Fistula a cause of isolation and stigma

May 25, 2013

She had prolonged obstructed labour and could not deliver her first baby normally. She was delivered by Caesarean section to save her life but it was too late to save the baby.

By Agnes Kyotalengerire
 
Real life
She had prolonged obstructed labour and could not deliver her first baby normally. She was delivered by Caesarean section to save her life but it was too late to save the baby. 
 
After operation, a catheter was fixed to drain urine and that marked the end of 23-year-old Christine Katusabe’s passing urine normally.
 
When the catheter was removed, Katusabe realized she was leaking urine. “I was advised to go home and return to hospital for treatment after I had healed,” she recalls.
 
“It was a horrible experience. The continuous leaking of urine made me stink and I would use pieces of clothes to pad my-self,” Katusabe narrates her tribulation.
 
However, one month down the road, the situation became unbearable for Katusabe’s husband.  
 
“He packed his bags and left me in the house. I have never seen him since,” she recounts. She says she felt dejected and hated herself.  
 
For the last eight years Katusabe has been confined to her house for fear of being ridiculed. 
 
Unable to bear the pain and isolation anymore, last year Katusabe decided to go to Kitovu Hospital in Masaka where she was diagnosed with a big hole on her urethra, a condition the health workers referred to as fistula. 
 
Though the hole was repaired Katusabe did not heal fully. And when she had about a fistula camp at Hoima referral hospital, she knew it was her time to seek help and rushed to the hospital. 
 
She was admitted and is among the 26 women (out of the 80 diagnosed with fistula) who haveundergone fistula repair in the on-going camp at the hospital. Katusabe is optimistic that soon her problem will be no more and she will be readily accepted in her community.
 
What do fistula experts say?
As Uganda joined the rest of the world to mark the first-ever International Day to End Obstetric Fistula on May 23, experts say fistula is still a major public health problem in Uganda, causing stigma and isolation among the affected women.
 
Dr Fred Kirya, a senior consultant surgeon and urologists at Soroti Referral Hospital, also on the team conducting the on-going fistula camp at Hoima hospital, says fistula is a huge health challenge in the western region, affecting especially the poor people.
 
“The number of patients coming to seek treatment is overwhelming. Though the target is to repair 80 women, in the last three days we have treated 26 women. 
 
Over 50 women have been screened, confirmed with obstetric fistula and are awaiting  surgery,” Dr Kirya said.
 
 The hospital director, Dr Francis Mulwanyi, is optimistic that the fistula camp that started on the 20th and runs up to 31st May will benefit the poor affected women.
 
“The cost of repairing a fistula is about $300-$400 (about sh780, 000 to sh104,000) an amount the majority of the patients cannot afford,” Dr Mulwanyi affirms.
 
Dr Kirya says majority of cases registered with obstetric fistula at the camp are women in the productive age of between 15 to 49 years, with a history of unattended prolonged obstructed labour.
 
Aside, Kirya says the high numbers of fistula cases in the region confirm the poor health indicators and high maternal mortality rate in the region.
 
Stella Mpanja, a senior nursing officer and fistula counselor at the hospital, attributes obstetric fistula in mothers below 20 years to high teenage pregnancy in the region
 
Other regions with high numbers of women affected by obstetric fistula include: Lango sub-region (Lira, Apach), Nebbi, Bugishu and Rwenzori regions. Kirya attributes it to poor terrain making it hard for the women to access health facilities in time.
 
How big is the problem?
Globally, it is estimated that about 2 to 3.5 million women may be living with fistula with 50,000-100,000 new cases occurring annually, most of which are in the sub-Saharan Africa and Asia.
 
In Uganda it is estimated that about 2.0% of women are suffering from obstetric fistula which comes to about 140,000 to 200,000 women, (Uganda Demographic Health Survey 2011report.)
 
With maternal interventions put in place by ministry of health in partnership with developmental partners like UNFPA, EngenderHealth, AMREF and other stake holders, out of the backlong, about 2,000 repairs are done every year.
 
However, Dr Peter Mukasa, the technical specialist Fistula Prevention and Management working with UNFPA and the health ministry says with poor health practices like reluctance to attend antenatal care and deliver in health facilities coupled with difficult delivery, about 1,900 new fistula cases keep coming up annually. 
 
“This is an indicator that our health system is still lacking,” Dr Mukasa says.
 
 He blames the trend on a good number of women affected by fistula not receiving the treatment required hence leaving a huge backlog in the communities.
 
“Even those who are able to seek treatment have to travel long distances to repair centres and wait for weeks to get repaired due to various constraints like a heavy backlog of cases, few surgeons, shortage of supplies and equipment,” he says.
 
Dr Kirya says in this modern time no woman should develop obstetric fistula because it is a totally preventable condition. 
 
He, however, says elimination of obstetric fistula requires collective effort and everybody has a role to play.
 

What is obstetric fistula?
 Dr Kirya describes an obstetric fistula as an abnormal opening between the vagina and the bladder/ureter or rectum of a woman that results in constant leaking of urine or faeces through the vagina.
 
Causes
Most of obstetric fistulas are caused by prolonged childbirth lasting more than 24 hours. “The pressure from the baby’s head injures the tissue in the birth canal creating a hole between the birth canal and the bladder or rectum,” he explains, adding it is the hole in the birth canal that causes continuous and uncontrolled leakage of urine, faeces or both.
 
A mother being counselled during the fistula screening process at the on-going  camp at  Hoima referral hospital
 
Who is at risk?
Dr Kirya says any woman could be at risk of fistula during delivery if she experiences prolonged labour and is not assisted by a skilled health care provider who can recognize complications and quickly take action.
 
He adds that young women who give birth before 20 years are at a greater risk of fistula because their pelvic bones are not fully developed. 
 
“As a result the baby may not be able to pass through the birth canal as quickly as is required thus injuring the tissue,” he explains.
 

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