Where should obstetric vesico-vaginal fistulas be repaired: at the district general hospital or a specialized fistula center?

Expanded surgical capacities are required to treat obstetric fistulas. Achieving a balance between relative ease of access to services and use of the appropriate clinical setting is difficult. This article asks, "Are obstetric fistulas best repaired locally, at the district hospital where more women would have greater access, or is it necessary to provide these services at a tertiary referral or fistula center, where specialized surgical procedures can be conducted? Each possibility has advantages and disadvantages. The author concludes that 3 critical factors are necessary to provide safe and effective fistula repair services: adequate, long-term funding to cover the costs of all aspects of the care; the presence of a surgeon who is a "fistula champion"; and adequate operating theatre time and supplies. Without external funding, these prerequisites are almost impossible to meet at rural district hospitals.