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International Journal of Sciences:
Basic and Applied Research
(IJSBAR)
ISSN 2307-4531
(Print & Online)
http://gssrr.org/index.php?journal=JournalOfBasicAndApplied
---------------------------------------------------------------------------------------------------------------------------
395
Psychosocial Effects of Obstetric Fistula on Young
Mothers in Western Kenya
Habiba C. Mohameda*, Kabunga Amirb, Thananga Ng’ang’ac
aFounder and Lead Director, Women And Development Against Distress In Africa (WADADIA)
Consultant Outreach Manager, Fistula Foundation
bMount Kenya University, Department of Psychology, Nairobi, Kenya
cBehaviour Technician, Key Program, Inc., Massachusetts, USA
aEmail: habiba@wadadia.org / habiba@fistulafoundation.org
bEmail: amirkabunga070@gmail.com
Abstract
Obstetric fistula has remained one of the most devastating complications a woman experiences in the course of
delivery in Kenya. Many women suffer long term morbidity and become social outcasts. The aim of this study
was to examine the psychosocial consequences of obstetric fistula on young women in the western Kenya
region. The study population consisted of women living with obstetric fistula, their families and care givers. The
sampling frame consisted of 190 primary respondents. The study adopted a cross-sectional descriptive survey
design. The data from the respondents was collected through questionnaires, interview schedules and Focus
Group Discussions. The Statistical Package for Social Sciences (SPSS) was used for data analysis. Descriptive
statistics such as frequencies, means, percentages and standard deviations were generated for data analysis. The
study results show that the main psychological effects of fistula were sadness, shame and loss of self-worth. The
study also points at stigmatization, social worthlessness and isolation as the main social effects of fistula. The
study recommends addressing negative cultural practices that contribute to obstetric fistula occurrence.
------------------------------------------------------------------------
*Corresponding author.
International Journal of Sciences: Basic and Applied Research (IJSBAR) (2016) Volume 26, No 1, pp 395-404
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This includes sensitization of the society about fistula to re-integrate the recovering fistula survivors so as to
reduce the associated stigma. Relevant groups and NGOs should offer counselling services to fistula victims on
issues that can affect their psychological and social wellbeing.
Key words: Obstetric Fistula; Psychosocial Consequences; Young Women; Western Kenya.
1. Introduction
Most young women, mainly from developing countries are living in shame and isolation because they suffer
obstetric fistula. The condition is directly linked to obstructed labour, which lasts several days. Obstructed
labour, apart from contributing high mortality rate, is estimated to cause 76% to 97% of all obstetric fistulas [1].
Nigusse and colleagues in The Causes and Consequences of Obstetric Fistula in Ethiopia indicate that 95.4% of
the fistulas are caused by childbirth. Studies have indicated that coitus, surgery, trauma and other causes
constitute only less than five per cent of the cases. The situation is no different in Kenya, where over 90% of all
obstetric fistulas are caused by prolonged obstructed labour. Obstructed labour was estimated to be the most
disabling maternal health condition ranking 41st in the Global Burden Disease (GBD) in 1990, representing
0.5% of burden of all conditions and 22% of all maternal conditions [2]. Obstetric fistula is by far the most
distressing long term condition following obstructed labour. Despite its devastating impact on the lives of
women, it is still largely neglected in the third world countries. The myths and misconceptions associated with
the condition serve to compound the situation. The condition is considered the poor woman’s burden because it
affects some of the most economically marginalized members of the population; mostly young and illiterate
women in remote regions of the world.
Obstetric fistula is a medical condition in which a hole develops between the rectum and vagina or between the
bladder and vagina, after long obstructed childbirth where emergency medical care is not available [3]. A hole
between the urinary bladder and the vagina is known as vesicovaginal fistula whereas a hole between the rectum
and the vagina is referred to as rectovaginal fistula [4]. The United Nations Population Fund [5] defines
obstetric fistula as a childbirth injury that has been largely neglected, despite the devastating impact it has on the
lives of affected women. From the preceding definitions, obstetric fistula is a childbirth injury that occurs to
mothers and is associated with prolonged obstructed labour. It is characterized by continuous leakage of urine
and/or stool via the birth canal.
Prior to the 19th century, obstetric fistula was considered an incurable condition, but later it was realised that
obstetric fistula could be diagnosed and treated [6]. By the first half of 20th century, the maternal mortality rate
had substantially reduced in western countries [7]. Today, obstetric fistula is virtually unheard of in western
countries. It has also greatly reduced in industrialized nations in Asia and Latin America. However, the
condition remains not only prevalent but also a pressing problem in Sub-Saharan Africa. This may be attributed
to ignorance, poverty and poor infrastructure. In these countries there is inadequate emergency obstetric care,
limited fistula repair services and lack of fistula surgeons to manage the affected women [8]. It is estimated that
there are 2 million women living with fistula around the world [9]. The UNPA, 2003 postulated that about 80%
of women living with fistula in the East African region lack fistula repair services each year.
International Journal of Sciences: Basic and Applied Research (IJSBAR) (2016) Volume 26, No 1, pp 395-404
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In Kenya, the 2014 Kenya Demographic Health Survey estimated that 1% of women of reproductive age have
had a fistula in their life. An obstetric fistula needs assessment report by the UNPA indicates that in Kenya,
there are 3000 new fistula cases every year; with the treatment capacity for obstetric fistula in Kenya being
pegged at a maximum of 1,000 clients per year [10]. However, most importantly, obstetric fistula affects mainly
marginalized groups and young uneducated females mostly living in geographically remote settings with limited
or no emergency obstetric care services and where fistula care in not a priority.
The World Health Organization (WHO) refers to fistula as the single most devastating morbidity of neglected
child birth. Indeed, WHO estimates that over 300 million women currently suffer from complications arising
from childbirth, with around 20 million new cases arising every year [11]. These complications include vaginal
fistula. It is also estimated that about 50,000 to 100,000 women develop obstetric fistula annually with at least
33,000 of these being found in sub-Saharan Africa, Kenya included [12]. Ahmed and Tunçalp [13] estimate that
for every maternal death, 20 to 30 women develop serious obstetric complications including fistula. Sadly, an
approximately 2 to 3 million women are living with untreated obstetric fistula [14]. A survey done by UNFPA
in 2014 in Kenya estimated that there are 3,000 new cases per year, with approximately one to two fistula cases
per 1,000 deliveries and only about 7.5% of women with fistula being able to access treatment [15. While it is
important to recognize that this data is largely hospital-based and therefore cannot be fully indicative of the
magnitude of the problem, the existence of such a high number of obstetric fistula victims highlights the failure
of health systems to provide high quality maternal health care including skilled medical attention and timely
emergency obstetric care. It is also a reflection of the socio-economic, regional and gender based inequities as
well as the patriarchal nature of African societies that hinder women from accessing high quality services. Most
cases that occur in rural and marginalized communities and fistula victims are often ostracized [16].
Studies have shown that fistulas are mostly often pregnancy-related (90.4%), followed by pelvic operation
related (5.3%), and then by sexual assault (4.3%) [17]. Hysterectomy was at one time the most common
gynaecological procedure leading to obstetric fistula [18]. One of the Millennium Development Goals adopted
by many countries including Kenya is to improve maternal health [19] but despite its wide adoption of maternal
health programmes, women suffer from a wide range of birth complications including obstetric fistula. Although
obstetric fistula can be repaired successfully, cultural, religious beliefs, patients’ non awareness of availability of
treatment facilities, and the cost of the repair have made access to the much needed care unobtainable for many.
There is therefore a dire need to sensitize the obstetric fistula victims of this condition on the availability of
treatment.
Fistula is a serious condition affecting more than 6 million women annually with over 90 % of these women
living in Third World countries [20] with estimated 40,000 women dying annually. Other obstetric fistula
associated complications include urinary, faecal or combined incontinence [21], physical and psychosocial
morbidity including societal stigmatization [22], divorce and separation [23] loss of income due to difficulty in
securing a job or livelihood [24], and reproductive system complications like infertility and amenorrhoea [25].
Apart from surviving the ordeal of obstructed labour, women with obstetric fistula face significant psychosocial
challenges [26]. Low self-esteem, feelings of rejection, stress, anxiety, mental health dysfunctions, and post-
International Journal of Sciences: Basic and Applied Research (IJSBAR) (2016) Volume 26, No 1, pp 395-404
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traumatic stress disorders, loss of dignity and self-worth, loss of sexual pleasure, depression and suicidal
thoughts are some psychosocial consequences that can follow this morbidity [27].
In Guinea, a study shows that women who develop obstetric fistula often suffer stigma, abandonment, loss of
self-esteem and social isolation [28]. In a study conducted in Nigeria, about 33% of women with obstetric
fistulas were depressed and 51% were bitter about life [29]. Divorce is very common immediately a woman is
diagnosed with fistula. For example, in a study in Niger among women affected with obstetric fistula, 63% were
divorced because of the condition [30]. According to reports in sub-Saharan Africa, more than 50% of women
suffering from fistula are divorced by their husbands. Other consequences include severe social stigmatization
and loss of support from families and communities.
In another study conducted in Zimbabwe [31], it was found that women with obstetric fistula faced the
following psychological problems: helplessness, sadness, suicidal thoughts, stigma and blame, feelings of
worthlessness, fear, shame and social withdrawal. In Zambia, a study on women with obstetric fistula receiving
care at Monze Hospital revealed that of the 45 women who were no longer living with their husbands, 67% of
them stated that this was due to their having fistula. In another study on incidence of depression in women with
obstetric fistula in Kenya, depression was present in 72.9% respondents, with 25.7% meeting the criteria for
severe depression. From the meta-analysis, in absolute terms, it is estimated that Kenya is one of the countries in
Africa that has the largest number of women of reproductive age (15-49 years) who have experienced vaginal
fistula symptoms, estimated at between 69,400 and 113,700 [32]. While the figures seem to be quite high,
studies determining the psychosocial effects of fistula on young women are elusive and very limited in Kenya.
This study set out to bridge this gap.
2. Objectives of the study
The following are the two objectives addresses in this paper:
i. To determine the social effects of obstetric fistula on young women in the western Kenya region.
ii. To determine the psychological effects of obstetric fistula on young women in western Kenya.
3. Research methodology
The study population consisted of women that are living with obstetric fistula, their families and care givers.
The sampling frame consisted of 190 primary respondents consisting of fistula survivors aged between 15-24
years from Kakamega, Bungoma, Trans Nzoia, West Pokot, Kisii and Migori Counties of Kenya. The secondary
respondents included 60 older fistula survivors aged above 25 years - ten from each county - and 60 Fistula
survivors’ significant others. The significant others were their husbands, parents or siblings. The study adopted a
cross-sectional descriptive survey design. The data from the respondents was collected through questionnaires,
interview schedules and Focus Group Discussions (FGDs). The Statistical Package for Social Sciences (SPSS)
was used for data analysis. The descriptive statistics such as frequencies, means, percentages and standard
deviations were used in data analysis. All the participants were informed about the purpose of the study and
assured of confidentiality and of the fact that the findings would not be used in such a way as to harm them.
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Their participation was voluntary and without expectation of any rewards. None of the respondents was denied
services for refusing to participate. A written informed consent was signed by all the respondents before they
could take part in the study.
4. Results and Discussion
The study sought to establish the distribution of respondents by age in the study areas and the results generated
as in table 1 below.
Table 1: Distribution of Respondents by Age
Status
<15yrs
15-18yrs
19-21yrs
22-24yrs
>24yrs
Total
%
Single
4
26
40
33
5
108
57
Married
0
13
22
13
8
56
29
Divorced
2
5
4
18
1
26
14
Total
6
44
66
64
14
190
From the results in table it was noted that the youngest client was aged 13 years old with the oldest being 26
years old. It was also noted that majority of the respondents were single (accounting for 57% of the
respondents) while those who were married accounted for about 29%. The remaining 14% of the respondents
were already divorced at the time of this study. On investigating the cause of divorce, it was noted that 18 out of
the 26 respondents (or 73% of the divorced respondents) were divorced due to their obstetric fistula condition.
A review of existing literature indicates that in Kenya, obstetric fistula is a big problem even though the actual
prevalence and incidence remain unknown. Its prevalence is not well quantified from a medical point of view,
particularly amongst the poor women. In Kenya, the UNFPA estimates that there are 3000 new fistula cases
every year, whereas the 2014 Kenya Demographic Health Survey indicates that 1% of women have ever had
fistula. There are areas in the country where the problem of obstetric fistula has not received enough attention.
Additionally, this study established that the real status of affected women is not well known in the community.
The study therefore concurs with most reviewed literature studies, which agree that obstetric fistula is a highly
prevalent condition with most of those who are suffering from it being silent about it because of the
stigmatization that comes with the disease. The study additionally identifies the condition’s impact on the
client’s emotional wellbeing and the mitigating measures. There is need to sensitise communities about this
condition so that they can help the fistula clients to open up about their situation, cope with it, and seek medical
attention.
The first objective of this study was to determine the social effects of obstetric fistula on young women in the
western Kenya region. To achieve this objective, the respondents were requested to complete a questionnaire.
Their responses were scored and results computed to establish the social effects the victims underwent as a
result of Obstetric Fistula. The results are represented in table 2 below:
International Journal of Sciences: Basic and Applied Research (IJSBAR) (2016) Volume 26, No 1, pp 395-404
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The study sought to find out the social effect of obstetric fistula from the clients perspective. The respondents
were asked to select to list all the social effects they had as a result of obstetric fistula.
Table 2: Social Effects arising from Suffering from Obstetric Fistula
Effects of Suffering from Obstetric Fistula
Frequency
Percentage
Stigmatization
174
35
Social inferiority
56
11
Socially worthless
144
29
Divorce
25
5
Isolation
98
20
Total
497
100
From table 2 above, 497 responses were generated from this question. Stigmatization (35%), social
worthlessness (29%) and isolation (20%) are seen as leading among the social effects of obstetric fistula.
Judging from the number of responses in relation to the number of participants, it is clear that most of the
participants were socially affected in more than one way. It is valid therefore to conclude that a fistula survivor
first experiences self-stigma which makes her to be isolated. This comes with the feeling of worthless and acts
as worthless leading to total isolation by the community.
It was very interesting to note that the demographics showed 14% of the participants as having been divorced
whereas only 5% of the responses cited having been socially affected by divorce. This could be because the
clients were affected in so many ways that they had to focus on the way most important for them. ‘My own
mother was so ashamed of me, she wanted me to hide in the kitchen; I wasn’t allowed to participate in any
domestic work or even greet visitors. That was more disturbing than being chased away by my husband,’ Said
Anne, when asked about her feeling on divorce.
For the fistula clients who went back to their family of origin after the divorce, the study sought to find out how
they were received by their families. It was observed that 20% of the respondents were positively received by
their families whereas 80% had challenges with members of their families. Relationships with their sister in-
laws seemed to be more strained compared to relationships with other members of the family. In the FGDs, the
respondents concurred that when effects of fistula disabled them from participating in such chores as cooking
during social functions, they were rendered totally inadequate and this reduced their dignity greatly and
increased social isolation and stigmatization. This is in agreement with many studies proving that in nearly all
cases, many women afflicted with fistula are divorced or separated. They also found that the rates of separation
increased the longer a woman lives with fistula, especially if she remains childless [33].
Similar studies show that fistula comes with a lot of stigma. For instance the smelly nature of vesico-vaginal
fistula exposes its victims to mistreatment and stigma, leading them to be ostracized by their relatives and
community. In many cases family members do not like sharing food with women with vesico-vaginal fistula at
International Journal of Sciences: Basic and Applied Research (IJSBAR) (2016) Volume 26, No 1, pp 395-404
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family events [34]. In Kenya for instance, the lives of women with fistula are devastating. A similar situation is
reported in a study [35] in Kaptembwa –Nakuru, Kenya. The study concluded that the foul odour emanating
from affected women leads to humiliation and severe social-cultural stigmatization and isolation.
The second objective of the study was to determine the psychological effects of obstetric fistula on young
women in the western Kenya region. To achieve this objective, the respondents were requested to complete a
questionnaire that had multiple choices. They were required to tick all that was applicable hence they could have
more than one response. Their responses were scored and results computed to establish the psychological effects
the victims underwent as a result of Obstetric Fistula. The results are represented in table 3 below:
Table 3: Psychological Effects arising from Suffering from Obstetric Fistula
Effects of Suffering from Obstetric Fistula
Frequency
Percentage
Hopelessness
52
10
Sadness
162
33
Suicidal ideation
5
1
Loss of self-worth
116
23
Shame
23
5
Social withdrawal
139
28
Total
497
100
The study results in table 3 above show that most victims (33%) experienced sadness, followed by shame (28%)
and then loss of self-worth (23%) as psychological effects of fistula. Although suicidal ideation had a small
percentage, as a psychological effect, it is an indication of the magnitude of the problem of fistula among young
women. This result corroborates the study [36] conducted in Zimbabwe. It revealed that women with obstetric
fistula faced the following psychological problems: helplessness, sadness, suicidal thoughts, stigma and blame,
feelings of worthlessness, fear, shame and social withdrawal. Similarly the results also agree with another study
in Kaptembwa –Nakuru, Kenya, which revealed that loneliness, separation and despair were the major effects of
fistula among the victims [37]. Other than collaborating finding from this gives insights on how family
members are affected by fistula survivors. The strained relationship between the survivor and her family
members shows how those family members feel about the client’s situation. This, therefore, indicates that the
fight against fistula cannot be won unless it is addressed by a comprehensive and holistic strategy targeting the
client, her family and immediate community members with effective and structured psychosocial support
services.
5. Conclusions and Recommendations
5.1 Conclusions
Obstetric fistula has remained one of the most devastating complications for one to experience in the course of
International Journal of Sciences: Basic and Applied Research (IJSBAR) (2016) Volume 26, No 1, pp 395-404
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delivery in Kenya. With many mothers not having access to skilled delivery, the incidences of obstetric fistula
may be higher than expected given the rampant prevalence of acute poverty and low literacy levels in western
Kenya. Many of these women suffer long term morbidity and often become social outcasts in their societies.
They experience psychological consequences such as sadness, shame, loss of self-worth and suicidal tendencies.
Socially, they suffer from stigmatization, social worthlessness and social isolation. They are simply social
outcasts in their communities.
5.2 Recommendations
i. There is need to address negative cultural practices that contribute to obstetric fistula. Communities
should be sensitised about fistula to re-integrate fistula victims or survivors in order to reduce the
stigma and improve the support structure for fistula survivors.
ii. Organisations implementing fistula interventions should offer effective psychosocial support services
to fistula clients who should include counselling services and skills / vocational training sessions to
fistula victims and survivors on issue that can affect their mental and social well-being.
iii. The government should encourage male involvement in fistula repair and management as they exert a
huge influence in the health matters of women.
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