The citizens of Third World countries encounter some horrendous conditions and for women one of the worst of these is vaginal fistula.

A fistula is a hole between the birth canal and either the bladder or the rectum, sometimes both. The hole occurs as a result of the unborn baby's head pressing against the soft tissue for some considerable time. The baby's head is pressed so tightly in the birth canal that blood flow to the surrounding tissues is inhibited or ceases altogether. The tissues die and eventually rot away.

An obstructed birth involving prolonged labour and lack of medical attention results in thousands of women developing fistulas annually. The World Health Organisation puts the number at between 50,000 and 100,000. In Ethiopia, approximately 9,000 women are affected by this horrific condition each year.

Fistula has virtually disappeared from Europe and North America due to better care during pregnancy and childbirth, and better access to professional help. However Africa and much of South Asia (Nepal, Pakistan, Bangladesh and Afghanistan) still have many instances of fistula.

Obstetric fistula had virtually no global attention until around 2003. As public awareness grew, the United Nations Population Fund (UNPFA) organised a global campaign called Campaign to End Fistula. Since this campaign started, the United States Agency for International Development (USAID) has dramatically increased its funding for the prevention and treatment of obstetric fistula.

African Woman
Credit: Wikimedia

Consequences of the condition

The end result of fistula is that the woman becomes incontinent as urine and/or faeces leak continually into the vagina. The condition results in severe social stigma. There is a continual unpleasant odour. The woman will be divorced by her husband, disowned by her family and ostracised by society. She will usually end up living on the outskirts of society. Often, because of the smell, she will not be allowed on public transport.

There are also perceptions that the woman is unclean and/or has venereal disease. The acid content of continual leakage of blood, urine and faeces causes severe burning to the legs. This, and the smell, is a never-ending reminder, to herself, of her condition. Many are repulsed by their symptoms equally as much as others are. The leaking can cause nerve damage leading to loss of mobility. Some drink less and less to minimise the leakage but then fall victim to dehydration. Kidney disease and kidney failure brought about by ulceration and infections can lead to death. The chances of a sufferer subsequently bearing a living baby are reduced by 75%.

The shame and stigma of the condition marginalises the victim. The loneliness brought on by her isolation from family and friends leads to depression and thoughts of suicide. Some believe that by lying prone the fistula will heal. These may present at hospitals unable to walk due to muscle wastage from remaining in bed, sometimes for years. With no means of earning a living some are forced into prostitution and some die of starvation. Most women have no idea that the condition is usually treatable.


There are a number of causes. Poor nutrition, poverty and disease results in minimal development of the skeletal structure. Bones are weak and underdeveloped. The victims are often small in stature with narrow pelvises, increasing the risk of difficulties during childbirth.

Lack of education and distance from hospitals or medical centres mean that help for childbirth problems is often sought too late to be of any benefit. By the time a distressed mother reaches hospital, she may be dangerously ill and vulnerable to the risks of anaesthesia and surgery.

Civil and political unrest, abject poverty and dangerous public health issues such as HIV and malaria put huge strains on any healthcare systems that might be in place. Hospitals have staff shortages and lack the supplies and technology to perform fistula repairs.

Early marriage and lack of access to gynaecological services, particularly during childbirth, are other factors. In Nigeria, around 54% of those affected were under twenty. Caesarian sections are either not available or performed too late to prevent fistula.


Reconstructive surgery is 90% successful in cases that are relatively uncomplicated. More complicated cases have a success rate of some 60%. If the surgery is successful, women live normal lives and some have more children. Although the operation is not expensive by Western standards (perhaps $US300) this is far more than most can afford. Many have no idea that treatment is available. Overcome with shame and embarrassment, they hide themselves away.

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Much can be done to lessen the risks of fistula. Traditional practices such as betrothal and marriage at very young ages carries a great risk of fistula but needs careful management. Discouraging early marriage, educating women regarding issues of pregnancy and childbirth, and granting access to family planning would be of great assistance. Skilled medical teams are needed to be accessible during childbirth.



There is one hospital in Ethiopia dedicated to helping fistula sufferers. In 1959, Doctors Reg and Catherine Hamlin went to Ethiopia to train midwives at the Princess Tsehai Hospital in Addis Ababa. They were staggered at the dozens of women with fistula and began treating them. As women heard that there was a way of repairing the damage caused by a fistula, more and more came to the hospital seeking help. The Hamlins treated some free of charge and eventually ran foul of the authorities. In 1975, the Hamlins opened their own hospital which is dedicated to treating women with fistula.

In 2011 over 2500 women were treated. Recovering patients are taught sewing so that they have the means to earn a living when they return home. Before being discharged the women are each given a new dress. Some are unable to return to their homes and may stay on as aides. The joy of being rid of the condition is immeasurable. In addition, a public health officer visits local areas to raise awareness and to encourage good midwifery practice. Surgeons visit remote villages and hospitals to perform operations on site.

Education is of the essence. At the moment, one in 27 Ethiopian women die in childbirth, less than a third see a doctor during their pregnancy and a mere 6% have someone with medical training with them when they give birth.

What a wonderful outcome if the 'End Fistula' campaign succeeds.