Unfortunately for an estimated half a million women and girls across sub-Saharan Africa, Asia, the Arab States region and Latin America and the Caribbean, childbirth lasted much longer than this proverb warns against – with devastating consequences.

Prolonged, obstructed labour can lead to maternal death, stillbirth, and a severe injury called obstetric fistula. The condition causes incontinence and leaves women susceptible to both physical ailments like infection and infertility, as well as mental health issues driven by social stigma and ostracization.

For twenty years, UNFPA has led the global Campaign to End Fistula, which aims to eliminate fistula by 2030 through prevention, treatment, social reintegration of survivors and advocacy programming. On the International Day to End Fistula 2023, see how UNFPA puts these strategies into action.

Prevention in Côte d’Ivoire

Averting serious childbirth injury can very much depend on who is in the delivery room. The UN has singled midwives out for their crucial role in “saving maternal and newborn lives and preventing morbidity, including obstetric fistula”.

But prevention efforts often occur well before the first pangs of labour. In Côte d’Ivoire, Pastor Kouakou Adou Kouamé – a member of the Ivorian Association for Family Welfare’s fistula support committee – works to spread information about the condition among and beyond his flock at the Bondoukou Baptist Church.

“We raise awareness in the communities, the villages,” he said. “It is not only our faithful that we reach.”

Pastor Adou uses his position at the pulpit to help people understand and avert the dangers of fistula. Particularly at weddings, he warns newlyweds against home births, which can heighten the risk of childbirth injury.

“Soon a child will come,” he tells them. “When a woman is in labour, she should be close to the health centre.”

Treatment in Madagascar

Reconstructive surgery serves as the main method for repairing obstetric fistula. Since 2003, UNFPA has directly supported more than 138,000 fistula surgeries.

Marie Jaqueline Raharimanana of Antananarivo, Madagascar underwent fistula surgery in 2020. She had sustained the childbirth injury following two full days of labour attended by a retired midwife, who refused to let Ms. Raharimanana go to a hospital.

“[The midwife] told my mother that there was no choice: Either we save the baby or we save the mother,” Ms. Raharimanana said. Her baby was stillborn, and Ms. Raharimanana was left with a devastating disability.

“As soon as the baby came out, I couldn't hold my urine anymore.”

For six months, Ms. Raharimanana was bedridden. She struggled with the loss of her baby and with shame over her condition, which she did not fully understand. Awareness of fistula around the world can be low, leading women and girls affected to miss out on treatment opportunities.

Cost and access can also be barriers to treatment in some countries. For instance, in Zambia, there are just eight doctors who perform fistula surgeries.

In September 2020, a relative of Ms. Raharimanana recommended she visit a doctor, who suggested going to a maternity ward in Antananarivo where doctors were performing fistula surgeries. Her first procedure took place six months after she went into labour.

Ms. Raharimanana said she has noticed an improvement in her condition since getting treatment, and continues to receive follow-up care. Today, she awaits her doctors’ sign-off on her dream of marriage and children. “The doctors reassured me I am not late and I fully trust them. Until I recover, I am not taking that road,” she said.

Social reintegration in Burkina Faso

A major component of treating fistula has more to do with society than surgery. Sadly, due to the incontinence brought on by the injury, survivors are often relegated to the periphery of their communities and abandoned by partners and family members.

Unfortunately, this was the experience of 48-year-old mother-of-five Noelie Nikiema. Ms. Nikiema sustained obstetric fistula during the birth of her last child ten years ago; afterwards, her husband left her and remarried.

Ms. Nikiema took refuge at her uncle’s home in Ouagadougou. “For eight years, I couldn’t leave the yard or receive visitors because of the uncontrolled leakage,” she told UNFPA.

Two UNFPA-supported interventions helped break her out of isolation and rejoin society: Free fistula surgery at the Schiphra hospital, which she obtained in November 2022, and a skills training course in weaving and dying fabric.

She has been running a weaving business out of her uncle’s backyard for four months now. “With this income, I manage to provide for the needs of my children and help the members of my new family,” she said.

Ivorian fistula survivor Odile Siekoua has been working as a community health agent since 2016. © UNFPA Côte d’Ivoire

Advocacy in Côte d’Ivoire

The UN highlights the central role fistula survivors can play as champions towards eliminating the injury’s occurrence.

Ivorian mother-of-two Odile Siekoua lived with obstetric fistula for 23 years before she was able to obtain UNFPA-supported treatment in 2012 to repair her condition.

Ms. Siekoua knows well the harm fistula can cause both to the body and mind. Her partner ostracized her due to her condition, as did her family. In 2010, after Ms. Siekoua was forced to flee her village amid Côte d’Ivoire’s post-electoral crisis, her sisters in Grand-Bassam only allowed her to stay with them temporarily, as they were upset by her incontinence.

Ms. Siekoua eventually found refuge in a landfill. “When it rained, I had to lie on top of my child to prevent him getting wet,” she said. “It wasn't until two years later that my first son helped me with transport back to Man."

After obtaining treatment for her condition in Man, Ms. Siekoua became a community health worker in 2016. Her aim is to sensitize her community to obstetric fistula in the hopes other women will not have to endure what she went through.

One of the women she has supported is 48-year-old Chantal Gonti. The fistula survivor was called a witch by her husband due to her condition, which she endured for 15 years before being referred by Ms. Siekoua for treatment.

Today, Ms. Gonti is a weaver and trader. “Before, I couldn't approach people,” she said. “My life has changed. I earn money to send my children to school and support myself.”