feed in the family helps alleviate the financial burdens of the bride's family. early marriages lead to early childbirth, which increases the risk of obstructed labor, since young mothers who are poor and malnourished may have underdeveloped pelvises. in fact, obstructed labor is responsible for 76 to 97% of obstetric fistulae. lack of healthcare even women who do make it to the hospital may not get proper treatment. countries that suffer from poverty, civil and political unrest or conflict, and other dangerous public health issues such as malaria, hiv/aids, and tuberculosis often suffer from a severe burden and breakdown within the healthcare system. this breakdown puts many people at risk, specifically women. many hospitals within these conditions have shortages of staff, supplies, and other forms of medical technology that would be necessary to perform reconstructive obstetric fistula repair. there is a shortage of doctors in rural africa, and studies find that the doctors and nurses who do exist in rural africa often do not show up for work. poverty hinders women from being able to access normal and emergency obstetric care because of long distances and expensive procedures. for some women, the closest maternal care facility can be more than 50 km away. in kenya, a study by the ministry of health found that the "rugged landscape, long distances to health facilities, and societal preferences for delivery with a traditional birth attendant contributed to delays in accessing necessary obstetric care." emergency cesarean sections, which can help avoid fistulae caused by prolonged vaginal deliveries, are very expensive. status of women in developing countries, women who are affected by obstetric fistulae do not necessarily have full agency over their bodies or their households. rather, their husbands and other family members have control in determining the healthcare that the women receive. for example, a woman's family may refuse medical examinations for the patient by male doctors, but female doctors may be unavailable, thus barring women from prenatal care. furthermore, many societies believe that women are supposed to suffer in childbirth, thus are less inclined to support maternal health efforts. prevention prevention is the key to ending fistulae. unfpa states that, "ensuring skilled birth attendance at all births and providing emergency obstetric care for all women who develop complications during delivery would make fistula as rare in developing countries as it is in the industrialized world." in addition, access to health services and education – including family planning, gender equality, higher living standards, child marriage, and human rights – must be addressed to reduce the marginalization of women and girls. reducing marginalization in these areas could reduce maternal disability and death by at least 20%. prevention comes in the form of access to obstetrical care, support from trained health care professionals throughout pregnancy, providing access to family planning, promoting the practice of spacing between births, supporting women in education, and postponing early marriage. fistula prevention also involves many strategies to educate local communities about the cultural, social, and physiological factors of that condition and contribute to the risk for fistulae. one of these strategies involves organizing community-level awareness campaigns to educate women about prevention methods such as proper hygiene and care during pregnancy and labor. prevention of prolonged obstructed labor and fistulae should preferably begin as early as possible in each woman's life. for example, improved nutrition and outreach programs to raise awareness about the nutritional needs of children to prevent malnutrition, as well as improve the physical maturity of young mothers, are important fistula prevention strategies. it is also important to ensure access to timely and safe delivery during childbirth: measures include availability and provision of emergency obstetric care, as well as quick and safe cesarean sections for women in obstructed labor. some organizations train local nurses and midwives to perform emergency cesarean sections to avoid vaginal delivery for young mothers who have underdeveloped pelvises. midwives located in the local communities where obstetric fistulae are prevalent can contribute to promoting health practices that help prevent future development of obstetric fistulae. ngos also work with local governments, like the government of niger, to offer free cesarean sections, further preventing the onset of obstetric fistulae. promoting education for girls is also a key factor to preventing fistulae in the long term. former fistula patients often act as "community fistula advocates" or "ambassadors of hope", a unfpa-sponsored initiative, to educate the community. these survivors help current patients, educate pregnant mothers, and dispel cultural myths that obstetric fistulae are caused by adultery or evil spirits. successful ambassador programs are in place in kenya, bangladesh, nigeria, ghana, côte d'ivoire, and liberia. several organizations have developed effective fistula prevention strategies. one, the tanzanian midwives association, works to prevent fistulae by improving clinical healthcare for women, encouraging the delay of early marriages and childbearing years, and helping the local communities to advocate for women's rights. treatment patients at the addis ababa fistula hospital in ethiopia are all treated free of charge. surgery the nature of the injury varies depending on the size and location of the fistula, so a surgeon with experience is needed to improvise on the spot. before the person undergoes surgery, treatment and evaluation are needed for conditions including anemia, malnutrition, and malaria. quality treatment in low-resource settings are possible (as in the cases of nigeria and ethiopia). treatment is available through reconstructive surgery. primary fistula repair has a 91% success rate. the corrective surgery costs about us$100–400, and the cost for the entire procedure, which includes the actual surgery, postoperative care, and rehabilitation support, is estimated to cost $300–450. initial surgeries done by inadequately trained doctors and midwives increase the number of follow-up surgeries that must be performed to restore full continence. successful surgery enables women to live normal lives and have more children, but it is recommended to have a cesarean section to prevent the fistula from recurring. postoperative care is vital to prevent infection. some women are not candidates for this surgery due to other health problems. in those cases, fecal diversion can help the patient, but not necessarily cure them. besides physical treatment, mental health services are also needed to rehabilitate fistula patients, who experience psychological trauma from being ostracized by the community and from fear of developing fistulae again. a study on the first formal counseling program for fistula survivors in eritrea shows positive results, whereby counseling significantly improved the women's self-esteem, knowledge about fistulae and fistula prevention, and behavioral intentions for "health maintenance and social reintegration" following surgery. challenges challenges with regards to treatment include the very high number of women needing reconstructive surgery, access to facilities and trained surgeons, and the cost of treatment. for many women, us$300 is a price they cannot afford. access and availability of treatment also vary widely across different sub-saharan countries. certain regions also do not have enough maternal care clinics that are equipped, willing to treat fistula patients, and adequately staffed. at the evangelical hospital of bemberéke in benin, only one expatriate volunteer obstetrics and gynecology doctor is available a few months per year, with one certified nurse and seven informal hospital workers. in all of niger, two medical centers treat fistula patients. in nigeria, more dedicated health professionals operate on up to 1,600 women with a fistula per year. the world is currently severely under capacity for treating the problem; it would take up to 400 years to treat the backlog of patients. to prevent any new cases of obstetric fistulae, about 75,000 new emergency obstetric care facilities would have to be built in africa alone, plus an increase in financial support and an even higher number of certified doctors, midwives, and nurses needed. another challenge standing between women and fistula treatment is information. most women have no idea that treatment is available. because this is a condition of shame and embarrassment, most women hide themselves and their condition and suffer in silence. in addition, after receiving initial treatment, health education is important to prevent fistulae in subsequent pregnancies. another challenge is the lack of trained professionals to provide surgery for fistula patients. as a result, nonphysicians are sometimes trained to provide obstetric services. for example, the addis ababa fistula hospital has medical staff without formal degrees, and one of its top surgeons was illiterate, but she had been trained over years and now regularly successfully performs fistula surgery. catheterization fistula cases can also be treated through urethral catheterization if identified early enough. the foley catheter is recommended because it has a balloon to hold it in place. the indwelling foley catheter drains urine from the bladder. this decompresses the bladder wall so that the wounded edges come together and stay together, giving it a greater chance of closing naturally, at least in the smaller fistulae. about 37% of obstetric fistulae that are treated within 75 days after birth with a foley catheter resolve. even without preselecting the least complicated obstetric fistula cases, a foley catheter by midwives after the onset of urinary incontinence could treat over 25% of all new fistulae. epidemiology obstetric fistulae are common in the developing world, especially in sub-saharan africa (kenya, mali, niger, nigeria, rwanda, sierra leone, south africa, benin, chad, malawi, mali, mozambique, niger, nigeria, uganda, and zambia) and much of south asia (afghanistan, bangladesh, india, pakistan, and nepal). according to the world health organization (who), an estimated 50,000 to 100,000 women develop obstetric fistulae each year and over two million women currently live with an obstetric fistula. in particular, most of the two million-plus women in developing nations who develop obstetric fistulae are under the age of 30. between 50 and 80% of women under the age of 20 in poor countries develop obstetric fistulae (the youngest patients are 12–13 years old). other estimates indicate about 73,000 new cases occur per year. obstetric fistulae were very common throughout the world, but since the late 19th century, the rise of gynecology developed safe practices for childbirth, including giving birth at local hospitals rather than at home, which dramatically reduced rates of obstructed labor and obstetric fistulae in europe and north america. adequate population-based epidemiological data on obstetric fistulae are lacking due to the historic neglect of this condition since it was mostly eradicated in developed nations. available data are estimations that should be viewed with caution. about 30% of women over age 45 in developed nations are affected by urinary incontinence. the rate of obstetrical fistulae is much lower in places that discourage early marriage, encourage and provide general education for women, and grant women access to family planning and skilled medical teams to assist during childbirth. history evidence of obstetric fistula dates back to 2050 bce, when queen henhenit had a fistula. the first acknowledgments of obstetric fistula date back to various egyptian documents known as the papyri. these documents, including rare medical engravings, were found of the entrance of a tomb located in the necropolis of saqquarah, egypt. the tomb belonged to an unknown physician who lived during the 6th dynasty. the translation of this document became possible with the discovery of the rosetta stone in 1799. in 1872, the ebers papyrus was discovered in a mummy from the theban acropolis. this papyrus, 65 feet long, 14 inches wide, consisting of 108 columns each about 20 lines, now resides in the library at the university of leipzig. the gynecological reference in this papyrus addresses uterine prolapse, but at the end of page three, there seems to be a mention of the vesicovaginal fistula, warning the physician against trying to cure it, saying, "prescription for a woman whose urine is in an irksome place: if the urine keeps coming and she distinguishes it, she will be like this forever." this seems to be the oldest reference to vesicovaginal fistula, one which articulates the storied history of the problem. james marion sims, in 1852 in alabama, developed an operation for fistula. he worked at the new york women's hospital. society and culture during most of the 20th century, obstetric fistulae were largely missing from the international global health agenda. this is reflected by the fact that the condition was not included as a topic at the landmark united nations 1994 international conference on population and development (icpd). the 194-page report from the icpd does not include any reference to obstetric fistulae. in 2000, eight millennium