Fistula causes infections, pain, and bad smell, and often triggers stigma and the breakdown of family, work, and community life.
Obstetric fistula is predominantly caused by prolonged obstructed labor, which is one of the five major causes of maternal mortality and accounts for eight percent of maternal death worldwide. During the prolonged obstructed labor, the soft tissues of the birth canal are compressed between the descending head of the infant and the woman's pelvic bone. The lack of blood flow causes tissue to die, creating a hole (fistula) between the woman's vagina and bladder (vesico-vaginal fistula or VVF) or between the vagina and rectum (recto-vaginal fistula or RVF) or both. This leaves the woman leaking urine and/or feces continuously from the vagina. Other direct causes of fistula include sexual abuse and rape, surgical trauma (iatrogenic fistula), and gynecological cancers and related radiotherapy treatment.
The risk of obstetric fistula often begins when young girls get pregnant or marry early, before their bodies are able to safely sustain a pregnancy. Adolescent girls are particularly susceptible to obstructed labor because their pelvises are not fully developed.
The New American interviewed Amina Sheikh Abdullah, a Somali woman in Eastleight — a suburb inhabited predominately by Somali immigrants in the Kenyan capital of Nairobi — who has suffered from a fistula for almost four years, beginning when she was 16 years old.
"I was in southern part of Somalia when I started suffering fistula, my husband chased me away and abused me.... [He said] 'he can't stay with a woman who smells all the time," said Amina.
"At that time I didn't realize that I was undergoing fistula until I reached Kenya hospitals, where I understand more about fistula," she added. "Now I can't even think about getting married to another husband because fistula is a very serious condition. It is so embarrassing because it causes frequent dripping of urine and in other cases leaking of stool."
Early marriage, marriage before the age of 18 years, is considered a major risk factor for fistula development. It is also associated not only with early childbearing, but also with reduced school attendance. This contributes to illiteracy, poverty, and low status in the community. Further, married girls and child mothers face constrained decision-making, including reproductive and maternity care choices, because they are often controlled by their husbands and relatives. Kenya's Children's Act prohibits marriage before age 18. Nonetheless, the 2008-09 Kenya Demographic and Health Survey (KDHS) shows that 24.6 percent of Kenyan women aged 20-24 had been married by age 18.
Fistulas lead to a sorry state for many women because their husbands abuse them or leave them, and their medical conditions make it hard to find work. According to the Human Rights Watch, many women and girls with fistula lead isolated lives, confining themselves to their homes due to the stigma and shame attached to the illness.
"My husband chased me away when I got this problem [fistula]. He used to beat me a lot. When I went back to my parents, my sister-in-law also became abusive saying she did not want a dirty smelly person in the home. I left, went to a nearby town, and rented a house. I started doing casual jobs like washing clothes and fetching water, but whenever it was discovered that I had a problem of [controlling] urine, I was chased away. Before long, everybody knew about my problem, and I stopped getting work. I used to lock myself in the house and cry the whole night, and sleep hungry," Nyaboke H. told Human Rights Watch.
In an interview, Anne Oduar, who has suffered from fistula for over five years and lives in Kibera, one of the most pronounced slums in Kenya, expressed her emotion to The New American: "I was married eight years ago. I have suffered fistula since 2004. My husband left me alone with my two children. I don't know what to do. I can't stand near someone for the reason that I am afraid other people sense the smell. I go to the government hospital many times but the medication that I received is 'Come back tomorrow.' I don't have enough money to treat myself," Oduar added.
Fistula decreases women's and girls' abilities to farm or do other economic activities. Although some women said they were able to work on their farms despite the pain and discomfort they suffered, others said they were not able to. Some lose jobs or are denied work when employers discover that they have fistula.
According to the World Health Organization, fistula strikes roughly 50,000 to 100,000 women and girls every year, mainly in resource poor countries in sub-Saharan Africa and Asia. In Kenya approximately 3,000 women and girls develop fistula every year, while the backlog of those living with untreated fistula is estimated to be between 30,000 and 300,000 cases. There are many doubts about these estimates because few studies have been conducted to establish the extent of this problem in the country.
Patients with fistula are stigmatized by the society. This is why many people do not know about it, because many patients rarely talk about their conditions for fear of stigma. Survivors who suffer fistula are also thought by some to be bewitched or cursed, or may be accused of being promiscuous. Women and girls with fistula are often abused, beaten, abandoned, and divorced by their husbands or are isolated in their homes or shacks outside their homes.
They avoid being in public for fear of smelling urine or stool and having to rush to the toilet frequently. Apart from smelling, it causes limping in patients, ulcers in the private parts, and isolation. Many have been neglected and some divorced by their husbands. Hence patients, apart from suffering from the medical conditions, suffer from psychological feelings that can make them suicidal.
Most fistulas can be repaired surgically even if they are several years old. Success rates for fistula repair by experienced surgeons can be as high as 90 percent, according to UNFPA. Successful surgery can enable women to live normal lives and even have children, but it is recommended to have a Cesarean section for future deliveries to prevent the fistula from recurring.
The New American interviewed one of the doctors from Kenyatta Hospital, one of the biggest Kenyan hospitals, on the treatment of fistulas. "Intestinal fistulas that do not causes symptoms often require no treatment. Fistulas that cause significant symptoms, however, usually require treatment, although they are frequently difficult to heal," said Garrard Wakesa.
"Fistulas sometimes require surgery. For example, when fistulas around the anus become very severe, they can interfere with the patient's ability to control bowel movements (continence). In this situation, the surgeon might make an opening (ostomy) to the skin from the bowel above the fistulas.... A woman may die, lose her child or face complications," Wakesa added.
Many women in Africa face a lot of barriers to accessing healthcare including lack of money, difficulty in reaching a health facility, and cultural barriers such as relying on herbal doctors who are mostly uneducated. Over half of married women ages 15 to 49 on the continent consider money to be a big problem in getting healthcare. This may reflect not only in poverty but also gender differences in control over household resources.
The Kenyan government's efforts to ensure affordable maternity care for poor rural women and girls have fallen far short of even its own goals. Upwards of three-quarters of the women and girls interviewed by Human Rights Watch described economic constraints as a barrier to accessing maternal health services and fistula repair surgery.
Photo: AP Images