FEATURE

Obstetric Fistula: A Preventable Tragedy

Suellen Miller, CNM, PhD, Felicia Lester, MPH, MS, Monique Webster, MPH, and
Beth Cowan, MD
Obstetric fistula disables millions of women and girls in developing countries, primarily in sub-Saharan
Africa and South Asia. The United Nations Population Fund (UNFPA) recently launched a global campaign
to end fistula, labeling this condition a preventable and treatable tragedy. Obstetric fistula overwhelmingly
results from obstructed labor, which occurs in cases of cephalopelvic disproportion and malpresentation.
Cephalopelvic disproportion often complicates deliveries in young, primiparous women of low gynecologic
age. Social factors, including young age at marriage and malnutrition of girl children, can also contribute to
cephalopelvic disproportion. These social etiologies must be addressed by prevention campaigns. Direct
prevention of fistula can occur during delivery when skilled providers identify women and girls at risk for
obstetric fistula and link them with innovative interventions, such as Fistula Prevention Centers, through
which they can more readily access emergency obstetric care, and by setting strict time limits for laboring
at home without progress. Community-based programs, such as the Tostan program in West Africa, use
social education to prevent fistula. Moreover, effective surgical techniques for fistula repair are available in
some settings and should be expanded to reach those in need. Midwives can play a key role in the prevention
and treatment of this tragic obstetric complication. J Midwifery Womens Health 2005;50:286 –294 © 2005
by the American College of Nurse-Midwives.
keywords: fistula, cephalopelvic disproportion, obstructed labor, parity, maternal mortality, maternal
morbidity

“My name is Telanish Shabera. I am 14 years old. I
was promised in marriage when I was 3, betrothed
at 10, and pregnant at 12. After 3 days of labor, I
was carried on a stretcher to a hospital, where my
baby died 2 hours later. The obstructed labor left me
incontinent. I smell, and I feel so ashamed.”1
INTRODUCTION
Vesicovaginal and rectovaginal fistulas are debilitating
complications of obstructed labor, which primarily affect
women and girls in developing countries. During prolonged
labor, the baby’s head compresses the vagina against the
mother’s pelvic bones, and if the compression continues
long enough, the tissue becomes necrotic, forming an
opening between the vaginal wall and the bladder or the
rectum.2,3 Obstetric fistula has been virtually eliminated in
developed countries, but it is still prevalent in many parts of
the developing world.4,5 Although it is difficult to deter-
mine precise rates, it is estimated that there are at least 2
million women living with fistula, primarily in sub-Saharan
Africa and South Asia, and some 50,000 to 100,000 women
are affected each year.6,7
Physical complications and comorbidities are associated
with fistula; some caused by obstructed/prolonged labor,
Address correspondence to Suellen Miller, CNM, PhD, Women’s Global
Health Imperative, University of California, San Francisco, 74 New Mont-
gomery Street, Suite 600, San Francisco, CA 94105-3444. E-mail:
smiller@psg.ucsf.edu
and others are sequelae of the fistula itself. These include
fetal demise, damage to the cervix or pelvic bones, neuro-
logical conditions such as foot-drop, leakage of urine
and/or feces into the vagina, urogenital infections, ammonia
dermatitis, genital lacerations, kidney infections, and am-
enorrhea.8,9 The psychosocial complications are also dev-
astating, and although they start with social isolation of
affected women due to offensive odor, many women are
abandoned, divorced, and ostracized. Women suffer for
many years, since fistula repair services are rare, and even
when available, women lack the knowledge that fistula can
be repaired and/or they lack resources for treatment.10
In this article, we discuss the prevalence and incidence of
fistula, review literature on the etiologies and enabling
factors that predispose to fistula, explain the comorbidities
and sequelae of fistula, and describe treatments, including
preoperative, intraoperative, and postoperative care. Pre-
vention efforts, including examples of community-based
prevention strategies, are emphasized. We conclude with
implications for midwifery practice and research. Advo-
cacy efforts aimed at prevention of fistula and treatment of
affected girls and women are proposed.
LITERATURE REVIEW
This article is based on a comprehensive review of the
literature, rather than a formal meta-analysis or systematic
review. Studies related to fistula were identified through
searches of the electronic databases MEDLINE, Popline,
Sociological Abstracts, and PubMed, as well as searches for

286 Volume 50, No. 4, July/August 2005

© 2005 by the American College of Nurse-Midwives 1526-9523/05/$30.00 • doi:10.1016/j.jmwh.2005.03.009
Issued by Elsevier Inc.
on-line, Web-based documents using the “Google” search
engine (http://www.google.com). Keyword searches con-
sisted of the following terms: obstructed labor OR pro-
longed labor OR fistula OR cephalopelvic disproportion
AND (age OR parity); gynecologic age; gynecologic age
AND (prolonged labor OR fistula OR obstructed labor);
and maternity waiting homes. We reviewed reference lists
of relevant articles to find additional citations. We con-
ducted Web site searches of international girl’s and wom-
en’s rights and health organizations, including United
Nations Children’s Fund (UNICEF), United Nations High
Commission for Human Rights, United Nations Population
Fund (UNFPA), the Population Council, Centre for Devel-
opment and Population Activities, International Center for
Research on Women, EngenderHealth, Tostan, and the
World Health Organization (WHO).
Authors attended conferences where new research on
fistula and obstructed labor was presented, including the
XVII International Federation of Gynecology and Obstet-
rics (FIGO) World Congress of Gynecology and Obstetrics
in Santiago, Chile, November 2003, and the WHO/Popu-
lation Council Technical Consultation on Married Adoles-
cents, Geneva, December 2003. One of the authors (MW)
visited the Hamlin Addis Ababa Fistula Hospital in Ethio-
pia in 1998. Another author (BC) repaired fistulas of
African immigrant women at the Harlem Hospital in New
York City and at the Princess Charity Maternal Child
Hospital in Sierra Leone.
Tables 1 to 3 display the majority of data-based literature
reviewed for this article; we have divided the literature into
the following categories: fistula, age/pelvic maturity/ob-
structed labor, and maternity waiting homes.
PREVALENCE AND INCIDENCE OF OBSTETRIC FISTULA
Accurate prevalence rates of obstetric fistula (globally and
nationally) are unavailable, due to inaccurate reporting,
underreporting, and shame, which keeps women from
complaining about fistula. There are certain countries in
South Asia, specifically Bangladesh, and in sub-Saharan
Africa, such as the Sudan, Ethiopia, Chad, Ghana, and
Nigeria, where fistula prevalence is reported to be high.10 In
2002, the UNFPA conducted a 6-month needs assessment
Suellen Miller, CNM, MHA, PhD, is Director of Safe Motherhood Programs,
the Women’s Global Health Imperative, University of California, San Fran-
cisco, Department of Obstetrics, Gynecology, and Reproductive Sciences, and
Adjunct Assistant Professor, University of California, Berkeley, School of
Public Health, Maternal and Child Health Program.
Felicia Lester, MD, MS, MPH, received her MPH in Maternal and Child
Health through the University of California, Berkeley and the University of
California, San Francisco Joint Medical Program.
Monique Webster, MPH, is a graduate of the Maternal and Child Health
program at the University of California, Berkeley School of Public Health.
Beth Cowan, MD, is a board-certified obstetrician/gynecologist, who is
currently completing an obstetrics and gynecology fellowship at the VA
Medical Center/University of California, San Francisco.
Journal of Midwifery & Women’s Health • www.jmwh.org
in 9 African countries, and estimated that there could be up
to 1 million women living with fistulas in Nigeria alone,
and that incidence rates could be as high as 2 to 3 per 1000
women in countries with high maternal mortality rates.10
Until better reporting methods become available, these
estimates and small-scale, usually facility-based epidemio-
logical reports will have to suffice.
ETIOLOGIES OF VESICOVAGINAL AND RECTOVAGINAL FISTULAS
In the United States and the United Kingdom, 70% of
fistulas are a result of pelvic surgery.11 Other nonobstetric
etiologies of fistula include malignancies, radiation therapy,
infection, and trauma. Based on a review by Cron,5 data
from the United States and the United Kingdom indicate
that fistula is rare in developed countries and almost never
results from obstructed or prolonged labor. A study from
UCLA cited by Cron found only 43 cases of fistula over 20
years, with only 2 cases due to obstetric causes; the other
cases were due to surgical complications and radiation
treatment.5 Also cited in Cron, a UK study found 166 cases
over 18 years, with only 21 of these due to obstetric
causes.5 By contrast, 1 region in Nigeria reported 377 cases
over 16 years, with 369 of these due to obstructed labor.5
Obstructed Labor
In developing countries, 90% of fistulas are caused by
obstructed labor.12 One study at the Addis Ababa fistula
hospital in Ethiopia noted an average labor duration of 3.9
days in patients who subsequently presented with a fis-
tula.13 During prolonged/obstructed labor, the soft tissue of
the vagina is trapped between the fetal head and the bony
pelvis. If the compression is not relieved, the tissue will
become necrotic. Usually between 3 and 10 days postpar-
tum, this necrotic tissue sloughs off and a fistula develops
between the bladder and the vagina (vesicovaginal) or the
rectum and the vagina (rectovaginal).9 Rectovaginal fistulas
occur far less frequently, comprising 10% of fistulas.10
Lack of skilled attendance at birth, lack of emergency
obstetric care, and lack of transportation to maternity
facilities contribute to the high rates of prolonged and
obstructed labor and resultant fistula in developing coun-
tries.
Direct and indirect factors predisposing to prolonged and
obstructed labor include malpresentation and cephalopelvic
disproportion. Malpresentation can occur in any woman,
but it is more frequent in grand multiparas with lax uterine
muscles.
The Relationship Between Cephalopelvic Disproportion and
Young Age
Young girls and women (aged 10 to 19) suffer dispropor-
tionately from fistula. Although more women aged 20 to 45
give birth than women in the age group 10 to 19, close to
50% of all fistula cases occur in women aged 10 to 19. In
287
 Table 1. Articles on Fistula
Authors
15
Ampofo et al., 1990
Arrowsmith et al., 199630
Elkins, 199431
Hamlin et al., 200219
Hilton, 20039
Ibrahim et al., 200017
Ijaiya and Aboyeji, 200418
Kelly, 199513
Muleta and Williams, 199933
Tahzib, 198316
UNFPA/EngenderHealth,
200310
Wall et al., 200414
Description
Nigeria: Case-control 241
cases vesicovaginal
fistula, 148 controls
Ethiopia: Records review of
combined historical cases
Ghana, Nigeria, United
States: Record review of
100 cases of fistula
repairs
Ethiopia: Needs assessment
Africa: Literature review
Nigeria: Cross-sectional
survey, convenience
sample, 31 cases
vesicovaginal fistula
Nigeria: Record review of 34
cases vesicovaginal
fistula
Ethiopia: Record review of
309 random cases of
vesicovaginal fistula
Ethiopia: record review of 91
cases of rectovaginal
fistula
Nigeria: Cross-sectional
survey of 1443 cases of
vesicovaginal fistula
Benin, Chad, Malawi,
Mali, Mozambique, Niger,
Nigeria, Uganda,
Zimbabwe: Needs
assessment
Nigeria: Records review of
932 cases of fistula
Key Findings
Prolonged labor contributed to 76% of cases of fistula; 27% of fistula in women
⬍15 y; 59% of fistula in women ⬍18 y
28.6% have urethral damage; 63.1% are amenorrheic; 17.4% have rectovaginal
fistula; 20% have foot drop
59% of successfully repaired fistula suffered long-term morbidities; 13% mild
stress incontinence; 5% amenorrhea; 10% foot drop
Estimate incidence of fistula in Ethiopia 8700/y (3/1000 births)
Majority of fistula in developing countries die to neglected obstructed labor; of
479 patients in Nigeria, 27% had perineal weakness, 8% lower limb
symptoms, 10%–12% had postrepair stress incontinence
Mean age at time fistula occurred: 15 y; mean age at marriage: 13 y; mean
height: 149 cm; mean duration of labor: 4 days; 87% had stillbirth; divorce
rate: 55%
Peak incidence in women 15–19 y
⬎50% of women rejected by husbands; 82% traveled at least 700 km for
treatment; suggested maternal waiting homes
All women had been divorced or abandoned by husbands
83% had prolonged labor; 33% ⬍16 y; 52% primiparous
Few fistula repair services available; inadequate training and supplies;
Affected women have little knowledge of treatment; rigorous research needed
Mean age at marriage: 15.5 y; fistula developed during first labors lasting
⬎48 h

Jos, Nigeria, 45.8% of the fistula cases occurred in primip-
arous women.14 In studies from Nigeria and Ethiopia,
adolescents constitute a disproportionate number of fistula
cases.13,15–18 In Ethiopia, it is estimated that 3 in 1000
parturients develop fistula, the majority of whom are under
20.13,19 A Nigerian case-control study of 241 cases of
fistula and 148 controls found that 27% occurred in women
15 years old or younger, and 59% occurred in women 18
years old or younger. Earlier age at marriage was also
significantly associated with risk of fistula (P ⬍ .01).15
The association between young age and fistula is most
likely secondary to the increased incidence of cephalopel-
vic disproportion in younger women. Neither young age
itself, early marriage, nor low parity alone are likely
independent risk factors for cephalopelvic disproportion
and subsequent obstructed labor and fistula, but they serve
as proxies for pelvic immaturity. Pelvic bone maturity is a
combination of the size and diameter of the pelvic bones as
well as the diameter of the pelvic opening. Moerman,20 in
a radiologic study of 90 early and middle adolescent girls in
the United States, found that the actual size of the birth
canal was smaller the first 3 years after menarche than at
age 18, and that the dimensions of the inlet, midplane, and
outlet of the birth canal of these young adolescent girls
were contracted. According to Treffers,21 the pelvic bones
of adolescents less than16 years of age may be immature,
particularly in the very poorest developing countries, where
onset of puberty is late. This delay in pelvic maturity may
correlate with the noted relationship between younger age
and more frequent incidence of obstructed labor.
Low Gynecologic Age
Zlatnik and Burmeister22 first defined gynecologic age as
the difference between chronologic age minus age at
menarche; Scholl et al.23 defined “low” gynecologic age as
less than 2 years between chronologic age and menarche.
Miller and Lester24 posited that low gynecologic age might
contribute to obstructed labor resulting in fistula. Although
decreasing in developing countries, the age at menarche

288 Volume 50, No. 4, July/August 2005

 Table 2. Articles on Association of Age, Gynecologic Age, Cephalopelvic Disproportion, and Obstructed Labor
Authors Description
27
Chumlea et al., 2003 USA: Cross-sectional study of
2510 females age 8–20
Moerman, 198220 USA: Longitudinal study of
clinical, laboratory, and
x-rays of 90 adolescent
girls
Treffers, 200221 Global: Literature review
Zlatnik and Burmeister, 197722 USA: Records review of 1005
girls ⬍17
Key Findings
Median age at menarche: 12.43
Pelvic inlet, midplane, and outlet clinically contracted during early adolescence
(⬍17); growth of pelvis continues for 3 y after menarche
Obstructed labor a major health problem for young adolescent girls,
particularly in specific geographic regions
Gynecologic age is the chronologic age minus age at menarche; Patients with
low gynecologic age (⬍2 y) have an increased likelihood of delivering a low
birth weight baby compared to those with gynecologic age ⬎2 y;
independent of chronologic age

remains higher than seen in developed countries.25–27
Higher age at menarche, together with younger age at
marriage, means that young, first-time mothers in devel-
oping countries are likely to have a lower gynecologic
age than adolescent mothers in developed countries,
even at the same chronologic age. Countries where the
mean age at marriage is age 15 or below, such as Nigeria,
Ethiopia, and Bangladesh, also exhibit high rates of
fistula.10,24
Malnutrition Related to Pelvic Immaturity
Other factors contributing to cephalopelvic disproportion
and therefore, prolonged/obstructed labor among girls in
developing countries, is chronic undernutrition and malnu-
trition, contributing to their being less likely to have
reached adult size by menarche.24 In a study of fistula
patients in Ethiopia, short height (less than 150 cm)
imparted a relative risk of fistula of 1.83.15 Early malnu-
trition with resultant underdeveloped bone structure may
have serious implications for women whose first pregnancy
occurs soon after menarche.28 The frequency of underde-
veloped pelvis and short height secondary to malnutrition
further contributes to the high rates of obstructed and
prolonged labor in some developing countries.29
COMORBIDITIES ASSOCIATED WITH FISTULA
Fistula is part of the obstructed labor complex, a multiple
organ syndrome, which also includes gynecologic, skeletal,
neurological, and dermatologic injuries.30 In a 3-country
study, 59% of women who had successfully repaired fistula
also suffered other morbidities.31 For reasons that are not
entirely clear and are still being studied, amenorrhea may
follow obstructed labor. Current theories attribute the am-
enorrhea to dysfunction of the gonadotropin hormonal
axis.5 Foot drop, a condition that causes dragging of the
foot and inability to walk without a cane or assistance, is
thought to be due to prolonged compression of the sacral
nerves by the fetal head as well as damage to the perineal
nerve. In a study of 479 fistula patients in Nigeria, 27% had
perineal nerve weakness and 38% had lower limb symp-
toms.9 Neurogenic bladder dysfunction can also result from
prolonged labor. Ammonical dermatitis and vulvar excori-
ation are commonly seen as direct sequelae of the constant
leaking of urine with vesicovaginal fistula.
SOCIAL CONSEQUENCES ASSOCIATED WIH FISTULA
As a result of the continuous leakage of urine and feces into
the vagina, affected women often have an offensive odor,
leading them to be ostracized by their husbands, families,
and community. For example, families do not want fistula
survivors preparing food or participating in family events.
In addition, vaginal injuries can result in a woman’s
inability to perform her expected duties, from manual labor
to having sexual intercourse with her husband.8 In societies
in which a woman’s worth is dependent on fulfilling her
marital (sexual) duties, this situation is devastating.8 In

Table 3. Articles on Maternity Waiting Homes

Authors Description Key Findings
39
Figa-Talmanca, 1996 Colombia and Cuba: Literature review Maternal mortality ratio in Cuba dropped from 118 to 29/100,000 between
and observations of maternity waiting 1962 and 1989; 30% of women in Cuba used a maternity waiting home in
homes 1989
WHO, 199640 Bangladesh, Indonesia, Malawi, Mongolia, Use of maternity waiting homes is associated with decreased maternal
Mozambique, Papua New Guinea, mortality, decreased perinatal mortality, decreased need for obstetric
Zimbabwe: 8 country-wide case studies interventions, and increased birth weight
of maternity waiting homes

Journal of Midwifery & Women’s Health • www.jmwh.org 289

Niger, fistula accounts for 63.3% of all divorces.32 Accord-
ing to an Ethiopian study of previously married women
with fistula repairs (n ⫽ 78), all the women’s husbands
either divorced them (n ⫽ 59) or abandoned them (n ⫽
19).33 Kelly13 reported that husbands had rejected more
than 50% of patients at the Hamlin Addis Ababa Fistula
Hospital. In a Nigerian study of 31 fistula patients, the
divorce rate, even after repair, was 55%; 87% of these
women had a stillbirth.17 Given that fetal death often occurs
during the obstructed labor that caused the fistula, the
subsequent amenorrhea, which can often be permanent and
even after repair lasts for up to 2 years,9 further compounds
the woman’s childless state and cultural valuelessness.

TREATMENT
Given the impact of fistula on women’s and girls’ health,
treatment and prevention are critical public health issues.
Treatment includes surgery to repair the fistula and reha-
bilitation, including stretching and mobilizing limbs atro-
phied secondary to perineal and sciatic nerve damage.
Physiotherapy is necessary for the rehabilitation of lower
limb weakness, foot drop, and lower limb contracture.9
Psychological and emotional counseling, skill building, and
outreach to locate women with fistula and transport them to
distant treatment centers round out treatment efforts.34
Although the success of fistula repairs is as high as 90%,
many women remain unaware of the availability of treat-
ment for their condition.10,35 It is estimated that 80% of
women with fistulas never seek treatment.10 One of the
main reasons women do not seek treatment is lack of
knowledge that anything can be done. Second, shame
associated with the condition often prevents women from
seeking help. In Benin, despite the significant morbidity
associated with fistulas, treatment is regarded as a “lux-
ury.”10 Indeed, the medical costs of repair, between $150
and $450 US dollars,8,10,34 as well as significant transpor-
tation issues, prevent many women from receiving care.
There are very few hospitals in developing countries with
the resources and trained staff to perform fistula repair, and
women frequently must travel far to reach treatment facil-
ities. At the Hamlin Addis Ababa Fistula Hospital, 82% of
the women had traveled 700 km or more to seek treat-
ment.13 The United Nations Population Fund’s Obstetric
Fistula Needs Assessment found that although fistula repair
is performed in several countries (Ethiopia, Kenya, Malawi,
Mali, Mozambique, Niger, and Nigeria among others), sites
within each country are few, and inadequate training and
supplies limit the availability of treatment.10 There are few
hospitals, such as the renowned Hamlin Addis Ababa
Fistula Hospital, where more than a 1000 patients are
treated annually, which are dedicated only to fistula repair35
(Figure 1).
Outreach, especially in rural areas, is crucial to recruiting
women for treatment. Ideas for spreading awareness in-
clude using radio messages, community plays, and educat-
Figure 1. Princess Charity Maternal and Child Hospital, Sierra Leone.
Reprinted with permission from Beth Cowan.
ing community outreach workers.10 For example, 70
women in Chad sought treatment after a successful mis-
sionary outreach campaign.10 Outreach by women who
have undergone fistula repair and returned to their commu-
nities can spread awareness of fistula and treatment avail-
ability; these outreach workers can be role models provid-
ing hope to fistula sufferers.36
Early Detection and Treatment
If a woman with a fistula manages to get to the hospital
while still in labor, and the hospital has trained personnel,
it is possible to encourage the fistula to close spontane-
ously. This can be accomplished by catheterization to avoid
urine flowing through the fistula. Likewise, fistula can be
prevented in women with prolonged labor by continuous
catheterization and administration of antibiotics postpar-
tum. Hilton, a pioneer in fistula treatment and repairs,
recommends Foley catheterization for 6 to 8 weeks to
promote spontaneous closure.9
Preoperative Care
Early detection and treatment of obstetric fistula is rare.
Patients arriving at fistula repair centers have often had the
fistula for months or even years, and are suffering from
malnutrition and anemia, which must be improved before
surgery. Physical therapy for lower limb weakness, muscu-
lar contractures, and foot drop, as well as psychological
counseling, begins preoperatively and will continue post-
operatively. Some women have been lying curled in a fetal
position for so long that they will need intensive therapy to
be able to walk again.
Immediate preoperative care should include a complete
physical examination. Fistulas are located by inserting a
Foley catheter into the bladder during the presurgical
evaluation and injecting a dilute solution of methylene blue
and/or sterile milk (Figure 2). A thorough rectovaginal
examination is performed to rule out rectovaginal fistulas.

290 Volume 50, No. 4, July/August 2005

Figure 2. Fistula examination. Reprinted with permission from the World
Health Organization/H. Rochat.
Recommended laboratory evaluations include a complete
blood count, a wet mount, and a check for sexually
transmitted diseases. All infections should be treated prior
to surgery (Box A).
Postoperative Care
Ureteral catheters should be left in place for 1 week, and
urinary catheters for 2 weeks. If catheters become blocked,
and the bladder distends, it is possible for urine to seep
through the fistula and jeopardize the repair. To ensure that
catheters do not become blocked, irrigation with normal
saline or dilute boric acid solution should be performed
daily. Patients may tolerate a soft diet on the first postop-
erative day and should progress to a regular diet by the
second day. Vaginal packing is removed on the third
postoperative day. The catheter should be clamped for short
periods on the day before removal to accustom the bladder
to distension. The patient is usually confined to bed for 2
weeks after the operation, so care to prevent bedsores is
essential, particularly for those patients who have neuro-
logical and muscular contractures and/or weaknesses (Fig-
ure 3). Postfistula repair stress incontinence occurs in
approximately 10% of patients.9 Although the majority
(60%–98%) of repairs are successful, there are diminishing
success rates with subsequent surgeries.9
The patient should be counseled to abstain from inter-
course for at least 3 months and should be provided with a
family-planning method if she desires. However, in some
low-resource settings, family-planning services are often
limited to condoms and/or instructions on the rhythm
method. Due to many men’s low compliance with con-
doms, treated women often plan to use abstinence. If the
patient becomes pregnant at any point after the repair, she
should be advised to go to the nearest hospital for delivery
by cesarean birth, if it is available.9 Lack of skilled birth
attendant, lack of transportation, lack of emergency obstet-
ric care, inability to pay hospital fees, and low status of girls
Journal of Midwifery & Women’s Health • www.jmwh.org
Figure 3. Addis Ababa Fistula Hospital Fistula Ward. Reprinted with permis-
sion from the World Health Organization/P. Virot.
and women are socioeconomic, cultural, and gender roles
that contribute to the sentinel obstructed labor. These same
factors may prevent the woman who had a fistula repair
from having a safe subsequent delivery. Thus, the fistula
may reopen during a vaginal birth.
PREVENTION OF OBSTETRIC FISTULAS
Fistula prevention involves strategies to educate communi-
ties about the cultural, social, and physiologic factors that
increase the risk for fistula. On the basis of physiologic
immaturity, characterized by small pelvic size in the years
immediately following menarche,21–24 it is advisable to
delay childbearing for several years after menarche to
prevent prolonged and obstructed labor and their sequelae.
This most likely will require influencing community values
concerning the role of women in society. Prevention of
obstructed labor and fistula should begin very early in each
girl’s life. For example, improved nutrition and campaigns
to raise awareness about the special nutritional needs of girl
children to prevent chronic malnutrition and to improve the
physical maturity of young mothers, as well as her overall
health, are part of holistic fistula prevention strategies.
Midwives, located in the rural communities where the most
at-risk girls reside, can be pivotal in promoting preventative
health practices that help prevent future development of
obstetric fistulas.
Another prevention strategy is to provide timely access
to safe delivery. Fistula can be prevented through early
detection of potential cephalopelvic disproportion and mal-
presentation and referral of girls and women likely to
experience prolonged/obstructed labor to emergency ob-
stetric care facilities. These prevention strategies may
include assessment of gynecologic age to determine pelvic
maturity; encouraging births with skilled attendants; imple-
mentation of time limits for labor dependent on the distance
from emergency obstetric care37; helping the family and
community develop an emergency transport plan for pro-
291
longed labor; and the use of Fistula Prevention Centers in
areas far from emergency obstetric care. The prevalence of
fistula in specific regions of countries should be mapped
and taken into consideration when developing regional
plans for construction of emergency obstetric care facilities.
Midwives can be key players in the early detection and
referral of cephalopelvic disproportion, malpresentation,
and prolonged, obstructed labor.
Fistula Prevention Centers
Fistula Prevention Centers24 are based on an earlier concept
of maternity waiting homes, defined by Dr. Jerker
Lilgestrand as “residential facilities, located near a medical
facility capable of providing essential obstetric care, where
women defined as ‘high risk’ can await their delivery and
be transferred to a nearby medical facility shortly before
delivery or earlier, should complications arise.”38 Maternity
waiting homes were first conceptualized for women with
known obstetric risk that would necessitate an operative
delivery, but they have been used for any woman deemed to
be at high risk for complications.39 A Safe Motherhood
Action Agenda38 reports that although maternity waiting
homes rely on a risk approach that is not advocated by the
Safe Motherhood Initiative, per se, in circumstances in
which “at-risk” women can be easily identified on the basis
of markers such as cephalopelvic disproportion or malpre-
sentation, maternity waiting homes may be appropriate. To
address the problem of fistula due to obstructed labor,
maternity waiting homes, reconceptualized as “Fistula Pre-
vention Centers,” could be established in geographic re-
gions where there is a high prevalence of young age at
marriage, young age at childbirth, and/or a high prevalence
of obstructed labor and fistula.24
Evidence exists to support the concept that morbidity is
reduced via use of maternity waiting homes. A WHO
report40 on maternity waiting homes looked at published
data and field communications from Cuba, Bangladesh,
Ethiopia, Zimbabwe, Malawi, Mongolia, Mozambique, Co-
lombia, Indonesia, and Nicaragua regarding the efficacy of
maternity waiting homes. The Cuban experience, in partic-
ular, suggests that maternity waiting homes play an integral
role in the reduction of maternal mortality and identified
women’s risk based on both physiologic factors as well as
by distance from emergency obstetric care. Anyone who
lived more than 4 hours from an emergency obstetric care
facility was entitled to stay at a maternity waiting home.39
Potential problems for Fistula Prevention Centers include
lack of funding, as such facilities are rarely self-sufficient;
difficulty establishing referral systems and reimbursement for
village-level practitioners; reluctance on the part of women
and their families for her to be away from home for an
undetermined period of time prior to delivery; and the finan-
cial burden this may pose. However, creative approaches to
address these problems have been implemented by many
programs and include allowing women to bring a person with
292
them to the Fistula Prevention Center to assist them; partici-
pating in income-generating activities, such as selling handi-
crafts, food, and t-shirts41; and linking other services to the
facility, such as education regarding maternal and infant
nutrition, family planning, and income generation skills.
Examples of Community-Based Prevention Strategies
Several community-based organizations and international
nongovernmental organizations have developed fistula pre-
vention strategies. The Bugando Medical Centre Project on
vesicovaginal fistula is an ongoing project in Mwanza, Tan-
zania, which may serve as a model for other programs.42,43
Numerous organizations and hospitals, including the Tanza-
nian Midwives Association, formed a loose network to pre-
vent fistula with 2 interrelated sociocultural and clinical
agendas. They work together to change family and community
attitudes that devalue girl’s health and lives, to improve
antenatal screening, encourage skilled delivery attendance,
and improve access to emergency obstetric care. In l997, the
Bugando project and the Kuleana Centre for Children’s Rights
developed a booklet called Haki z a ngu, j e? (What about my
rights?) to raise awareness about fistula, to advance girls’
social status, and to delay early marriage and childbirth. More
than 50,000 copies were widely distributed to religious lead-
ers, community-based organizations, schools, and health cen-
ters. The booklet concludes with the following quote: “All
people, including girls and women, have the right to educa-
tion, good health care, freedom from violence, nutritious food,
rest and relaxation, make decisions, be respected, be valued,
be loved.”42,43
The Tanzanian Midwives Association also works to prevent
fistula, both by improving clinical care and by advancing girls’
social status and delaying childbirth. All Tanzanian Midwives
Association members take a refresher course on screening for
risk of fistula (age and position of baby) and referral and
transport for prolonged labor. Together with local health
workers and community leaders, the Tanzanian Midwives
Association conducts village meetings to help communities
advocate for girls’ and women’s rights to health. One such
activity was a poster competition. Among the submissions was
one of a girl refusing to marry until she finished school;
another showed men devising a way to carry a woman to the
hospital during prolonged labor. These posters were among
the pictures featured in a 1999 calendar, and the images were
painted into wall size murals and placed in public locations
such as markets and hospitals.42,43
Tostan, which means “breakthrough” in the Wolof lan-
guage of Senegal and The Gambia, is a community-based
educational organization in West Africa. Tostan works to
increase women’s age at marriage and to lower maternal
mortality through holistic education and development ac-
tivities.44 For example, their approach to tradition is to
examine how some traditional practices benefit all, whereas
other traditional practices, which may benefit men, may not
benefit or may actually harm women.44 After intensive
Volume 50, No. 4, July/August 2005
educational work, Tostan holds regional meetings in which
village leaders declare publicly that they support the rights
of girls and women and that they will end traditional
practices harmful to women and girls. To date, 1271
communities have participated in these public renuncia-
tions of harmful traditional practices.45
United Nations Population Fund, EngenderHealth, and
the International Federation of Gynecologists and Obstetri-
cians (FIGO) are working to bring attention to the problem
of obstetric fistula globally. Their emphasis is on both
treatment and prevention, but as is often the case with
public health issues, there are conflicting priorities between
the two. As Maggie Bangser, Director of the Women’s
Dignity Project, a regional initiative in Eastern Africa to
address gender and health equity with a specific focus on
obstetric fistula, said in a recent interview: “It’s one thing to
repair the horrific physical damage. It’s harder but even
more urgent to prevent the damage in the first place. That
means confronting the social and economic ills that under-
lie girls’ vulnerability to fistula.”46
CONCLUSIONS AND RECOMMENDATIONS
Given that millions of women in the developing world
suffer from obstetric fistula, this tremendous public health
issue requires immediate attention. Increasing the resources
and skilled staff available locally to treat obstetric fistula is
an important and necessary step toward improving the lives
of women currently living with this condition.
Midwives in developed and developing countries can
support ongoing efforts, such as those of United Nations
Population Fund, EngenderHealth, and FIGO, to help
prevent and treat fistula. Midwife researchers and clinical
midwives in contact with women with fistula should play a
role in epidemiologic research to discover the prevalence
and incidence of fistula and help map where the prevalence
and incidence are highest. In some areas, where lack of
trained personnel limit the proportion of affected women
who can be treated, midwives could be trained to assist in
and/or perform fistula repair surgeries, as well as to
counsel, reeducate, and participate in the preoperative and
postoperative rehabilitation of fistula survivors. Midwifery
advocates and community workers can conduct outreach
information, education, and communication campaigns to
alert women, families, and decision makers in remote
communities to the availability of fistula repair centers and
work on the policy level for more treatment centers and
more training of providers in fistula repair.
Midwives everywhere can help address cultural and
societal values to improve the health status of women.
Midwives can strive first to understand these norms and
then to work with communities to promote girls’ reproduc-
tive and education rights. Delaying childbearing by delay-
ing marriage will allow young women to complete their
physical development and decrease their chance of having
an unattended obstructed labor.
Journal of Midwifery & Women’s Health • www.jmwh.org
Another goal is increasing access to emergency obstetric
care. Midwives in high-prevalence areas can take a lead in
advocating for and working in Fistula Prevention Centers in
regions where emergency obstetric care is inaccessible.
Student midwives looking for international placements and
those midwives who are interested in working internation-
ally may help by volunteering to work in fistula centers or
with organizations working to prevent fistulas. The need is
great, and the resources are limited, but awareness about
this devastating condition is growing, and organizations,
communities, and governments are rallying behind the call
for attention to obstetric fistula. The disparity between
fistula rates in developed and developing countries strongly
suggests that obstetric fistula related to prolonged, ob-
structed labor can be prevented. Midwives, with their
caring, skills, training, and proximity to the community
have been champions of many reproductive health and
rights campaigns; midwives can be at the forefront of the
prevention and treatment of obstetric fistula.
We thank Erica Chong and her colleagues in the Gender, Family, and
Development Program of the Population Council, and Debbie Rogow, Editor of
the Quality/Calidad/Qualité Journal, for providing information on community
outreach strategies.
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