(November 2002) Maternal morbidity and mortality haven’t been a major concern of most developed countries for generations, but in the developing world childbirth is a leading cause of death. Each year, more than 500,000 women die of causes related to pregnancy and giving birth. Yet the deaths are just the tip of the iceberg: For every death, at least 30 more women suffer serious illness or debilitating injuries.

Perhaps the most devastating injury, obstetric fistulas disproportionately affect poor and young women. An obstetric fistula is an abnormal opening between the vagina and the bladder or rectum (or both) that results from extreme pressure and tissue damage during prolonged or obstructed labor, when the fetus will not fit through the mother’s pelvis. If a Caesarean section delivery is not available to end the ordeal, the baby is usually stillborn and a fistula forms, permitting the uncontrollable passage of urine and feces into the vagina.

Fistulas can abruptly transform young women on the threshold of motherhood from objects of societal admiration into pariahs shunned by even their own families. Women who suffer fistula have not only lost their babies (in most cases), but are also constantly leaking urine and feces, producing a foul odor. Women with fistula usually feel shamed or disgraced, and are often deserted by their husbands and cut off from family, friends, and daily activities, resulting in a life of destitution.

The women most at risk include very young women and women having their first birth; women whose growth has been stunted because of poor nutrition or childhood illness; women in rural areas; and those who use traditional care and home delivery. It is estimated that some 2 million women, predominantly in Africa and the Indian subcontinent, suffer from fistula. Each year, another 50,000 to 100,000 women are affected, most under age 20.

Fistula can be surgically repaired but only where trained surgeons and good postoperative care are available. Only two centers in Africa specialize in fistula care: one in Addis Ababa, Ethiopia, and the other in Jos, Nigeria. The operation costs about US$150, a fee beyond the means of most women who are affected.

Beyond treating fistula after it has occurred, governments and health workers can strive to:

  • Ensure access to medical care that can address life-threatening conditions;
  • Provide postpartum care and postabortion care;
  • Promote family planning;
  • Provide adequate prenatal care; and
  • Improve girls’ nutrition and increase women’s age at first birth.

The latter interventions, the earliest preventive measures, can help ensure adequate growth of the pelvis, reducing the chances of obstructed labor and its debilitating consequences. Addressing chronic undernutrition and micronutrient deficiencies can also increase women’s resistance to infections, hypertension, and other illnesses during pregnancy.

Taken together, these interventions could have substantial benefits. The payoffs in reduced suffering and increased productivity may be well worth the investment.

Lori Ashford is a senior policy analyst at PRB.

This article is excerpted from the PRB policy brief Hidden Suffering Disabilities From Pregnancy and Childbirth in Less Developed Countries

For More Information

For information on the UNFPA’s campaign against obstetric fistulas, read this press release.  


For information on the Addis Ababa Fistula Hospital, read UN Office for the Coordination of Humanitarian Affairs, “UN Campaign Aims to Tackle Fistula in Africa,” Nov. 4, 2002 (www.IRINnews.org, accessed on Nov. 21, 2002) and “Hospital a Beacon of Hope in a Ravaged Land,” The Irish Times, Oct. 24, 2002 (www.ireland.com/, accessed on Nov. 22, 2002).