NAIROBI, 19 July 2010 (IRIN) - It is both preventable and treatable, but obstetric fistula plagues the lives of thousands of women in Kenya every year, leaving them incontinent and ostracized. Here are some reasons why:

Information deficit

Lack of reproductive health education means there is widespread ignorance of the basic facts about fistula - a tear in the birth canal caused by prolonged obstructed labour, or by sexual abuse, surgical trauma, gynaecological cancers and related radiotherapy treatment. According to the UN Population Fund (UNFPA), there are 3,000 new cases per year in Kenya, with about one to two fistulas per 1,000 deliveries.

Many affected women are not aware that fistula can be repaired. Misinformation about fistula leads to delays in seeking treatment. Some women think incontinence is normal after delivery.

Lack of fistula awareness, even among medical personnel, also hinders timely referrals. The limited number of health personnel also sometimes means that nurses, for instance, can only provide new mothers with the most basic information, and do not integrate fistula in health chats.

Cost

Fistula corrective repair surgery, when heavily subsidized, costs about 30,000 Kshs (about US$375) at the main referral hospital, Kenyatta National Hospital (KNH) in Nairobi, which is prohibitive for many of those affected. In private hospitals the cost is at least five times as much. Only 7.5 percent of women in Kenya are able to access treatment, according to UNFPA.

Besides treatment, there are other costs - pads, soap, ointments - stretching resources for women who often cannot even afford to travel to towns in search of treatment. Furthermore, affected women are often incapacitated meaning they cannot earn money.

Medical personnel

Trained surgeons and nurses are in short supply. Kenya has about 10 trained fistula surgeons, of whom only four (one retired) are considered sufficiently expert to handle complicated cases and train others. Three of the experts are based in Nairobi which Human Rights Watch (HRW) deems unsustainable in the long-term.

While theatre equipment and supplies are not a major hindrance to fistula repair, routine repair remains rare and is mainly done only at KNH and Jamaa mission hospital in Nairobi, and the Moi Referral and Teaching Hospital in Eldoret, Rift Valley.

"Fistula services are stretched; it is like mopping the floor with the tap open. We are overwhelmed by the numbers alone," Khisa Wakasiaka, a reproductive health and vesico-vaginal fistula repair specialist and trainer, said. Medical personnel have also been accused of neglect,  leading to women developing fistulas in hospitals during delivery.

Infrastructure

Inadequate hospitals to handle Caesarean births and poor roads in rural areas are among barriers to emergency obstetric care and referrals. Traditional birth attendants (TBAs) attend up to 28 percent of all births in Kenya, the same as the number of births assisted by nurses and midwives, notes the Kenya Demographic and Health Survey (KDHS) preliminary report for 2008-09. TBAs may not be sufficiently well trained to refer women to hospitals, yet obstructed labour occurs in 5 percent of live births and is one of the four major causes of maternal mortality and morbidity.

Culture

Most fistulas occur among women living in poverty, in cultures where a woman's status and self-esteem may depend almost entirely on her marriage and ability to bear children, notes UNFPA. "We still believe in marriage for children. If you can't have children, what are you there for?" said specialist Wakasiaka.

Early marriage/pregnancy: The risk of obstetric fistula often begins when young girls get pregnant early, before their bodies are able to safely sustain a pregnancy. The unease surrounding sex education in Kenyan schools is one of the reasons for early pregnancy due to a lack of accurate reproductive health knowledge, notes HRW in a July report, entitled, I Am Not Dead, But I Am Not Living - Barriers to Fistula Prevention and Treatment in Kenya.

Female Genital Mutilation/Cutting (FGM/C): Infibulation, practised in some communities, which involves the cutting and sewing up of a girl's genitalia leaving a match-stick size hole for the passage of menstrual blood is especially harmful. This hole is then crudely cut open during childbirth, something which could end up severing the bladder.

Myths

Fistula is sometimes linked to taboo conditions such as HIV/AIDS, abortion and infertility. Fistula survivors may be thought to be bewitched or cursed, or may be accused of being promiscuous. There is also a refusal by some women to give birth in hospitals due to the belief that they will receive injections that will cause infertility, or be forced to have unnecessary Caesarean births.

Stigma

Women and girls with fistula are often abused, beaten, abandoned, and isolated. Without repair, fistula may cause a fetid odour, frequent pelvic and urinary infections, painful genital ulcerations, infertility and nerve damage to the legs. Affected women may miss out on crucial information on treatment and support, due to a lack of social interaction.

"Home therapies": Due to the stigma associated with leaking urine, women sometimes refuse to drink water, making the urine more concentrated and resulting in the burning of the vulva; some also develop kidney disorders. In some communities, women seek to control the seepage of urine by inserting hot rods in an attempt to "seal" the fistula, causing more damage.

Rape: According to the Nairobi Women's Hospital, which runs a Gender Violence Recovery Centre, in 2010, there has been an increase in the number of reported gang rape cases, with the number of perpetrators increasing from 11 to 20 per act. Of the 2,487 cases reported in 2010, 52 percent were women, 45 percent children and 3 percent men. The centre receives an average of 15 survivors per day, mainly from Nairobi.