By Hilary Mabeya
Health is one of the key elements of the social pillar of Vision 2030 that envisions Kenya as a middle level industrialized country by 2030.
Obstetric Fistula (OF) cripples the woman in the physical and psychosocial domains and, consequently, economically, resulting in a big blow to attainment of the vision.
Moreover, OF is a manifestation of lack of access to quality of maternal and neonatal health services which is also reflected in other maternal and neonatal health indicators. Kenya continues to register unsatisfactory maternal and neonatal health indicators.
Latest data shows Kenya is ranked at 138 with 362 maternal deaths per 100,000 which although lower than the earlier 488/100,000 still accounts for 14 per cent of deaths among women aged between 15 and 49 years old. Kenya was not able to achieve Millennium Development Goals especially 4 (reducing child mortality) and 5 (improving maternal health).
In Sub-Saharan Africa, only Rwanda, Ethiopia, Malawi, Cape Verde and Tanzania are on course to achieve goals 4 and 5. In 2015, Kenya was already in the 8th year of implementing its long term Economic blueprint, the Kenya Vision 2030, which is being implemented in 5-year rolling Medium Term Plans (MTP).
By the time the SDGs were adopted in 2016, the second MTP (2013-2017) was in its third year of implementation. Maternal mortality is none-the-less a relatively uncommon event making assessment of severe maternal morbidities also called ‘near miss’ morbidities a more feasible strategy for evaluating maternal health.
The direct causes of maternal mortality, also reflected in near miss morbidities, include: hemorrhage, infections, hypertension, prolonged and obstructed labor, unsafe abortion among others. The only effective intervention to address such complications is delivery under skilled attendance.
The free Maternal Care Program has immensely contributed to reduction of maternal mortality in Kenya. The increased utilisation of maternity services in public health facilities has contributed to the overall increase of deliveries in health facilities from 44 per cent in 2012/13 to the current 70 per cent.
The overall impact is to reduce OF. There are wide regional differences in facility delivery rates and the spatial distribution mirrors the differentials in poor maternal and neonatal health indicators and the occurrence of Obstetric Fistula (OF).
Among the consequences of prolonged or obstructed labor are the formation of obstetric fistula (either urinary or fecal) and a host of other morbidities, including neurological affections such as foot drop, fetal death. The pathogenesis is chemic necrosis of urinary, vaginal and or rectal tissues due to prolonged pressure of the impacted fetal head.
Obstetric fistula can only be prevented by prompt identification of obstructed labor – usually through careful monitoring of labor with partographs and prompt emergency Caesarian Section. The challenges of preventing OF are tied to issues of access to high quality of Emergency Obstetric and Neonatal Care (EMONC) capable of detecting and promptly managing obstructed labor.
These are complex and multisectoral Dr Mabeya PhD, a specialist Obstetrician/Gynecologist/Fistula Surgeon is the Chief Executive Officer Gynocare Women’s and Fistula Hospital Eldoret. factors.
Contributing factors have been conceptualized under the three delays model: The first delay encompasses factors that affect the ability of the pregnant woman do identify the need to go to the health facility at onset of labor. The second delay includes factors that influence her capacity to reach the facility promptly.
The third delay includes facility factors that determine readiness to provide the woman with timely and high quality EMONC services including emergency Caesarian Section. For women who go into labor and reach the facility early, obstructed labor is a clear indication of poor quality obstetric care.
If any part of this cascade of events and actions fails for a woman with obstructed labor and Caesarian Section is delayed, the sequelae include development of OF. Once a woman develops an OF, she face a myriad of challenges including self and social stigma, gross impairment of their capacity to function in society and medical consequences of OF.
Some find little support from family or society because of lack of awareness about OF, its cause and treatment. Access to OF care is challenging due to few facilities that have expertise to provide the highly specialised surgical repair services. Moreover, even after surgical repair, there is need for re-integration into society through dealing with psychosocial and economic rehabilitation.
OF is both preventable and treatable, but women experience delays in seeking repair due to a number of barriers affecting access to fistula repair, including information and awareness, psychological barrier, physical and geographical barriers, socio-economic and cultural barriers and facility shortages.
