by UNFPA in 2017 prevented 6.2 million pregnancies, prevented 15,500 maternal deaths and averted 1.7 million abortions, in the 46 countries that received focused support. 

Counselling and other forms of support – such as livelihood skills, literacy, job training and health education – may also be necessary to help women reintegrate into their communities, rebuild their lives, and regain their dignity and hope after surviving a fistula.

Follow-up is also crucial for all women and girls who have had a fistula, for example, helping to ensure they do not develop the injury again during subsequent births, and helping to protect the survival and health of both mother and baby. Women and girls who have been deemed inoperable or incurable also require special and sustained attention and support to ensure they can manage their fistula in a hygienic and dignified manner.

Prevention is key

Prevention is the key to ending fistula. Ensuring skilled birth care at all births and providing timely and high quality emergency obstetric care for all women and girls who develop complications during delivery would make fistula as rare in developing countries as it is in the industrialized world. Additionally, providing family planning to those who want it, significantly reduces maternal disability and death.

The underlying factors that contribute to women’s and girls’ marginalization – including lack of access to quality health services and education, persistent poverty, gender and socioeconomic inequality, child marriage, adolescent pregnancy, and failure to protect human rights and empower women and girls – must also be addressed. UNFPA advocates for universal health coverage, provides voluntary family planning commodities and in certain countries implements income-generating activities as part of the reintegration program.

These underlying factors are likely to be exacerbated due to COVID-19, as health systems struggle to cope with the pandemic and as sexual and reproductive health services are potentially sidelined. UNFPA estimates that COVID-19 could result in an additional 13 million child marriages taking place that otherwise would not have occurred between 2020 and 2030. Moreover, we are noticing significant disruptions to family planning services. If these continue for an average of six months, the world could see 47 million women in 114 low- and middle-income countries being unable to access modern contraceptives. As a result, unintended pregnancies and thus the incidence of obstetric fistula is likely to increase.

UNFPA's response in the Arab region

UNFPA works together with national governments to prevent obstetric fistulas from occuring in the first place. The most effective way to do so is to increase access to quality maternal health services, such as family planning, skilled birth attendance and emergency obstetric newborn care. Through its global Supplies Programme, UNFPA supports provision of family planning services and commodities. A recent achievement was the expansion of available contraceptives in Morocco. UNFPA cooperated with the government and University Mohammed V in Rabat and Sidi Mohammed Ibn Abdelah University in Fez and implemented a new long-acting reversible contraceptive. UNFPA also supports the training of midwives, for example in Tunisia where they recently expanded the training opportunities by establishing a master’s and post-graduate education. Moreover, UNFPA Tunisia also supported legal revisions and expanded the responsibilities of midwives increasing their autonomy. “Midwives and nurse-midwives who are educated and regulated to international standards can provide 87% of the essential care needed for women, adolescents and newborns” 

UNFPA also supports treatment of obstetric fistula, in Yemen for example, where UNFPA supports Al-Thawra Hospital located in the capital, Sana’a, enabling women to access fistula repair surgeries for free. Read the personal stories of Najat and Sahar, both midwives and fistula survivors. UNFPA also supports rehabilitation and reintegration of women who survived obstetric fistula. Some country offices provide income generating activities 

At the regional level UNFPA advocates for universal health coverage, which is inclusive of sexual and reproductive health services. Only this way can we tackle obstetric fistula in a holistic manner. During a humanitarian crisis, UNFPA aims to continue with the  minimum initial service package, and can swiftly procure the essential and life-saving commodities. Additionally, the regional office raises awareness and funds to support the obstetric fistula programmes throughout the Arab states region.