Obstetric fistulas are almost entirely preventable. The continuum of care requires a three-part approach. It is critical to prevent marriage and childbearing by very young girls; provide access to adequate medical care for all pregnant women; and repair the fistula and its effects on those who suffer from it.

These measures have far-reaching implications, involving cultural change, investment of resources and responsible policy decisions and new patterns of behavior by all concerned.

• Often legal and social change is required to improve the status of women and give young girls better nutrition, access to medical care, primary education and other options for life besides childbearing, as well as the option of postponing marriage-and thus pregnancy-until they are fully grown.

• Men's involvement is crucial in achieving change. Some cultures believe difficult labor indicates the wife has been unfaithful. Men often decide when and whether to seek medical care, and they usually provide or arrange transport to it.

Providing access to medical care:

• Experience shows fistulas result from three classic delays that must be addressed: a delay in the decision to seek medical attention; a delay in reaching a health care facility; and a delay in receiving care once present at the facility.

• Investment in primary and reproductive health care systems, including transportation, should be a priority. Training for midwives and traditional birth attendants should stress timely referral of likely obstructed labor pregnancies to skilled care centers.

• Reproductive health care involves access to family planning, skilled attention during childbirth and referral and transport to skilled obstetric care for women at risk of a difficult delivery.

Treatment:

• In areas where many women await treatment, fistula centers should be created, perhaps attached to major regional or teaching hospitals but with their own operating theaters, along with hostels to house the women before and after surgery.

• Women with obstetric fistulas, often in hiding and unaware that a cure is possible, must be located, identified and persuaded to come in for treatment and counseling.

• The surgery is delicate and technically difficult. A specially trained surgeon and support staff, and access to an operating facility are required.

• Attentive post-operative care involving a catheter or rectal bypass is critical for 10- 14 days while the surgery heals, in order to prevent infection.

• Success rates for primary surgical repair range from 88 to 93 percent, decreasing with successive attempts.

Education is also an important part of the treatment.

• Fistula survivors who have been shunned and isolated typically suffer from intense feelings of shame, self-loathing and depression. They may be suicidal and blame themselves for their situation.

• Education and counseling can restore selfesteem and bring relief, and can repair the emotional and psychological damage.

• Social rehabilitation programs can help women reintegrate themselves into their communities following surgery. Studies show that 90 percent return successfully.

Taking action:

The Hamlin Fistula Hospital in Addis Ababa, Ethiopia, has treated more than 20,000 women since it opened in the 1970s and reports a 93 percent success rate in repairing urinary-tract fistulas.

Hospital capacity is 1,200 women per year, far less than demand, which continues to increase. Satellite centers are planned elsewhere in Ethiopia. Former patients have become nurses, hospital staff, and outreach workers to other fistula sufferers throughout Ethiopia. One has even become a surgeon. The Ethiopian government has given a land tract for another center, and the hospital gives local doctors two-month training courses to raise capacity. But funds are lacking to finance an expansion of facilities or training.

The Family Life Centre in Nigeria has been struggling with a nationwide deterioration of basic health services in its attempt to help some of the country's estimated 1 million women with unrepaired fistulas. The Nigerian National Foundation on Vesico-Vaginal Fistulas works to raise public awareness of the problem, promote an end to child marriages, provide midwife services, and secure support for the Centre.

In Mwanza, Tanzania, the Bugando Medical Centre, which serves an area of eight million people and is the country's second largest referral hospital, set up a special clinic for fistula treatment. With one radio announcement, the clinic attracted scores of patients and treated 150 over two years. Educational outreach included workshops for doctors, nurses and midwives; a pocket-sized booklet story of a young girl with a fistula; information sheets distributed nationwide; and wall murals to raise awareness of the problem. Of 50 patients studied, 20 reported no cash income whatever and the rest indicated low-income status. Their immediate cure rate was 80 percent.