International Day to End Obstetric Fistula
<p>In 1959, an Australian obstetrician named Catherine Hamlin answered an advertisement in The Lancet. The Ethiopian government was looking for doctors to set up a midwifery school in Addis Ababa, and Hamlin, with her husband Reg, took the job expecting to teach. Instead, women began arriving at the hospital with an injury the Hamlins had been taught was an academic rarity, something seen only in old textbooks. The women leaked urine constantly, smelled of it, and had usually been abandoned by their husbands and shunned by their villages. The Hamlins had never repaired such a wound. They taught themselves from manuals and by writing to other surgeons, and within three years they had operated on three hundred patients. The condition was obstetric fistula, and the day that now bears its name, observed every 23 May, exists because injuries like the ones the Hamlins saw have never gone away.</p>
<h2 id="what-obstetric-fistula-actually-is">What obstetric fistula actually is</h2><div class="ad-unit ad-in-article" aria-label="Advertisement">
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<p>Obstetric fistula is a hole that opens between the birth canal and the bladder, or between the birth canal and the rectum, caused by prolonged and obstructed labour. When a baby cannot pass through the pelvis and labour drags on for days without surgical help, the soft tissue trapped between the baby’s head and the mother’s pelvic bone loses its blood supply and dies. The result is a permanent opening through which urine, and sometimes faeces, leaks uncontrollably. The labour itself almost always ends in a stillbirth, so the injury arrives hand in hand with the loss of a child.</p>
<p>The cruelty of the condition lies partly in how thoroughly it has been beaten elsewhere. In countries with well-resourced maternity care, a woman whose labour stalls is given an emergency caesarean section before the damage can occur, which is why fistula has all but vanished from Australia, Britain and the United States. Where it persists, it tracks poverty with grim precision: it appears where hospitals are distant, where roads are poor, where skilled birth attendants are few, and where girls marry and bear children before their bodies have finished growing.</p>
<p>It is worth being precise about the scale, because vague language has long obscured it. The World Health Organization and UNFPA estimate that somewhere around half a million women are living with untreated obstetric fistula at any given time, concentrated in sub-Saharan Africa and parts of South Asia, with tens of thousands of new cases each year. The very imprecision of these figures is itself part of the problem: the women who develop fistula are exactly the women least likely to appear in any official record, living in remote districts, withdrawn from public life, often never reaching a clinic at all. A condition that hides itself is a condition that is easy for budgets and statistics to overlook.</p>
<h2 id="where-the-day-comes-from">Where the day comes from</h2>
<p>The International Day to End Obstetric Fistula has a clear and recent origin. The United Nations General Assembly adopted resolution 67/147 on 20 December 2012, designating 23 May as the annual observance, and the first commemoration was held on 23 May 2013. The day did not appear from nowhere. It grew out of the Campaign to End Fistula, launched in 2003 by the United Nations Population Fund (UNFPA) together with the World Health Organization and a network of partners. The campaign had spent a decade building treatment programmes, training surgeons and gathering data, and the UN resolution gave that work a fixed point in the calendar and a permanent place on the global health agenda.</p>
<h2 id="a-history-written-by-surgeons-and-patients">A history written by surgeons and patients</h2><div class="ad-unit ad-in-article" aria-label="Advertisement">
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<p>The medical story of fistula stretches back far longer than the campaign. Surgeons in the nineteenth century experimented with repair techniques, but the modern era of treatment is inseparable from the Addis Ababa Fistula Hospital, which Catherine and Reg Hamlin founded in 1974 as the world’s first hospital dedicated entirely to the injury. Over her lifetime Catherine Hamlin, who continued operating into her nineties and died in Ethiopia in 2020, oversaw the treatment of more than sixty thousand women. The hospital trained generations of surgeons and demonstrated something the wider world had been slow to grasp: that an injury producing such profound shame could, in most cases, be closed in a single operation lasting an hour or two.</p>
<p>That fact reframes the whole subject. A woman who has spent years sleeping on a mat away from her family, unable to attend church or market, can sometimes walk out of hospital dry within weeks. The surgery does not always succeed on the first attempt, and the most severe injuries remain difficult, but the great majority are repairable. The history of fistula is therefore not only a history of suffering but of a problem that medicine learnt how to solve and then struggled to deliver where it was needed most.</p>
<p>The surgical lineage reaches back further still. The American physician James Marion Sims, working in Alabama in the 1840s, developed an early operation for vesicovaginal fistula, and his name remains attached to the surgical position and the speculum he devised. His legacy is now deeply and rightly contested, because he refined his technique by operating repeatedly on enslaved Black women, often without anaesthesia and without anything resembling consent. That history sits uncomfortably beneath the modern campaign, a reminder that the knowledge now used to restore dignity to the poorest women was first extracted from women who had no power to refuse. The day’s emphasis on the consent, comfort and humanity of patients is, in part, a deliberate correction of where this surgery began.</p>
<h2 id="why-the-day-matters">Why the day matters</h2>
<p>The argument for the observance is partly one of visibility. Fistula is, by its nature, a hidden condition. The women who have it tend to withdraw from public life precisely because of the symptom, so they are rarely seen and rarely counted. A day on the calendar forces the subject into press releases, parliamentary statements and hospital open days that would otherwise never mention it. Awareness, in turn, loosens funding for the surgical camps and the training programmes that do the actual repairing.</p>
<p>There is a second argument, harder-edged than awareness. Fistula is a measure of how well a health system protects women at their most vulnerable moment. A country can chart its progress in maternal care by watching its fistula cases fall, and the injury’s persistence is a standing indictment of the gaps that remain. Ending it means tackling the things that cause it: child marriage, malnutrition that stunts pelvic growth, the absence of skilled birth attendants, and the simple problem of getting a labouring woman to an operating theatre in time. This is the same web of access and dignity that runs through the <a href="/specialdate/international-day-of-womens-health/">International Day of Women’s Health</a>, and the connection is not rhetorical but clinical.</p>
<h2 id="how-the-day-is-marked">How the day is marked</h2>
<p>On 23 May, UNFPA, national health ministries and fistula treatment centres hold awareness events, surgical campaigns and conferences, usually built around a theme chosen for that year. Hospitals in Ethiopia, Nigeria, Bangladesh and a dozen other countries often time free surgical camps to coincide with the date, treating clusters of women who have travelled long distances. Survivors who have been repaired and reintegrated frequently speak at these events, which matters more than it might sound: a woman standing dry and confident in front of an audience is the most direct possible rebuttal to the belief that fistula is a curse or a punishment rather than a wound.</p>
<h2 id="variations-across-the-affected-regions">Variations across the affected regions</h2>
<p>Because the day exists to serve specific places, its character differs by country. In Ethiopia the observance leans heavily on the legacy and ongoing work of the Hamlin hospital network. In Nigeria, which carries one of the heaviest fistula burdens, government and NGO efforts focus on the north, where rates are highest and where early marriage is most common. In Bangladesh and parts of South Asia, the emphasis often falls on reaching women in remote rural districts who may not know that treatment exists. The traditions of the day are practical rather than ceremonial; what unites them is the pairing of surgery with the unglamorous work of finding the women who need it.</p>
<h2 id="the-weight-of-stigma">The weight of stigma</h2>
<p>The physical injury is only half of what fistula does. Constant leaking makes a woman unwelcome in shared spaces, unable to work, and often unwanted at home, and the isolation can last for years or decades. That pattern, in which a private condition becomes grounds for public exclusion, is one the wider human-rights calendar keeps returning to; the work of replacing exclusion with understanding runs through observances such as the <a href="/specialdate/international-day-against-homophobia-and-transphobia/">International Day Against Homophobia and Transphobia</a>, and the parallel is not accidental, since both confront the way communities push people to the margins for things outside their control. Much of the day’s messaging is therefore aimed squarely at the stigma rather than the wound: the insistence that fistula is a medical injury and not a moral failing, that it is no one’s fault, and that it can usually be repaired. Reintegration programmes attached to treatment centres provide counselling and sometimes vocational training, on the understanding that closing the hole is not the same as restoring a life.</p>
<h2 id="fun-facts">Fun facts</h2>
<ul>
<li>Catherine Hamlin was twice nominated for the Nobel Peace Prize and continued performing fistula surgery in Addis Ababa until shortly before her death at the age of ninety-six.</li>
<li>The Addis Ababa Fistula Hospital, opened in 1974, was the first hospital anywhere in the world devoted entirely to a single childbirth injury.</li>
<li>Many fistula repairs take only one to two hours, yet the women treated have often lived with the injury, and its isolation, for ten years or more before reaching surgery.</li>
<li>The Hamlins learnt to perform the operation from scratch by consulting textbooks and corresponding with other surgeons, having never been trained in it.</li>
<li>The UN resolution creating the day, number 67/147, was adopted on 20 December 2012, making this one of the youngest health observances on the international calendar.</li>
</ul>
<h2 id="a-closing-reflection">A closing reflection</h2>
<p>There is a particular kind of injustice in a condition that is both preventable and curable yet still ruins lives, because it means the suffering is not a fact of nature but a consequence of decisions about where to build a hospital and how to train a midwife. The women who develop fistula did nothing to invite it; they were simply in the wrong place when their labour went wrong. What the day asks, beneath the conferences and the themes, is whether the gap between a one-hour operation and the women who cannot reach it is one the world is genuinely willing to close, or one it has quietly learnt to live with.</p>
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