From Silence to Systems Change” is a powerful health-systems and social-justice feature that reframes obstetric fistula in Somalia not merely as a clinical childbirth injury, but as evidence of deeper failures in maternal health access, emergency referral, health financing, gender equity, social protection, and national accountability. The article’s central message is clear: fistula is not only a physical rupture; it is a fracture in the health system, a wound to social justice, a crisis of human dignity, and a test of national leadership.
The article moves beyond sympathy and calls for systemic prevention. It argues that the highest achievement of a health system is not how many women receive fistula repair after suffering, but how many women are protected from ever developin fistula in the first place. This aligns with global evidence: obstetric fistula is commonly caused by prolonged, obstructed labour without timely access to high-quality medical care, and it often leaves women with chronic incontinence, medical complications, depression, social isolation, and deepening poverty.
In the Somali context, the article is especially important because it links fistula to Universal Health Coverage, fragile-state health system reform, maternal benefit packages, emergency obstetric care, referral transport, survivor reintegration, and national leadership. Somalia’s maternal mortality burden remains extremely high, with the World Bank reporting 563 maternal deaths per 100,000 live births in 2023, making prevention of childbirth-related disability and death a national development priority.
What should be done before fistula occurs?
Fistula prevention must begin long before obstructed labour reaches a hospital. It requires a life-course, community-based, and health-system approach.
1. Before pregnancy: prevent the social roots of fistula
Fistula often begins before labour starts. It may begin with poverty, adolescent pregnancy, early marriage, poor nutrition, illiteracy, lack of family planning, and limited decision-making power for women and girls. Prevention therefore requires keeping girls in school, delaying early marriage, improving adolescent reproductive health education, expanding access to voluntary family planning, and strengthening community awareness on safe motherhood.
Communities should understand that prolonged labour is a medical emergency, not a family matter to be managed silently at home. Religious leaders, traditional leaders, women’s groups, youth groups, civil society, and local health workers should all be engaged to reduce stigma, promote antenatal care, and encourage early care-seeking.
2. During pregnancy: identify risk early
Every pregnant woman should have timely, respectful, and quality antenatal care. Antenatal care should not be limited to routine check-ups; it should include birth preparedness and complication readiness. This means identifying high-risk pregnancies, counselling families on danger signs, planning where the woman will deliver, arranging transport options in advance, identifying blood donors where appropriate, and ensuring the family knows when and where to seek emergency care.
Women in remote, rural, displaced, or insecure areas should receive special attention because distance, poverty, insecurity, and transport barriers increase the risk of delayed care. The attached article rightly emphasizes that prevention must be adapted to Somalia’s realities: geography, poverty, internal displacement, insecurity, and uneven service delivery.
3. During labour: prevent prolonged obstruction
The decisive moment in fistula prevention is labour. No woman should remain in obstructed labour for hours or days without skilled intervention. Prevention requires skilled birth attendance, functioning maternity units, timely use of partographs, rapid recognition of obstructed labour, immediate referral when needed, and access to emergency obstetric and newborn care.
The key standard is simple: competent obstetric care must be respectful, prompt, and affordable. Evidence on fistula prevention emphasizes that women will use institutional care when services are trusted, valued, timely, and financially accessible.
4. At facility level: make emergency care real, not theoretical
A health facility cannot prevent fistula merely by existing. It must be ready. That means trained midwives, available doctors or surgical teams, clean delivery rooms, emergency obstetric protocols, caesarean-section capacity, anaesthesia, blood supply, infection prevention, newborn care, referral communication, and 24/7 readiness.
A facility that lacks blood, staff, transport, theatre capacity, or decision-making authority may unintentionally become part of the delay. For fistula prevention, “routine maternity care” is not enough; the system must be able to manage complications immediately.
5. At financing level: remove the cost barrier
A woman in obstructed labour should never have to wait while her family searches for money. Financial delay can become physical injury, stillbirth, disability, or death. This is why the article’s link to UHC and health financing reform is essential. WHO defines Universal Health Coverage as access to the full range of quality health services when and where needed, without financial hardship.
For Somalia, fistula prevention should be included in a publicly protected maternal benefit package covering antenatal care, skilled delivery, emergency obstetric care, referral transport, caesarean section when medically indicated, fistula repair, rehabilitation, psychosocial support, and reintegration.
How fistula is a fracture in the health care system
Fistula is a visible outcome of invisible system failures. It shows where the health system failed to protect a woman at the right time.
It is a fracture in service delivery when skilled birth attendance, emergency obstetric care, surgical capacity, blood supply, and referral systems are unavailable or unreliable.
It is a fracture in health financing when families must pay out-of-pocket before receiving emergency maternal care, causing dangerous delays.
It is a fracture in governance and accountability when no system tracks where fistula cases come from, which facilities failed, how long referrals took, and what preventable delays occurred.
It is a fracture in equity when rural women, internally displaced women, adolescent girls, and poor households face the highest risk because they are farthest from care and least protected by institutions.
It is a fracture in social protection when survivors are repaired surgically but return to poverty, stigma, abandonment, and exclusion.
This framing is strongly supported by the United Nations, which has described women living with fistula as evidence of health systems failing to deliver universally accessible, timely, and quality obstetric care.
Why fistula is beyond routine maternity health care. ?
Fistula is beyond routine maternity care because it is not simply about pregnancy follow-up or delivery attendance. It requires a full emergency, social, financial, and accountability system.
Routine maternity care may provide antenatal visits and normal delivery services. Fistula prevention requires much more: emergency obstetric readiness, surgical care, referral transport, blood supply, caesarean capacity, maternal death and near-miss audits, digital registries, community surveillance, survivor reintegration, and long-term psychosocial support.
Fistula is also beyond routine maternity care because its consequences extend beyond the body. Survivors may experience chronic incontinence, marital breakdown, loss of income, depression, isolation, stigma, and social exclusion. UNFPA highlights that fistula can lead to chronic medical problems, depression, social isolation, and deepening poverty.
Therefore, ending fistula requires more than hospitals. It requires parliament, ministries of health and finance, national insurance structures, district authorities, religious and traditional leaders, civil society, media, academia, private transport providers, development partners, and communities. This is exactly the article’s strongest contribution: it places fistula elimination within national systems reform, not only within clinical repair campaigns.
Fistula should be treated as a national warning signal. Before it appears, the system has already missed several opportunities: educating the girl, protecting the adolescent, supporting the pregnant woman, preparing the family, equipping the facility, financing emergency care, arranging transport, and acting rapidly during obstructed labour.
To end fistula in Somalia, the goal must shift from repairing suffering after injury to preventing suffering before injury. That is the true meaning of moving from silence to systems change.