Today, the 23rd May 2017, is the fourth International Day to End Obstetric Fistula. The day was first observed by the UN in 2013, but fistula has been a silent death for generations for millions of girls and women in developing countries.. The Foundation for Women’s Health Research, and Development (FORWARD) began working to end fistula nearly two decades ago through our programmes in Nigeria, Tanzania and Sierra Leone.

Fistula doesn’t get the attention it deserves and many policy makers haven’t even heard of the issue. At a global level, millions of women are being failed, and at a local level women who develop fistula during childbirth almost always become shunned and stigmatised in their communities with no idea of how or where to get support. This is all due to barriers that hinder their inability to exercise their sexual and reproductive health rights and access good quality maternal healthcare.

Last week the World Health Organisation released new data revealing that a staggering 1.2 million adolescents die every year, and almost all of these deaths are preventable. In the top five causes of death among females aged 10-19 years in 2015 sits maternal health conditions. Maternal health conditions include complications during pregnancy and child birth such as haemorrhage, complications from unsafe abortion and obstructed labour. Girls aged 10-19 years face multiple challenges and their needs are frequently ignored or inadequately addressed by policy makers.

Obstructed labour is what causes fistula: when the baby’s head exerts prolonged pressure on the mother’s pelvis causing tissue damage and creating a hole. If they don’t die from blood loss while delivering or from infection and kidney failure after the birth then women are left with one hole from which urine or faeces and menstrual blood leaves her body, with little control over any of these bodily functions. Many affected girls and women end up traumatized, ostracized and dehumanized.

It is estimated that more than 2 million women live with untreated obstetric fistula in sub-Saharan Africa and Asia and between 50,000 to 100,000 women develop obstetric fistula every year. This figure clearly does not capture the full impact of obstetric fistula on women and girls.

Recent research conducted by FORWARD and our partners highlights the clear links between fistula, child marriage, child pregnancy and female genital mutilation. Girls who are forced into child marriage before the age of 18 invariably experience early sexual initiation and early pregnancy at a time when their bodies are not physically developed for child birth. Prolonged and obstructed labour is particularly prevalent among child mothers with immature pelvises. There is also strong evidence that type III female genital mutilation – infibulation or stitching up of the vagina – may prolong labour, increasing the risk of fistula.

The World Health Organisation also recognises a causal relationship between prolonged and obstructed labour and fistula, the fact that FGM is also associated with prolonged and obstructed labour means it is reasonable to presume that the conditions are linked to women and girls living with FGM.

FORWARD carried out participatory research on fistula in Tanzania with our partners UTU Mwanamke. As part of the study the participants shared insights on how becoming pregnant at a young age makes girls more likely to develop fistula. A young women from Mpwapwa shared that, “Pregnancies at an early age result in complications during delivery like getting fistula and sometimes it causes death.” She went on to say, “There was a certain girl who married at the age of 14 or 13. She got pregnant and went to Mpwapwa for delivering. Because she was too young, she faced delivery problems, developed fistula and died.”

Fistula is a disability that affects poor, vulnerable and marginalised girls and women. Girls and women who are most at risk of developing fistula are those that live in communities where their sexual and reproductive health and rights are not protected or upheld. Their educational attainment, their status in the household and their economic dependence all affect their decision making powers regarding pregnancy and reproductive health. But most importantly many lack access to emergency obstetric care due to poor infrastructure in many rural areas in Africa.

Fistula affects mostly those left behind, often those whose lives are affected by multiple factors; social norms that promote child marriage, FGM and the condoning of domestic violence result in a lack of choices and early and multiple pregnancies.  If we are to address obstetric fistula we must continue to make these links and understand the factors that cause fistula. With each rights violation that girls and women suffer, more of their choices over their bodies and their futures are taken away. The 2030 Agenda for Sustainable Development sets out clearly that no one can be left behind as we strive for a more prosperous world for all.

We must, as a global community, do more. Fistula is treatable, we must enable girls and women who are living with fistula now to access the treatment they need and provide holistic support for them to re-integrate in to their communities. But most importantly fistula is preventable. Ending harmful traditional practices like FGM and child marriage would significantly decrease the likelihood of girls becoming child mothers and developing fistula due to early and repeated pregnancy. FORWARD works globally to safeguard the rights and dignity of African women, for over 30 years we have been working on FGM, child marriage and obstetric fistula; we will continue to push for the links between these issues to be recognised and understood, we call on global leaders to join us.

Written by Jenny Vaughan, Senior Campaigns and Advocacy Officer at the Foundation for Women’s Health Research and Development (FORWARD).