Thursday, 24 January, 2019
By Dr Elizabeth Wala
An obstetric fistula is a hole between the vagina and rectum or bladder that is caused by prolonged obstructed labour, leaving a woman incontinent of urine or faeces or both. Thousands of women across Sub-Sahara Africa who are living with Obstetric Fistula cannot lead a normal life. Isolation and social segregation is their daily reality; they find themselves ostracized and disowned by their own families and the community.
This creates a massive psycho-socio impact on the quality of life the patients live and curtails their contribution to their families, nurturing their children and actively participating in the communities in which they live.
Obstetric fistula is a severe maternal morbidity which can affect any woman or girl who suffers from prolonged or obstructed labour without timely access to an emergency Caesarean section. It is one of the most devastating consequences of neglected childbirth and a stark example of health inequity in the world.
Although obstetric fistula has been eliminated in industrialised countries, it continues to afflict the most impoverished women and girls in the developing world, mainly those in rural and remote areas. The World Health Organisation records that Obstetric Fistula affects between 50,000 to 100,000 women worldwide each year. In Kenya, two women get Obstetric Fistula per 100 births. This results in 2,400 new cases annually, according to data provided by Amref.
In the course of my work, I have interacted with a great number of patients – turned by the social stigma into victims. I’d like to anonymise one of these encounters that our teams have come across to bring the story home.
Esther Nairesiae,* a resident of Narok County was married off at 15 years and soon after got pregnant. In a sad turn of events arising from a complicated labour, Esther lost her baby during childbirth and as she was coming to terms with this, she discovered that she had developed Obstetric Fistula. It took her 12 long years to understand what was happening to her body and a few more to get help.
During this period, a lot changed. She could no longer continue with her beading business. After a corrective procedure backfired, she temporarily lost the ability to bear children. Moreover, as if putting the final nail on the coffin, her husband abandoned her. We can only imagine how painful, confusing and heart wrenching this period in Esther’s life must have been and what psychological trauma it caused her and her loved ones.
Sadly, hers – to varying degrees – is the story of many other women across the country who are living in pain and shame due to Obstetric Fistula. The more painful part which we should share as a society is that Obstetric Fistula is both preventable and treatable.
Esther caught her lucky break when our team of fistula specialists identified her problem during a screening exercise at a medical camp hosted by Beyond Zero Medical Safari in Narok County at the close of 2018.
The number of women requiring surgical repair services was staggering. Of the 299 women who got screened, 67 were suffering from Obstetric Fistula. They were operated on and discharged to return to society and linked up with a local Community Based Organisation to help reintegrate them back into society.
Obstetric Fistula results from prolonged obstructed labour especially when it occurs in the absence of skilled medical care. Unskilled medical care and unrefined traditional medicine is a harsh reality for many women in rural and hard to reach areas.
Early childbearing is a major cause of obstructed pregnancies which is one of the causal factors for Obstetric Fistula. In the cases we witnessed in Narok, the majority of the women with this condition were married quite young, some as early as 12 years of age. They got into the family way before their bodies were ready for childbearing.
Faced with these realities, we must speak up against child marriages and support campaigns geared towards eradicating the practice.
Additionally, we need to advocate for better access to sexual and reproductive health services and ensure that our daughters and mothers have access to skilled professionals during pregnancy and delivery. This will ensure that no woman dies while giving birth.
The current capacity for fistula surgical repair services in Kenya is less than 1000 patients every year or less than 50 per cent of the estimated annual incidence, an indication that Kenya is in dire need of medical personnel trained in management of female genital fistulae including prevention, repair and reintegration back into the society.
Indeed, collaboration and partnerships between different organisations and institutions will help in the reduction of stigma associated with fistula for thousands of women suffering from this condition.
We have seen the fruits of the partnership with Beyond Zero through which we have screened over 500 women for obstetric fistulae and conducted over 100 successful repairs in the first two surgical repair camps. As we move to other counties in 2019 and beyond, we hope to impact the lives of more women in need of fistula repairs.
Despite remarkable achievements, a lot more can be done to help thousands of women who are still living with the pain, stigma and shame of fistula. The National Hospital Insurance Fund (NHIF) has continued to review benefit packages to members and now reimburses surgical packages including fistula repair. However, the premiums are still a barrier to many women suffering from fistula. The waiting period of 60 days also presents a challenge as the stigma of fistula prevent many women from coming for repair once identified. It would be ideal if this was waived.
Like many other countries in the Africa, Kenya lacks policies governing fistula prevention and care. However, major inroads are found within the constitution and the Health Act 2017 which provides for citizens health rights. The National Ministry of Health is concluding on a National Framework on Fistula Management that will provide policy direction towards the eradication of fistula in Kenya.
To end Obstetric Fistula, there is a need to deepen universal access to reproductive health services, elimination of gender-based social and economic inequities, promotion of education and broader human rights, especially for girls, and fostering of community participation in finding solutions, including through the active involvement of men. Ensuring access to fistula treatment (surgical repair) for all women and girls is also a key strategy for eliminating it.
For the sake of girls, families, communities and the nation, we must all answer to this call.
Dr Wala is the Program Director for Health Systems Strengthening at Amref Health Africa
Amref’s Fistula programme, established in 1992, aims at improving the quality of life for women with debilitating childbirth injuries through prevention, surgical repair and community interventions.*Esther’s case was anonymized to protect patient confidentiality.