The necrotic tissue sloughs off, leaving a hole between the vagina and bladder (vesicovaginal) or vagina and rectum (rectovaginal) (Figure 2). The woman develops incontinence of urine and/or stool, and is affected by multiple devastating medical and psychosocial sequalae. Figure 1 Obstructed labor. Illustration from A Sett of Anatomical Tables, With Explanations, and An Wortmannin ATM Abridgment, of the Practice of Midwifery, by William Smellie, printed in 1754. Figure 2 Simple vesicovaginal fistula. A metal catheter through urethra is visible through destructed bladder. Copyright? Worldwide Fistula Fund, used by permission. Epidemiology There are no worldwide, comprehensive surveys that estimate the incidence and prevalence of OF. The vast majority of known OF cases occurs in parts of sub-Saharan Africa and South Asia (Figure 3).

The World Health Organization (WHO) estimates that more than 2 million women live with the condition and up to 100,000 new cases occur each year.1 However, because many of the women who are deeply affected by OF are unable to access care, these figures may be severe underestimates. Indeed, one study has found that 1 million women are affected by OF in Nigeria alone, and another suggests that 70,000 new cases occur annually in Bangladesh.2 Figure 3 World Health Organization map of obstetric fistula. Reproduced with permission from Wall LL, Arrowsmith SD, Briggs ND, Lassey A. Urinary Incontinence in the Developing World: The Obstetric Fistula. Geneva, Switzerland: World Health Organization; 1991. …

History This complication of labor has likely existed for as long as women have been giving birth: vesicovaginal fistula (VVF) is mentioned in ancient Hindu writings on medicine, and a VVF was found in the mummy of Queen Henhenit, the wife of 11th dynasty pharaoh Mentuhotep II, who reigned about 2050 BCE.3 In 1845, OF was described by Dr. J. Marion Sims as ��hopelessly incurable.��4 Upon encountering a young slave woman with OF and initially resolving the condition as irremediable, Sims then dedicated the next 4 years to developing surgical solutions to this condition. Using slave women as his subjects, he was able to successfully repair a VVF in 1849. Due to significant medical advances, including safer cesarean deliveries and the development of obstetrics into a scientific specialty, by the mid-1900s OF practically disappeared in the industrialized world.

Who Is at Risk? Women who are afflicted with OF today are not much different from women with OF prior to the 1900s: they are young, primiparous, poor, uneducated, and with virtually no access to obstetric care. Child marriage remains common in resource-poor nations, putting these girls at high risk for premature childbearing and cephalopelvic disproportion, which can cause obstructed labor. A very high Entinostat percentage of girls in Ethiopia (25%), Uganda (42%), and Mali (45%) are married and give birth by the age of 18. Their risk of fistula development is as high as 88%.