An Exploratory Study of Reintegration of Women Following Obstetric Fistula Surgery in West Pokot,Kenya

Abstract

Globally, obstetric fistula has been eradicated in developed countries although it continues to pose challenges to women living in sub-Saharan Africa and Asia. The condition continues to contribute to maternal morbidity in Kenya, causing immense physical and psychological suffering and disrupts women’s socioeconomic life. Following corrective surgery, experiences of Pokot women in their quest for social reintegration, a broadly neglected aspect of their healing process, are documented in an exploratory study. Primary data were collected over a 2-month period in rural Kenya using in-depth interviews with women who had undergone surgery and key informants. Thematic data analysis based on grounded theory revealed avenues for reintegration including successful surgery, family and community support, counseling, follow-up care, income generating activities, and skill training.

Introduction

Obstetric fistula is a maternal condition caused by obstructed labor that leads to pain and disability to patients (Gwyneth & Bernis, 2006). Globally, it is estimated that more than two million women are living with obstetric fistula (Vesico Vaginal Fistula [VVF]) with an additional 50,000 to 100,000 new cases each year (WHO, 2005, 2010). The condition is most prevalent in sub-Saharan Africa and Asia.

Urinary and fecal incontinence associated with the condition often results in social stigma and isolation of the patient. The prevalence in West Pokot is estimated at one in every 1,000 women (Mabeya, 2004) although the national prevalence in Kenya is 1% (Kenya National Bureau of Statistics, Ministry of Health, National Aids Control Council, Kenya Medical Research Institute, & National Council for Population and Development, 2015). The illness typically affects women and girls who are young, illiterate, and with little or no access to emergency obstetric care, and in cases where referral system is inefficient (McFadden, Taleski, Bocking, Spitzer, & Mabeya, 2011).

Obstetric fistula often causes suffering and misery in the lives of women. The women suffer symptoms of constant leaking of urine and feces, infections, bladder stones, and infertility (Rochat, 2011). Psychologically, women also suffer from depression and emotional loss (Khisa et al., 2011) in addition to loss of dignity and self-identity and interrupted social roles as women (Mselle, Moland, Evjen-Olsen, Mvungi, & Kohi, 2011). Social stigma poses a challenge to the women in addition to economic constraints posed by the illness (Khisa & Nyamongo, 2012; Roush, 2009). Divorce and separation often occur following the illness (Roush, 2009; Yeakey, Chipeta, Rijken, Taulo, & Tsui, 2009), further complicating the lives of women with the condition. Thus, their social well-being is compromised as they may no longer freely participate in gender roles as before the illness owing to the physical illness and societal beliefs and stigma that the condition attracts.

The condition is treated by corrective surgery. In spite of the successes recorded from corrective surgery, the women continue to suffer from social isolation, and gaining entry into their disrupted social networks is often a long and arduous journey (Khisa & Nyamongo, 2012). There is now a growing literature on the period following corrective surgery albeit few studies examine their social reintegration (Turan, Johnson, & Polan, 2007; Yeakey, Chipeta, Rijken, Taulo, & Tsui, 2011). The author attempts to add to this growing corpus of literature with an examination of context-specific reintegration needs of a group of women while incorporating the views of health care providers in the region. The focus on the challenges women face in environments with limited access to health care personnel provides insights into how fistula programs may ameliorate these challenges.

Method

Study Settings

The study was done in 2010 in West Pokot, a rural district in north western Kenya. The climate is semi-arid. The district has a dilapidated road network and little motorized transport. The area is mainly inhabited by a nomadic pastoralist tribe of the Pokot people. There are few and widely dispersed health facilities. Consequently, the majority of inhabitants rely on traditional healers during illness, and women rely on traditional birth attendants during labor.

Two facilities serve as referral for obstetric emergencies: one government district hospital and one mission hospital, both located at the extreme southern edge of the expansive district. Sentinelles NGO based in the district sponsors fistula surgeries at the Ortum Mission Hospital conducted by visiting surgeons from African Medical and Research Foundation (AMREF) and Moi Teaching and Referral Hospital. The NGO also conducts follow-up visits for the women in their homes following discharge. Using Sentinelles as the entry point, eight women were interviewed: four during home visits, three when they paid visits to the NGO offices for further help, and one rescued woman who was residing at the NGO premises after being chased away by her family. Key informants were identified from the community, NGO, and health facilities serving women with obstetric fistula in the region.

Data Collection

Using Sentinelles as the entry point, eight women who had undergone surgery were interviewed using an in-depth interview guide: four during home visits, three when they paid visits to the NGO offices for further help, and one rescued woman who was residing at the NGO premises after being chased away by her family. Information about their experience with obstetric fistula and the factors that influenced their reintegration after surgery was sought. Key informant interviews were held with people involved in direct care of fistula patients in the district including two of the following: nurses, social workers, surgeons, and former traditional birth attendants who were currently voluntary advocacy members. Key informants provided validation of data provided by the women and offered expert insights into this topic in an area that they have worked for varied periods ranging from 3 to 10 years.

The study participants were interviewed to obtain information regarding two main research questions:

• Research Question 1: What factors influence the social reintegration of obstetric fistula survivors?

• Research Question 2: How might we improve the effectiveness of the reintegration process for fistula survivors?

The in-depth interviews were taped, transcribed, and translated with the help of a native Pokot speaker. Data were analyzed thematically following grounded theory approach (Strauss & Corbin, 1990). Thematic data analysis was done through initial reading of the transcripts to identify categories and themes using inductive coding. The emerging themes from transcripts were identified and are presented in the “Results” section of this article. Ethical approval from the Kenyatta National Hospital/University of Nairobi ethics research committee was obtained, and a research permit was granted by the Ministry of Education, Science and Technology. The study participants gave verbal consent after being informed of their rights in relation to the study. Those who required further support were enrolled with Sentinelles NGO, which assists women with obstetric fistula in West Pokot. All participants’ names have been changed to ensure anonymity.

Study Results

The women were aged between 17 and 30 years. Four of the women were healed, whereas the other four were still incontinent of urine and were awaiting further surgery. Only two women had children, the other six had no surviving children because the fistula occurred during their first baby, except in one case who had developed fistula in two consecutive pregnancies. Two were married, two had never been married, one was separated although living in the same compound with her husband, and three were divorced. The interviews occurred 3 to 36 months after corrective surgery, and all women’s surgery and follow-up had been sponsored by Sentinelles, AMREF, and Ortum Mission Hospital. All women interviewed had undergone more than one surgical operation: four of them were healed, whereas four others were still incontinent of urine.

Interviewing both women survivors and key informants elicited various reintegration needs for women following fistula surgery. These findings provide insights into what women experienced as they sought social healing after obstetric fistula corrective surgery and their opinion on what services ought to be in place to aid their social reintegration. The women identified services that would significantly improve the process of their reintegration in the community to include family support, counseling, income generating activities, skill training, successful surgery, and government support.

Family and Community Support

Generally, a patient having support from the members of the family, for example, a mother to the patient, was deemed to have played a positive role on their reintegration. Notably, all survivors except one had at least one family member sympathetic to their plight and who supported and encouraged them. Often, this supportive family member came from the natal rather than the matrimonial family. The importance of family support is best illustrated by Chepengat, an obstetric fistula survivor who was 17 years old and single at the time of interview. Chepengat lived with her mother following her fourth VVF surgery.

I persevered; nothing was of help at all. My mother she encouraged me saying it is not my fault, my father is passed away. The community kept away. When neighbours talked about me behind my back after the surgery, the stigma was there but I would mingle. I have my own friends though despite the stigma. I could not get any counselling after discharge; it was only in the hospital that they counselled me. I could have benefited if they continued counselling and exercises after I went home. I have not received any training but I make charcoal and sell to make money. It has helped me to buy maize, soap and food. (Chepengat, 17 years, single)

Another survivor explained the importance of family and community support among other factors vital in regaining the normal life she had before the fistula illness:

I also believe an income generating activity can assist me. I think I can start selling vegetables in my place. My family, once I am well repaired I will win my love from my husband and make plans for our family together. The community should work communally with me as we used to. Like mkandaa [Women’s merry go round] I would be very happy if they did. I think counselling will be good and I may need it. I may also like to train in making handicrafts maybe gourds to store milk. (Katiraya, 26 years, separated)

In general, key informants felt that the family should support the survivor by offering them unconditional acceptance and help in reintegrating the fistula survivor through supporting her in education and income generating activities. The family can also help in getting the patient to the hospital for repair and subsequent follow-up visits. Above all, it was felt that the family should accept the fistula survivor, given the fact that most survivors are ostracized and neglected. A key informant (KI) described both supportive and unsupportive family scenarios in this excerpt:

Some stay well and are helped by their parents though others are neglected. There are two types of neglect here, by parents and by the husband. We tell the family not to stigmatise her. They should show her love and accept her as their child, just like the rest. We tell them if they stigmatise her she won’t live well. They should celebrate her being alive then help her start a business. They shouldn’t also accept to marry her off too quickly. (KI 05, Traditional Birth Attendant [TBA]/Voluntary Advocacy Member [VAM])

According to a key informant, the community support role is twofold: accepting back the survivors as well as being aware of the contributing factors to the formation of obstetric fistula so that they can prevent it. They further explained that “childbirth is a community affair amongst the Pokot people” (Key Informant (KI) 01, VVF surgeon) demonstrating the centrality of community role in both preventing the occurrence of fistula and helping reintegrate the women after surgery.

According to a social worker and a VVF nurse, the use of local elders, Sapana tribe festivities, Barazas (meetings), and use of faith-based organizations such as churches were deemed as culturally appropriate ways of passing information about fistula and reducing stigma. In these forums, messages on VVF may be intertwined with other topics such as early forced marriage and female genital mutilation.

Social stigma was felt to negatively affect the reintegration of women into the community following corrective surgery. This stigma must be dealt with in reintegration efforts because although subtle, it may seriously impede the survivors’ healing. A social worker explained,

The effect is much in that when we meet them in the village she looks like she is not feeling well. She does not have friends. The friends are not there who can give her moral support. Then also the family kind of discriminates her by not taking care of her well. If she wants transport to come to the office for a review or anything of the sort, like they would not let her. ( Social worker, KI 07)

The women who undergo surgery after discharge are accepted to society after a ritual is performed as described by a nurse:

What I know most of these women don’t go back to their husbands unless a cleansing ceremony is done. Otherwise they belief she still has a bad omen that she can still leak [urine] if married by another person. Just to show that this person is free and can be married by another person. But with the help of Sentinelles group I don’t think that practice is still there. ( Nurse, KI 06)

Counseling

Survivors begrudged the lack of counseling services as one of the factors that hampered their reintegration. Several survivors pointed to the fact that they would have liked to utilize and benefit from counseling after discharge. Often, participants intertwined their thoughts on what in their opinion were best strategies of reintegrating one back into society after reparative surgery. These strategies are illustrated in the excerpt below from an in-depth interview with a participant who at the time was studying a tailoring course at a polytechnic:

To reintegrate, advice [the woman] on how to live, go back to her husband but be told on how to live . . . abstain [from sexual intercourse] and check on when to give birth. The government could look at the state of the household, money, food depending on what she needs she should be helped. Another thing is to be taught and be talked to (counselling). This way they can teach other survivors and be role models. For me my training is important. Education comes first, I want to finish the course am doing. Another thing is if I got a small salary. My job would prevent me from having many thoughts, of thinking I need this or that. Or if one opened a business for me, would I have thoughts? (Chepkiror, 24 years, divorced)

The importance of counseling was corroborated by key informants. A surgeon who has worked with fistula patients for close to 4 years explained that some family members, especially the spouse, may need counseling to be able to accept survivor. They provided expert opinion on the issue of counseling:

Even counselling is a major issue, they [NGOs] have been trying but they’re still not having it right. They just have somebody to talk to them but you know it’s not like they have a counsellor attached to them. They ask someone in the hospital to do it and in our hospital counselling is part of community [health]. They say that every nurse should be trained on how to do counselling. So when you make it that amorphous at times in the crisis, pregnancy etc. the first thing that comes to your mind is a psychiatric nurse when you think about counselling. Then if you ask the leadership they tell you every nurse should be a counsellor! So you see that every now and then. So I can say that I’ve had a problem, I send them [fistula patients] back to the NGOs, they look for this nurse who is a psychiatric nurse, who does not work with them full time. (VVF Surgeon, KI 01)

Couple counseling concerning the corrective surgery and encouraging support from the husband is very vital as seen in this explanation: “Surgery helps them . . . we advice them to abstain, but husbands don’t cooperate. We attempt to counsel the husbands in Ortum. But some don’t cooperate” (Traditional Birth Attendant, KI 05).

Income Generating Activities

Being able to conduct an income generating activity was perceived by survivors as a factor that boosted their ability to lead a normal life after corrective surgery. Participants gave examples of agricultural and business activities they had engaged in that enhanced their reintegration. Often, discussions of economic support and livelihood led into participants suggesting suitable skills and other forms of training that would help them generate income. Cheptoo, a beneficiary of capital to start a vegetable business, explained how this had helped her:

When somebody is better they can plough maize and sell . . . there is no otherwise until they’re assisted and come up to manage on their own. They should be supported in a small way. For instance I was given Ksh. 100 and I sold up to Ksh 2, 000 to get to be self-reliant. (Cheptoo, 23 years, separated)

Similarly, a woman who had been assisted by the church to start a ballast business after fistula surgery observed that this was useful to her reintegration.

The church has helped me. I have stopped many cultural practices. When I got healed I had good strength. I started ballast business and had money for clothes; I had better thoughts and clear thinking. After operation we were taught on how to support ourselves. With family we relate well but no form of support since I am stable now. But they are not able to financially assist. They have loved and owned me. I have settled well. I think when you have money they will not isolate you so having capital to do business is a good thing. (Cheptiros, 20 years, divorced)

A social worker gave practical insights into how women may be assisted to generate income and be self-reliant during reintegration drawing from their experience. Notably, given the low literacy and numeracy skills of some women, they may benefit from capital that enables them do goat rearing instead of being given cash money.

Training

The participants often expressed the desire to acquire formal education and skill training. One participant who was undergoing training at the polytechnic attributed her social reintegration to be positively influenced by her training. She had this to say about her training:

The work of your hands is blessed and can help you. I would say if I had a job I wouldn’t suffer the way I did. Like now I have gone for tailoring and it has helped me. If I had someone else to donate money to start my clothes business I would be very happy. (Chepkiror, 24 years, divorced)

Despite survivors reiterating the need for skill and vocational training, this training may not be feasible to a large number of them owing to several factors highlighted by a key informant. First, most of these women have little basic education hence insufficient capacity to grasp most courses taught at polytechnic. Second, some are married, and to participate in such training, they would need consent from their spouse, which may not be easily achieved. Furthermore, such training would interfere with their gender roles as married Pokot women. Skill training in this study was considered feasible in circumstances where the survivor had adequate basic education and was separated from the spouse as in the case of Chepkiror or single. Training in making handicraft may require less formal training but needs careful consideration of available raw materials in the environment. A social worker who has worked with fistula survivors for more than 3 years explained the possibility of skill training after surgery in the excerpt below:

You know the level of literacy contributes to that [skill/vocational training]; the success of it or the failure of it. As I told you most of the girls are married. And apart from that they are illiterate. They have not gone to school. We are talking about primary standard one, two dropouts. So taking them to vocational training is very hard. That is point number one, illiteracy. Secondly the husband might not allow her to go for that. So those strong forces or factors may hinder them to go for vocational training. (Social worker, KI 03)

Surgery

Participants emphasized the importance of corrective surgery to women suffering from the condition. On answering this question, most participants quickly reverted to surgery, explaining that this was the first and most important step toward a normal life. The success of the surgery and subsequent continence was seen as the first step to reintegration, and unsuccessful repair seen as leaving the women in the same or worse off state of alienation. This sentiment is captured in the following excerpt with a survivor who had undergone multiple unsuccessful repairs:

Operation is the only solution. As long as an operation is not forthcoming you are still abandoned and discriminated. What is good is for us is support on income generating activity and counselling on safe sex and abstinence to give proper healing. Like I was told to stay 6 months before sex and get a baby after 2 years and I go to antenatal care at 3 months then go to hospital to delivery at 8 months; I cannot stay at home as it will cause obstructed labour and another fistula. I found what helped me most was the combination of these as one strategy alone is not enough. (Chepengat, 17 years, single)

A participant who was at the time of interview separated from her husband stated that her unsuccessful attempt at reparative surgery was a hindrance to getting back to her marriage and normal life.

Government Support

Key informants stressed the government’s role in prevention of the condition, although the interviews sought to elicit the government’s role in supporting women who have already undergone corrective surgery. Government support concerned with immediate management of women living with fistula included making fistula surgery free for the patients and opening fistula repair centers and training more surgeons, nurses, physicians, managerial staff, and social workers to manage fistula patients. This quote from a social worker who was a key informant in the study best captures the need for a holistic approach to obstetric fistula and the need to involve the relevant government ministries in providing essential obstetric care services closer to the villages.

There isn’t much I can say except that we have to involve everybody. I think the government should play a major role in containing fistula and its causes. Like providing all the medical facilities a village or a setting should have. Then also we have the issue of sensitization. We should put more effort on sensitizing the community on fistula, its causes and the way forward on it. Then lastly, from the parts we have seen fistula does not happen they have embraced other cultures. So I think it is also good for those who are still practicing the Pokot culture, the Pokot think it is good for them, it is harming them a lot. (Social Worker, KI 07)

Other government roles elicited include improving infrastructure to reduce distance traveled by mothers in labor, addressing health system factors such as improving the number of health personnel, improving health facilities to handle comprehensively emergency obstetric cases, and availing ambulances to transfer obstetric emergency cases during referral.

NGOs require support and collaboration with government. Similarly, the community may be willing to support the survivors; they in turn need to be facilitated to do so because it is expensive to maintain normal hygiene and balanced diet for her. A key informant explained this situation further:

I don’t think all NGOs help these women. The idea of them living and waiting at the Voluntary Advocacy Member (VAM) home is good but what if I have no soap or sanitary towels? The VAM may not have the resource to help the woman, which is difficult. We had girls who were fleeing forced marriage. But Sentinelle lacked a place to keep them. We stayed with them but after three or so months we returned them back to their parents. (KI 05, Traditional Birth Attendant/VAM)

Discussion

Obstetric fistula is increasingly being studied in Kenya albeit mostly in form of facility-based studies (Khisa et al., 2011; Mabeya, 2004; McFadden et al., 2011) and population-based studies (MOH & UNFPA, 2004; Mwangi & Warren, 2008) with results showing that women who suffer from the condition face physical and psychological symptoms and socioeconomic challenges. Follow-up studies to evaluate the postsurgical period conducted in the African region include Turan et al. (2007) in Eritrea; Nielsen et al. (2009) in Ethiopia; and Pope, Bangser, and Requejo (2011) in Tanzania. The follow-up studies have provided insights into the needs of fistula survivors in the period following corrective surgery. This section discusses the study findings, drawing reference from these studies while situating the reintegration of women in the broad context of women’s reproductive health.

In the study, the success of surgery and subsequent continence was seen as the first step to reintegration, and unsuccessful repair seen as leaving the women in the same or worse off state of alienation. Similarly, Pope et al. (2011) demonstrated that women who have residual symptoms of weakness, pain, and urinal incontinence after surgery find difficulty in reintegration in Tanzania. Surgical repair, therefore, has an important role in the life of a woman living with obstetric fistula for two main reasons. First, surgery gives a fistula patient hope of recovery improving her mental state. Second, it regains continence and affords the woman freedom to interact with the general community. Thus, it is seen as the first step toward reintegration. For instance, the women with residual symptoms in the Tanzania study perceived themselves as not yet healed and reported a low perception of their quality of life (Pope et al., 2011). The current study did not directly measure quality of life although it points to better social reintegration among women with successful repair in the post-corrective surgery period. Nielsen et al. (2009) demonstrated that successful surgery improved quality of life and social reintegration to a level comparable with the pre-fistula state among women in Ethiopia.

Participants felt that psychological and moral support is essential to the reintegration of women following fistula surgery. The need to receive counseling services is not a finding unique to this study. A study conducted in Eritrea among fistula patients established the need for a standardized counseling program for fistula patients (Turan et al., 2007). In a later study in Eritrea, Johnson et al. (2010) demonstrated a significant and positive impact of a formal counseling program on fistula patients. The study aimed to evaluate the short-term impact of pre- and post-surgery counseling by trained counselors established that counseling improved patients’ knowledge on fistula, improved their self-esteem, enhanced their mental health, and helped them have positive behavioral intentions (Johnson et al., 2010). My study further confirms the vitality of counseling given the psychological burden the illness places on women and social stigma associated with it. The study findings suggest that women are likely to benefit from counseling that focuses on return to normalcy, possible return to fertility, or dealing with permanent loss of fertility and couple counseling. The counseling sessions may be followed by information, education, and communication on exercise, hygiene, adequate intake of water, and nutrition.

Several scholars have demonstrated the importance of family and community support to the reintegration of fistula patients (Diallo, 2009; Mohammad, 2007; Pope et al., 2011). Similarly, in this study, moral support and acceptance from family and the larger community were emphasized. Given that fistula is a stigmatized condition in the region, it is expected that the women would feel isolated even after surgery. Furthermore, reintegration is often a social process that requires a supportive social environment. In cases where this support is lacking, the women would find it difficult to settle back to their previous gender roles as before the illness. Women who felt a lack of social support, albeit in subtle forms, were still sensitive to it and pointed it out as a hindrance to their social reintegration. In a study of women who had undergone fistula repair surgery in Tanzania, Pope et al. (2011) demonstrated the significance of family support to patient reintegration. In their study, 68% of the women who had undergone surgery found assistance from family members to conduct chores and start businesses that helped their reintegration into the community. Similar to our study, supportive family members were often a sister or a mother, all relatives from the natal family of the patient.

Mohammad (2007) recommended an integrated approach to treatment of fistula patients basing on a reintegration program in Nigeria, with emphasis on the importance of community support. Similarly, Diallo (2009) described a social immersion strategy for the reintegration of women following obstetric fistula surgery in Guinea. After discharge, the women live with a host family who also carry out sensitizations in churches and other social gatherings. They also undergo communication skills. The program was noted to have improved the women’s self-esteem and emotional health. Mwangi and Warren (2008) in a study conducted in Kenya recommend that fistula survivors be linked to social support programs for rehabilitation and reintegration. Family and community support is therefore crucial to the social reintegration of people with stigmatized illness.

Economic empowerment and self-reliance were common themes among participants. This was commonly depicted through participants’ expressed need for income generating activities and skill training. In fistula survivors’ interviews, feelings of need to generate one’s own income as before the illness were expressed freely. This was further stressed on by key informants who noted that resource was often not available for this venture. Furthermore, women who had a source of income after surgery and discharge felt it had improved their chances of being accepted back into their community. Similar findings have been recorded in a comparative study in Tanzania where women felt that having a form of work in the fields or having a form of trade after surgery made them feel normal again (Pope et al., 2011). The study in Tanzania established other factors that improved reintegration of women following repair surgery as family support, which facilitated both access to treatment and reintegration; all women reported they needed follow-up discussions with health care providers on general health and concerns about future pregnancies. These findings are similar to the West Pokot study findings. Similarly, Nielsen et al. (2009) observed that 22% of women stopped working after fistula occurred, whereas 75% went back to their previous occupations following surgery.

Having a form of work and economic advancement is therefore important in reintegrating fistula patients. International guidelines on management of fistula have emphasized the need to consider economic empowerment of women following fistula surgery (Gwyneth & Bernis, 2006). The WHO (2006) guidelines on the management of obstetric fistula recommend that after surgery and discharge from hospital, patients may need counseling and socioeconomic support to aid reintegration (Gwyneth & Bernis, 2006).

In this study, women reported receiving some assistance toward fertility concerns. Women who conceive after corrective surgery received follow-up care during the antenatal period and were advised and facilitated to deliver in hospital under skilled birth attendance to avoid recurrence of fistula. Follow-up care during post-surgery period should aim at holistic and complete healing, and go beyond physical healing. For instance, Nielsen et al. (2009) demonstrated poor obstetric outcome (stillbirth) in four out of five women who conceived after surgery. Long-term follow-up up to a year is encouraged, and antenatal care in the subsequent pregnancy is most ideal.

Notably in this study, participants felt the government does not do enough to reintegrate women after surgery. This feeling dominated most interviews. The role of the state in prevention of fistula was also insufficient to supplement the work of NGOs doing community education on obstetric fistula often with meager resource to do this. Government must take up the lead in health education and other programmatic approaches.

Study Limitations

Considering the small sample size and exploratory nature of this study, we are not able to weigh the significance of responses on reintegration. Statements and conclusions made are thus limited in as far as the methodological approaches applied here permit.

Significance of the Study

This exploratory study provides an insight into what is known in obstetric fistula research in Kenya. Specifically, it adds to the dearth of qualitative research on the topic, providing as it does an avenue for women to voice their experiences in the recovery period. Often, as shown in the literature, care of women with obstetric fistula stops at surgery and perhaps a follow-up visit to the clinic. This approach assumes that fistula illness is confined to the biomedical, thus neglecting the psychosocial and economic challenges posed by the illness. Besides, the WHO recommends reintegration as a key component in the guiding principle in management of women with obstetric fistula. However, there is a little information on the manner in which reintegration should be done. What constitutes reintegration for the women, and what support do they need to return to normal life as before the illness?

Faced with a topic on which little is known, there was need to hear in an exploratory manner, from an emic perspective, the women’s views on what would aid their reintegration. As such, qualitative approaches to health research were best suited to explore the problem. Using in-depth interviews and key informants, the qualitative research provides a fresh perspective and rich data on women’s and health care provider perspectives on reintegrating women after obstetric fistula surgery. Certainly, in a country that has seen an increase in the number of free surgeries per year to ameliorate the suffering of women from this illness, there is sufficient prerequisite to explore the possibilities of recommended holistic care of fistula patients. The results offer practical points to what potential there is to improve the health and quality of life for women following obstetric fistula surgery. As such, the findings of this study led to conceptualization of a bigger study in the country.

Conclusion

The health care system in West Pokot is insufficient to meet the basic and emergency obstetric care of its inhabitants. Furthermore, women who develop maternal complications as obstetric fistula face similar challenges in obtaining treatment. The weak health system in the region poses big challenges for women with fistula to access corrective surgery, which requires sophisticated technical capacity. The participants after surgery are faced with reintegrating into a community that previously shunned and isolated them. There is no structured reintegration program for women with obstetric fistula after reparative surgery in West Pokot.

Social reintegration of fistula patients requires a combination of services aimed at improving their social, psychological, and economic recovery and well-being. They include family and community support, counseling, follow-up care, income generating activities, and skill training. Government support and significance of successful surgery are emphasized. Reintegration needs of women, although similar, may vary depending on context, necessitating a careful balance when addressing the perceived versus real needs of a fistula survivor. The role of government to reintegrate fistula patients may be realized in clearing backlog of cases by offering free surgery because most affected women are disadvantaged socioeconomically, training and capacity building of health workers to treat VVF, and upgrading government facilities to perform fistula repair surgery. Implicit in the last role is the provision of a functional health system for both prevention and treatment of obstetric fistula in the district.

Obstetric fistula is a complication of childbirth that leads to women’s physical and psychological suffering and disrupts their socioeconomic well-being. With the setting of scarce published research on reintegration of patients following obstetric fistula corrective surgery in Kenya, the exploratory study sought to document the experiences of Pokot women. Through thematic data analysis, the author situates the contextual reintegration needs of women to include emergent themes of reintegration that comprises biomedical, psychological, social, and economic approaches.

Recommendations

A holistic approach to fistula programs to incorporate surgery with other measures that improve social reintegration is likely to improve the well-being of women following surgery. There is need for a larger study in the country to further test the significance of different strategies in reintegrating women following corrective fistula surgery. Areas of further research emanating from this pilot study led to the conceptualization of a 1-year cohort study of fistula patients from three regional repair centers in Kenya, which focuses on reintegration as one of the main objectives of the study.