By Dr Ritah Waddimba Nakigudde
Five years ago, 37-year-old Lodious Agaba walked into a health facility in Mubende expecting the universal joy of childbirth: a safe delivery and a healthy baby. She returned home with her baby, but also with a devastating, unforeseen complication which happened - a continuous, uncontrollable leakage of urine.
Agaba sought care at Mubende Hospital, but medications failed to heal her. As the weeks turned into years, the physical discomfort of constantly needing pads deepened into a profound psychological trauma. She quietly withdrew from the fabric of community life, missing family events, avoiding gatherings, and abandoning her church activities.
“I cried until my tears dried,” she recalls.
Gradually, she learned to live in the shadows, enduring a condition that stripped away her dignity, her confidence, and her social life. Her husband, Jovan, describes those five years as a grueling ordeal for their entire family, marked by relentless emotional stress and social isolation.
Agaba’s story is heartbreaking, but it is not unique. It is the face of obstetric fistula in Uganda.
The Shifting Blueprint of a Preventable Crisis
Obstetric fistula, an abnormal opening between a woman’s birth canal and her bladder or rectum is one of the most severe, tragic childbirth injuries.
The World Health Organization (WHO) is clear: it is almost entirely preventable through timely access to high-quality emergency obstetric care. According to the Ministry of Health, Uganda continues to record an estimated 1,900 to 2,000 new cases annually, adding to the thousands of women already living untreated in communities across the country.
Historically, fistula has been viewed as a tragedy born of geography and infrastructure, the result of prolonged, obstructed labor in remote villages far from a hospital.
However, emerging data reveals a stark, deeply troubling shift in the blueprint of this crisis. The call is no longer just about getting women to a hospital; it is also about what happens to them once they are in the hospital.
A groundbreaking 2026 study published in the International Journal of Women’s Health by researchers from Mbarara University of Science and Technology (MUST) reveals that 56% of fistula cases treated at a tertiary referral hospital in southwestern Uganda resulted from surgical injury during obstetric procedures, specifically, caesarean sections.
This is what clinicians call iatrogenic fistula—injury inadvertently caused by medical intervention. The MUST study documented a staggering escalation in surgery-related fistula over the last fifteen years, skyrocketing from just 9.6% of reported cases in 2009 to nearly 49% in 2025.
This trend demands urgent, clear-eyed reflection from everyone in leadership. It tells us that our health system’s readiness, response, and quality of care may be fracturing at the exact moment women trust us the most.
Inconsistency: The Silent Enemy of Safe Motherhood
Emergency Obstetric and Newborn Care (EmONC) is the foundational cornerstone of safe motherhood. It relies on a health worker's ability to rapidly recognize and decisively manage life-threatening complications. However, the effectiveness of EmONC depends entirely on the consistency with which it is taught and practiced.
Currently, obstetric training in Uganda is uneven. While some health workers receive robust, hands-on practical preparation, many others are deployed with limited exposure, low surgical volume, or inadequate clinical mentorship. Consequently, the response to the exact same clinical emergency varies wildly from one provider to another, or from one facility to the next.
These inconsistencies carry fatal and debilitating consequences. Delays in identifying a misaligned fetus, poor management of difficult labor, and hesitant or poorly executed surgical decisions directly translate into preventable structural injuries.
From a health systems perspective, obstetric fistula is the ultimate diagnostic indicator of a breakdown in quality. The WHO Quality of Care Framework reminds us that positive maternal outcomes require a triad: skilled health workers, functional health systems, and respectful care. When any one of these pillars' wobbles, a mother pays the price.
The Clear Evidence That Change Is Possible
The human cost of these systemic gaps is staggering, but Agaba’s eventual recovery after receiving specialized surgical repair proves that restoration is possible. Still, treatment alone cannot be our primary strategy. Every case of obstetric fistula represents a catastrophic missed opportunity, a blank space in training, preparedness, or response that should have been bridged.
We must shift our resources and resolve decisively toward prevention. To do this, we need to standardize the competencies of those on the front lines.
Fortunately, we do not have to guess if this works; we have local, empirical evidence that it does. The same 2026 Ugandan study highlighted a powerful solution: following the implementation of Essential Training in Operative Obstetrics (ETOO), a highly practical, skills-based surgical curriculum, intervention facilities recorded a 51% reduction in iatrogenic fistula cases over a five-year period, with cases dropping from 39 in 2020 down to 19 in 2024.
Standardized, competency-based training delivers measurable, lifesaving outcomes. It systematically eradicates surgical error, builds clinical confidence, and protects women from preventable harm.
A Call to Action for Decision-Makers
As we commemorate the International Day to End Obstetric Fistula, the Ministry of Health and committed partners, such as Pathfinder International through the UK-funded EMPOWER programme, are already demonstrating what is achievable through targeted, intentional investments in healthcare provider capacity. But these bright spots cannot remain isolated interventions. They must become the national standard.
To our policymakers, health planners, and development partners, the mandate is clear:
- Institutionalise Standardised Training: We must transition away from fragmented, ad-hoc workshops. Standardised, practical emergency obstetric and operative training must be institutionalised across all levels of maternal health service delivery, from Health Centre IVs to regional referral hubs.
- Strengthen Clinical Governance: We must enforce continuous, on-site mentorship and rigid quality assurance mechanisms to ensure every single provider is certified and competent to manage obstetric emergencies safely.
- Scale Up Investment:We must scale and sustain funding for provider preparedness so that no woman ever leaves a Ugandan health facility with a life-altering injury caused by a gap in clinical skills.
Ending obstetric fistula in Uganda is entirely within our reach. It requires us to ensure that every birth is attended by a healthcare worker equipped with standardized, high-quality emergency obstetric skills.
Ugandan women do not just need accessible health systems; they deserve a system that safeguards their dignity and consistently delivers quality, life-saving care at every single point of service.
Let us all work together to build a healthcare system where giving life no longer means losing one's dignity.
Dr Ritah Waddimba is a public health specialist and development leader expert in health systems strengthening in Uganda. She is the Country Director of Pathfinder International in Uganda