What is Fistula?

Obstetric fistula—a hole between the bladder and the vagina or the rectum, or both—is a childbirth injury caused by prolonged, obstructed labour, without timely medical intervention; typically, a Caesarean section. The baby almost always dies during labour.

During unassisted prolonged labour, the sustained pressure of the baby’s head on the mother’s pelvic bone damages her soft tissues, creating a hole—or fistula—between the vagina and the bladder and/or rectum. The pressure prevents blood flow to the tissue, leading to necrosis.

Eventually, the dead tissue sloughs off, damaging the original structure of the vagina. The result is a constant leaking of urine and/or feces through the vagina.

Fistula occurs when emergency obstetric care is  unavailable to women who develop complications during childbirth. This is why women living in remote rural areas with little access to medical care are mostly at risk.

Before medical advancements, fistula was quite common in Europe and the United States. Today, it is almost unheard of in high-income countries, or in countries where obstetric care is widely available.

Poverty, malnutrition, poor health services, early childbearing and gender discrimination are interlinked root causes of obstetric fistula. Poverty is the main social risk factor because it is associated with early marriage and malnutrition, and it reduces a woman's chances of getting timely obstetric care.

In addition, because of gender inequality in many communities, women do not have the power to choose when to start bearing children or where to give birth.

Childbearing before the pelvis is fully developed, as well as malnutrition, small stature and generally poor health conditions, are contributing physiological factors to obstructed labour. However, older women who have already had babies are at risk as well.

Fistulas, or holes in organs, can occur for various reasons in different parts of the body, such as the lungs or digestive tract. Tissue damage resulting from prolonged obstetric labour and resulting in incontinence is called obstetric fistula. Tissue damage between the bladder and vagina is called vesicovaginal fistula. While tissue damage between the rectum and vagina is called rectovaginal fistula. Most times, if the rectum sustains a fistula, the bladder will also have been damaged resulting in the leakage of both urine and faeces.

The vaginal canal can also be ruptured by violent rape. In 2003, thousands of women in eastern Congo presented themselves for treatment of traumatic fistula caused by systematic, violent gang rape that occurred during the country's five years of war. So many cases have been reported that the destruction of the vagina is considered a war injury and recorded by doctors as a crime of combat.

Fistula is most common in poor communities in sub-Saharan Africa and Asia where access to obstetric care is limited. About two million women remain untreated in developing countries and between 50,000 and 100,000 new cases occur each year. But good data on fistula prevalence is scarce. Needs assessments conducted as part of the Campaign to End Fistula suggest that these figures could be higher.

Fistula is a relatively hidden problem, largely because it affects the most marginalized members of society: young, poor, illiterate women in remote areas. Many never present themselves for treatment. Because of the shame and stigma associated with the condition, they often chose to suffer alone, remaining ignored. The Campaign to End Fistula is working to break the silence around this condition and the stigma attached to it.

Prevention, rather than treatment, is the key to ending fistula. Making family planning available to all those who desire it would considerably reduce maternal deaths and disabilities. Complementing that with  skilled birth attendance and emergency obstetric care for women who may develop complications during delivery would reduce the rate of  fistula in developing countries.

These interventions are part of UNFPA and partners  overall strategy in the Campaign to End Fistula and ensure safe motherhood. Addressing social issues that contribute to the problem—such as early pregnancy, girls illiteracy, poverty and women's lack of power—is also important to help prevent fistula from occurring in the first place.

Yes, fistula is treatable as well as preventable. Reconstructive surgery can, in most cases, mend the injury. Two weeks or more of post-operative care are needed to ensure a successful outcome. Counselling and support are also important to address emotional damage and facilitate social reintegration. The average cost of fistula treatment —including surgery, post-operative care and rehabilitation support— is around $400.

Sadly, most women living with fistula are either unaware that treatment is available or they cannot afford it. In addition, treatment capacity, in most areas where fistula is common, cannot meet the demand due to high number of patients.

As with any surgery, fistula repair does carry some risk. Possible complications after a fistula surgery includes infection, urinary problems and breakdown of repair, most of which can be effectively managed. Only in rare cases do patients die.

The documented fatality rate for fistula surgery ranges from 0.5 to 1 per cent in sub-Saharan Africa. Careful screening and management before surgery is vital, as women with fistula tend to be malnourished and more susceptible to diseases. Post-operative care and close long-term follow-up is needed in managing both the surgical and medical problems that may occur.

Female genital mutilation or cutting (FGM) is condemned by most governments because of its potentially devastating consequences, both during or directly following the procedure and subsequently, for women’s sexual and reproductive health. UNFPA is committed to helping end this practice.

Due to several contributing factors, FGM is commonly found in many of the contexts where obstetric fistula is also prevalent. FGM can lead to serious difficulties during childbirth. With significant risks of hemorrhage (bleeding) for the mother, FGM can also lead to the increased risk of death or the need for resuscitation of the newborn.

Evidence shows that while some types of FGM do not contribute to the development of obstetric fistula, the radical form, also called infibulation (the stitching up of the vagina), may prolong the expulsion phase during delivery, especially if significant scarring is present.  

However, there is insufficient evidence to conclusively show that it contributes to obstructed labour or obstetric fistula. It is known that a woman with radical FGM is at increased risk of traumatic fistula from having her genitalia cut open during labour, to allow the birth of the baby. 

It is important to recognize that a traumatic fistula is not at all the same as a classic obstetric fistula, which is caused directly by unrelieved obstructed labour.

In 2003, UNFPA and its partners launched the first-ever global Campaign to End Fistula. Its overall goal is to eliminate fistula as a public health issue in developing countries as it already happened in developed countries.

The Campaign promotes interventions to:

• Prevent fistula from occurring;


• Treat women who are effected;


• Renew the hopes and dreams of those who suffer from the condition.

The campaign's approach includes bringing the issue of fistula to the attention of policy-makers and communities, sensitizing the general public to reduce the stigma associated with it, and helping women who have undergone treatment live their normal lives again.

The Campaign is present in more than 50 countries across sub-Saharan Africa, Asia, the Arab region and Latin America. In each country, the Campaign functions in three phases:

• First, a needs assessment is carried out to determine the extent of the problem and the avaliable resources to treat fistula in that area;


• Second, each country that completes the needs assessment phase receives financial support for planning, raising awareness, developing appropriate national strategies and building capacity;


• Third, a multi-year implementation phase begins, with interventions to prevent and treat fistula. Activities include improving obstetric care, training health providers, creating or expanding and equipping fistula treatment centres, as well as helping women reintegrate into their communities.

UNFPA's long involvement in programmes to reduce maternal mortality and morbidity makes the Fund uniquely qualified to tackle the challenge of fistula. Moreover, fistula touches on nearly every aspect of UNFPA's mandate, including reproductive health and rights, gender equality and empowerment, and adolescent reproductive health.

Because of the factors that contribute directly and indirectly to fistula, addressing this issue can serve as an entry point for overall improvements in women& reproductive health and rights. At the same time, fistula is a window allowing UNFPA to see where reproductive health services are failing to safeguard women health, especially for the poorest and most vulnerable members of society.