The Experience of Women with Obstetric Fistula following Corrective Surgery: A Qualitative Study in Benadir and Mudug Regions, Somalia

Obstetric fistula is a severe maternal morbidity which can have devastating consequences for a woman's life and is generally associated with poor obstetric services leading to prolonged obstructed labour. The predisposing factors and consequences of obstetric fistula differ from country to country and from community to community. The World Health Organization estimated that more than 2 million women in sub-Saharan Africa, Asia, the Arab region, Latin America, and the Caribbean are living with the fistula, and some 50,000 to 100,000 new cases develop annually with 30,000–90,000 new cases developing each year in Africa alone. This study aimed at describing and exploring the experiences of women living with obstetric fistulas following corrective surgery in Benadir and Mudug regions, Somalia. Women living with obstetric fistula who had surgical repairs at Daynile and GMC fistula centers and key informants were identified purposively. Twenty-one individual in-depth interviews among women with obstetric fistula and eight key informant interviews were conducted. Thematic analyses were used. Codes were identified, and those codes with similar connections were organized together as to form themes. Detailed reading and rereading of the transcribed interviews were employed in order to achieve and identify themes and categories. Themes, categories, and subcategories illustrating the experiences of women living with obstetric fistula emerged from the thematic analysis of individual in-depth and key informant interviews. These were challenges of living with OBF which include “wounds around genitalia, bad odour, incontinences of urine and feces, stigma, isolation, divorce, powerlessness, dependency, financial constraints, and loss of healthy years” and coping mechanisms which include “withdrawal from the community and improved personal hygiene.” Women with obstetric fistula experience serious health and social consequences which prevents them fulfill social, family, and personal responsibilities. We recommend expansion of BEmONC services to underserved areas, capacity building for local OBF surgeons, and improved media campaign and birth preparedness at community levels.


Introduction
Obstetric fistula is one of the most serious tragedies in childbirth injuries. It is a medical condition that involves an abnormal opening between the bladder and the vagina (vesicovaginal fistula) or between the rectum and vagina (rectovaginal fistula), or both, leading to uncontrolled leakage of urine and/or feces caused by prolonged, obstructed labour, without access to timely, high-quality medical treatment [1]. e prolonged, constant pressure of the fetal head in the birth canal cuts off the blood supply to the soft tissues surrounding the woman's bladder, rectum, and vagina.
Somalia has some of the worst maternal health indicators in the world. e fertility rate is very high as are infant and maternal mortality rates (MMR of 850 per 100,000 live births), malnutrition is chronic, early marriage is common, and most births are delivered at home without the presence of a skilled birth attendant (attended by TBAs). Somalia is also the leading country in female genital mutilation "FGM" (98%) and has the highest rate of Type III FGM (infibulation called pharaonic), with 79% of all Somali women having undergone the procedure, which is a major contributing factor for obstetric fistula [2]. Women in Somalia live in a highly insecure context where healthcare infrastructure and maternal health programs have been disrupted and limited in availability for decades. Facilities tend to be dilapidated, basic equipment and medications are in short supply, and there are few trained medical personnel in the country. All these factors are contributive to the high rate of maternal mortalities and morbidities such as obstetric fistula [3].
Obstetric fistula can be caused by prolonged labour which is mostly unrelieved, lack of access to a C-section, and low quality of C-section which can lead to iatrogenic fistula. A study found that iatrogenic fistulas occur in women who faced emergency obstetric surgery, often to address a ruptured uterus. Majority of women with iatrogenic fistulas had a history of previous cesarean section, suggesting that women who undergo C-section are at heightened risk for iatrogenic fistula during a subsequent surgery [4].
Women who experience obstetric fistula suffer constant incontinence of urine or feces or both, shame, anxiety, social segregation, and other health and social problems. It is estimated that more than 2 million young women live with untreated obstetric fistula in Asia and in sub-Saharan Africa [5,6]. Obstetric fistula victims often experience feelings of powerlessness, physical injury, emotional breakdown, depression, divorce, erosion of social capital, and loss of health years [7]. UNFPA reported that 50,000-100,000 new cases develop annually in which the majority of the cases (99%) occur in the developing world.
Exploring and describing the experience of obstetric fistula patients and sharing with individual full stories of their own feeling will fill the gap of no baseline data, information, and stories of the occurrence, severity, consequence, and impact of the tragedy of obstetric fistula among Somali women. Discovering and documenting the plight of women with obstetric fistulas in their own voices excavates insight into the nature of this demoralizing problem and thus assists as a call for policymakers concerned with reproductive health to discourse the complex issues that propagate this preventable condition. e study aimed at exploring and describing the experiences of women who had obstetric fistulas following corrective surgery in Benadir and Mudug regions, Somalia. Specially, our research focused on the challenges that obstetric fistula victims experience and their coping mechanisms.

Study Area, Study Participants, and Sampling.
e study was conducted in Benadir and Mudug regions, Somalia. e participants were recruited from Daynile Hospital (Benadir region) and Galkayo Medical Center (Mudug region).
Benadir region or Mogadishu, the Somalia capital city, is the most populous region in Somalia which is located in the coastal area of the Indian Ocean. On the other hand, Mudug region is the most centrally located region in Somalia. e region contains two federal states namely Puntland in the north and Galmudug in the south. Although the country has some tertiary medical care facilities that are equipped to do fistula repair, there are no trained Somali doctors who can do fistula repair, and the whole country relies on foreign doctors who come for campaign [8].
Purposive, nonprobability sampling of women with obstetric fistula and key informants were employed, and the information was gathered.
e research investigator with one assistant carried out 21 face to face in-depth interviews for obstetric fistula survivors who had corrective surgery in Daynile and Galkayo medical center hospitals in Benadir and Mudug regions, respectively, and 8 key informants of family members, traditional birth attendants, professionals (doctors, midwives, and nurses), policy makers, and fistula donor staffs who had first-hand knowledge about the community and provided insights into the nature of the obstetric fistula problem and gave recommendations for solutions. ey were purposively selected based on the information they possess and relevance to obstetric fistula. e sample size was based on information need in which we stopped after we realized that we reached the information we needed and data saturation in which we reached data saturation on 21st respondent in the in-depth interviews who were in the hospital for recovery of their fistula operations (the participants were interviewed in the hospital within 4 weeks after surgery) and 8th respondent in the key informant interviews.
e investigator fully explained the information sheet to the participants which contained the purpose of the research, procedures, and benefits as well as the associated emotional risk of having to remember the challenges.

Study
Design. An institution-based qualitative descriptive approach was chosen to investigate the live experiences of women with obstetric fistula after corrective surgery.
is qualitative descriptive approach was done using individual in-depth interview on women with obstetric fistula and key informant interviews from participants of different sectors related to obstetric fistulas. In order to minimize recall bias since participants were asked about their live experiences, respondents were given sufficient time for adequate recall of long-time memories as to solicit full experiences. Also high-quality interview guides (interview guide related to obstetric fistula that was approved by experienced obstetric fistula consultant which was previously applied to other countries such as Africa) for both in-depth and key informant interviews were used as to minimize unwanted and irrelevant stories. And lastly, the research interviewer and the assistants had full background on the types of biases that can mislead and deflect the study. To clarify the questions, the interview guide was pretested with two obstetric fistula survivors who were recruited from Garowe city and were not included the study.

In-Depth, Open-Ended
Interview. Twenty-one women who had undergone surgical repair of obstetric fistula were interviewed using an in-depth, open-ended interview guide. Before the start of the face-to-face interview, the obstetric fistula survivors were asked to complete a short personal profile questionnaire to capture out the information related to characteristics of the women (Table 1) like age, residence, marital status, literacy, number of children, occupation, obstetric history, and corrective surgery-related issues. e information sheet, consent form, and the interview guide for obstetric fistula survivors were all translated from English to the local language "Somali language" by English-Somali translator. Data were collected with the local language "Somali" using digital audiotape recording. e investigator asked permissions from participants for tape recording before he started the interviews. e recorded audio were transcribed (converted audio data to texts), and then the transcribed texts were translated from Somali back to English for analysis. e purpose of the audio recording was to accurately record the information from the participants. Only one participant was below the age of 18 during the interview, and we found her assent and also her mother was asked to sign the consent form. All the interviewed respondents knew local name for obstetric fistula "Iskufuran" and have heard this name before.

Key Informant Interview. Key informant interviews
were held with eight people who had first-hand knowledge and involved obstetric fistula patients including family members, traditional birth attendants (TBAs) and health professionals including fistula consultant, MoH and fistula donor staffs, midwives, nurses, and policy makers. e key informant interviews were conducted to obtain in-depth information and opinion regarding the research questions. Key informants contributed validation of data provided by the obstetric fistula patients and offered expert recommendations and insights.

Data Analysis.
A person fluent in Somali transcribed the audio from the recorded in-depth and key informant interviews supplemented by the investigators field notes. e Somali transcripts were then translated back to English language for analysis. Another person who is fluent in both English and Somali crosschecked the accuracy and completeness of the translations before data were ready for coding. e themes and categories from the in-depth interviews of obstetric fistula survivors and key informants interviews are summarized in Table 2.
All the transcripts were cautiously read sentence by sentence two times in order to become familiar with the transcripts. Codes were identified, and those codes with similar connections were organized together as to form themes. Content analyses were used. Detailed reading and rereading of the transcribed interviews were employed in order to achieve and identify themes and categories which allowed finding themes that represent broader ideas, categories, and subcategories that were more specific. is process facilitated the investigator to cross-check all the transcriptions from the respondents and recognize the data saturation point where no new information are emerging in both interviews. e narrations of the study represent respondents' descriptions of their own opinion and experiences with obstetric fistula. e themes and categories are summarized in Table 2.

Sociodemographic Characteristics of the Participants
In-Depth, Open-Ended Interviews. Twenty-one women with obstetric fistula were interviewed in both Benadir and Mudug Regions. Among the interviewed women in this study, 80.9% (n � 17) were recruited from Daynile hospital, Benadir region, and 19.1% (n � 4) from GMC hospital, Mudug Region. e ages of the study participants ranged from 15 to 55 years with both mean and modal age of 27 years. In the current ages of the respondents, 47.6% (n � 10) were aged 15-24 years, 33.3% (n � 7) aged 25-34, and 19% (n � 4) aged 35 or above. According to the ages at which women developed fistula, majority of the participants (85.7% (n � 18)) developed obstetric fistula at the age between 15 and 24 years. From the educational prospective of the study participants, majority (71.4% (n � 15)) had no formal education, while only 28.6% (n�6) had formal education. Among those who had formal education, only one woman had education beyond secondary level. is means that, the majority of the data were found from women with no or little formal education. According to the residence of the interviewed women, 57.1% (n � 12) were from rural areas before the development of obstetric fistula and 42.9% (n � 9) were living urban areas. e average years of women living with obstetric fistula were between 1 and 29 years although the majority 52.4% (n � 11) were living with obstetric fistula for less than 4 years. One woman has been living with obstetric fistula for up to 29 years. She believed that, obstetric fistula is not a disease, but rather a curse from her husband because she was troublesome to her husband and his extended families. Another old woman who has been living with this condition for up to 18 years thought that, she suffered this condition because she did something bad to Allah and therefore it is punishment from Allah.
All the interviewed women were married before the development of the obstetric fistula; however, during the time of the interview, 47.6% (n � 10) were divorced because of the condition, 42.9% (n � 9) were still married, and 9.5% (n � 2) were widowed. One young woman explained that her husband divorced her because of the suffering of the obstetric fistula as he could not tolerate the constant bad odour of the urine incontinences. Of the study participants, 85.7% (n � 18) had only one obstetric fistula surgery, 9.5% (n � 2) had experienced surgeries between 3 and 4, and only one woman had surgery above 4. According to the participant's place of last delivery, majority of them 76.2% (n � 16) gave birth at home assisted by traditional birth attendances, whereas 23.8% (n � 5) gave birth at health facility with the assistant of skilled birth attendants.

Key Informant Interviews.
Eight key informant interviews were conducted which include family members, traditional birth attendants (TBAs), and health professionals like fistula surgeons and consultants, fistula donor staffs, midwives, nurses, and policy makers who all had first-hand knowledge of either obstetric fistula or the community and provided their opinions and insights into the nature of the obstetric fistula problems and gave recommendations for solutions. e professional key informants have worked for periods ranging from 2 to 39 years, as shown in Table 3.

Challenges of Living with Obstetric Fistula.
e Obstetric fistula survivors in this study reported different challenges of living with obstetric fistula which were termed as physical, psychosocial, and socioeconomic challenges (as stated in Table 2). ese challenges were subgrouped into categories and subcategories.

Physical
Challenges. All of the study participants reported some sorts of physical challenges associated with obstetric fistula trauma. Majority of the respondents experienced some forms of physical problems such as irritations,  Five of the twenty-one interviewed women in the indepth interview experienced incontinences of urine and feces simultaneously. e above quotes from the experiences of women living with obstetric fistula reveal that women who develop obstetric fistula suffer continues dribbling of urine and feces which prevents them from attending community gatherings such marriage and wedding ceremonies, mourning ceremonies, and community festivals. ese quotes also describe, how women with obstetric fistula manage the incontinence of urine and feces. Women mentioned that, they usually wear sanitary pads or hijab outfits to minimize and limit constant dribbling of urine.

Psychosocial Challenges.
e study participants narrated that they experienced psychological challenges due to the immediate or long-term consequences of obstetric fistula which includes stigma and isolation, reduced social support, and disrupted marital relationships.

Stigma and Isolation.
All the interviewed women complained that they suffered continuous stigma and isolation which is the effect of the urine incontinence and the odour. e degree of the stigma and discrimination was however different among survivors. For instance Muno (pseudonym) is 27-year-old obstetric fistula victim. She experienced dismissal from her small job (cloth washer) due to the neighbouring family's intolerance of her constant bad odour.

I was domestic worker, I used to wash clothes of the neighbouring families. Some of the families heard that I'm a urinating woman and they chased me. Yes they said: we don't want you, you are not clean (you are dirty). I was really stigmatized by the neighbouring families. You lose your job because of this condition. e worst consequence of the OBF is the isolation. (Muno, 27 years old, lived with obstetric fistula for 8 years)
Also the key informants narrated that women with obstetric fistula face different challenges from their community which include stigma and isolation. According to KI01 (policy maker), obstetric fistula survivors experience marginalization and stigma from their own communities: One of the first thing that obstetric fistula patients face is that, their husbands will abandon them, their family members will abandon them, and also the society may abandon them, so they will be put in a corner separately from the rest of the family. Yes that is why they develop serious psychological problems. (KI01, policy maker) Another woman who is obstetric fistula victim explained that she faced stigma from the neighbouring families; Muniro, 26-year-old woman lived obstetric fistula for nine years, narrated that she was constantly stigmatized. is surgical repair is her seventh repair since all the previous six surgical repairs were unsuccessful.

I was sick for nine years because of this fistula condition.
Every year I go to hospital and I don't have successful surgery. Yes all the people in this small village "Halabokhad" have heard about my problem so whenever I come outside, they gossip about me. Yes Walahi I can't go to community meetings in our village. My shopping is limited. (Muniro, 26, lived with obstetric fistula for 9 years) e interviewed key informants and women with obstetric fistula described that fistula is not only a medical condition but also interferes with the social integration. One of the key informants "KI04, nurse" explained that Obstetric fistula is not only a medical condition but it's also more of social and cultural problem. One of the first thing that fistula patients face is the stigma from the society so they are segregated, simply because of the condition they are living with. (KI04, nurse) Regarding the above narrations from both key informants and women living with obstetric fistula, the women face abuse, rejection, abandonment, and ostracization from both their couple and the community.

Disrupted Marital Relationships and Immediate
Divorces.
e interviewed women indicated that they cannot have normal sex life in their marriage after sustaining obstetric fistula. Although some of the participants were still living with their spouses and kept their marriages, their relationship with their husband were limited. Only four women reported that they are the only wife of their husband and gets support from him. Majority of the obstetric fistula victims were either divorced or their husband turned away from them and married second wife. Since the women with obstetric fistula cannot fulfill marital obligations, they were rejected and humiliated by their community. ey also faced continuous abandonment from their spouse because the women failed to fulfill sexual obligations.

Socioeconomic
Challenges. Ten of the interviewed women were divorced following the onset of obstetric fistula. eir husbands indicated that he was sickened by their condition and their inabilities to have normal sex life. In Somali society, though divorce is religiously allowed, it is shameful and affects the women more than men since they are dependent on their husbands throughout their lives. Most illiterate and unskilled women divorced by their husbands often return to their families. For instance, Safiyo (Pseudonym) is 17 years old obstetric fistula victim. She was a domestic worker in a neighbouring family. She experienced dismissal from her job due to the family's intolerance of her constant bad odour.
I was working as a domestic worker, I used to sweep and clean the house, wash clothes, cook foods and sometimes take care of the children of that family. ey heard that I cannot control urine. Yes I was frequently changing the clothes and wear pads. Eventually they sacked me. ey said: "we don't want a urinating girl any more." I lost my job. (Safiyo, 17 years old, lived with obstetric fistula for 2 years)

Dependency and Powerlessness.
Based on the religion and cultures in the Somali society, the wives are directly dependent on their husbands. All of the interviewed women indicated that they are still struggling to survive and waiting for support from either their husbands or their extended families. Only one participant "Safi" reported that she is dependent and gets support from her children. For instance, Hamdi, 20 years old, explained that she was a farmer before she sustained this condition, but currently unable to continue farming and lives on what she gets from her family.

I used to cultivate my farm every season like the people in this area but after developing this condition, I adopted to stay home and wait on what Allah gives me. (Hamdi, 20 years old, dependent to her family)
Another woman reported that, she lost her small business due to the frequent pain and the leakage of the urine which made it difficult for her to continue her business. One participant emphasized the powerlessness that she experienced throughout her life. is limited power of the women in the Somali society was related to the domestic work that girls do during childhood followed by other responsibilities with in the family. Women in this society face limited freedom followed by dependency and low status of women.

Profound Poverty and Financial
Constraints. All the respondents had insufficient income. In the meantime, all of them had to use more money to keep themselves clean and neat and at the same time, seek medical treatments to recover for their obstetric fistula problem. According to a family member of the obstetric fistula patient, the effect of this medical condition limited their financial income. He stated that She was in good health, she used to herd the family goats in the day time. Yes, as we are nomads, women are responsible for goat herding and mostly constructs the portable family house which the women ties the roofs to support the hut, but now she can't participate in any activities in the family. Yes, she needs daily support and family members to think how they can give her financial and moral support. (KI06, family member of the victim) One of the interviewed women experienced financial constraints having lost her livelihood and income sources and stated that: Since I developed this condition "OBF," I was depending on one single source. at source is what I get from my family especially my parents. When I want to go and pay something, I have to beg my parents and wait for some days. Everything in this world is money. e health care is too costly here in Somalia. (Barni, 21 years old, lived with obstetric fistula for 4 years).

Coping Mechanisms.
e interviewed women in this study revealed different efforts to normalize and cope with their emotions which resulted from obstetric fistula through isolating themselves, hiding their story, and always keeping good physical hygiene and purity which provided relief and helped them calm down their stress and anxiety. For instance, 23-years-old "Maryamo" who lived with obstetric fistula for 2 years stated that It is not easy to live with this problem [obstetric fistula]. My concern was people not to know that I cannot control urine. Withdrawal from the community and improved personal hygiene were the two strategies that women with obstetric fistula used to cope with their condition. As the above statements describe, women who are living with obstetric fistula were frequently changing their clothes to avoid the bad odour and wetness resulted from obstetric fistula.

Discussion
e challenges encountered by the interviewed women were similar to the reports by previous researches [7,[9][10][11] that obstetric fistula brings consequences of physical challenges, including sores, skin rashes, and wounds around the genitalia, bad smell, and incontinences of urine and feces. Psychosocial challenges include stigma and isolation, disrupted marital relationships, divorce, suffering and loss of the baby, and socioeconomic challenges, which includes powerlessness, dependency, limited social support, financial constraints, profound poverty, and loss of healthy years. e findings of this study is also consistent with those studies conducted in Ethiopia [6,12,13], Burundi [14], DR Congo and Bangladesh [15], Kenya [9], Ghana [16], Nigeria [17], and Tanzania [11] regarding the physical, psychosocial, and socioeconomic challenges experienced by obstetric fistula survivors.
e study found that obstetric fistula patients have fears to retain and share sexual activities with their husbands in the future. is finding is consistent with a study conducted in West Pokot, Kenya [9] which concluded that fistula victims still have fear to have sex with their husbands even after successful repairs.
In this study, women affected by obstetric fistula usually encounter immediate divorce as shown by the study result which was about 47.6% (n � 10). Divorce is common in obstetric fistula patient. Due to the onset of obstetric fistula, some husbands divorce their wives because of bad odour and leakage of the urine that is disgusting to them. Others divorce their wives because of fistula survivors cannot satisfy them sexually while others divorce because the obstetric fistula women cannot produce another children in the future and it may take them years to recover. is was similar to previous studies conducted by Landry et al. [18] and Gebresilase [7]. In this study, about two-fifths are still married although their husbands decided to marry second time. is is true and corroborates the explanations of the key informants that, due to the condition of their wives, the husbands always try to find second or third wives.
Another research conducted in Malawi [19] reported that obstetric fistula victims do not get much support from their husbands because of the polygamous practices. Our study finding was also similar in its report that some of the husbands neglect their wives because of the fistula condition and prefer to stay with their second or third wives.
is study has similar outcome with several studies conducted in African countries [9,15,16,20], which agreed that women who lived with obstetric fistula frequently wash their clothes and use perfumes to cover the offensive odour. Studies conducted in Kenya and Nigeria [9,17] reported that husbands ostracize their wives after developing obstetric fistula and do not want to share life and eat with them at both house and family events. is study reported similar findings on the victim's inability to satisfy their husbands sexually and the neglect they suffer because of the disease.
Previous reports by Kimani et al. [10] and fistula foundation [3] revealed that some women with obstetric fistula suffer from "foot drop," which is the inability to walk properly without help, due to injury to the common fibular and sciatic nerves caused by prolonged labour. Similarly, key informants in our study revealed that women who develop obstetric fistula suffer nerve injuries that can cause foot drop and long-term walking impairment.
e key informants acknowledged that women with obstetric fistula can develop foot drop; but, among the interviewed women who lived with obstetric fistula, none of them reported that they experienced nerve injury or foot drop.
It was further revealed that women living with obstetric fistula face daily life challenges including inability to attend community gatherings, have sexual relationship with their husbands, earn money, attend religious prayers, work and participate in small businesses, and eat with others [18]. Our study also corroborates this finding. Majority of the participants explained that they were not attending religious prayers since they developed obstetric fistula. e participants also lamented lack of participation in social activities; they do not even have enough courage to attend community gatherings like festivals or wedding ceremonies because of the wound and bad smell resulted from the obstetric fistula. Concerning personal earnings, interviewed women reported that they are facing financial constraints and their income is almost zero now.
Despite the fact that majority of the women interviewed suffered neglect and abandonment from their husbands and communities, family and relatives were the most reliable source of income and moral support for women living with obstetric fistula. Although there was a limited resource, family members including parents, siblings, and their children play a key role in supporting and rendering assistance for food, water, clothes, and personal hygiene. e participants revealed that they were getting assistance from their family members when seeking medical treatment. 8 Obstetrics and Gynecology International Respondents in this study exhibit similar efforts to normalize and cope with their emotions through isolating themselves, hiding their story, and always keeping good physical hygiene and purity which provided relief and helped them calm down their stress and anxiety. is study is interested in the various mechanisms and strategies that obstetric fistula survivors use to cope with their condition. As reported by previous studies [7,16,17,21], people with medical illnesses and conditions use different coping strategies as to manage their life problems. Similarly, the study participants explained various techniques and strategies they use to cope with their condition. e participants isolated themselves from other people, put on Hijab outfits to cover the bad smell, and always carry extra clothes and water in order to control the urine incontinence and bad odour.
As reported in previous studies [7,16,20], participants in this study also use artificially made sanitary towel in order to reduce or control the embarrassing odour and to absorb continuous leakage of urine. ey also frequently change clothes and use Hijab outfits to cope with the problem. In order to control and prevent wetting seats and chairs because of the incontinences of urine and feces, the victims dressed in three or four "diracyo", the traditional wears Somali women wear. e interviewed women use withdrawal strategy to cope with their problems. ey always avoid sitting and staying with or attending community gatherings. Many of them stay at home every time and restrict their movements because of the fear of stigma from the community and the uncontrollable leakage of urine and feces.

Conclusion and Recommendations
e direct statements of women living with obstetric fistula from two regions of Somalia (Benadir and Mudug) and key informants involved in obstetric fistula presented in this study ensure the validation of the study findings. is study finding addresses the experiences of women living with obstetric fistula and their coping mechanisms in Benadir and Mudug regions, Somalia. e experiences they lived with were almost similar to other findings in sub-Saharan African countries, especially East African societies which have related socioeconomic issues regarding the obstetric fistula challenges. e study findings demonstrate the challenges that women with obstetric fistula experience. ese include physical challenges "wounds around the genitalia, bad smell, and incontinences of urine and feces," psychosocial challenges "stigma and isolation, disrupted marital relationships, divorce, suffering, and loss of the baby," and socioeconomic challenges "powerlessness, dependency, limited social support, financial constraints, profound poverty, and loss of healthy years." Findings of this study highlighted how the poverty, illiteracy, women's dependency to their husbands, low status of women, traditional beliefs and practices, and limited antenatal care utilization twist together to produce the devastating problem of obstetric fistula in Somalia. Women living with obstetric fistula cannot fulfill social, family, and personal responsibilities due to the obstetric fistula challenges. e basic health care system in Somalia is very weak and insufficient to meet essential obstetric care of pregnant women.

Recommendations
(1) e basic health care system in Somalia is very weak and insufficient to meet essential obstetric care of pregnant women. Basic Emergency Obstetric and Newborn Care "BEmONC" should be expanded to all areas to address prolonged and obstructed labour which in turn prevents women to develop obstetric fistula. (2) Since the country mostly relies on foreign fistula surgeons, training and capacity building of local fistula surgeons should be provided.
(3) Fistula facilities should be upgraded to perform fistula repair surgery. (4) Continuous awareness and extensive public media campaign towards ANC attendance and birth preparedness should be implemented at community levels "generate media attention." (5) Advocates should be designed that are working at all levels whether national, district, or community levels. (6) Community development should focus on promoting safe motherhood practices including provision of family planning, adequate child spacing of pregnancies, and focused antenatal care. (7) Increased human resource and funding for obstetric fistula including training TBAs, increasing the number of skilled birth attendants, and ensuring appropriate distribution of all the trained skilled birth attendants to all geographical locations. (8) Government should bring means of social reintegration and women empowerment mechanisms after surgical correction of women with obstetric fistula.

Data Availability
e data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
e authors declare no conflicts of interest in this work.