NKHATA BAY, Malawi – Jacqueline was just 15 when she fell in love with a boy from another village. The two eloped, initiating a customary marriage rather than a formal one. But Jacqueline kept the relationship a secret from her mother, Margaret Kumwenda, who grew worried about her daughter’s increasing distraction and frequent disappearances.

When Ms. Kumwenda learned about the elopement, she was upset, even asking the police to take action against the boy. “They told me that he was still a minor, and all they could do was counsel him and Jacqueline,” she recently recalled to UNFPA, the UN sexual and reproductive health agency.

The counselling seemed to work for a time. Jacqueline, who had always been a hardworking student, applied a renewed dedication to her studies. Ms. Kumwenda hoped her daughter would finish her education before getting serious about her relationship.

But dropout rates are high for girls in Jacqueline’s remote community, which is an hour’s walk from the nearest school. Early marriage is often seen as inevitable for teenage girls, who commonly receive little information – if any – about their sexual and reproductive health and rights.

With no hope for a different future, Jacqueline, too, decided to leave school. One day, she packed up her belongings and ran away with her husband, moving to Mzimba District.

“We tried looking for her, but to no avail,” Ms. Kumwenda said.

Childbirth injury and abandonment

Jacqueline soon became pregnant and, at age 16, went into labour at a local health facility. The delivery was obstructed, prolonged and agonizing, resulting in an obstetric fistula – a traumatic childbirth injury in which a hole is torn in the birth canal. Adolescent girls, in particular, are vulnerable to obstructed labour and obstetric fistula. 

Eventually Jacqueline delivered a baby girl. The baby thrived in the days following the birth, but Jacqueline did not. Like most fistula survivors, she began to leak faeces and urine, and her injuries failed to heal. 

“My life was lonely as I couldn’t go out of the house because I was wetting myself,” Jacqueline later recounted to UNFPA. For months she was isolated, confined indoors by her injuries.

Then one day, her husband decided to send her away. Tragically, abandonment by a spouse or family is common among fistula survivors. Afraid of contacting Ms. Kumwenda directly, the boy sent an anonymous message through an intermediary: Your daughter is unwell and wants to come home.

Human rights at stake

The reunion was bittersweet for Ms. Kumwenda. She was relieved to have her daughter home, and overjoyed to meet her baby granddaughter. At the same time, her daughter’s condition devastated her. 

“I didn’t know what to do,” said Ms. Kumwenda. 

An untreated fistula can cause serious physical ailments – not only chronic incontinence but also frequent infections and possible infertility. But obstetric fistula is not simply a health issue. It is a human rights issue. 

In most of the world, obstetric fistula is preventable with access to emergency obstetric care – usually a Caesarean section. Today, this condition overwhelming affects the most vulnerable women and girls: those with limited access to the comprehensive sexuality education that would enable them to prevent an adolescent pregnancy, those who experience child marriage, and those without access to a skilled birth attendant and competent emergency care during delivery.

The consequences of fistula only compound the hardships these women and girls face. They experience stigma, discrimination from communities, families and employers, and often lasting psychological harm.

A new path

But Ms. Kumwenda refused to give up. “I remembered that there was a woman in our community who always talked about a similar condition, and how she can help to get it treated,” she recalled.

The woman was a fistula ambassador for the Spotlight Initiative, a gender equality programme funded by the European Union and implemented by UNFPA and other United Nations agencies. “She agreed to come to our house the next day,” Ms. Kumwenda said.

Soon, Jacqueline was referred to the Nkhata Bay District Hospital, and from there she was scheduled for surgery at the district health office, supported by the Spotlight Initiative. 

“I don’t know what could have happened if I didn’t come here,” she said at the hospital, after the repair surgery.

UNFPA and Spotlight are also working with the local community to address the root causes of obstetric fistula: the vulnerabilities of women and girls. Together with the Nkhata Bay District Council, they are empowering women and girls with knowledge about sexual and reproductive health and rights.

As for Jacqueline, she is now healed and able to think about her future – and that of her two-year-old daughter – and she has some powerful new role models. “I thank those who helped me get well again,” she said.

BISSAU, Guinea-Bissau – “I didn't know what obstetric fistula was, let alone that it could be treated,” says 33-year-old mother-of-two Maria. 

Maria’s dream of expanding her family took a tragic turn in 2016. She was in eastern Guinea-Bissau, in Batafa region, when her labour pains began; but after more than 12 hours, she remained unable to deliver.

Maria was evacuated to the Simão Mendes National Hospital in Guinea-Bissau’s capital, but upon her arrival three hours later, an echography revealed her baby had died in utero.

Hours later, after being discharged from the hospital, Maria felt herself leaking bodily fluids. She had suffered an obstetric fistula, a devastating injury resulting from prolonged, obstructed labour, which causes incontinence.

Around the world, half a million women and girls are estimated to be living with obstetric fistula. Despite the condition’s prevalence, many women and girls who have sustained the injury find themselves abandoned and ostracized by family and community – resulting in both physical and psychological trauma.

Sadly, this was the case for Maria. “I used to think about suicide because of the severe stigma I suffered,” Maria said. “My family completely abandoned me.”*

Creating a virtuous cycle

As fistula does not just affect bodies, but lives and minds as well, the UNFPA-led Campaign to End Fistula works with communities around the world to provide both fistula repair surgeries and psychosocial support geared towards helping women and girls reintegrate into society.

In Guinea-Bissau, UNFPA worked in partnership with the government of Guinea-Bissau to provide free fistula repair surgeries to 42 women – three of whom were offered scholarships to train as midwives at the country’s National School of Health.

“This training opportunity will be rewarding for my integration into society,” says Vitoria, who received one of the scholarships. “I hope it will be extended to more women who are victims of this terrible disease.”

The programme aims to empower survivors to rejoin communities, with the knock-on effect of fortifying Guinea-Bissau’s cadre of midwives. These providers have been singled out for their critical role in preventing the occurrence of obstetric fistula in the first place.

“To end fistula, we need to make sure that all women and girls have timely access to trained midwives and high-quality obstetric care,” UNFPA Executive Director Dr. Natalia Kanem said on the 2023 International Day to End Obstetric Fistula. “That’s why UNFPA is working to scale up the midwifery workforce and close the global gap of nearly 1 million midwives.”

A chance at fistula repair heard over the airwaves

In 2021, Maria heard a radio advertisement that changed her life. It was for the treatment of obstetric fistula, and described the condition’s symptoms as similar to those she experienced.

She had not known the name of her condition, but received a diagnosis of obstetric fistula after seeking care at the Simão Mendes National Hospital in Bissau.

Two surgeries were required to repair her injury; the second was completed in 2022.

"After the repair, my life completely changed,” Maria said. “I feel wonderful. I don't use pads anymore."

*If you are struggling with suicidal thoughts, depression, trauma or any other mental health concerns, please seek help and advice from a trusted health provider as soon as possible.

NORTH-WESTERN PROVINCE, Zambia – Around the world, half a million women and girls are thought to be living with obstetric fistula, a serious childbirth injury that can cause incontinence and result in significant medical and mental health issues. In Zambia, as of 2018, more than 33,000 women and girls had been affected.

For over a decade, the Government of Zambia and UNFPA have partnered to provide fistula survivors with life-transforming surgeries aimed at healing their physical and psychological wounds. Many of these procedures are conducted at fistula camps held at Zambia’s main provincial hospitals, where three or more doctors gather to perform surgeries for several days.

Dr. Paul Musoba is one of just eight fistula surgeons in the country. On the occasion of the International Day to End Obstetric Fistula, UNFPA sat down with Dr. Musoba, who works at the Solwezi general hospital in Zambia’s North-Western Province, to learn more about what drew him to this field of surgery, the challenges he encounters in his work and the successes that have made him proud to be a fistula surgeon. This interview has been edited and condensed.

What inspired you to become a fistula surgeon?

Early in my practice as an obstetrician and gynaecologist, I encountered many women and girls who had suffered greatly from obstetric fistula. Seeing women and girls abandoned and ostracized due to their constant leakage of urine, faeces or both was the starting point of my desire to change the narrative.

Taking inspiration and mentorship from some of Zambia’s senior fistula surgeons, I first participated in a fistula camp in 2019. I was able to observe, assist and eventually undertake fistula surgeries. It is definitely a specialized skill that requires constant practice and exposure.

It is quite fulfilling, but at the same time, challenging.

Can you talk about the scope of the problem of fistula in Zambia?

Pregnancy and childbirth should be among the happiest times in a woman’s life. Sadly, this is not the case for thousands of women and girls not only in North-Western Province, where I am located, but across Zambia at large.

At the Solwezi general hospital, I often encounter women and girls who have developed obstetric fistula, some of whom have lived with the condition for years.

How do you approach meeting the specific needs of fistula patients?

My journey begins with me getting to understand their situation. The trauma suffered by many of my clients during delivery is heartbreaking, as it goes beyond the physical. I focus throughout not only on healing their physical wounds, but also supporting their emotional and psychological healing.

During fistula camps, my surgical work typically begins at 7:30 a.m. and ends at 6 p.m., with 15-minute intervals in the operating theatre between clients. This maximizes on time against high demand.

The process concludes with a hospital discharge of a happy, “dry” and “continent” client. It makes me proud to be a fistula surgeon.

What are some of the challenges you face while working to support women and girls affected by fistula?

Every year, I repair an average of ten fistula clients, at either the Solwezi general hospital or during fistula camps at other hospitals. However, I know there are many other women suffering with fistula who are not able to access treatment due to lack of information or challenges in accessing health care.

Getting to expectant mothers, as well those suffering from fistula in their communities, is therefore one of the biggest challenges I face. Many women in North-Western Province live in remote areas located far from health facilities, often resulting in home deliveries – a key risk factor for obstetric fistula in the event of obstructed labour.

Additionally, for many fistula survivors, societal stigma still remains a major issue. Successful reintegration is a key priority post-surgery.

Can you share a story from your work with fistula patients that has stuck with you?

My recent encounter with an 18-year-old fistula survivor stands out to me. She developed obstetric fistula due to obstructed labour and delayed access to emergency health care, and lost her baby.

For two years she lived with fistula and could not continue with her education. But with the help of community health workers, she was able to access surgical care, and I successfully repaired her fistula.

Throughout this process, she was very jovial and optimistic; her confidence put pressure on the team. I personally made a follow-up visit four months after her operation, and the girl we had discharged had an even brighter smile.

She told me: “Dr Musoba, thanks to you, I have now gone back to school and am looking forward to completing my education!”

KINSHASA, Democratic Republic of the Congo/KURIGRAM DISTRICT, Bangladesh/KILIFI, Kenya – Pemba was called “ndoki,” or “witch,” by her community, including her father and siblings. Sojina felt like a prisoner in the room she was banished to, forbidden to step outside even to worship. Jamila’s career as an early childhood development teacher came to an end.

All three women had undergone prolonged, obstructed and agonizing labour. All three lost their babies. And all three developed obstetric fistula, the childbirth injury that left them leaking urine and faeces and rendered them pariahs in the only homes they knew.

Pemba, from a village in Bandundu region in the DRC, was 15 when she found herself pregnant and abandoned when her boyfriend fled to neighbouring Angola. “My baby did not survive. I cried for three days and couldn’t eat. After the delivery, I started to see permanent urine flows.” The boyfriend eventually returned and wanted to marry her, but her village and family said she was cursed. A sister living in the capital paid for her to go there to seek care, but because of the permanent odour, she was stigmatized, unwelcome to join in meals, greeted with humiliations and insults.

“My father no longer considered me his daughter. He hadn’t spoken to me for almost five years even when he was in Kinshasa,” Pemba said. “When I asked to return to the village, he refused. He demanded my sister kick me out of her house, so for the past three years, I have been living with friends.”

“Something terrible happened and changed everything”

Sojina was six - eight weeks away from her due date when she began experiencing severe pain. Married at 16, she first became pregnant at 18 and delivered a healthy baby boy. Now here she was, five years later, in days-long excruciating pain, which her husband and family members assured her would disappear with rest. But no longer able to tolerate the situation, she went to a health facility, where she was told the devastating news that she had been in labour all that time, and now the baby was dead. In a matter of days, she started leaking urine uncontrollably; the doctor told her it would stop after a few days. It didn’t.

Because of the stigma surrounding fistula survivors in Bangladesh, Sojina’s husband made her return to her father’s rural village alone, where she was isolated in a room nobody else entered.

“I was devastated. My first child was not with me. I was heartbroken by the loss of my second child. I was about to lose my husband,” she recalled. “The only things I could do were to wash my clothes and stay in that room like a prisoner.”

“I was too embarrassed to go to work”

For the past five years, Jamila had been visiting clinics for treatment. The pain and leaking worsened during her period, and she had to change her clothes constantly. “I was too embarrassed to go to work because of the stares and discrimination from my peers for smelling of urine,” she said. An enthusiastic early childhood development teacher, Jamila, 35, lost all passion for her work, as her condition took an emotional toll on her.

In Kenya, an estimated 3,000 new fistula cases are recorded every year, and only 7.5 per cent of the women are able to access medical care.

Jamila’s ray of hope came when a community health volunteer told her about a free fistula camp organized by UNFPA and partners including Amref Health Africa, Kilifi County Government, M-Pesa Foundation and Flying Doctors Society of Africa. During the one-week camp, 119 women who had been ostracized by their communities were screened, while 30 patients were admitted for fistula reconstruction surgery and other gynaecological cases, including Jamila.

“I am now hopeful that I can become a mother again and go back to pursuing my career,” she said. “I want to make up for the time lost while living with fistula.”

New livelihoods, new lives

Seven years after developing fistula and of living with its dire consequences, Pemba was told by a community health worker about FisPro DRC, a UNFPA partner that treated her for free and also taught her the craft of basket weaving as a way to reintegrate into society as many women with the condition have virtually zero employment opportunities.

“I have seen a total change in my life,” said Pemba, now 22 and who has re-established a relationship with her father. “I hope that I will have a husband and that one day I will have children. I hope basket weaving will be an opportunity to start a job. This will allow me to be independent and have the means to return to my village.”

As for Sojina, who had nearly given up hope for a better future, a government field worker trained in fistula screening learned about her condition. He immediately contacted Kurigram District Hospital, where she was diagnosed and referred to the UNFPA-supported LAMB Hospital for a fistula repair and, like Pemba, livelihood training.

“They gave me ducks, which I am breeding and selling their eggs to earn money for my family,” said Sojina, now 25. “I am hopeful that I can rebuild a better life for myself. I returned home to my husband and child and we began our new life together.”

Juba, SUDAN - Soft-spoken, compassionate, and cheerful; Hayat Peter is one of the nurses who is contributing to ending obstetric fistula in Juba,South Sudan. A registered nurse by profession for the last 22 years, she has helped many patients. However, assisting fistula patients to regain their dignity is one of the biggest moments in her career, according to Hayat.

The 42-year-old is a mother of nine children, seven of which are adopted. Her husband died in 2007 while on duty as a police officer in Yambio State.  Ever since she had to take care of her family as a single mother. Apart from being a mother, her other life-long dream was to help women suffering from Obstetric fistula. Hayat works at the gynecological section of Juba Teaching Hospital, the country’s only referral hospital, and she is one of the 23 nurses trained by Amref Health Africa in partnership with UNFPA, in South Sudan to support fistula patients and offer obstetric care. “I am happy that I was trained to help women suffering from Fistula, I have supported over 200 fistula surgeries, I am proud of that,” she confirms. 

Obstetric fistula is one of the most serious and tragic childbirth injuries. A hole between the birth canal and bladder and/or rectum, it is caused by prolonged, obstructed labour without access to timely, high-quality medical treatment. A mother with Fistula suffers from urinary and or fecal incontinence. 

The horrible ordeal fistula patients go through leads to abandonment by family and community members, but for Hayat, she provides hope and care to them; “I do not feel they are dirty, I talk to them, we laugh, hold hands, and hug, I burn an aromatic incense around the women which produces a scented smoke that makes them feel comfortable and happy,” she explains.

During her 22-years nursing career, Hayat says most fistula patients are between 13-15 years something she attributes to early pregnancy and inadequate access to health facilities.

WHO (2018) states that 19.4% of births in South Sudan are attended to by skilled health personnel. This notwithstanding, about a third of all girls in South Sudan get pregnant before turning 15 (UNICEF, 2020).

"It is important to sensitize and educate young girls as well as communities not to expose them to sexual abuse, child marriage, and early pregnancies because their bodies are not developed enough to handle pregnancy,” says Hayat.

Her highest moments are when the survivors she serves call to express gratitude from the farthest parts of South Sudan, “Fistula survivors still call me to appreciate the free surgery that transformed their lives and this is not just once, it is rewarding and makes me proud,” she adds with beaming smile. 

To meet the ever-growing need for services for Fistula patients, Amref Health Africa in South Sudan in partnership with UNFPA mentors and trains health workers and sets up fistula repair teams from various states of South Sudan. These teams include fistula surgeons, medical officers, operating theatre nurses, midwives, ward nurses, and anesthetists in obstetric fistula surgery and care for fistula patients. 

Since 2019, with the support of UNFPA, Amref has restored the dignity of 80 fistula patients through surgeries in South Sudan.

South Sudan has a limited number of facilities that offer obstetric fistula repair. The medical camps are periodic compared to the backlog of over 60,000 cases. Hayat urges Amref and its partners including UNFPA to support more camps for women to pick up the pieces of their lives broken by fistula and rebuild a better life for themselves.

Obstetric fistula is preventable but also surgically curable once it occurs. In the past few years, AMREF, UNFPA and partners launched the Campaign to End Obstetric Fistula, now active to prevent and treat fistulas in more camps and to rehabilitate fistula survivors.

MFANGANO ISLAND, Kenya – In her four years at Sena Health Centre, midwife Goretti Adhiambo has seen too many lives lost to complications in pregnancy and childbirth. “We provide all the basic maternal health services at the health centre including antenatal care, but complicated cases have to be referred to the mainland hospital for specialized care,” she explained. 

Her health centre is located on the remote Mfangano Island in Kenya’s Homa Bay County. Reaching the mainland town of Mbita for treatment requires at least an hour’s boat ride – two, if the waters are choppy. During an obstetric emergency, this delay can be deadly.

In 2018, Ms. Adhiambo treated a young woman with labour complications. The woman was referred to the mainland for specialized care but died while being ferried to Mbita. “She was barely 18 years old, and to lose such a young life was very painful for my colleagues and me,” Ms. Adhiambo recalled.

Today, Ms. Adhiambo is the midwife in charge, overseeing the care of expectant mothers and newborns. And she has a new tool in her arsenal that can help identify complications long before they become life-threatening: an ultrasound device.

Putting tools in the hands of midwives

For years, pregnant women on Mfangano Island have had to travel to the mainland not only for emergency obstetric care, but also for diagnostic services as simple as an obstetric ultrasound screening. Such tools are often only available at specialist health facilities located in major towns and urban areas. As a result, pregnancy complications are often only identified at great effort and expense, too late for treatment, or not at all.

But this is starting to change.

Through a partnership between UNFPA, AMREF International University and the Phillips Foundation, portable ultrasound technology – and the training to go with it – are being made available to midwives from far-flung health centres in remote parts of Kenya.

Ms. Adhiambo and others recently learned how to use the portable machine, known as the Lumify Probe, from experienced sonographers who guided them on skills including: confirming whether a pregnancy is viable, visualizing and recognizing the number of fetuses, identifying where in the uterus the placenta is, and detecting the position of a fetus. By being able to spot issues, such as breech position of the fetus or multiple pregnancy, midwives are able to provide better advice, monitoring and referrals. 

“When midwives become proficient in providing basic obstetric ultrasound at point of care, early detection of pregnancy complications and timely referral to higher level health facilities can occur,” said Priscilla Ngunju, a project coordinator with AMREF International University. “Our hope is that more mothers are able to access at least one obstetric screen, done before 24 weeks of gestation, in keeping with the World Health Organization recommendations.” 

Empowered to save lives

The trained midwives also received Lumify Probe devices for their health facilities. And because the device is portable, the midwives are able to carry it with them when conducting home and community visits, expanding the reach of these critical services.

In addition to eliminating the cost of transport to the mainland, the programme has greatly lowered the cost of ultrasound screenings. Ultrasound screenings at the clinic cost Ksh 500 (about $5), while they can be double or triple the cost at specialist health facilities. 

Ms. Adhiambo says she is happy the expectant mothers she serves at Sena Health Centre will be spared these burdens.

“I learned a lot from the training, including how to interpret an ultrasound image, locating the placenta and detection of serious birth defects,” she told UNFPA. “I can now use my skills to save the life of a mother.” 

It’s easy to ignore things you don’t know anything about. Obstetric fistula is one of those things. But it’s a devastating childbirth injury to women who experience it, usually fatal to unborn babies (90 per cent of cases end in stillbirth) and – here’s the encouraging news – not only treatable but preventable. 

Obstetric fistula is a hole in the birth canal caused by protracted, obstructed labour in the absence of timely medical care, leaving women to leak urine and faeces. Left untreated, it can lead to infection, disease and infertility. Sentenced to a life of misery, stigma and isolation – husbands and families abandon them, communities ostracize them, employment opportunities vanish – they can suffer from mental health issues and deepening poverty.

The injury has all but disappeared in rich countries but persists in poorer  countries with inadequate maternal health care – an estimated 500,000 women and girls live with the condition. Young bodies not ready for childbirth in cases of child marriage or unintended pregnancy are especially vulnerable. Women can develop fistula because they cannot afford transportation to a health facility or the services of a skilled birth attendant like a midwife. 

The injury can be prevented by sexual and reproductive health care, access to contraception and access to skilled birth attendants and high-quality emergency obstetric care. With its many partners, UNFPA leads the Campaign to End Fistula, which works in more than 55 countries on prevention, treatment and rehabilitation efforts. It can be treated with reconstructive surgery, though many women and girls don’t know about treatment, can’t access it or can’t afford it. UNFPA has supported more than 120,000 surgical repairs, including for Beatriz Sebastião, pictured above © UNFPA Mozambique.

UN Member States adopted a resolution to end fistula by 2030. To that end, the theme of this year’s observance is “End Fistula Now: Invest in Quality Healthcare, Empower Communities!" Obstetric fistula is a development and public health issue, but it’s also a human rights issue, one that grants everyone the right to health and a life of dignity.

When is the International Day to End Obstetric Fistula?

Every year on 23 May, the International Day to End Obstetric Fistula is observed by the international community as a way to rally action, commitment and support to ending obstetric fistula.

What is the history behind the day?

In December 2012, 167 countries co-sponsored a biannual resolution of the United Nations General Assembly that called on all Member States to support UNFPA and its partners in the Campaign to End Fistula. In addition, the UNFPA-backed resolution acknowledged the plight of millions of women and girls living with obstetric fistula by designating 23 May as the International Day to End Obstetric Fistula, first observed in 2013.

Subsequent resolutions have called for the dramatic acceleration of actions and commitment to end obstetric fistula by 2030, reinforcing the need for urgent efforts and greater investment to address and improve sexual and reproductive, maternal, newborn and child health, as well as to eliminate the root causes of fistula, such as poverty, inequalities and failure to ensure education, economic opportunity, gender equality and human rights for all.

Why is the day important?

A sign of global social injustice and inequity stemming from weak health and social protection systems, obstetric fistula is driven by poverty, gender and socioeconomic inequality, lack of education, child marriage and early/adolescent childbearing, among other things. Women and girls at risk of or living with fistula face economic, social, cultural and logistical barriers to care and to survival, further deepening pre-existing inequalities.

The condition is generally and often treatable, but more critically, it is largely preventable – developed countries have all but eliminated obstetric fistula. The same should be true for developing countries. Everyone deserves a life of dignity, and the day serves as a reminder that we cannot ignore such a promise.

UNITED NATIONS, New York – First things first, what is obstetric fistula?  

What it is: Obstetric fistula is a traumatic childbirth injury that robs a woman or girl of her health, rights and dignity. It is a hole between the birth canal and bladder that causes uncontrollable urinary incontinence. A hole between the birth canal and rectum causes faeces to leak. 

Why it happens: Prolonged, obstructed labour during childbirth. The sustained pressure of a baby’s head against the mother’s pelvis cuts off blood supply, causing tissue to die and fall away; the hole left is called a fistula. Obstetric fistula accounts for eight per cent of maternal deaths, and 90 per cent of all cases in which a fistula occurs, result in stillbirth.  

Who it affects and where it happens: An estimated 500,000 women and girls in more than 55 countries throughout sub-Saharan Africa, Asia and the Pacific, the Arab States and Latin America and the Caribbean are estimated to be living with fistula, with thousands more occurring every year.  

Below, five more things you should know: 

1. There are different types of obstetric fistula. 

While the most common type is a hole between the birth canal and bladder (called vesicovaginal fistula), other types include: 

Rectovaginal fistula: Hole between birth canal and rectum

Urethrovaginal fistula: Hole between birth canal and urethra (carries urine from bladder out of the body)  

Ureterovaginal fistula: Hole between birth canal ureters (carry urine to bladder) and birth canal

Vesicouterine fistula: Hole between bladder and uterus

Some fistulas are caused during gynaecological procedures (e.g. hysterectomy) and Caesarean sections due to substandard health care and inadequate surgical skills training/competence. These are called iatrogenic fistulas. Traumatic fistulas are caused by sexual violence, especially in conflict areas; the destruction of the vagina is considered a war injury. 

2. The physical, social and psychological consequences are devastating. 

The lives of women with the condition are defined by lifelong physical and emotional suffering. 

The condition can lead to infections, ulcerations, kidney disease, painful sores, infertility and death. The smell from constant leakage isolates women who are often shamed and stigmatized, abandoned by their friends and families and ostracized by their communities. They suffer from depression and suicidal thoughts and other mental health issues. Denied livelihood opportunities, they are driven deeper into poverty and vulnerability.  

3. Young girls are particularly vulnerable. 

While it does not discriminate by age, young girls are particularly vulnerable because their bodies may not be ready for childbirth. Nine in ten births to girls between the ages of 15 and 19 occur in marriage or union. Worldwide, pregnancy and childbirth complications are the leading cause of death among girls between the ages of 15 and 19. It’s just one more reason UNFPA works to eradicate the harmful practice of child marriage.  

4. It is rooted in poverty and gender inequality.  

Obstetric fistula has all but disappeared in rich countries with quality health care systems and skilled professionals who can perform Caesarean sections. Midwives are a vital part of the solution. The International Confederation of Midwives states “ending obstetric fistula requires the full involvement of midwives at the community, national, regional and global levels.” 

Apart from a lack of quality health services, poverty is a major social risk because it is associated with early marriage and malnutrition. 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.

In addition, because of gender inequality in many communities, women don’t have the autonomy or agency to decide when to start having children or where to give birth. 

5. It is treatable, but perhaps even more important, it is largely preventable. 

Up to 95 per cent of fistulas can be closed with surgery. A surgical repair costs $600, well beyond the reach of most women with fistula – if they’re even aware of the exact medical condition they have and that treatment exists. Through its assistance to countries and the Campaign to End Fistula UNFPA has supported more than 121,000 life-changing repairs since 2003 and trained thousands of health workers to prevent and treat fistula.  

But before ever reaching the treatment stage, focus should be on prevention. Such measures include access to family planning, skilled birth attendants and emergency obstetric care. Addressing societal factors that contribute to fistula – child marriage/early union and pregnancy, girls’ education, poverty and women’s lack of empowerment – is also part of the Campaign to End Fistula strategy. 

To have one’s life compromised for bringing forth new life is a devastating fate. But with awareness and will, the goal of eradicating the condition by 2030 is achievable.  

UNITED NATIONS, New York – Celebrated around the world throughout the year, Mother’s Day is exactly that: celebratory. But for some women, motherhood can be fraught. Women have become mothers below ground in wartime (Ukraine), under bridges after hurricanes (Honduras), in flooding hospitals during monsoon season (Bangladesh) and among post-earthquake wreckage (Haiti). 

They have become mothers not by choice, but…: 

…against their will as a result of rape – by a partner or stranger – or where sexual violence is used as a weapon of conflict. 

…because it is expected of them by their cultures and families, even if they are not physically or emotionally ready for pregnancy. 

…without knowing how conception works due to a lack of comprehensive sexual education. And when they do know, they have become mothers because of a lack of access to adequate family planning services. 

Parenthood comes with sacrifices, no doubt. Even before mothers left the workforce in droves during COVID-19 to care for children attending school remotely, they were already shouldering much of the burden for child-rearing, housework, emotional labour and caring for ageing parents. They may have had to forego higher degrees, promotions or relocations. If they return to work after raising children, they may have outdated skills and face the “motherhood pay gap.” With long retirements due to longevity, their “choices” may leave them in precarious financial situations. 

But the steepest price some women pay for becoming pregnant is never having the chance to experience motherhood. The global maternal mortality ratio is 211 deaths per 100,000 live births in 2017. The Sustainable Development Goals call for reducing that number to 70 deaths per 100,000 live births by 2030.

Below, five things to know about motherhood. 

1. Maternal mortality rises in humanitarian and fragile situations. 

It’s not surprising that everything is harder in humanitarian or fragile contexts. In regards to fertility, women must contend with everything from becoming pregnant when they might not want to – because of limited access to family planning services and contraception or because of the increased risk of gender-based violence in these settings – to challenging pregnancies and childbirth due to a lack of antenatal and postnatal care and obstetric care. According to a UNFPA report, more than 500 women and girls die in emergency situations every day from complications due to pregnancy and childbirth. In conflict-roiled Yemen, a woman dies in childbirth every two hours. Approximately 120,000 pregnant and lactating women in Tigray, Ethiopia are malnourished. About 4.8 million unintended pregnancies will occur in Afghanistan by 2025 as a result of health system disruptions and gender inequality.

According to the 2017 Fragile States Index, 15 countries were considered to be “very high alert” or “high alert” (from highest to lowest: South Sudan, Somalia, Central African Republic, Yemen, Syrian Arab Republic, Sudan, the Democratic Republic of the Congo, Chad, Afghanistan, Iraq, Haiti, Guinea, Nigeria, Zimbabwe and Ethiopia), and these 15 countries – the majority considered humanitarian and fragile contexts – had maternal mortality ratios as high as 1,150 (South Sudan). For countries, the target is no more than 140 deaths per 100,000 live births by 2030.

As the report states, “Emergent humanitarian settings and situations of conflict, post-conflict and disaster significantly hinder progress… In crisis and disaster settings, the breakdown of health systems can cause a dramatic rise in deaths due to complications that would be easily treatable under stable conditions.”

2. Mothers aren’t recognized nearly enough for everything – and we mean everything – they do. 

Another non-shocker: women do more unpaid work than men. 

A 2019 report from the International Labour Organization (ILO) puts it bluntly: “Across the world, without exception, women carry out… more than 75 per cent of the total hours [of unpaid care work] provided. Women dedicate on average 3.2 times more time than men to unpaid care work. There is no country where women and men perform an equal share of unpaid care work. As a result, women are constantly time poor, which constrains their participation in the labour market.”

Globally, in households with young children, women spend more time on unpaid care work. In 2018, mothers of children 5 years old and younger accounted for the lowest employment rates (47.6 per cent) compared with fathers (87.9 per cent), non-fathers (78.2 per cent) and non-mothers (54.4 per cent). 

A sizeable reason for the disparity is gender inequality overall. According to the ILO, the value of women’s unpaid care work accounts for 6.6 per cent of global GDP, or $8 trillion; that number for men represents 2.4 per cent of global GDP, or $3 trillion. 

Under Sustainable Development Goal 5 of Gender Equality is Target 5.4 – the recognition and valuing of unpaid care and domestic work – to be achieved by 2030. 

3. Women die in childbirth from many preventable causes.

According to the World Health Organization, five major complications – many preventable or treatable – account for three quarters of maternal deaths: severe bleeding, infections, high blood pressure during pregnancy, complications from delivery and unsafe abortion.

Other causes merit more examination, namely maternal deaths as a result of homicide, suicide and drug overdose. In the United States, one study reported all three as leading causes of pregnancy-associated* deaths, with homicide rates higher than in other countries. In the UK and Ireland, one report concluded that improvements in care might have led to different outcomes in pregnancy-associated deaths by suicide, substance misuse and homicide. And studies in Ethiopia and Egypt found higher prevalence of suicidal behaviour among pregnant women compared to the general population.

*A pregnancy-related death is “‘the death of a woman while pregnant or within one year of the end of a pregnancy… from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.’... A pregnancy-associated death is a maternal death attributable to a condition unaffected by the pregnancy and occurs within one year of the pregnancy.”

4. Women become pregnant as a result of sexual violence.

According to the 2022 State of World Population report, rape-related pregnancies are equally or more likely to occur than pregnancies from consensual sex. In addition, intimate partner violence (IPV) is linked to higher rates of pregnancy. Those experiencing IPV are roughly twice as likely to have their partner refuse to use contraception and twice as likely to report an unintended pregnancy.

5. We don’t value motherhood nearly enough.

If we did, wouldn’t we eradicate childbirth injuries like obstetric fistula?

Wouldn’t we support mothers suffering from postpartum mental health issues?

Wouldn’t every new mother be given proper time to bond with her child and recover her health without risk of losing her job?

Wouldn’t we not assume that all women everywhere are destined to become mothers, thereby devaluing motherhood as an inevitability rather than an aspiration?

Wouldn’t child care and domestic responsibilities be evenly divided?

And wouldn’t we truly make motherhood a choice by giving women and girls the information, resources and support they need: Access to sexual and reproductive health services, comprehensive sexuality education, family planning services and contraception, access to higher education and economic opportunities, protection from violence and above all, gender equality that would render the world safer, healthier and more prosperous not only for them but for everyone.