Johns Hopkins Bloomberg School of Public Health: The INFO Project

An obstetric fistula is an abnormal opening between the vagina and the bladder or rectum. The fistula results in the uncontrolled passage of urine or feces from the bladder or rectum into the vagina (10). Fistulas also can have nonobstetric causes, such as laceration, rape, and other sexual trauma.

Fistula afflicts millions of women in developing countries. Each year an estimated 50,000 to 100,000 more women develop obstetric fistulas (39, 63).

Most obstetric fistulas could be avoided if women could delay childbearing until after adolescence, if skilled attendants¹ could monitor all labors, and if women could have timely access to good emergency obstetric care. Moreover, most women who develop fistulas could be treated surgically to have the damage repaired.

Obstructed labor can occur when the fetus will not fit through the mother’s pelvis (cephalo-pelvic disproportion), when the fetus is not positioned correctly for delivery (malpresentation), or when uterine contractions are ineffective in delivery (40). An obstructed labor is considered prolonged after 24 hours, and it can last one week or more unless the fetus is delivered surgically.

In prolonged labor the unrelenting pressure of the entrapped fetal head against the mother’s pelvis can cut off the flow of blood to the soft tissues of the bladder, vagina, and rectum. If the mother survives, prolonged obstructed labor usually ends with the death of the fetus, followed by fetal decomposition to the point that it can slide out. The mother’s injured pelvic tissue soon sloughs away, leaving a fistula between adjacent organs (69).

If the fistula is between the vagina and bladder (vesico-vaginal, or VVF), urine leaks from the vagina; if the fistula is between the vagina and rectum (recto-vaginal, or RVF), feces leak. The great majority of fistulas are vesico-vaginal. Estimates of the extent of recto-vaginal fistulas are few but include 7% in a case series of patients in Ethiopia (31) and 4% in a series of patients in Nigeria (70). An estimated 6% to 24% of obstetric fistula cases are combined VVF and RVF (31, 70, 71).

Obstructed labor—the immediate cause of obstetric fistula—is one of the leading causes of maternal illness and death in sub-Saharan Africa and South Asia (40, 55). Worldwide, obstructed labor occurs in an estimated 5% of pregnancies and accounts for an estimated 8% of maternal deaths (11, 35, 78).

Surgical Repair Usually Succeeds Surgeons can repair fistulas successfully in 80% to 90% of cases (3, 4, 17, 65). There are internationally recognized techniques for fistula repair (66). The specific method used usually depends on the surgeon’s preferences and the nature of the fistula (52). Most surgical experts recommend waiting two to three months after the fistula has occurred before attempting repair in order to avoid operating on dying tissues (28). If a fistula is suspected immediately following an obstructed labor, the patient may initially receive continuous bladder drainage to avoid stretching the injured tissues, which would impede healing. Prompt catheterization increases the likelihood of spontaneous closure of some fistulas (23, 67). The patient may also receive treatment for anemia and malnutrition and antibiotics to prevent infection (23). Repair often is more difficult on patients with extensive scarring from prolonged obstructed labor. Successful repair can depend on both the initial state of the fistula and the skill of the surgeon (71), as well as on the quality of post-operative care (33). Especially in difficult and complex cases, even after a fistula is repaired, the patient may continue to suffer from involuntary loss of urine (stress incontinence) because the urethral sphincter may be permanently damaged (17). This post-surgical problem occurs in an estimated 10% to 12% of patients (24). In the worst cases the patient may need a permanent urinary diversion operation (19, 71). Recovery after surgery generally takes two weeks, during which the patient needs to drain her bladder through a catheter. Most patients can leave the hospital after 14 to 21 days. Women with successfully repaired fistulas are advised not to resume sexual relations for three or four months to give tissues time to heal fully. The length of recovery varies with the extent of the damage repaired (30, 71). In women with fistula the normal menstrual cycle may not return for two years or more after the pregnancy that caused the fistula (24). After successful surgical repair, normal menstruation can return rapidly. In some cases, however, it may never return. A Nigerian study examined 162 women with successfully repaired obstetric fistulas. Before the repair 66 of the patients had had amenorrhea for several months to 15 years. For 58 of these women, menstruation returned within six months after the repair (15).

Worldwide, each year more than half a million women (529,000 estimated in 2000) die from largely preventable pregnancy-related causes (1, 77). An estimated 99% of such deaths occur in developing countries (78).

For each maternal death in a developing country, many other women suffer from illness and disability due to complications during pregnancy and childbirth. For example, in Bangladesh for each maternal death, an estimated 153 other women suffered a serious maternal medical problem; in India, 175; in Egypt, 297; and in Indonesia, 908, according to research in the late 1990s (16).

Adolescent women are particularly susceptible to obstructed labor, because their pelvises are not yet fully developed (see “Early childbearing increases risk”). Women who suffer from malnutrition could also be at particular risk because the body’s growth may have been stunted in childhood.

In developed countries obstructed labor is almost always promptly remedied by cesarean section delivery. In developing countries, however, many women do not survive obstructed labor—usually because the complications are not recognized in time or because emergency care is unavailable, due either to great distance or high cost.

If a woman survives obstructed labor, she often sustains multiple physical problems—not only the fistula itself but also recurring infections, paralysis of muscles in the lower legs (termed “foot-drop”), amenorrhea, infertility, and damage to vaginal tissue that may make sexual intercourse impossible (4, 10, 69, 71, 80).

Once obstetric fistulas occur, most require surgical repair; they usually cannot heal by themselves (69). Most surgical repair is successful (see box, right), but many women, especially those who deliver without medical attention, may not know that the fistula could be repaired or may not be able to get care (10, 63, 71).

Moreover, few medical practitioners in the developing world have training in fistula repair. While a few specialized fistula hospitals or fistula units within general hospitals exist in some African countries, most hospitals and clinics in developing countries do not have the facilities to treat fistulas successfully or do not consider fistula repair to be an important medical priority (69).

¹ The term “skilled attendant” refers exclusively to people with midwifery skills (for example, doctors, midwives, nurses) who have been trained in the skills necessary to manage normal deliveries and diagnose or refer obstetric complications (79).