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Walden University
Background of the Study
According to the World Health Organization, obstetric fistula is an abnormal connection between
the vagina, rectum and/or bladder which may develop after prolonged and obstructed labour and
lead to continuous urinary or faecal incontinence. A hole between the urinary bladder and the
vagina is regarded as vesicovaginal fistula whereas a hole between the rectum and the vagina is
known as rectovaginal fistula (Tunçalp 2015). Obstructed labour is one of the leading causes of
maternal mortality in developing countries and with it, comes other morbidities, the most
devastating being obstetric fistula. It is estimated that for every maternal death, 20-30 women
develop serious obstetric complications including fistula. These women, apart from surviving the
ordeal of obstructed labour, face the physical and psychosocial challenges of living with obstetric
fistula (Ahmed 2015).
The World Health Organization (WHO) estimates that there are at least 2,000,000 women living with
obstetric fistula and an annual incidence of 50,000 to 100,000 cases in the world, although almost no
population-based surveys on fistula have yet been undertaken and data remains scarce (WHO 2006).
Estimates suggest that at least 3 million women in poor countries have unrepaired vesicovaginal
fistulas, and that 30,000-130,000 new cases develop each year in Africa alone (Wall 2006).
It is estimated that 13.2 percent of genitourinary fistula results from provider error. In one
review, four out of five iatrogenic fistulas developed following surgery for obstetric
complications: cesarean section, ruptured uterus repair, or hysterectomy for ruptured uterus.
Hysterectomy was the most common gynecological procedure leading to fistula (Raassen 2014).
Difficulties in estimating incidence and prevalence rates arise from the fact that most cases occur
in remote geographical settings, the condition is rare and the fistula victims are often ostracized
(Tuncalp 2015). While the most cited incidence is 1 to 2 per 1,000 deliveries and a
corresponding estimated worldwide incidence of 50,000 to 100,000 new cases annually, the
methodology used for these estimations has been challenged.
In the first half of the 20th Century, maternal mortality underwent a precipitous decline
throughout Britain, Canada, the United States and other developed nations particularly the
European nations following improvement in maternal care (Loudon, 1992). This meant that the
obstetric fistula vanished from the clinical and social experience of the Western world. Though
Vesico Vaginal Fistula (VVF) was once common in Western Europe and the United States, it’s
virtually unknown in these regions today. According to Lewis 2006) fistulas found in the
industrialized countries are caused by radiation therapy for malignant diseases or through
accidental surgical injury to the bladder during hysterectomy (Lancet, 2006).
In Sub-Saharan Africa alone, a recent review of obstetric fistula symptoms from demographic
health surveys and multiple cluster indicators surveys (MICs) showed that fistulas were most
often pregnancy-related, followed by pelvic operations and sexual assault (Maheu- Giroux
2015). Maheu-Giroux et al. (2015) noted that the prevalence of women in DRC reporting that
their fistula was a result of sexual violence which was the highest prevalence of sexual-assault-
related fistula, compared with an overall prevalence of 4.3%.
In Kenya, about 3000 fistula cases are estimated to occur every year with an incidence of 1/1000
women (UNFPA, 2006). The national incidence of obstetric fistula is estimated at 5,300 new
cases every year with only 15% receiving treatment. This has created a backlog estimated at
300,000 (MOPHS and MOMS, 2010).
Problem Statement
Many women have VVF’s and might need to be repaired globally. In Kenya there is an estimated
1000 obstetric fistula (OF) new cases each year, with only 7.5% currently treated (UNFPA, 2004).
But even after the introduction of free maternity services, cases of obstructed labour leading to
vesico vaginal fistulas in Kenya are still occurring. The Kenyatta National Hospital serves as the
referral point of fistula management department with other new cases of Vesico- vaginal fistula
happening every day. It is therefore for this reason that there is an indication for a study to be
conducted to find out the contributing factors of vesico-vaginal fistula in Kenyatta National
Hospital. The study is supported by the data in table 1.1 showing the number of vesico- vaginal
fistula cases per a 1000 thousand deliveries who attended clinic 66 at KNH from June to
December 2014.
Table 1.1
JUNE 161 12.9 16.1
JULY 163 13.1 16.3
AUG 174 14.0 17.4
SEP 184 14.8 18.4
OCT 184 14.8 18.4
NOV 185 14.9 18.5
DEC 195 15.7 19.5
TOTAL 1246 100
Justification of the Study
The purpose of this research is to determine contributing factors of vesico vaginal fistula at
Kenyatta National Hospital. The research aims to identify the demographic factors, economic
factors and socio-cultural factors contributing to Vesico vaginal fistula at KNH.
Vesico vaginal fistula has physical, psychological and social consequences to the mother, the
family and the community as a whole. Obstetric fistula has been the most devastating of all
pregnancy complications. The continuous leakage of urine causes a bad odour which may lead to
isolation divorce, stigmatization and rejection by the society. The victim does not engage in
economically gainful activities due to the low self-esteem and the stigmatization thus becoming
an economic burden to the society. They are also a burden to the health care system because
fistula repair is expensive. Vesico vaginal fistula also leads to high maternal mortality rates in the
This study on Vesico Vaginal Fistula is therefore very important as it will help local and
international health organizations, government and Ministry of Health to identify factors that
cause VVF during deliveries and define ways to reduce VVF prevalence.
The study will also create awareness of VVF among members of the society on prevention,
control of obstetric fibula and taking care of the victims of this maternal complication.
Research questions
i) What are the demographic factors contributing to the occurrence of vesico vaginal fistula at
Kenyatta National Hospital?
ii) What are the economic factors contributing to the occurrence of vesico vaginal fistula at
Kenyatta National Hospital?
iii) What are the socio cultural factors contributing to the occurrence of vesico vaginal fistula at
Kenyatta National Hospital?
Significance of the study
The study results will help to reduce the physical, psychological and the social effects of vesico
vaginal fistula that VVF patients undergo due to isolation, divorce and stigmatization.
The study will also help in reducing the maternal mortality in the country because development
of obstetric fistula is directly linked to one of the major causes of maternal mortality- Obstructed
It will also help medical staffs to understand the contributing factors of fistulas at KNH and
improve on medical attention they give to these patients.The hospital management team, health
organizations and other stake holders will also incorporate the study results to reduce and bring
into control the prevalence of VVF in the country. Findings of this study will also contribute to
the body of knowledge by providing more literature on factors causing VVF and help future
medical researchers design better medications.
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