A/HRC/45/19 annually, between 50,000 and 100,000 women develop obstetric fistula. 28 Women and girls living with untreated obstetric fistula can risk chronic incontinence, which leads to a range of other physical conditions, including frequent infections, kidney disease, painful sores and infertility. The physical injuries can also lead to social isolation and psychological harm. Affected women are often unable to work, and some are abandoned by their families, thereby deepening their poverty (A/73/285 para. 4). 2. Uterine prolapse 46. Uterine prolapse is another maternal morbidity with serious repercussions for women’s lives and well-being. Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken and no longer can support the proper positioning of the uterus. In its most severe stage, the uterus may come out of the vagina completely. The physical symptoms of uterine prolapse depend on the severity of the condition, and can include lower-back pain, abdominal pain, painful sexual intercourse, stress urinary incontinence and discomfort in the pelvic area. 47. A number of factors put women, mostly in developing countries, at risk of this condition, such as higher numbers of births within a short space of time, giving birth at a young age, inadequate nutrition, lack of rest during and immediately after pregnancy and prolonged or difficult labour, including the use of harmful birthing practices.29 The global prevalence of uterine prolapse is estimated to be anywhere between 2 and 20 per cent among women under the age of 45.30 In addition to physical discomfort, it can also adversely affect women’s mental health by impairing their ability to work and can put them at risk of emotional and physical abuse. 3. Postpartum depression 48. Postpartum depression refers to a nonpsychotic depressive episode that begins in the postpartum period, usually within 1 to 12 months after delivery.31 Its symptoms include feelings of guilt, anxiety, inconsistent sleeping patterns and fatigue, as well as feelings of being inadequate and unable to cope with the infant, with some women seeing themselves as “bad”, inadequate or unloving mothers. A variety of risk factors have been identified as predictors of postpartum depression, which include depression or anxiety during pregnancy, stressful recent life events, poor social support, a previous history of depression, obstetric and pregnancy complications and intimate partner violence.32 49. The global prevalence of postpartum depression has been estimated at 100‒150 per 1,000 births. Prevalence rates have been found to be even higher in low- and middleincome countries. Shortages of mental health resources, inequities in their distribution and inefficiencies in their utilization are key obstacles to ensuring mental health.33 Treatment of postpartum depression is challenging, as it often goes undiagnosed. For instance, in many places, women may not participate in postnatal visits; where they do, the focus of the visit 28 29 30 31 32 33 See www.who.int/news-room/facts-in-pictures/detail/10-facts-on-obstetric-fistula. It is important to recognize that fistula can also be caused by sexual violence, known as traumatic fistula, which is also a serious human rights concern. See, for example, United Nations Mission in South Sudan and OHCHR, “Access to health for survivors of conflict-related sexual violence in South Sudan” (May 2020), para. 37. Amnesty International, Unnecessary Burden: Gender Discrimination and Uterine Prolapse in Nepal (London, 2014), p. 18. Karen Hardee, Jill Gay and Ann K. Blanc, “Maternal morbidity: neglected dimension of safe motherhood in the developing world”, Global Public Health, vol. 7, No. 6 (2012), p. 610. Donna E. Stewart and others, Postpartum Depression: Literature Review of Risk Factors and Interventions (University Health Network Women’s Health Program, 2003), p. 21. Ibid., pp. 2 and 19. Ravi Prakash Upadhyay and others, “Postpartum depression in India: a systematic review and metaanalysis”, Bulletin of the World Health Organization, vol. 95, No. 10 (2017). See also Jane Fisher and others, “Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review”, Bulletin of the World Health Organization, vol. 90, No. 2 (2012). 11