Putting Women First: Treating Obstetric Fistula and Empowering Mothers

“If I had been taken to deliver my child in the hospital, this would not have happened,” she said.

“Even when I pleaded to be taken, they still refused to take me. I was completely rejected, even by my own family. Nobody wanted to sit near me. My only companion was the stench smell.”

These were the words of an elderly woman I met in the summer of 2023. She lives in a small rural town outside of Soroti, Uganda, and had spent 50 years suffering from obstetric fistula before she received life-altering surgery that restored her bladder function and her dignity at Terrewode Women’s Community Hospital.

We highlighted her story of utter despair, resilience and hope in our recent short film, “Fistula: A Film to Promote Better Maternal Health Care Globally,” currently an official selection at the  World Health Organization’s 2024 Health for All Film Festival.

May 23 is the International Day to End Obstetric Fistula, an occasion established by the United Nations to raise awareness of the condition and promote advocacy. Much of my work revolves around collaborating with global partners to eliminate obstetric fistula and other disparities in global women’s health. Unfortunately, there is still much work to be done.

Obstetric Fistula is a hole that develops between the vagina and bladder and/or rectum causing continuous leakage of urine or stool. It is a devastating childbirth injury caused by prolonged, obstructed labor in which the baby’s head is trapped in the pelvis for hours, and sometimes days, when women don’t have access to timely obstetric care. The condition is completely preventable like most other causes of maternal mortality and morbidity.

It is estimated that more than 2 million women suffer from this condition and almost all of them live in low-income countries, primarily in rural communities where vast gender inequality and lack of access to basic healthcare are intricately connected. 

Before the widespread establishment of midwifery and safe cesarean delivery services over a century ago, obstetric fistulas wreaked havoc on the bodies of women even in the United States. That was when maternal death from pregnancy and childbirth was close to 900/100,000. But with the advancement of safe obstetric care practices, we have managed to reduce maternal mortality by 90% to the current 10.4/100,000 live births in 2023 and we have all but eliminated obstetric fistula from high-income countries, leaving women in low-income countries behind. 

Sadly, even in the U.S., Black and Native American women continue to have a 3-4 times higher risk of maternal mortality than caucasian women from mostly preventable causes. This disparity is very much true in our own state of Minnesota.  

The fact that women in low-income countries still suffer from obstetric fistula,  a psychologically, physically, and socially crippling condition, and that the lifetime risk of maternal death is as high as 1 in 49 in low-income countries (similar to what it was in the U.S. over a century ago) compared to 1 in 5,300 in high-income countries, is one of the most shameful health inequities of our time. Shameful because we know how to make childbirth safe for all women if we only choose to prioritize maternal health irrespective of the lottery of one’s birth.

When a woman dies from childbirth, or is debilitated by a childbirth injury like obstetric fistula, her entire family and community suffers because she is often the central caretaker. We can’t afford to take a woman’s life for granted.

Although there are heroic women’s health organizations like Terrewode Women’s Community Hospital providing holistic therapeutic and reintegration care for women with obstetric fistula, they cannot fix the many social, economic, political and cultural factors that are baked into our system that perpetuate these inequities. 

For most women and girls, particularly those who live in rural communities and low-income countries, inequities start when a girl is denied education so she can provide labor at home, where she is given in marriage without her consent at a young age and becomes pregnant before her body is fully mature; where she often lacks the power to negotiate when and how many times  she becomes pregnant or when she can access medical care; and where she is likely to suffer from preventable pregnancy-related complications simply due to lack of access to safe, respectful and timely obstetric care. All of this happens in an environment where she carries her family and community on her shoulders as a caregiver, often tolerating many forms of gender-based violence.  

Doing away with preventable childbirth injuries and death will require individual families, communities, regional and country leaders, educational and financial institutions, women’s health organizations and the world at large to prioritize gender equity and to put resources behind initiatives that promote access to effective family planning and maternal care services. It will require policies and legal infrastructures that eradicate gender inequities. It will require equal representation of women in leadership so women’s issues are prioritized at the highest level. It will also require going beyond sustainability goals by instead setting accountability goals with real consequences.    

The International Day to End Obstetric Fistula is a shameful reminder that we are continuing to let women down. I dare us to act, to do something — anything — that is in our power to ensure that no woman has to suffer or die in order to bring another life into this world. 

What is in your power to do? Can you set an intention and carry through with it? 

Rahel Nardos, MD, MCR, is an associate professor in the Division of Female Pelvic Medicine and Reconstructive Surgery (FPMRS) at the University of Minnesota Medical School and the Director of Global Women's Health at the Center for Global Health and Social Responsibility. Learn more about Dr. Nardos’ work at the Center for Global Health and Social Responsibility’s website: globalhealthcenter.umn.edu/global-womens-health.