It was during my third year of urology residency when, at my husband’s holiday work party, I was first asked about obstetric fistula management by one of his colleagues. Because of his work at the nonprofit organization Save the Children, I was less surprised about the nature of the question, and more shocked at my inability to fully engage in a response. I did not have a clear understanding of the impact of obstetric fistulas worldwide, nor did I know about the social and cultural implications of this devastating condition. I returned home to learn more about the condition in the urologic literature, to review concepts of surgical fistula repair, and to understand the societal significance of this ailment.

Obstetric fistulas have devastating impacts for women in the developing world. On an individual level, women often become ostracized from their families and communities. Witnessing the reality of what this can look like for a young woman is heartbreaking. Many of the patients we treat are starting a family, entering a time in their lives of hope and new beginnings. When this experience results in obstetrical fistula, women can find themselves in situations of complete despair: having experienced pregnancy loss, finding they may never be able to have children, and with little social support to navigate this tragedy.

On a societal level, obstetric fistulas rob communities of productive members who can contribute as mothers, workers, and community leaders. Unfortunately, in the developing world, due to a combination of early motherhood, prevalence of non–center-based births, and inadequately-resourced medical facilities, fistulas are more common. Due to hyperspecialization of the surgical repair, treatment is often unavailable or prohibitively expensive. Addressing this need can have transformational impacts on the lives of women, their families, and their communities (Figures 1 and 2).

Figure 1. Clinic setup with patients waiting to be seen.

Figure 2. Dr Richter outside exam room.

Figure 3. International Organization for Women and Development volunteers run a suture clinic for Rwandan Medical Students.

Figure 4. Dr Richter and colleagues in operating room.

Figure 5. Lee Ann Richter, MD, associate fellowship director, Section of Female Pelvic Medicine and Reconstructive Surgery, associate professor of urology and obstetrics and gynecology, Georgetown University School of Medicine.

I first had the opportunity to work in Rwanda on a fistula mission with the International Organization for Women and Development (IOWD) as a fellow in Female Pelvic Medicine and Reconstructive Surgery. The IOWD is a nonprofit organization dedicated to providing underserved women of Rwanda free specialized surgical services that are otherwise not readily available or affordable. The IOWD fistula mission is dedicated to surgical correction of fistulas, and multidisciplinary fellowship-trained, board-certified surgeons commit time and travel at their own expense so that Rwandan women may have access to this specialized care. Because the organization is deeply committed to advancing the global health agenda, IOWD surgeons work closely with governmental and nongovernmental partners to ensure programs are integrated within local health systems so that contributions are sustainable.

Until surgical capacity is developed in Kigali, international nongovernmental organizations such as the IOWD play an important role in meeting local needs. The IOWD runs 3 fistula mission trips annually, always returning to the Kibagabaga hospital in Kigali. With this reliable schedule, the IOWD assures that patients have the opportunity to return for postoperative follow-up on a yearly basis. By working at the same hospital for every mission, IOWD surgeons play an active role in teaching local Rwandan medical students and residents about proper examination and treatment of fistula. Throughout the mission, IOWD surgeons give lectures and do hands-on simulation surgical training for medical students and residents at the hospital (Figure 3).

Since 2015, I have traveled to Rwanda to repair fistula for women who suffer from this debilitating condition. My work in the field involves yearly travel to Kigali for a 2-week medical mission evaluating and operating to repair fistula. My role has developed from participating surgeon to that of leadership of the missions and within the IOWD. Since 2017, I have served as a mission team leader, responsible for overseeing all clinical and surgical activities. I also serve as member of the IOWD Medical Board, advising the organization on how to improve and expand access to fistula care.

To describe the magnitude of impact, our team typically examines approximately 150 women each mission and performs up to 40 surgical cases (Figure 4). Through partnership with the Rwandan government, Rwandan ob-gyn residents and attendings are permitted to take leave from their clinical responsibilities to operate and examine patients with the IOWD teams throughout the mission. These partnerships in the field have resulted in further professional development for local Rwandan physicians, ultimately with the hope that in the future there will be local capacity to meet needs.

An important benefit to the consistency of the IOWD presence within the Kigali community is that we have been able to observe developments in the types of fistulas that present to us over time. Concerns that we may be seeing increasing numbers of iatrogenic fistula occurring from C-section (rather than from obstructed labor) led to an important research project. In 2021, our paper titled “Characteristics of Genitourinary Fistula in Kigali, Rwanda; 5-Year Trends,” was published in Urology.¹ It demonstrated that from 2013 to 2017, there was a significant increase in the proportion of fistula involving the ureters, uterus, and cervix, and that the majority of these fistulas occurred after C-section. With this information, the IOWD has been working to identify the regional health centers where C-sections resulting in fistula occur so that additional resources can be provided directly to these areas in the form of surgical instruction and coaching from IOWD ob-gyn volunteer physicians. With research identifying trends in the causes of fistula in the communities we serve, we have been working to elevate awareness and employ strategies to prevent fistula.

At the MedStar/Georgetown Female Pelvic Medicine and Reconstructive Surgery Fellowship program, we have been committed to including international fistula work in the training for our fellows for over 10 years through thoughtful planning and fundraising. It is also a requirement that our fellows perform an education project with hospital residents to build local capacity and sustainability. Prior projects have involved hands-on labs, interactive lectures, and surgical workshops for Rwandan physicians and students. This service-based experience for physicians in fellowship can be career changing, as I have seen with our fellows and experienced firsthand in my own training (Figure 5). With exposure to fistula comes an understanding of the prevalence of this condition and its impact on communities and individuals. It additionally expands the ability of an early career specialist to assess and care for complex fistula at home. I am so grateful for the Urology Care Foundation Humanitarian Grant for helping us deliver fistula care and grow local surgical capacity and also for inspiring the next generation of surgeons to continue this important work, both internationally and in their own communities.