When people first learn about obstetric fistulas and their disastrous effects, the usual reaction is to reject hearing more-the subject is just too unpleasant. Rejection is exactly what happens to fistulas' survivors.

An obstetric fistula is an injury of a woman's birth canal that most often occurs when a very young girl is pregnant and experiences a long and obstructed labor. The baby usually dies. The mother, if she survives, suffers tissue damage to the birth canal that becomes an opening between the vagina and the bladder or rectum. This creates a constant leakage of urine or feces, sometimes both.

The results are devastating. The girl is unable to stay dry. Her genital area ulcerates from the wetness and she suffers from frequent infection. The smell of urine or feces is constant and humiliating. Rather than being comforted as a survivor, the girl may be considered unclean and ostracized from her family and community, even blamed for her own condition. Often she is abandoned by her husband. On top of this, the girl grieving for her stillborn child may also suffer pain or crippling from nerve damage to her legs.

Fistulas afflict at least an estimated 2 million females, nearly all of them young, very poor and living in the developing world. These are places where malnutrition and stunted growth make obstructed labor more likely, or where the culture or political strife leads to pregnancies among very young girls. In many of these places, access to medical care is limited or mistrusted, and Caesarean delivery is largely unavailable.

• The World Health Organization estimates that some 2 million females are living with obstetric fistulas, and that another 50,000 to 100,000 new cases occur yearly.
  
  
• Estimates come from actual cases of women seeking treatment in hospitals and clinics and are likely to be grossly low. Reliable data are nonexistent.
  
  
• The shame associated with fistulas means uncounted numbers of women live with the probelm for years, isolated and unaware that a cure is possible.

Fortunately, fistulas can usually be corrected surgically, and these girls can resume a normal life once they are repaired.

The best solution, however, is threefold:

• Postpone marriage and sexual relations for very young girls;
  
  
• Provide access to adequate medical care for all pregnant women; and
  
  
• Repair physical damage through medical intervention and the emotional damage through counseling.

Fistulas were once widespread in Europe and America and other wealthier areas, but were all but eradicated by modern medical care after the early 1900s. They are almost completely preventable.