2.3.4 Obstetric Fistula

Facts/messages: Obstetric fistula is a hole in the birth canal caused by prolonged labour without prompt medical intervention, usually a Caesarean section. The woman is left with chronic incontinence and, in most cases, a stillborn baby. Left untreated, fistula can lead to chronic medical problems, including ulcerations, kidney disease, and nerve damage in the legs.

At least 2 million women in Africa, Asia and the Arab region are living with this condition, and some 50,000 to 100,000 new cases develop each year. The persistence of fistula is a stark example of continued poor maternal and reproductive health services and an indication of high levels of maternal death and disability. Obstetric fistula occurs disproportionately among poor girls and women, especially those living far from medical services.

Methodology: In 2003, a Mapping Exercise on Obstetric Fistula was developed by Engender Health to provide an insight on how clinical services for fistula clients are organized. It looks at fistula from the viewpoint of the clients who seek services, the professional staff who provide surgical repairs and care for the women as they recover from surgery and the ministry of health, stakeholders and partners who collaborate in fistula programmes. The questionnaire is intended to rapidly capture the obstetric fistula situation at one specific moment in time in order to flag issues for further investigation and plan and/or improve obstetric fistula services.

The method involves a series of rapid assessments using a simple nine-question survey instrument combined with observation of clinical facilities and interviews with Ministries of Health (MoH) and local policy-makers. Interview administrators and professional staff (physicians, nurses and midwives), as well as fistula clients whenever possible. Include fistula clients who a) Are awaiting repair surgery; b) Are immediately post-surgery and recovering in the post-operative ward; c) Are significantly (> 6 months) post-surgery and d) Have carried a pregnancy post-surgery and delivered by C-section. Visit and observe clinical facilities and wards, waiting areas and operating theatres, whenever possible. If feasible, review logbooks. Information from the women receiving services allows for a deeper and more accurate evaluation of the quality of services provided. This tool allows adding relevant questions on maternal and newborn health services, HIV/STI and prevention of mother-to-child transmission (PMTCT).

The Obstetric Fistula Working Group developed a framework for monitoring and evaluation of fistula elimination programmes at the national level, including indicators on prevention, treatment and reintegration.

To improve data availability, the Geneva Foundation for Medical Education and Research and the WHO developed a tool for centralized data entry, analysis and comparison across sites. A compendium of indicators assists countries in reinforcing health information systems and to contribute to national household surveys in addressing the issue of obstetric fistula. Also, a standardized fistula module for inclusion in country demographic health surveys and national health maternal information systems has been developed and used in the DHS.

Primary Sources:

  • Ministries of Health;
  • DHS.

Secondary Sources:


  • UNFPA/Engender Health (2003). Questionnaire/Mapping Exercise on Obstetric Fistula.

36  Calculations, and a discussion on reliability, validity and implications of the concept can be found in: Casterline, J. B. and S. W. Sinding (2000). “Unmet need for family planning in developing countries and implications for population policy.” Population and Development Review 26(4): 691-723. Note that “unmet need” is not synonymous to “effective demand”, which also involves the ability to pay. In addition, “effective demand” has an element of strength of preference, which is absent from the notion of “unmet need”, as some economists have pointed out. Finally, the “unmet need” concept does not consider the other side of the issue of fertility preferences, namely wanted births that do not materialize.
37  Reports of total and wanted fertility in most recent surveys obtained from: Demographic and Health Surveys’ StatCompiler. Web site: www.orcmacro.org, accessed 8 March 2004.
38  ORC MACRO, International, Demographic and Health Surveys.
39  USAID (2006): New Estimates of Unmet Need and the Demand for Family Planning. DHS Comparative Reports 14. Chapter 1.1. The Concept and Measurement of Unmet Need. See also: UNSD (2011). Indicators for Monitoring the Millennium Development Goals: Definitions, Rationale, Concepts and Sources (Updated Version). At present, attempts are underway to come up with a simpler concept of unmet need, that does not require so much information. This simplified concept will replace the current standard definition, but the change may not yet be reflected in the updated MDG indicator manual.
40  For more information see: http://www.endfistula.org.
41  Report of the Secretary-General (2010). Supporting efforts to end obstetric fi stula. A/65/268.
42  This tool has been used extensively in various different countries by UNFPA and Engender Health. Report of Findings is available at: http://www.fistulanetwork.org/FistulaNetwork/index.php?option=com_content&task=view&id=292.