Radhika was 11 years old when her labour began.
She had become pregnant a month after her first menstrual period. When her labour grew difficult, her family kept her home for 24 hours, as tradition in her community required. When the local health post could not help her, a family member took her to a hotel. There, after many days, she delivered a stillborn baby. And she came home with a hole in her body that would take over a decade and seven operations to try to repair.
That hotel room was not a failure of nature. It was a failure of every system that should have protected an 11-year-old girl.
Obstetric fistula is what happens when prolonged, obstructed labour tears a hole between the birth canal and the bladder or rectum. It causes continuous incontinence. It causes infection and nerve damage. In Radhika's case, it left her unable to use her legs for months. It also causes the kind of shame that makes women disappear from their own lives. After her labour, Radhika was not allowed to sleep inside her family home. Others shunned her because of the odour from the continual leakage. Her partner abused her. Her parents disowned her. She had never heard of fistula before it happened to her.
"My life became very, very difficult," she says.
This is not a rare story. It is a common one, told with different names and different villages but the same pattern: a girl married young, a pregnancy too soon, a labour too long, a system too absent.
Globally, an estimated 500,000 women are living with obstetric fistula today, down from 2 million two decades ago. That decline reflects what becomes possible when skilled midwives, emergency obstetric care, and political commitment reach the women who need them most. Yet Asia and the Pacific still account for an estimated 219,056 of those remaining cases, and Nepal carries its share of that burden.
In Nepal, an estimated 4,300 women are living with untreated fistula, with between 200 and 400 new cases added every year. They are concentrated in the places hardest to reach: in Karnali and Sudurpaschim, where roads close in winter and a woman in obstructed labour can be hours from the nearest facility capable of performing a Caesarean section; in the Madhesh plains, where girls marry young, give birth young, and bear the physical cost of both. Behind every one of those numbers is a woman whose story looks a great deal like Radhika's.
This year's International Day to End Obstetric Fistula carries a theme that deserves to be written into every health budget in this country: "Her health is a right: Invest in ending fistula and childbirth injuries." That framing does real work. We talk about maternal mortality constantly, and rightly. But for every woman who dies in childbirth, an estimated 20 to 30 more survive with a severe injury. Survival without dignity was never the goal.
UNFPA, the United Nations sexual and reproductive health agency, has supported over 153,000 fistula repair surgeries worldwide since 2003. In Nepal, the work runs from policy to the operating table. UNFPA supported the Ministry of Health and Food Safety to develop Nepal's Fistula Elimination Roadmap 2024-2030, with a clear goal: an obstetric fistula-free Nepal by 2030.
In 2024, as part of that roadmap's implementation, UNFPA supported a door-to-door fistula campaign in Jajarkot, a district still recovering from the 2023 earthquake. More than 200 Female Community Health Volunteers were oriented and conducted household visits, reaching over 20,000 households and screening more than 40,000 women aged 15 and above. That is what committed outreach looks like in practice.
The clinical infrastructure is expanding too. In 2025, UNFPA provided financial assistance for 35 fistula repair surgeries across three hospitals and supported the expansion of fistula repair surgery at two federal hospitals. Three Nepali surgeons were trained in advanced fistula treatment at the newly established centre of excellence at the Koohi Goth Hospital in Karachi, Pakistan, and are now back in Nepal and performing surgeries. The surgical repairs provided to women like Radhika at UNFPA-supported facilities, including the B.P. Koirala Institute of Health Sciences, are provided free of charge, with transport costs covered.
But surgery alone does not close every wound.
Even when a fistula is physically repaired, some women continue to experience incontinence because of the complexity of how the bladder functions after years of injury. Radhika has had seven operations and is about to have an eighth. She still has difficulty walking. She still experiences some incontinence. A month after each surgery she goes back to her house-to-house cleaning job because she cannot afford not to. She has a supportive partner now. Life is better. But when asked what would have helped her most, she does not ask for more surgery. She says: "I would have liked social help and training."
That is the gap this system has not yet filled. Women who survive fistula, even women who are surgically repaired, often return to communities that still treat them as damaged, to economies that offer them no foothold, to lives where independence remains out of reach. Ending fistula means treating the injury and dismantling the conditions that make it so devastating: child marriage, economic exclusion, the stigma that turns a medical condition into a life sentence.
Prevention, in the end, is where this ends for good. Fistula does not happen when a skilled birth attendant is present, when emergency care is accessible, when a girl is not married at 11. Nepal has invested in all these things, with UNFPA support at every stage of the national roadmap on midwifery, on Emergency Obstetric and Newborn Care network strengthening, on child marriage prevention. But the gap between Kathmandu and the most remote districts of this country remains stark. That gap is not an abstraction. It is the distance between a safe birth and a lifetime of surgery.
The economic argument for closing that gap is real: untreated fistula costs the global economy an estimated $691 million annually in lost productivity alone. The moral argument does not require a dollar figure. A woman's right to survive childbirth with her body and dignity intact should never depend on her economic value.
Nepal has made commitments, at the 2019 Nairobi Summit and through the ICPD@30 process. The Fistula Elimination Roadmap is proof that those commitments can be translated into a plan. What the plan now needs is sustained financing: health infrastructure, surgical capacity, supply chains that reach the last mile, and the community-based rehabilitation support that women like Radhika have been asking for all along.
Radhika took herself to the hospital. Nobody came for her. She navigated a system that was largely not designed with her in mind, and she fought, over 11 years and seven operations, to reclaim her life. She is still fighting.
No other girl should have to.
Haridass is the UNFPA Representative in Nepal. UNFPA is the United Nations sexual and reproductive health agency. In Nepal, UNFPA works to ensure every pregnancy is wanted, every childbirth is safe, and every young person's potential is fulfilled.