Obstetric fistula disables millions of women and girls in developing countries, primarily in sub-Saharan Africa and South Asia. The United Nations Population Fund (UNFPA) recently launched a global campaign to end fistula, labeling this condition a preventable and treatable tragedy. Obstetric fistula overwhelmingly results from obstructed labor, which occurs in cases of cephalopelvic disproportion and malpresentation. Cephalopelvic disproportion often complicates deliveries in young, primiparous women of low gynecologic age. Social factors, including young age at marriage and malnutrition of girl children, can also contribute to cephalopelvic disproportion. These social etiologies must be addressed by prevention campaigns. Direct prevention of fistula can occur during delivery when skilled providers identify women and girls at risk for obstetric fistula and link them with innovative interventions, such as Fistula Prevention Centers, through which they can more readily access emergency obstetric care, and by setting strict time limits for laboring at home without progress. Community-based programs, such as the Tostan program in West Africa, use social education to prevent fistula. Moreover, effective surgical techniques for fistula repair are available in some settings and should be expanded to reach those in need. Midwives can play a key role in the prevention and treatment of this tragic obstetric complication.

Background. Research suggests that estrogenic endocrine-disrupting chemicals interfere with lactation. Objectives. (1) to determine if estrogenic persistent organic pollutants (POPs) are associated with shortened lactation duration; (2) to determine whether previous breastfeeding history biases associations. Methods and Results. We measured selected organochlorines and polychlorinated biphenyls (p, p′-DDE, p, p′-DDT, o, p′-DDT, β-hexachlorocyclohexane, hexachlorobenzene, and PCBs 44, 49, 52, 118, 138, 153, and 180) in serum from 366 low-income, Mexican-American pregnant women living in an agricultural region of California and assessed breastfeeding duration by questionnaires. We found no association between DDE, DDT, or estrogenic POPs with shortened lactation duration, but rather associations for two potentially estrogenic POPs with lengthened lactation duration arose (HR [95% CI]: 0.6 [0.4, 0.8] for p, p′-DDE & 0.8 [0.6, 1.0] for PCB 52). Associations between antiestrogenic POPs (PCBs 138 and 180) and shortened lactation duration were attributed to a lactation history bias. Conclusion. Estrogenic POPs were not associated with shortened lactation duration, but may be associated with longer lactation duration.