• In Narok, the practice of marrying off girls at the age of 12 years is increasing cases
• There are only 12 repair surgeons for the entire country, according to experts
Soon after Pauline Omuronji was discharged from hospital last year, having given birth to a baby girl, she found herself incontinent.
Without any warning or urge, she would suddenly feel water leaking down below.
The 19-year-old says she was besieged with worry and shame after developing the condition, her mind constantly preoccupied with the next gush of urine.
“I stayed in the house for fear of embarrassing myself in public. It was a hard time,” she says.
Pauline’s mother says she laboured for 12 hours in the first birth facility they went to and an additional nine hours at Kakamega Referral Hospital, where she was referred after her situation became critical.
She eventually gave birth naturally but had developed fistula — a hole in the birth canal between the vagina and the bladder (for some it can be between the rectum, causing faeces to leak), causing her severe incontinence.
If not addressed on time, a prolonged, obstructed labour can cut off blood supply to tissues in a woman’s pelvis. When the dead tissue then falls away, she is left with a hole in the birth canal, known as a fistula, according to the UN Population Fund (UNFPA).
To help control the leaks, Pauline used tatters to trap the fluid, but the materials would only absorb so much. She was in constant discomfort from using these scraps of clothes for days on end.
The UNFPA states that fistulas can lead to chronic medical problems, depression, social isolation and deepening poverty, which was evident for Pauline.
“I could only buy adult diapers when going for a hospital visit or to church. It was very expensive. I had to limit my fluid intake when stepping out,” she says.
The mother of one lives with her mother and two of her siblings in a house fashioned from mud. Financial constraints in Pauline’s family meant she had to stop attending school last year, she said, and soon afterwards, she met a boy from her village in Mumias town, Kakamega county.
“I did not know him very well, I met him through another girl I knew. He said we should go to his home,” Pauline recounts. The boy was a year older than her and was her first sexual partner.
The encounter resulted in her pregnancy and when she told the boy, he refused responsibility, she says as her voice drops to a whisper.
She never saw him again.
I could only buy adult diapers when going for a hospital visit or to church. It was very expensive. I had to limit my fluid intake when stepping outPauline Omuronji
Women and Development Against Distress in Africa (Wadadia) has been dealing with scenarios like Pauline's. Wadadia founder and lead director Habiba Mohamed says the leading factors that expose teenagers to fistula include teenage pregnancy, early marriage, cultural practices like FGM, poverty and poor health-seeking behaviours.
Mohamed is also the regional programme director for Africa at the Fistula Foundation. She says among adolescent fistulas, about 84.7 per cent are obstetric.
Dr Carey Otulo, a gynaecologist and fistula surgeon, explains that this is because their pelvises are not fully developed, making them less able to handle pregnancy and childbirth. Most teenagers typically develop vesicovaginal fistula, where urine passes through the vagina, causing them to leak urine.
Rates of teenage pregnancy in Kenya remain high. According to the 2022 Kenya Demographic Health Survey, an estimated 15 per cent of women aged 15-19 years old have been pregnant at some point.
Teen pregnancies were found to be more common among poor, rural communities, where a lack of proximity and access to health facilities also means fistulas are more common.
Florence Wanyonyi, the reintegration officer at Wadaida, handled Pauline’s case.
“The contributing factors in Mumias and much of Kakamega county are poverty,” she says.
“When the leading sugar miller in the country went down, the community was plunged into poverty. Girls became targets of commercial motorbike operators and other prying men.”
Wanyonyi says once the girls become pregnant, they feel ashamed to attend antenatal care, which puts their pregnancy at risk.
“Many will labour for long hours at home and when they go to health facilities, they do not get immediate care, which worsens their situation,” she says.
Mohamed adds that these are young girls who are supposed to be in school. “They are children that should be nurtured and protected and not be turned into mothers,” she says.
Pauline only began accessing antenatal services four months into her pregnancy and says she didn’t know much about sexual and reproductive health before then.
"Most of the emphasis from school was on hygiene and cleanliness. We are taught about sex but not a lot," she recalls.
HINDRANCE TO CARE
Effective treatment is possible through surgery but requires skilled doctors who are scarce in Kenya. Only 12 facilities are able to offer fistula repair services, with only 12 repair surgeons for the entire country, according to experts.
Untreated fistula not only brings stigma but also puts women at risk of frequent infections, kidney disease, painful sores and infertility, according to the United Nations Fund for Population Activities (UNFPA).
Surgery enables girls to re-enter society, bear more children and have a fulfilling sex life, but the high cost of the procedure means it is not covered by the National Hospital Insurance Fund (NHIF), making treatment impossible for a disease that afflicts the poor.
“We are looking at between Sh70,000 or more,” says Mike Aduol, the Fistula Foundation monitoring and evaluation officer. “The more severe and complicated the tear, the more expensive. At the moment, all hospitals that treat (fistulas) are funded by NGOs.”
Between 2014 and 2022, the Fistula Foundation Treatment Network (FFTN) supported more than 11,000 women to access fistula surgeries across 10 hospitals in Kenya.
Among these women, 616 (about 6 per cent) were adolescents between the ages of 10-19 years, with 22.8 per cent of the teenagers below the age of 15, and 2.6 per cent (1 in 20) just 10 years old.
This “is a significant number, considering their age,” Mohamed said. “The most affected are those in the rural setting, with poverty being a hindrance to care.”
Multiple experts shared that data and knowledge on teenage fistulas is limited, with many healthcare workers being unfamiliar with the condition and cases only being recorded when they are brought to the attention of a local clinic.
The government is yet to develop policies that would create a reporting mechanism for fistula cases as well as address other elements of fistula.
According to the Fistula Foundation’s data, between 2014 and 2022, Narok county was leading in teenage fistula (116), followed by Pokot (59), Bungoma (55), Kisii (51), Uasin Gishu( 46), Homa Bay (35) and Kakamega (23).
In Pauline’s home country, Kakamega, the incidences of teenage fistulas are concentrated in the rural areas. Between 2016 and 2022, Wadadia recorded at least 23 cases within the areas they operate in the county.
But many more cases are likely to be going unnoticed, according to the Fistula Foundation.
In Narok, the medical condition is highly stigmatised, and the cultural practice of marrying off girls at the age of 12 years is fuelling the issue.
“Many young girls develop fistula,” says Nampayo Koriata, a fistula champion and founder of the Koriata Fistula Trust in Narok South.
“Community members secretly call me when they need me to take a girl to see a doctor. Hospitals also reach out to me to connect girls with medical centres.”
Koriata said girls do not dare to speak about it, even after being healed.
“It is a stigmatised condition among the pastoralist community. Nearly all girls carry the condition into adulthood.”
One of the girls who agreed to speak to us turned us down at the last minute. She was the third to decline our interview for fear of being known.
Doctor Otulo performs between 20 and 30 surgeries every month at the Narok Referral Hospital.
“I see cases as young as nine years, the average is between 12 and 15,” says the surgeon, who handles fistula cases in the South Rift region, including Kericho, Kisii and Nakuru.
Koriata and Habiba run empowerment programmes to reintegrate girls and women in the community. The programmes are meant to give survivors a new lease on life.
"To address fistula, we need to have a holistic intervention on teenage pregnancy,” says Dr Dan Okoro, sexual and reproductive health officer at UNFPA. “Girls need to be empowered with information. And communities need to be sensitised if we are to deal with this issue."