A framework for analyzing the determinants of obstetric fistula formation.

Obstetric fistula, a devastating complication of prolonged obstructed labor, was once common in the Western world but now occurs almost exclusively in resource-poor countries. Although much has been written about the surgical repair of obstetric fistulas, prevention of fistulas has garnered comparatively little attention. Because obstetric fistulas result from obstructed labor (one of the common causes of maternal death in impoverished countries), this study assesses the obstetric fistula problem using a framework originally developed to analyze the determinants of maternal mortality. The framework identifies and explicates three sets of determinants of obstetric fistulas: the general socioeconomic milieu in which such injuries occur (the status of women, their families, and their communities); intermediate factors (health, reproductive status, and use of health care resources); and the acute clinical factors that determine the ultimate outcome of any particular case of obstructed labor. Interventions most likely to work rapidly in fistula prevention are those that have a direct impact on acute clinical situations, but these interventions will only be effective when general socioeconomic and cultural conditions promote an enabling environment for health care delivery and use. Sustained efforts that impact all three levels of determining factors will be necessary to eradicate obstetric fistula.