In this unmatched case control study, we examined factors associated with obstetrics fistulae in three selected hospitals in Kenya. Our analysis identified having none or primary education, making decision to seek delivery services after six hours from onset of labour, and reaching a health facility after two hours as risk factors for developing obstetrics fistula. Other risk factors included delay caused by referral to another facility and duration of labour of more than 24 hours. This is one of the first analytical studies to evaluate obstetric fistula in Kenya. Previous studies been mainly descriptive thus limiting the understanding of risk factors.
Similar case control studies carried out in Nigeria [10, 13] identified low levels of education and labour duration of more than 24 hours as risk factors for obstetrics fistula occurrence. However, the study did not evaluate the delay in making the decision to seek delivery services and in reaching health facilities. In a descriptive study from Zambia , women were asked where they delayed and 67.5% said they delayed at home. This delay at home was not evaluated for association with fistula occurrence. It is important for a woman to be in a health facility once she is in active labour in order to get proper management and good outcome. Cultural beliefs, economic constrains and attitude towards services in health facilities could contribute to this delay . Attendance by unskilled persons who did not recognise impending complications early enough to seek emergency obstetrics services could also contribute to delay in seeking delivery services . Increasing awareness and importance of timely health facility delivery and dangers signs in pregnancy among pregnant mothers and the community is important in reducing this delay. Community health workers could be used to raise this awareness.
In this study we considered the duration of time they took to reach the health facilities irrespective of mode of transport. Taking more than two hours to reach a health facility was a significant risk factor for developing obstetric fistula. Findings by Melah from Nigeria  show that distance of more than 3km from the women’s homes to the health facilities is a risk factor for obstetrics fistula. Transport problems and long distances have been identified as contributors to delay in reaching the health facilities [16, 17]. Maternal waiting shelters for pregnant women who live long distances from the hospitals to stay in when they reach near term or expected dates of delivery, will help in reducing this delay in the short term . In the long term, access to functional hospitals needs to be improved through better transportation or distribution of health facilities. Communities could also initiate low cost transportation system which will enable the women to get to the health facilities in time.
Primary health care facilities in Kenya do not offer emergency obstetrics services for women with obstructed labour and therefore they have to be referred to district hospitals or higher levels for possible caesarean section and other management. The duration taken to get to the referral facility adds to delay in getting appropriate management and this is specially so when coupled with delay in seeking delivery services and delay in reaching a health facility. Thus there is urgent need to build the capacity of primary level health care to conduct emergency obstetrics care and also to improve referrals between health facilities.
In this study difference in antenatal attendance among cases and controls was not significant. Findings in studies from Nigeria [10, 12, 13, 16], indicate that not attending antenatal care was a significant risk factor for developing fistula. This non-significant finding could be explained by the increased advocacy for antenatal care attendance in Kenya where women are asked to present their antenatal cards when they take their children for immunization. Antenatal attendance was relatively high among cases but women still delayed in making the decision to seek delivery services. There is therefore need to improve on quality of the antenatal services to increase awareness of importance of timely hospital delivery.
Compared to controls, cases were shorter (44.3% <150 cm), had no formal employment, had lower antenatal attendance and had either no formal education or only reached the primary school level. These findings are comparable to other studies in Africa [12, 16, 18]. Mean age at first pregnancy among cases in this study was higher than in most studies in Africa, [16, 19, 20] however; the difference between cases and controls was not significant as an independent risk factor. This could mean that the fistula cases were not due to mainly an underdeveloped pelvis and highlights the importance of timely appropriate delivery services for complicated deliveries.
Half of the cases in this study had parity of two and above. This is consistent with findings by Holme from Zambia . Most of the multi-parous women had delivered at home in earlier pregnancies and did not realize the need of timely health facility delivery. As we plan preventive measures, we need to take this into account and tailor our interventions to cover multi-parous women.
In this study, almost a quarter of the cases were divorced and all of them attributed the divorce to fistula development. This proportion is lower than figures in other studies from Ethiopia and Nigeria [12, 19, 21]. The lower proportion in this study could be explained by the fact that polygamy is practised within most communities without actually divorcing the other woman. In Zambia, the proportion of divorced women with fistula is similar to findings in this study . Being divorced after onset of fistula together with the fact that 34% of cases report to have stopped working after onset of symptoms of fistulas how the social effect of obstetrics fistula among women.
In this study, the controls were all taller than 150 cm and thus this variable could not be added to the model to evaluate for its association with obstetrics fistulae occurrence. The data collected were mainly self reported by the participants and specifically the data on circumstances surrounding delivery could not be verified from partographs which are usually kept at facilities they delivered in. Recall bias was minimized by including women who delivered within the previous five years. The retrospective recall of labor and transportation time makes the time only approximate. In future studies, there is a need to separate fistulae occurring in the first versus subsequent pregnancies because while their causes may overlap, there is likely to be distinct factors in the first pregnancy (small pelvis) that differ with fistulae formation in subsequent pregnancies (malposition). This study doesn’t give indications on magnitude of obstetrics fistula due to limitation of the study design and it is also hospital based.