Obstetric Fistula: The Cost of Surviving Childbirth

In 2007, I spent a year as a trainee and surgeon at Addis Ababa Hamlin Fistula hospital in Ethiopia, a hospital dedicated to caring for women with obstetric fistula.

At the end of a long day in the operating room, I would walk into the beautiful hospital garden hoping to find one of my patients to learn about her story without the urgency of morning rounds. I heard many stories of pain and resilience, but one sticks out in my memory.  

My patient, whom I’ll call Sinedu, told me she was in labor for six days — two of which were spent trying to give birth at home and the rest bouncing between healthcare facilities until she found an obstetrician who could deliver her baby.

“The doctors finally pulled the baby out with an instrument. I remember that my baby had bones sticking out on the side of his head,” she said, tearing up. 

“He survived for the time being, but I was too weak to feed him. My breasts were dry as a bone. After five months of struggling for survival, my baby died. I believe he died from starvation.”

But the tragic ordeal wasn’t over. Sinedu developed an obstetric fistula, a hole between her bladder and the vagina due to obstructed labor. Obstetric fistula is a devastating yet preventable childbirth injury due to lack of access to timely and safe obstetric care.   

“What was worse was the burning,” Sinedu continued, talking about the continuous leakage of urine she was experiencing after her fistula. 

It took her 20 years to receive treatment. Unfortunately, her bladder was severely damaged and, unlike most fistula patients whose bladder function can be restored with surgery, hers was deemed unrepairable.

She underwent a diversion surgery involving a makeshift bladder from her bowel that drains urine into a bag attached to her abdomen. This time, she was back in the hospital due to a wound infection.

I asked about her plans for the future.  

“I have lived enough,” she said. “I am already 40, so from now on, I should think about my death.”

A woman dies every two minutes from pregnancy or childbirth causes, with nearly 95% of those deaths occurring in low- and lower-middle-income countries, according to the World Health Organization. Up to 80% of maternal deaths are preventable.

Today, May 23, is the International Day to End Obstetric Fistula, dedicated to raising global awareness of one of the most devastating childbirth injuries that continues to plague women in low-income countries.

When normal vaginal delivery isn’t possible due to complicating factors such as a birth canal being too narrow, a baby being too big or other maternal conditions, timely assisted vaginal delivery or cesarean section is needed for safe delivery. 

When this is not available, the baby’s head is trapped in the pelvis for days, causing traumatic injury to the bladder or bowel, leading to continuous leakage of urine or stool. Most babies don’t survive.

In the United States, although obstetric fistula is almost nonexistent, women can still experience bladder fistula from injuries during c-section and rectal injuries from severe perineal tears during birth.

One in four women suffer from long-term chronic pelvic floor disorders like urinary and fecal incontinence, pelvic organ prolapse and chronic pelvic pain, most of which are associated with childbirth. They often suffer in silence due to the stigma associated with these conditions and lack of knowledge and/or access to specialty urogynecology and pelvic floor rehabilitation care. Primary care providers can play a critical role in helping women with pelvic floor disorders get the care they need. 

Minnesota has a large immigrant and refugee community. I get referrals for patients with chronic untreated obstetric fistula or bladder injuries incurred from c-sections during childbirth in their native countries or refugee camps. Unfortunately, these conditions are often missed or dismissed due to systemic barriers to care.

Obstetric fistula is preventable. The United Nations Population Fund is leading an effort to mobilize the global community to end obstetric fistula through their roadmap to end fistula by 2030. But it takes a village. The first step is awareness of the high cost of poor maternal care on women, their families and their communities.

Dr. Rahel Nardos, MD, MCR, is an associate professor at the University of Minnesota and the director of Global Women’s Health at the Center for Global Health and Social Responsibility. She was an executive producer on the film, Fistula: A Film to Promote Better Maternal Health Care Globally, which was an official selection at the World Health Organization's Health for All Film Festival in 2024.