New Study Reveals Significant Decline in Global Obstetric Fistula Cases
The substantial reduction in prevalence, revealed by new data collection, is likely a result of international prevention efforts, skilled birth attendants, and access to emergency obstetric care and surgical care for caesarean sections.
Global rates of obstetric fistula—a preventable, treatable childbirth injury that often leaves women incontinent—are substantially lower than previously estimated, according to a study published last month in BMJ Global Health.
A research team led by Bloomberg School of Public Health’s Saifuddin Ahmed, PhD, MBBS, professor in Population, Family and Reproductive Health, conducted an analysis of obstetric fistula prevalence across 55 low- and middle-income countries targeted by the United Nations Population Fund’s Campaign to End Fistula. The researchers estimate about 457,000 women ages 15–64 and roughly 386,000 women of reproductive age (15–49) were living with obstetric fistula in 2020. This is lower than earlier estimates by the World Health Organization of more than 2 million women living with obstetric fistula.
Previous estimates were largely based on anecdotal evidence from the early 1990s rather than population-level data. The study is thought to be the first of its kind to use statistical modeling to generate a more accurate prevalence rate.
“Our findings suggest the burden of obstetric fistula is substantial but considerably lower than previously believed,” says Ahmed, lead author of the study. “This reflects real progress in maternal health over the past two decades, even as serious gaps remain.”
The authors attribute the lower-than-expected global estimates to improvements in maternal health over time, including increased access to skilled birth attendance, emergency obstetric care and cesarean delivery, alongside steep declines in maternal mortality since 1990. The United Nations Population Fund’s “Campaign to End Fistula” has substantially increased access to surgical care and awareness of the issue.
Obstetric fistulas are most often caused by prolonged, obstructed labor that goes untreated. The condition is largely preventable through timely access to quality maternal care, including skilled birth attendants and emergency obstetric services. When fistulas do occur, most can be repaired through surgery with appropriate follow-up care.
Because obstetric fistula is rare and often hidden, reliable data are difficult to obtain. The researchers analyzed data from 31 Demographic and Health Surveys conducted in 22 countries in Asia and Africa that included questions about urinary and fecal incontinence. They then corrected those self-reported symptoms using detailed information about timing, childbirth history, and treatment outcomes to isolate cases likely caused by childbirth.
The researchers adjusted for misclassification using results from two large population-based validation studies in Bangladesh and Ethiopia, where suspected fistula cases were confirmed through clinical examination. Those studies found that only about one-third of women who reported fistula-like symptoms actually had obstetric fistula, underscoring the risk of overestimation when relying on self-reports alone.
To estimate prevalence in countries without survey data, researchers used predictive statistical models incorporating maternal mortality ratios and regional patterns in 55 countries considered to have non-negligible levels of fistula.
The prevalence of obstetric fistula varied widely by region. Sub-Saharan Africa had nearly twice the prevalence rate of Asia, about 71 cases per 100,000 women compared with 36 per 100,000.
West and Central Africa showed the highest regional burden within sub-Saharan Africa, while the Arab States region, including Afghanistan, Somalia, Sudan and Yemen, had the highest prevalence rates overall. Nigeria, Ethiopia and the Democratic Republic of Congo had large numbers of affected women.
Despite the revised numbers, the nearly half a million women living with obstetric fistula represents an enormous unmet need for surgical treatment, social reintegration and long-term care.
The study also highlights a growing concern: as cesarean deliveries increase in low-resource settings with limited surgical capacity, surgery-related fistulas may become more common.
“Obstetric fistula is entirely preventable and treatable,” Ahmed notes. “Eliminating it will require sustained investment in quality maternal care, safe surgery, and health systems that reach women before, during, and after childbirth.”
The findings are intended to guide governments, donors and global health organizations as they work toward the UN goal of ending obstetric fistula by 2030.
“Global, Regional and National Estimates of Obstetric Fistula Prevalence” was co-authored by Saifuddin Ahmed, Rene Genadry, Bridget Asiamah, Mengjia Liang, Vandana Tripathi, and Erin Anastasi.
