Putting vaginal fistulas on the international social work map: A critical perspective

Introduction

This article is about vaginal fistulas and the women who suffer from them, particularly Kenyan women. Following the lead of Lorber and Moore (2002: 1), we take the position that health conditions such as vaginal fistulas are not just a physical state but a socio-cultural phenomenon with potentially far-reaching consequences. In doing so, we are not just interested in the biomedical aspects of vaginal fistulas but also their socio-cultural and political implications.

Our work is informed through an electronic database search identified from MEDLINE, SAGE, Scopus, Taylor & Francis and PubMed databases, as well as search engines such as Google Scholar. Our literature search used the following key words: vaginal and/or obstetric fistulas, gender, women, health, Africa and/or developing countries and social/gender construction of illness. From these sources, we define what vaginal fistulas are, what causes them and what it means to live with them.

We theorise vaginal fistulas through the frameworks of critical social work and Black feminism. Focusing on Black Kenyan women, we describe the effect of living with vaginal fistulas, notably the shame, impoverishment and isolation. We argue that gender-, race-, class- and age-based oppressions influence the likelihood of developing the problem, accessing decent health care and recovering from the condition. With the World Health Organization (WHO) (2009), we see vaginal fistulas as a major international public health problem that requires urgent attention. We conclude with the call for international social work efforts to help with the promotion of prevention and treatment measures, including those related to cultural practices that place girls and women at risk of developing a health condition that can ruin their lives.

What are vaginal fistulas and how are they caused?

A fistula is a passage, channel or hole between two organs in the body. Vaginal fistulas involve an unhealthy communication between women’s vaginas and bladders, urinary tracts, colons and/or rectums. Early records of vaginal fistulas came in the 19th century, when American gynaecologist James Marion Sims (1852) documented cases of some of the Black women slaves he was treating. Then, as they do today, vaginal fistulas produce a constant and involuntary leakage of urine and/or faeces, making sufferers incontinent and prone to a variety of infections (Riley and Spurlock, 2006; Sims, 1852). Being incontinent, one’s own excrement is one of the easiest ways for adults to lose their dignity (Walley et al., 2004) and has profound effects on daily living.

Vaginal fistulas are caused by tissue damage that leads to a tear, which forms a hole or channel between two body organs. In this article, we will focus on the two main types of vaginal fistulas: vesico (front) and recto (back). Most commonly, vaginal fistulas occur from obstetric trauma (Sims, 1852), with 90 percent being caused by obstructed labour (Miller et al., 2005). This occurs when birthing mothers spend close to or more than 3 days trying to push out babies that do not fit through their immature birthing canals (Wall, 2006). The trauma of trying to do so creates tears and holes between organs that are ordinarily contained from one another, leading to the formation of a fistula (Wall, 2006). The problem is exacerbated when well-meaning but misguided traditional birth attendants misadvise and/or practise traditional but medically harmful procedures on the labouring woman (Wall, 2012b). This may include exercising random cuts on their vaginas with the hope of helping the baby through the birthing canal or instructing the mothers-to-be to drink large amounts of water, which rather than aid the delivery of healthy babies overinflates their bladders, which puts pressure on neighbouring organs and leads to tears or perforations that form vaginal fistulas (Rahimi et al., 2013).

Premature motherhood predisposes young women to developing vaginal fistulas, particularly Black women whose pelvises are anatomically narrower (Briggs, 1993, as cited by Wall et al., 2005). The young women are not sufficiently developed to deliver children without surgical intervention and without access to caesareans; the babies may develop fully but then become stuck in the birthing canals during delivery (Wall, 2006). Premature motherhood is often related to underage and sometimes forced marriage. An Aljazeera report (2014) noted that underage marriage is still a major problem in Kenya despite the new constitution banning the practice.

Malnutrition is another factor that predisposes women to developing vaginal fistulas. Prolonged and complicated labour is usually more common in younger women who are malnourished, which leads to ‘… malpresentation and cephalopelvic disproportion’ during the birthing process (Turan et al., 2007; Wall et al., 2005: 288). Many developing societies do not prioritise feeding the girl child with proper nutritious foods (Konje and Ladipo, 2000). This results in undergrown pelvises in women, which may obfuscate the passage of the baby’s head during birth as it compresses the vagina against the mother’s pelvic bones (Konje and Ladipo, 2000; Udipi et al., 2000). If this obstruction is not cleared immediately through a caesarean delivery, ‘the tissue becomes necrotic, forming an opening in-between the vaginal wall and the bladder or the rectum’ (Miller et al., 2005: 286). This opening forms vesico and recto vaginal fistulas, respectively (Miller and Lester, 2003; Neilson et al., 2003; Turan et al., 2007).

Vaginal or rectal trauma causes the remaining 10 percent of vaginal fistulas (Wall et al., 2005). In war-torn and conflict-infested regions, sexual violence is a common cause of traumatic fistulas. Rape, through forced heterosexual intercourse, forced infibulation and/or the violation of women with objects such as guns or rods can create vaginal fistulas that remain long after the assault (Longombe et al., 2008; Onsrud et al., 2008). Included in this 10 percent and overlapping the larger more common (obstetric) cause of vaginal fistulas are the young girls prematurely inducted into sex through forced marriage and expected to bear children shortly after the onset of menarche (Ikamari, 2005; Otoo-Oyortey and Pobi, 2003).

Recognising that the vast majority of the millions of girls and women affected live in chronic poverty in developing countries, Cook et al. (2004) described vaginal fistulas as a socio-culturally conditioned illness of the poor (Cook et al., 2004; Miller et al., 2005; Wall, 2006). The rates of vaginal fistula in Africa support the idea that poverty and oppression are underlying causes. Africa has an estimated 1.033 billion people (Chen and Ravallion, 2004; Cook et al., 2004; WHO, 2010) and is home to the largest number of the world’s absolute poor (World Bank, 2000) and so many sufferers of vaginal fistulas (Ukachukwu et al., 2009).

Living with vaginal fistulae

Across the world, at least 2 million women and girls are estimated to live with vaginal fistulas, with up to 100,000 new cases each year (De Bernis, 2007). In Kenya alone over 3000 new cases are presented to the Kenyatta National Hospital (KNH) annually (Ministry of Health and United Nations Population Fund (UNFPA), 2004: 13). Yet, the magnitude of the problem is likely to be much higher, given this figure is only based on the number of women who seek treatment in hospitals in their home countries (Cook et al., 2004). A study by Neilson et al. (2003) reports that prevalence figures for vaginal fistulas across the world are difficult to estimate because so many of the women who suffer from them live in remote areas where access to health services is not available or is very limited. Compounding the problem is the relative scarcity of research in the area. At the time of writing this article, we found few studies, systematic reviews or surveys conducted in regions where the incidences of vaginal fistulas are high.

Women with vaginal fistulas usually report uncomfortable physiological anomalies in the genital areas, often producing smelly pus and blood in their urine that can cause kidney and urogenital infections (Banke-Thomas et al., 2013). This often causes itchiness, irritation, a burning sensation and soreness (Turan et al., 2007). Incontinence, as described earlier, is common and among other effects can dramatically diminish self-esteem and alter the women’s relationships to their own bodies, denying them the pleasure of feeling attractive, sexual beings. Other less predictable problems can stem from vaginal fistulas, such as joint weakness and foot drop, which can be temporary or permanent (Khisa and Nyamongo, 2012; Women’s Dignity Project and Engender Health, 2006). They are symptomatic of other problems relating to fibular nerve damage and muscle weakness, literally making it hard for sufferers to flex their feet from their ankles (Banke-Thomas et al., 2013; Wall, 2006).

From a strictly biomedical perspective, these symptoms are not likely to be life threatening. Yet for most, these experiences are profoundly debilitating, often with serious socio-cultural and economic implications (Wall et al., 2005). Most vaginal fistula sufferers find that the condition incapacitates them, making it difficult, if not impossible, to perform normal daily activities such as farming, socialising and sexual intimacy with spouses. Exacerbating the problem is the inadequate and inaccurate reproductive sexual health education, which usually means there is widespread ignorance of the basic facts about vaginal fistulas.

Although vaginal fistulas are non-contagious, the incontinence and an accompanying stench from constant leakage typically render victims as social outcasts. Because girls and women with vaginal fistulas are unable to control the constant flow of urine and/or faeces, they may be mistakenly thought to have venereal disease, which may be interpreted as a sign of infidelity, and often leads to them being divorced by their husbands, shunned by their communities and unable to work or care for their families (Bimbola and Cleland, 2013; Wall et al., 2005). It is not an overstatement to say that women living with vaginal fistulas are often treated as social lepers and/or pariahs, rejected and ostracised by their immediate and wider society (Ahmed and Holtz, 2007; Bimbola and Cleland, 2013; Cook et al., 2004). Derived from the Latin word ‘Lepra’ meaning ‘scaly’, leprosy (the disease itself) is still considered one of the most infectious, thus feared, diseases that cause debilitating social repercussions for the sufferer (Naafs and Noto, 2012).

The women who develop vaginal fistulas due to birthing complications experience multiple losses. There is usually the loss of their babies, who die as a consequence of being trapped in birthing canals (Wall, 2012a) and the loss of their identities as wives and mothers which in an African setting elevate their societal status (Roush, 2009). Once divorced, the women are likely to carry the stigma associated with such social failing for the rest of their lives. As Wall et al., (2005) points out,

… infertility is a hard phenomenon to deal with to any couple from any culture but you just cannot undervalue the importance of fertility in an African culture where large families are a source of pride and wealth to the family. (p. 1425)

The level of stigma the women with vaginal fistulas usually face causes most to suffer a deep sense of hopelessness and shame. In her book Hospital by the River, Hamlin (2001) reports how some women are so injured (both by the disease and the pain of the rejection they experienced) that they refuse to go back home even after receiving successful surgical services at the Addis Ababa Fistula Hospital. In a study conducted in Kenya on the experiences of women living with vaginal fistulas in West Pokot, women reported that stigma manifested itself from subtle to obvious discrimination and isolation, which continued even after corrective surgery (Khisa and Nyamongo, 2012). In another cross-sectional study conducted by Khisa et al. (2011), women with obstetric fistulas were so predisposed to depression that they recommended holistic mental health care service and family support to ensure their survival.

Yet, there is still hope as much can be done to remedy these problems. Some studies report that with additional social support and counselling, women living with vaginal fistulas may be able to successfully reintegrate back into their communities following a fistula repair (Ahmed and Holtz, 2007). For this to happen, however, much work needs to be done, including educating wider communities in the causes and symptoms of vaginal fistulas, eliminating the misinformation that discriminates against sufferers, and allowing family members, friends and communities to support rather than shun those afflicted.

Why should social workers care about vaginal fistulas? What is their role?

Health and wellbeing are central to quality of life, and it is not surprising that social work in health is one of the largest and oldest areas of practice for social workers all over the world (Cleak and Turczynski, 2014). Social workers play a major role in supporting individuals, families and communities to deal with health difficulties because our primary purpose is to enhance the wellbeing of people and empower them to function, develop and thrive successfully in their communities (International Federation of Social Workers (IFSW), 2000). Our mission is to assist individuals, groups and communities experiencing social problems, including those caused, or at least compounded, by oppression, discrimination and injustice (Mullaly, 2010). Irrespective of our location, we are committed to the pursuit of social justice, which means treating people with respect and dignity, irrespective of their status or resources (Freire, 1998; Mullaly, 2010). Given the unequal access to resources, education and technology, Western social workers have a responsibility to assist social workers and their constituencies in less affluent parts of the world (Nagy and Falk, 2000).

In Western countries, health conditions such as cancer, diabetes, epilepsy, depression and anxiety have been successfully incorporated into the social work practice (Cowles, 2012). Vaginal fistulas are no different other than that they affect women in a different context and in a different part of the world. Discounting the problem as not being relevant to social workers just because it is not in our ‘backyard’ is not ethically viable. We have a moral and professional responsibility to advocate for the disadvantaged, victimised, marginalised and vulnerable vaginal fistula victims in their quest to improve their quality of life.

Social workers across the world should care about vaginal fistulas because so many women are affected by the condition, and so profoundly. They/we need to care because there is so much that needs to be done, and so many of us have the skills and resources to create the changes necessary to prevent girls and women from developing the problem and assist those who are sufferers. Mmatli (2008) contends that most African countries have not fully recognised social work as a profession that can be used strategically to redress the social, economic and health problems that Africans face. African social workers certainly need to be proactive in efforts to prevent and treat vaginal fistulas and their causes. However, given the scale and severity of the problem, African social workers need supportive alliances with Western/European social workers if significant progress is to be made in addressing the causes of vaginal fistulas and making treatment available.

Social workers need to care about the issue of vaginal fistulas and take actions to redress them and their associated problems, because we/they have the capacity to work with women on such sensitive, complex cross-cultural issues. Our emphasis on social wellbeing makes us well placed to understand not just the biomedical dimensions of the problem, but also the socio-economic and cultural experiences. Collectively, we can intervene by campaigning for resources to ensure that affected women are made aware that fistulas may be repaired by relatively simple surgery. As a profession, we have the skills to offer counselling to those affected, while also advocating for women’s basic human and civil rights (Mmatli, 2008). By helping to generate global awareness of the problem, we can campaign for changes to policies and practices that predispose so many girls and young women to developing vaginal fistulas. Supporting the Millennium Development Goals, notably the sixth goal of improving maternal health, we can contribute to community education programmes that aim to increase the number of well-educated and skilled birth attendant deliveries (Vandemoortele, 2002). This action alone promises to markedly reduce the cases of obstetric vaginal fistulas in resource-poor countries (Keri et al., 2010).

Another important step is to demystify the myths associated with how the condition develops, what it says about those who suffer from it and what it might mean for afflicted women in the future. Social workers can help to liaise with other professionals such as psychologists, medics, counsellors and community workers to develop an interdisciplinary approach that will ensure a holistic outlook in helping to combat the issue of vaginal fistulas.

How do critical perspectives help us understand vaginal fistulas?

Drawing from critical theory, critical perspectives are concerned with questions about power, authority, status, resources and social change (Allan et al., 2009; Fook, 2002). Difficult questions about who is likely to enjoy (unearned) privilege, and who is likely to suffer the effects of oppression, are also part of contemporary critical perspectives (Mullaly, 2010). These questions are directly relevant to the problem of vaginal fistulas because the structural experiences of oppression related to gender, class, race and age are inseparable to understanding the likely victims of vaginal fistulas and whether timely, adequate and non-discriminatory treatment is likely to follow. To put it simply, it is not a coincidence that being female, young, Black and poor, and living in the ‘Third World’ dramatically increases the chances of acquiring the condition and associated poor treatment.

bell hooks (2000: 1), a Black feminist, defines feminism as a movement to end sexism, sexist exploitation and all forms of oppression. Black feminist ideas are relevant to understanding women’s experiences of vaginal fistulas because they require us to confront uncomfortable questions about power and resources. Rather than turn our attention to the technical, individual and/or physiological dimensions of the problem, Black feminism places race, gender and class squarely on the agenda. With other critical perspectives, it helps us to avoid shying away from questions about the burden of disease, in preference for more individual readings of the problem. Racism, classism and sexism are crucial to understanding the intersectional nature of oppression and conditions such as the vaginal fistula, which is symptomatic of it. It appreciates that impoverished Black women have long been blamed as vectors for their own ill health and suffering (Amaro et al., 2001).

Our critical perspective draws on the ideas of Black women’s liberation from the women’s movement of the 1960s because they were the early advocates of Black feminism – women who sought to improve women’s experiences and promote equality between men and women (Bortin et al., 1994). It is founded in the works of bell hooks, Maria Stewart and Patricia Collins who challenged Black women to ‘reject the negative images of Black womanhood so prominent in their times and arguing that racial and sexual oppression were the fundamental causes of Black women’s poverty’ (Collins, 1999: 3). According to Collins, Black women’s oppression is structured along three intersected dimensions: (1) exploitation of their labour for no or minimal wage; (2) denying the rights and privileges extended to their White counterparts; and (3) controlling the images of representation that tied them to slavery (Collins, 1999: 8–9).

Black feminist thought involves concepts shaped by Black women that explain experiences they face, as Black women (Collins, 1999). The lead author of this article is a Black Kenyan woman who has first-hand experience of extreme poverty and patriarchal oppression. She knows from life experience, not just the literature, that so many Kenyan women are forced to marry young (Cook et al., 2004; Otoo-Oyortey and Pobi, 2003), have unsupervised home births (Otoo-Oyortey and Pobi, 2003) and lack access to health care due to poverty and socio-cultural and geographical obstacles (Wabuge, 2014). She has observed malnutrition and the practice of girls and women being the last to eat but the first to perform household labour. As a social worker, she has witnessed how common it is for women with vaginal fistulas to be seen as vectors of their own wretchedness (Amaro et al., 2001) – blamed and shamed for a condition they have little if any control over. She has seen the implications for their sexuality and identity, particularly the denial of their value as women and human beings – rendered invisible, ignored and shunned because of their foul smell. She has often wondered how differently their lives would be if they were male, White and/or affluent, and how governments, researchers and medical practitioners would have handled their health conditions. If these women were not subject to sexism, racism and classism, would their health conditions make them suffer the same indignities, depression (Khisa et al., 2011), misery, loneliness and shame (Amaro et al., 2001; Hamlin, 2001)? A Black feminist perspective encourages such critical questions to be asked (hooks, 2000).

Focusing on Kenya, what needs to happen?

In this final part of the discussion, we focus on Kenya. It is a country where at least 3000 women per year present with the problem in the biggest public hospital and where malnutrition, underage marriage and premature motherhood are common. Kenya is an East African country with a land mass of 581,313 km² (Factbook, 2012), where 79 percent of the people reside in rural communities with women being prime contributors of household income by engaging in subsistence farming or herding cattle. The World Bank ranks it number 145/186 in the Human Development Index with half of its 44 million population living in absolute poverty (World Bank, 2014). As we have suggested above, social workers have the potential to play an important role in helping to resource and support a range of activities to prevent and treat vaginal fistulas.

According to a needs assessment conducted by the Kenyan Ministry of Health, the problem of vaginal fistulas requires lobbying and advocacy to prevent women from developing the condition, not just more access to surgical procedures for those who have already acquired it (Ministry of Health and UNFPA, 2004). Yet, for this to happen, there needs to be a greater willingness to focus on the problem of vaginal fistulas and their associated causes, including the unavailability of quality obstetric care and family planning services, especially in remote rural areas. In doing so, attention must be given to existing inadequacies in health systems, underage marriage, premature childbearing and harmful birthing methods – all of which are often tied to forms of gender discrimination (Creanga and Genadry, 2007; Donnay and Ramsey, 2006; UNFPA, 2003).

Preventing vaginal fistulas means eradicating key socio-cultural factors that cause them. Practices such as early marriages and female genital cutting need to be addressed, as does nutrition which will help reduce the likelihood of stunted growth, particularly underdeveloped pelvises that cannot accommodate babies’ heads (Miller et al., 2005). Although most Kenyans are aware of the constitutional law barring Kenyan women from being married before the age of 18 years, most may not be aware of the long-term consequences of obstetric fistulas caused by early pregnancy and childbirth. While such socio-cultural practices can take years to change, they are crucial to long-term success (Shefren, 2009). Social workers can play a lead role in this domain, using their advocacy and empowerment expertise to highlight the seriousness of practising such harmful ‘traditions’. They/we can lobby for support from influential community leaders who can promote awareness of the issue of vaginal fistulas and place them on agendas for discussions in village forums (Mmatli, 2008).

Providing timely and decent care to women who have, or are at risk of having, obstetric complications would also help to reduce new cases of obstetric fistulas (Miller et al., 2005; Wall, 2012b). This needs to include access to emergency obstetric care, family planning services and sexual health education for girls and women, across the urban/rural/remote divide (Wall, 2012b). Resources need to be channelled into hard-to-reach areas where women have immense difficulties trying to access health care when they are in labour. Some of this work is underway, but much more is needed, including the greater availability of medics.

In the last decade, the Kenyan government has initiated a programme where local social workers identify traditional birth attendants working in remote areas to be trained in basic birthing practices, including how to manage birthing complications. Reducing the risks of labour is important because doctors and hospitals are largely inaccessible for women living in remote villages and who experience complications in their labour (Ministry of Health and UNFPA, 2004). To ensure the safety of the women and their children, further work is still needed to ensure that traditional birth attendants do not provide inaccurate advice or rely on antiquated practices that carry additional risks of developing a vaginal fistula (Ministry of Health and UNFPA, 2004). For example, traditional birth attendants often advise women struggling in labour to drink copious amounts of water. This does not help with the delivery of the baby, but leads to the rupture of the bladder, making vaginal fistula more likely.

Irrespective of their location, women with existing vaginal fistulas need to be able to access treatment. Treatment can be in the form of reconstructive surgery to close the tear or hole in the vaginal area, as well as physiotherapy to help mobilise limbs that may have developed any form of nerve damage due to immobility (Miller et al., 2005). Social workers should liaise with affected women to link them to treatment, counselling and any other resources necessary for them to access these services. Part of our role is to humanise the process as much as possible, to avoid causing more psychological pain than clients may already be experiencing. Kenyan social workers will also need to know how to build rapport with all the agencies where referrals can be made as such referrals may not be automatic.

Through its biggest national hospital, the KNH, the Kenyan government has been collaborating with social workers and doctors from non-governmental organisations such as African Medical and Research Foundation (AMREF) and Freedom from Fistula (FFF) to provide annual medical camps. During these camps, the partnering organisations invite both national and international surgeons to help cope with the high demand of fistula patients who show up when the camps are advertised. Statistics from the KNH show that over 95 patients underwent successful surgery during the weeklong camp that was held in Nairobi in 2012. This proved to be a very effective way of treating a lot of patients within a short period (AMREF and KNH, 2013). These organisations also fund the hospital fistula-related programmes and initiatives as well as donate equipment to hospitals for the provision of fistula or maternity care to the women. Nevertheless, Kenya has a severe shortage of fistula experts, given there are still only 10 fistula surgeons who provide treatment for about 700 women of the 3000 new cases every year (IRIN, 2010; UNFPA, 2013). With so many women left untreated, and for so many years, the number of existing cases threatens to overwhelm doctors. Social workers, especially social workers from affluent countries, could play a role in helping campaign for more doctors to assist in these camps and in the hospitals more generally.

The other challenge to the treatment of vaginal fistulas is that the surgery costs about US$375 per person (IRIN, 2010). Bearing in mind that in 2005, 45.9 percent of all Kenyans lived below the national poverty line and in 2013 earned an average of US$930 – with women earning on average much less than this, meaning few women with vaginal fistulas can afford the costs (World Bank, 2014). To most Kenyan women, coming up with this amount of money is a far-fetched dream, so they remain with the condition and suffer in silence.

There are also not enough hospitals offering vaginal fistula care to patients. There are only three known hospitals for fistula care: (1) KNH, (2) Moi Referral Hospital and (3) Gyno-care Centre. To put this in perspective, the KNH is the biggest public hospital in Kenya and is located in Nairobi – the capital city of Kenya. The Moi Referral Hospital is the only referral hospital in the Rift Valley region of Kenya and is located 313 km North West of Nairobi, while the Gyno-care Centre is a small privately owned clinic funded by the international community. It is also located more than 300 km from Nairobi but less than 20 km from the Moi Referral hospital. All these three hospitals strive to serve thousands of women who present with vaginal fistulas and live in rural remote villages far from the capital city. It may take several hours for a woman seeking obstetric treatment to walk from her village to the nearest bus station and a day or two to travel to Nairobi with limited public transport, harsh weather and rough geographical terrain. (Wabuge, 2014).

Strategies jointly issued by the WHO, the United Nations International Children’s Emergency Fund (UNICEF) and the UNFPA recommended that for every 500,000 people, there should be four facilities offering basic and one facility offering comprehensive essential obstetric care (WHO et al., 2009). As Creanga and Genadry (2007) note, ‘It is difficult to properly prevent and treat obstetric fistulas in the absence of not only data and evidence but also facilities’ (p. 153). Again, lobbying for more treatment facilities and helping to raise funds to pay for fistula treatment are viable activities to which social workers across the world could contribute (also see Miller et al., 2005).

Concluding comments

Women with vaginal fistulas ordinarily face profound socio-cultural, psychosexual, emotional and financial difficulties. Similar to a wide range of other health-related conditions, including breast and cervical cancers, depression, epilepsy and diabetes, vaginal fistulas need to be understood as such, not just as a physical state or a narrow medical condition. Much needs to be done to significantly reduce the debilitating consequences of this condition. Support for prevention and treatment requires material resources and cross-cultural understanding. Yet, because it is mostly young, Black, poor, ‘Third World’ women who are most susceptible to developing and sustaining vaginal fistulas, the intersectionality of gender-, race-, class- and age-related oppressions should not be ignored. That is why we have advocated for the use of a Black feminist approach to the issue.

Social workers are well placed to offer assistance in relation to the conceptualisation, awareness, prevention and treatment of vaginal fistulas because we are part of a profession committed to social justice, one that seeks to enhance human wellbeing irrespective of gender, class, race, ethnicity, age, ability and geographical location. Local Kenyan social workers can offer the women much needed social support. Counselling and resource brokerage are part of the work, as is creating a wider awareness of the condition, including how it is acquired and addressed. It also involves working alongside community organisers to try to ensure women with vaginal fistulas in remote villages get information about their condition, available treatment options and the financial support most will need to access treatment. Then for the women who go into hospital, Kenyan social workers can (and do) work with other hospital staff to ensure a holistic approach to treatment. However, given the challenges, local social workers could achieve more if international social workers helped to generate a global awareness of the problem and raise the necessary resources to allow more women to have their vaginal fistulas repaired. Collectively, Kenyan and international social workers need to work together to campaign for changes to policies and practices that predispose so many girls and young women to developing vaginal fistulas.