By Jyotsna Ghosh

The incredible success of Nicholas Kristof and Sheryl WuDunn’s Pulitzer Prize winner (and best-seller) Half the Sky helped focus American attention on the worldwide problem of obstetrical fistulas. Largely eradicated from Europe and North America with the advent of increased bridal age, delayed child-bearing age, and improved prenatal and delivery care, obstetrical fistulas—essentially tears near the vagina generally sustained in childbirth–continue to afflict at least two million women globally, according to the World Health Organization. WHO estimates a minimum of 100,000 new cases annually, nearly all in the developing regions of Africa and Asia. However, women’s advocacy groups point out that the WHO data are from 1989 and probably represent significant under-reporting of the true extent of the problem, due to poor record-keeping and to the shame attendant upon the condition.

Many factors contribute to the development of obstetrical fistulas. Kristof and WuDunn, like many of the international organizations working to prevent and treat the condition, trace fistula development back to the poverty and low status of women. Because girls in some traditional societies are not valued highly, they receive less nurturance and less actual nourishment than their brothers do. Malnourished, they are married early in puberty, their skeletal structure having had neither the time nor the nutrition needed to mature fully. As a result, the pelvis is often stunted, dramatically raising the risk of obstructed labor when a child is born.

Obstructed labor is frequently also prolonged labor. Contractions continue, but the narrowness or malformation in the pelvis does not permit the baby to pass through the birth canal. Instead, its head presses on the pelvis, sometimes for many days. The pressure cuts off the blood supply to delicate tissues. It is not uncommon, in such cases, for both the mother and infant to die if an emergency Caesarean section is not undertaken. Even if the mother is ultimately able to deliver successfully, in 90% of cases the infant will not survive. For the mother, the extended period of tissue “blood starvation” means the vaginal tissues will subsequently die and fall away. The woman is left with a hole between her vagina and her bladder or between her vagina and her anus. Urine and feces commonly drip from this hole. Ulcerations result. Infections have easy access to the internal organs. The kidneys are often affected, particularly since women desperate to limit the leakage may drink very little and consequently become seriously dehydrated. It is also very common for the duration of pressure during delivery to damage nerves in the legs and lower back, sometimes leaving women unable to walk. Nearly always, women who suffer long-standing, un-repaired obstetrical fistulas are unable to become pregnant.

Their infertility is one reason the victims of this preventable trauma are “social lepers” discarded by their families. Other reasons, however, also contribute to their isolation. The urinary and fecal incontinence is not only embarrassing and debilitating to the women themselves, but also causes them to exude a foul odor that leads to shunning by others. Half the Sky recounts histories of women cast out of their homes, lying in their own filth, unable to fend for themselves, and lacking the knowledge of the availability of medical treatment and the means with which to seek it.

For such women, the medical sequelae of obstetrical fistula are only part of the problem. The humiliation and social exclusion from family and community are just as devastating. Generally, victims are not allowed to prepare food and may be forbidden to participate in prayers or other religious activities. Furthermore, most are grieving mothers who have lost a newborn and know they will never be able to give birth again. All of these circumstances exacerbate the physical torment of the condition itself.

Organizations such as Campaign to End Fistula emphasize that obstetrical fistulas are treatable, generally for as little as the equivalent of $300 USD. Plastic surgery is effective, yet beyond the means of most women suffering from the condition. Not surprisingly, those working to raise awareness of obstetrical fistulas seek donations from wealthier nations, but they also stress the fact that treatment is not the ultimate goal. Prevention– through education, through empowerment of women, through improved access to medical care, and perhaps most importantly, through addressing the underlying poverty and oppression of women– is considered essential. Only 58% of women in developing countries give birth with the assistance of a physician or a professional midwife. Since an average of 15% of all births (including those in which pelvic stunting and other poverty-related conditions are not a factor) require emergency medical intervention, the risk for obstetrical fistula is clear and frightening. Entirely preventable, this affliction has been too long ignored.