A fistula is an abnormal connection or passageway between two organs or vessels in the body. These connections can occur in various body parts, such as the digestive tract, urinary system, or even between blood vessels. Fistulas can develop due to various medical conditions, infections, trauma, or surgery. Though fistula is mostly associated with giving birth, there are different types of fistulas including Gastrointestinal Fistula, Vesicovaginal Fistula (VVF) , Rectovaginal Fistula (RVF) and Obstetric Fistula. Patients with fistula require surgery to correct the abnormal connection of body organs for improved quality of life.
In most African settings, fistula is often associated with witchcraft and is perceived as a divine punishment for involvement in morally unacceptable activities. Those affected by this condition often face stigmatization and discrimination, leading some to endure significant hardships.
Fistula surgeries in Kenya are very expensive, ranging from Ksh100,000 to 150,000. Further, the number of qualified surgeons is less than 15 with only three authorized to tackle complex surgeries.
Consequently, there is always a backlog of patients waiting for surgical procedures. Makueni County, located in the former Eastern Province, shares a common challenge with other Counties in Kenya, dealing with the backlog issue, which results in many women leading lives marked by stigma and hardship.
Fistula cases are extremely sensitive and frequently concealed. Women afflicted with birth-related fistulas often tend to withdraw from social gatherings and employment, resulting in depression and isolation. Some even neglect basic bodily needs like drinking water and eating, fearing uncontrollable soiling of their clothing.
Previously, due to the absence of records regarding the number of women suffering from fistula, especially those who choose home deliveries with Traditional Birth Attendants, the County lacked the necessary data to advocate for any action. The County only permitted willing medical donors, such as Amref, to establish temporary tent camps for treating such cases. As these medical camps were highly unsustainable, typically operating for only a few months, the data collected from them motivated the County to implement strategic initiatives.
These initiatives included establishing a walk-in clinic at Makueni County Referral Hospital Level 5 Hospital, raising awareness, providing counseling for stigmatized women, offering free surgeries and conducting home visits to check on the affected women.
Implementation of the practice
Following a medical camp organized in 2019 by Amref Flying Doctors and Safaricom, the County acknowledged the imperative need to formulate a sustainable strategy for the resolution of the fistula challenge.
In May 2022, the County Department of Health convened a series of meetings involving different stakeholders, including Jhpiego, to deliberate on and devise multiple strategies aimed at reinstating the dignity of mothers and helping women suffering from fistula.
The shortage of trained medical professionals posed a significant challenge that demanded attention. To address this issue, in February 2023, the County enlisted a surgeon, an anesthetist, a counselor, and other medical experts for training at Gynocare Women's and Fistula Hospital in Eldoret.
Given the absence of a tailored Kenyan curriculum for training such medical professionals, the County opted to have them trained using the International Federation of Gynecology and Obstetrics (FIGO) curriculum. Simultaneously, they embarked on a mission to develop a Kenyan curriculum in collaboration with the Ministry of Health (MoH), seven other fistula surgeons, Amref Flying Doctors, the Fistula Foundation, UNFPA, Kenyatta National Hospital (KNH), and the University of Nairobi.
From July 31st to August 2nd 2023, the team conducted a workshop to create an Obstetric Fistula repair curriculum. Jhpiego assisted in the curriculum development by proposing two supplementary modules, "Advanced" and "Expert," to enhance the curriculum. Currently, the curriculum is undergoing the submission process for approval by the medical board.
As a result of this training, Makueni County has gained an additional Obstetric Fistula-qualified surgeon who can repair simple fistulas (Level 1) and refer complex cases for support from expert surgeons.
On March 27, 2023, the County Government initiated routine fistula services at the hospital, as part of the Gynecology Department. During the inaugural week of the program, the team performed successful free surgeries on 27 women. From March to October 2023, the County has extended its services to more than 120 women in need of fistula-related repairs. Further, the County provides a weekly screening program each Tuesday as a strategy to fight Obstetric Fistula.
To ensure comprehensive care for patients after their hospital discharge, the County dispatches teams to conduct home visits and monitor the patient's progress. This proactive approach enables the medical team to promptly address any potential recurrence of fistula by arranging for immediate hospital visits if necessary.
Further, the County has implemented a continuous campaign strategy to enhance awareness, which includes engaging journalists to cover success stories associated with fistula and educating the local community to reduce stigma. The County has created a database of 38 fistula champions who have received counseling and are willing to speak openly about fistula-related issues, to motivate others to seek medical assistance.
This initiative is aligned with the County's prospects to enhance the health sector articulated in the CIDP.
Click the link below to learn more about this initiative