We Need to End Obstetric Fistula

I chose not to have children, yet several communities where I have worked in the Democratic Republic of the Congo know me as Maman Ashley. This is how core to womanhood motherhood is. The way we revere motherhood is universal. Paradoxically, the way we normalize the suffering of mothers is also universal.

We see this in how women are denied pain management when in labor, regardless of income. We see this in the depleted budgets for maternal health services and in the unacceptable increase in the global rate of maternal mortality—women dying during pregnancy or childbirth, often from preventable causes. We see it, heartbreakingly, in the persistence of injuries like obstetric fistula, an almost entirely preventable childbirth trauma.

Obstetric fistula happens when women go through prolonged labor without medical care, and a hole develops between the birth canal and either the bladder or rectum. Without maternal health care and treatment, it is one of the most ghastly and debilitating injuries that childbirth can cause, affecting an estimated two million women and girls worldwide. It is also the most common obstetric concern in lower-income countries.

I have seen the toll of these horrific injuries on women during my travels as a goodwill ambassador for the United Nations Population Fund (UNFPA), the U.N.’s sexual and reproductive health agency. In the DRC, I witnessed a fistula repair surgery, the mother gripping my right hand, my left wiping her brow, as doctors sewed her perforated vagina. Some years later, a woman named Marima invited me to attend her surgery in South Sudan. She had been living with a torn rectum and vagina for seven years, incontinent and covered with bedsores and ulcers. She had suffered through nine disastrous days of obstructed labor at home, with no midwife and the nearest health clinic out of both physical and financial reach.

Last year I asked in an op-ed if we as a society truly value mothers. Having now spent both my first birthday and my first Mother’s Day without my own mom, that question continues to haunt me. The numbers of pregnant women and girls dying every year—largely from preventable causes—are shattering: Nearly 300,000 perished in 2020. That is one mother, some in their early teens, every two minutes. Some 6 percent of these deaths are from obstetric fistulas, and for each of those deaths, as many as four to five more women will live with an obstetric fistula injury. Why such grim numbers? Because the women afflicted by obstetric fistulas face systemic gender discrimination and social marginalization. They were born into impoverished communities depleted of resources, where sexual and reproductive health concerns are largely neglected, even though these concerns are essential for human life.

This suffering must stop. We must revere the mother as much as we revere motherhood, and we must invest in maternal health care. Women worldwide should have access to qualified midwives and other health workers while they are trying to give life to another human being. And we must fight for the right to contraception: Half of all pregnancies in the world are not intended. Too many women and girls cannot get the contraception they need or want, because they don’t know where to go, can’t afford it or their partners don’t want them to use it.

UNFPA has worked relentlessly for two decades to end obstetric fistula, enabling more than 129,000 women, many living in places of extreme poverty, to have life-changing repair surgeries.

In the developed world, few of us have ever heard of obstetric fistula. Perhaps because we do not talk openly about vaginas. We certainly don’t want to talk about the ones that are damaged, violently torn in prolonged childbirth. It is especially galling that fistula happens to adolescent girls who are forced to marry men. Their young pelvises are not adequately developed for childbirth, and obstructions are more common. Women with fistulas are often ostracized by their own communities, abandoned even by their closest family. Adding tragedy to trauma, in nine out of 10 births that result in a fistula, the baby will die.

Repairing these women’s bodies can be dangerous work in places where sexual violence is rampant. In addition to supporting women with obstetric fistula, we—the citizens of the world and members of the human family—must support the health care workers who risk their lives to restore these women’s bodily functions and help them reclaim their dignity. The surgery I witnessed in the eastern Congo was at Panzi Hospital, whose founder, gynecologist Denis Mukwege, has been awarded the Nobel Peace Prize for his work repairing fistula in spite of attempts on his life. He is now living with full-time security, locked inside his medical compound.  He and other surgeons operate under dire circumstances. Prior to surgery, they have to scrub their hands with water from the river and a bar of soap. During the operation I watched, the electricity went down for hours before sparking back on.

Marima’s surgery was in a public hospital in the war-ravaged town of Bentiu. UNFPA had flown in surgeons from Uganda and Nigeria to South Sudan to repair her fistula and several others’. I visited the mothers in that ward on their small cots, who were smiling and eagerly awaiting their turn in the operating room. They told me their upcoming surgeries revived their hopes that they could better care for their children.

The women most likely to incur fistulas are also the women least likely to access a school, join the workforce, own property, or choose if, when and whom they will marry—and at what age. We must fund programs that help survivors reintegrate into the societies that shamed and rejected them. If they learn new skills, they can earn their own living and make choices about whether, when and how many children they will have.

Unforgivable inequalities result in health and social systems ignoring the most marginalized women and girls in their moment of greatest need—when trying to bring new life into the world. We must demand— with them—investments in reproductive health care, accountability at all levels, and action to end gender discrimination.

In December 2022, U.N. Member States adopted a resolution committing to end fistula by 2030. If we don’t support this resolution, we are morally contradicting ourselves. We cannot revere motherhood while allowing fistula to tear women to pieces. We must show up for mothers who experience such needless trauma.

While I will never understand what these women have gone through, I do understand the challenges of health care in such underdeveloped places. Two years ago, during my annual stay in a Congolese rainforest, I tripped over a tree root and broke my leg in four places. The only painkiller available was a stick to bite on. A man named Jean set my leg twice and others improvised a stretcher. After 67 hours being carried through the rainforest, riding on a motorbike holding my loose bones together with my hands and traveling by bush plane, I came to a Level 1 trauma unit in Johannesburg. After this experience, I often think of the mothers who go through childbirth without any of the help I received, and it stokes my fire to help them further.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.