In less-developed countries,<unk> e usually develop as a result of prolonged labor when a cesarean section cannot be obtained. Over the course of the three to five days of labor, the unborn child presses against the mother's vagina very tightly, cutting off blood flow to the surrounding tissues between the vagina and the rectum and between the vagina and the bladder, causing the tissues to disintegrate and rot away.<unk> e can also be caused by poorly performed abortions, and pelvic fracture, cancer, or radiation therapy targeted at the pelvic area, inflammatory bowel disease (such as Crohn's disease and ulcerative colitis). Other potential causes for the development of<unk> e are sexual abuse and rape, especially in conflict/postconflict areas, and other trauma, such as surgical trauma. In the developed world, such as the US, the primary cause of<unk> e, particularly rectovaginal fistulae, is the use of episiotomy and forceps. Primary risk factors include early or closely spaced pregnancies and lack of access to emergency<unk>  care. For example, a 1983 study in Nigeria found that 54.8% of the people affected were under 20 years of age, and 64.4% gave birth at home or in poorly equipped local clinics. When available at all, cesarean sections and other medical interventions are usually not performed until after tissue damage has already been done. Social, political, and economic causes that indirectly lead to the development of<unk> e concern issues of poverty, malnutrition, lack of education, early marriage and childbirth, the role and status of women in developing countries, harmful traditional practices, sexual violence, and lack of good quality or accessible maternal and health care. Poverty Poverty is the main indirect cause of<unk> e around the world. As obstructed labor and<unk> e account for 8% of maternal deaths worldwide and "a 60-fold difference in gross national product per person shows up as a 120-fold difference in maternal mortality ratio," impoverished countries produce higher maternal mortality rates and thus higher<unk>  rates. Furthermore, impoverished countries not only have low incomes, but also lack adequate infrastructure, trained and educated professionals, resources, and a centralized government that exist in developed nations to effectively eradicate<unk> e. According to UNFPA, "Generally accepted estimates suggest that 2.0-3.5 million women live with<unk> e in the developing world, and between 50,000 and 100,000 new cases develop each year. All but eliminated from the developed world,<unk>  continues to affect the poorest of the poor: women and girls living in some of the most resource-starved remote regions in the world." Malnutrition One reason that poverty produces such high rates of fistula cases is the malnutrition that exists in such areas. Lack of money and access to proper nutrition, as well as vulnerability to diseases that exist in impoverished areas because of limited basic health care and disease prevention methods, cause inhabitants of these regions to experience stunted growth. Sub-Saharan Africa is one such environment where the shortest women have on average lighter babies and more difficulties during birth when compared with full-grown women. This stunted growth causes expectant mothers to have skeletons unequipped for proper birth, such as an underdeveloped pelvis. This weak and underdeveloped bone structure increases the chances that the baby will get stuck in the pelvis during birth, cutting off circulation and leading to tissue necrosis. Because of the correlation between malnutrition, stunted growth, and birthing difficulties, maternal height can at times be used as a measure for expected labor difficulties. Lack of education High levels of poverty also lead to low levels of education among impoverished women concerning maternal health. This lack of information in combination with obstacles preventing rural women to easily travel to and from hospitals lead many to arrive at the birthing process without prenatal care. This can cause a development of unplanned complications that may arise during home births, in which traditional techniques are used. These techniques often fail in the event of unplanned emergencies, leading women to go to hospital for care too late, desperately ill, and therefore vulnerable to the risks of anesthesia and surgery that must be used on them. In a study of women who had prenatal care and those who had unbooked emergency births, "the death rate in the booked-healthy group was as good as that in many developed countries, but the death rate in the unbooked emergencies was the same as the death rate in England in the 16th and 17th centuries." In this study, 62 unbooked emergency women were diagnosed with<unk> e out of 7,707 studied, in comparison to three diagnosed booked mothers out of 15,020 studied. In addition, studies find that education is associated with lower desired family size, greater use of contraceptives, and increased use of professional medical services. Educated families are also more likely to be able to afford health care, especially maternal healthcare. Early childbirth In sub-Saharan Africa, many girls enter into arranged marriages soon after menarche (usually between the ages of 9 and 15). Social factors and economic factors contribute to this practice of early marriages. Socially, some grooms want to ensure their brides are virgins when they get married, so an earlier marriage is desirable. Economically, the bride price received and having one less person to 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<unk> e. 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 suffer from shortages of staff, supplies, and other forms of medical technology that would be necessary to perform reconstructive<unk>  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<unk>  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<unk>  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<unk> e 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.
Obstetric fistula
Lymphocele
Vaginal stenosis
Vesicouterine fistula
Urethrovaginal fistula
Cystocele
Uterine prolapse
Urogenital fistula