Fistulas: Better prevented than medicated later

Today is World Obstetric Fistula Day. Twenty years on, we are still treating obstetric fistula. Ten years since the introduction of free maternity care, we are still grappling with a highly preventable condition that should be almost extinct by now.

This condition exposes the underbelly of our healthcare systems; a clear indication that we may make several steps forward, but where it really matters, we are still back-peddling.

Nasenya* arrived in the hospital at night. This was not how she had imagined she would set foot in the capital city. She may have imagined a ride in a dusty white Probox, the only form of public transport she had ever used.  A ride in an ambulance was not something she could have conjured up. 
Yet here she was, being wheeled into the emergency department, sent far away for a treatment that was not available at the local hospital. 

In Nasenya’s short life, she experienced a lifetime’s worth of hell.  It had started when Nasenya was only 15. She was put through the female genital cut at 4 a.m., squatting on a cold stone, eyes tightly closed, holding back the horrendous scream that threatened to rip right through her. She could not embarrass her father by screaming in horror, yet that was all she wanted to do.

Even before Nasenya knew what healing meant, her father received a large herd of cattle, and she was escorted out of the only place she knew as home. 

She was now the gleaming, new, and prized possession of a 58-year-old man, the seventh wife! She had just turned 16.

Fast-forward to two years later. A well-worn and psychologically battered Nasenya was rescued from her prison by a near-death experience.

Her chief role was to provide her new husband with several children and he got right down to business to ensure his progeny was expanded.

A young and pregnant Nasenya went into labour, a harrowing experience that lasted three days under the watchful eye of the village’s traditional birth attendant. She eventually lost consciousness and woke up in hospital. She had lost her baby and had nearly succumbed to sepsis. It was a fight to get Nasenya to the hospital, just so that she could get much-needed medical attention.

She was quickly evacuated to the referral hospital and managed to survive the threat to her life. At the same time, she was diagnosed with an obstetric fistula. The challenge was, her “owner” (read husband) wasn’t done playing with his toy. He wanted his wife back home to get down to the business of making babies since she was considered to have wasted the first opportunity.

It was clear that Nasenya was not going to get an opportunity to get the correct treatment and the required time to fully heal from the complication. After surgery, a patient needs at least three months before she can engage sexually and an additional three years before she can conceive.

The conniving medical team informed her next of kin that Nasenya needed to go for treatment at the national hospital, hence the need for referral.

This physical removal was necessary to allow Nasenya to fully heal and hopefully find a way out of this unfortunate situation.

The intricate surgery to correct obstetric fistula is now offered in multiple hospitals across the country, both public and private. This was not the case a decade ago.

Obstetric fistula is a disease of poverty. Many patients lived with the condition, stigmatised and isolated from their communities because they had no access to care. The few facilities that provided the care were too far away and the service was too expensive.

Thanks to partnerships between the government, development partners, obstetricians and gynaecologists across the country – not forgetting private hospitals – fistula care is now decentralised and more accessible to our women.

At least six fistula centres are now in existence in Kenya and many county referral hospitals are able to offer the service.

A chat with Dr Carey Francis, the county obstetrician and gynaecologist at the Narok County Referral Hospital, paints a grim picture. The founder and pioneer fistula surgeon in the county notes that he cannot seem to stay ahead of the patient numbers.

Moving from operating an average of eight women a month a decade ago, he is now at 24. 
Why the rise? A lot can be attributed to the population growth rate, increased awareness about fistula repair and an improved road network for physical access.

With the support of Amref Africa Foundation and The Flying Doctor Service, Dr Francis and his team are able to provide fistula surgery through medical camps across the country, including Narok.

To support these efforts, the Fistula Foundation supports ongoing surgical treatments in public and private facilities across Kenya.

However, the real thorn in our flesh is the fact that we are NOT preventing fistula occurrence in the first place! Free maternity care was supposed to guarantee access to quality obstetric care. This is the first step to eliminating fistula. However, the challenges we had at independence are still here today as Dr Francis states emphatically.

Unless we manage the cultural contributors to fistula formation, we shall continue to count the numbers. Early marriage, resulting in adolescent pregnancies in girls with no access to proper maternity care, is the perfect recipe for this disaster.

In Narok County, quality maternity care is still a mirage for many. The whole county, vast as it is, depends on the county referral facility.  This is the only hospital with a gynaecologist. The only other facility with a functional operating theatre is Transmara Sub-County Hospital; yet a timely caesarian section is the single most effective way to prevent obstetric fistula.

The need for functional maternity units cannot be overstated. These units need adequate human resources, infrastructure and the medical supplies necessary to prevent fistula as the starting point for fistula prevention. We cannot wait to repair obstetric fistula.  We must aspire to prevent it in the first place!

That is when we actually appreciate that our health systems are working.

Dr Bosire is an obstetrician/ gynaecologist