Anita began experiencing urine leakage after a difficult childbirth in June this year. The condition left the 27-year-old mother unable to walk properly. Anita (not her real name) is resident of Nyagatare District. After going into labour, she spent days at a local health centre before she was referred to Nyagatare District Hospital. Doctors later informed her that her baby had died. Attempts to induce labour failed, and they performed a procedure to remove the baby. She later underwent another operation after her legs swelled but began leaking fluid resembling urine two days afterwards. Further examinations revealed that her bladder had been damaged. “I had no control over it. I would simply find myself wet,” said Anita. ALSO READ: From fistula to recovery: One woman’s journey after a C-section An earlier attempt to repair the injury had failed, and the leakage returned after four days. She was later treated by a team from the International Organization for Women and Development (IOWD) during its medical mission at Kibagabaga Hospital in Kigali. After the operation, the leakage stopped, and she regained the ability to walk. “The entire process was covered by Mutuelle de Santé,” she said. What is fistula? Obstetric fistula is an abnormal opening between the birth canal and the bladder or rectum that causes leakage of urine or stool. It often develops after prolonged, obstructed labour, although injuries during childbirth surgery can also cause it. While many cases can be repaired, severe tissue damage may leave some women with lifelong complications. ALSO READ: Fistula repair: Giving women back their dignity, one stitch at a time Since beginning its work in Rwanda in 2010, the IOWD has conducted 4,965 patient examinations and 1,700 surgeries at the hospital. Danielle Locke, its director of nursing, said surgery treats the injury but does not address all the factors that cause it. “We can do the repair, we can put the band-aid on the problem and do the surgeries to fix the women, [but] we are only doing just that, putting the band-aid on the problem,” Locke told The New Times on Saturday, October 17, when and her team visited women recovering from fistula surgery at Kibagabaga Hospital. How fistula develops Obstetric fistula commonly develops when labour is obstructed for an extended period. The baby's head compresses tissues in the mother's pelvis, cutting off their blood supply. The tissues eventually die, leaving an opening between the birth canal and the bladder or rectum. “When that labour is obstructed, essentially what it does is it causes the tissues in the lower part of her pelvis, when it's compressed against the baby's head, the tissue dies,” Locke explained. The resulting opening causes urine or stool to leak without the woman's control. Fistula can also result from injuries during a Caesarean section, making safe surgical techniques essential for prevention. ALSO READ: Life-changing fistula surgery is rewarding - surgeon Persistent leakage may cause skin irritation and make walking difficult. The associated smell can expose women to stigma and rejection, while some lose their jobs, struggle to attend school or become financially dependent on relatives. The consequences can affect entire families, particularly when a woman was previously responsible for supporting them. “If she's a primary breadwinner for a family, if she's a farmer or she has a job and subsequently can't work, there's impact against the family,” Locke said. ALSO READ: Local medics, IOWD on why they embraced fistula fight According to the World Health Organization (WHO), obstetric fistula is largely preventable through timely access to quality obstetric care, delaying the age of first pregnancy and addressing harmful practices. WHO's 2018 estimates put the number of new cases worldwide at between 50,000 and 100,000 annually, while more than two million women and girls were estimated to be living with untreated fistula in Asia and sub-Saharan Africa. However, a study published in BMJ Global Health in 2025 estimated that about 458,000 women aged 15 to 64 were living with obstetric fistula globally, including approximately 226,000 in sub-Saharan Africa. The researchers noted that estimates remain uncertain because of limited data and differences in how cases are identified. ALSO READ: Fistula: Fixing the fate worse than death Prevention starts before pregnancy Preventing fistula requires action before pregnancy, during antenatal care and throughout labour and delivery, the expert said. This includes educating girls and women about reproductive health, preventing early marriage and teenage pregnancy, promoting good nutrition and ensuring access to antenatal services. “Prevention in the first place starts with awareness,” Locke said. She explained that teenage pregnancy can increase vulnerability, particularly when young mothers delay antenatal visits, seek help late during labour or face financial barriers to healthcare. Empowering girls and women to make informed decisions about their health is therefore important, she said. Good nutrition supports the mother's health and the baby's development. Antenatal visits allow health workers to monitor pregnancy, identify potential risks and advise women on preparing for delivery. Although these measures cannot prevent every complication, they can help ensure that women receive appropriate care when concerns arise. ALSO READ: Sorrows and smiles for women with fistula Women also need to understand the normal progression of labour and when to seek help. Healthcare professionals, in turn, must recognise signs of complications and know when intervention is necessary. “It's about educating existing healthcare professionals to make sure that they understand what is normal during the birth process and what is abnormal during the birth process,” Locke said. Antenatal care should be accompanied by a delivery plan involving skilled health workers who can monitor the mother and baby and respond to emergencies. Labour monitoring should follow established WHO guidance, including the Labour Care Guide, which helps assess labour progress and the well-being of both mother and child. When labour becomes obstructed, a woman may need urgent referral to a hospital capable of providing emergency obstetric care, including a c-section where indicated. Health workers at rural facilities must recognise when a complication exceeds their capacity and arrange timely transfer. Delays can allow serious damage to occur before a woman reaches a hospital. Distance, transport difficulties and gaps in referral systems may all prevent women from receiving care in time. Safe delivery also depends on properly trained doctors and surgeons using techniques that reduce the risk of injury to the bladder and surrounding tissues. Preventing fistula therefore requires skilled health workers, accessible emergency services and functioning referral systems, rather than focusing only on individual medical decisions. IOWD supports this work in Rwanda through a programme that combines fistula surgery with training and education for local healthcare professionals. Locke said the organisation works alongside Rwandan institutions, including Kibagabaga Hospital and the University of Rwanda. The team also supports safe c-section practices by helping educate healthcare professionals on techniques that can reduce the risk of childbirth injuries. Recognising the signs Persistent leakage of urine or stool after childbirth is a key sign of possible fistula and should prompt medical assessment. “The primary sign is leaking, the constant leaking where the woman has no control over it,” Locke said, urging women experiencing these symptoms to seek care rather than suffer in silence. Women should also seek medical attention if they notice a bulge or mass in their genital area, she said. “If they are leaking urine or if they are seeing a bulge or a mass in the private areas, it’s okay to look for help,” Locke said. Immaculée Kantengwa, a midwife at Kibagabaga Hospital, said some women delay seeking treatment because they believe their condition cannot be treated or is caused by witchcraft. By the time they reach hospital, the damage may have progressed and become harder to treat. “There is no reason to feel ashamed or fear being mocked for seeking treatment; women should definitely go to hospital when they notice a problem,” Kantengwa said. When surgery cannot help Although most fistula patients can be treated, some women have extensive tissue damage that makes surgery impossible. Previous unsuccessful repairs can also complicate treatment. “Majority can be fixed, but some cannot. It's just the severity of the trauma. Sometimes, there's not much tissue left to repair with,” the surgeon explained. For women whose injuries cannot be repaired, care focuses on helping them manage the condition and its effects on their daily lives. “For such kind of patients, we have supplies that we can use, waterproof panties, for example. We are able to give the women what are like face cloths or fabric liners and waterproof panties,” Locke said. She explained that the washable supplies help women manage leakage and reduce odour. The supplies do not cure the condition, but help women preserve their dignity when surgery is not an option. The effects can extend beyond the physical injury. Women may be abandoned by their husbands, rejected by relatives or excluded from their communities, where fistula is sometimes wrongly attributed to witchcraft. She added that the consequences can last a lifetime when women cannot access treatment or affordable supplies to manage the condition. Locke said families and communities have an important role in supporting women who need treatment, including those whose injuries cannot be reversed. Raising awareness that fistula is a medical condition, encouraging women to seek care and providing practical support can help reduce the isolation they experience, she said.
