Barriers to obstetric fistula treatment in low‐income countries: a systematic review

A systematic review and meta-analysis on the recovery time of obstetric fistula in Ethiopia, 2023

INTRODUCTION

Obstetric fistula is a birth injury that causes the vagina to open abnormally. As a result, women may experience urinary leakage, which can lead to isolation, depression, and a lower quality of life. Due to the scarcity of evidence regarding the average recovery time for obstetric fistula in Ethiopia, Therefore, this study aimed to assess the recovery time for women with obstetric fistula in Ethiopia.

METHODS

Between September and 8 November 2023, published studies were searched using online databases including PubMed, Hinari, Epistemonikos, and Google Scholar. The systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Study quality was assessed using Egger's test and a visual inspection of funnel plot symmetry. Statistical analysis was performed using STATA version 17 software. A random-effects model was employed for analysis, and the Cochrane Q-test and I² statistics were used to assess heterogeneity among studies.

RESULT

A total of six studies were included in this analysis. The minimum and maximum median survival times were 2.67 and 5.19 weeks, respectively. The pooled median recovery time was 4.05 weeks (95% CI: 2.92, 5.18) based on the random effects model. Heterogeneity among the included studies assessed by the I² statistic was 97.72% (p = 0.000). The p-value for Egger's regression test (0.017) was significant, indicating evidence of publication bias.

CONCLUSION

The findings reveal a pooled median recovery time of 4.05 weeks, with considerable heterogeneity. Although these figures provide valuable insights, the presence of publication bias was evidenced by the asymmetric funnel plot and significant Egger's test. Efforts to address publication bias are essential to improve future meta- the reliability of the surveys has increased.

REGISTRATION

The protocol for this systematic review was pre-registered on the International Prospective Register of Systematic Reviews (Registration Number: CRD42023270497).

Awareness on obstetric fistula and associated factors among women health development army, in the South Gondar zone, Amhara region, Ethiopia: A cross sectional study

Background and Aims

Obstetric fistula is a severe birth injury that profoundly impacts women's health, social well-being, economic stability, and psychological state. While it can be prevented with timely emergency obstetric care, a significant barrier in many developing regions, including the study area, is the lack of awareness among women. This study aimed to evaluate the level of awareness about obstetric fistula and the factors influencing it among the Women Health Development Army in the South Gondar zone of the Amhara region, Ethiopia, in 2020.

Methods

A community-based cross-sectional study was done from July to December 2020, involving 633 women. Participants were selected using a multistage stratified sampling method. Data were collected using a pretested, interviewer-administered structured questionnaire. Data entry was performed using EpiData version 3.1, and analysis was conducted with SPSS version 23.0. Multivariable logistic regression models were employed to identify influencing factors, with a p < 0.05 considered statistically significant.

Results

This study found that 55.3% (95% CI, 51.6%-57.2%) of study participants had a good awareness of obstetrics fistula. Significantly associated factors include; no history of ANC (AOR = 0.52: 95% CI, 0.31, 0.86), living >30 min away from a health facility (AOR = 0.43: 95% CI, 0.23, 0.81), no history of abortion (AOR = 0.37: 95% CI, 0.19, 0.72), Injectable and implant users (AOR = 3.60: 95% CI, 1.98, 6.53), having four to six pregnancy (AOR = 1.87: 95% CI, 1.22, 2.87) and lack of communication material in the house (AOR = 0.19: 95% CI, 0.10, 0.37).

Conclusions

This study found that 55.3% of women have a good awareness of obstetrics fistula. ANC follow-up history, abortion history, type of family planning, type of communication, number of pregnancies, availability of health facility, and distance of health facility were significantly associated with awareness of obstetric fistula. Hence, local and national efforts should be made to enhance access to information at home and basic maternal health services including antenatal care.

The burden of iatrogenic obstetric fistulas in Sub-Saharan Africa: Systematic review and meta-analysis protocol

BACKGROUND

Obstetric fistulas are abnormal open connection(s) between the vagina and the urinary tract or the rectum resulting from tragic injuries sustained by mothers during childbirth that lead to urine and/or faecal incontinence. Due to the rapidly growing middle class in sub-Saharan Africa (SSA) and the corresponding quest for hospital delivery and caesarean section, surgery-related (iatrogenic) obstetric fistulas are on the rise. Worryingly, there is scanty data on surgery-related fistulas. This review aims to collate empirical evidence on the magnitude of iatrogenic obstetric fistulas in SSA, generate country-specific data and explore factors that influence obstetric surgery-related fistulas.

METHODS

All relevant databases, PubMed, LILACS, CINAHL, SCOPUS and Google Scholar will be searched from 1st January 2000 to 31st March 2024 using search terms developed from the major concepts in the title without restrictions by language. The Cochrane Library, African Journals Online, Data Base of African Thesis and Dissertations Including Research (DATAD-R D Space) and preprint repositories will also be searched. Reference lists of relevant studies will be searched and experts in the field will be contacted for additional (unpublished) studies. The search output will be exported to Endnote where duplicate studies will be removed. The deduplicated studies will be exported to Rayyan where study screening and selection will be conducted. At least two authors will independently select studies, extract data and assess quality in the included studies using pretested tools. Disagreements between reviewers will be resolved through discussion. Data analysis will be performed with RevMan 5.4. Comparative binary outcomes will be reported as odds ratio (OR) or risk ratio (RR) and for continuous outcomes, mean difference and standard deviations (SDs) will be used. Non-comparative studies will be analysed as weighted proportions. Heterogeneity between studies will be assessed graphically and statistically, and where a significant level is detected, the random-effects model meta-analysis will be performed. All estimates will be reported with their 95% confidence intervals (CIs). Where data permit, we will conduct subgroup and sensitivity analyses to test the robustness of the estimates on key quality domains. The overall quality of the evidence will be assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

EXPECTED STUDY OUTCOMES

This systematic review and meta-analysis uses rigorous methods and best practices to attempt to collate all empirical evidence and estimate country-specific proportions of iatrogenic (surgery-related) fistulas among obstetric fistula patients across countries in SSA. This review will explore context-specific variables, provide insights into their impact and relate them to the type and experience of personnel performing the obstetric procedures that lead to obstetric fistulas. The findings of the full review are expected to inform the development of national and regional Training Programs for Medical Officers, support the development of a consensus "minimum acceptable standard of care" and inform quality assurance standards for clinicians involved in the provision of surgical obstetric care.

Experiential Narratives of Factors Limiting and Boosting Access to Support Services for Women with Obstetric Fistula in Southeast Nigeria

PURPOSE

Obstetric fistula is a chronic health condition that leaves affected women battered and traumatized, thereby exposing them to social recluse life as a result of associated discomfort and odor. Support services to those with challenging health conditions are reputed to help cushion the adverse effects on them; thus women with fistula and other chronic diseases receiving adequate support will help them to cope and recuperate from such illnesses. This study explores the factors limiting and boosting access to support services for those with obstetric fistulainNigeria.

MATERIALS AND METHOD

Focus Group Discussions and In-depth Interviews were employed to obtain data from 44 participants. The thematic data analysis method was deployed in analyzing the data collected.

RESULTS

Factors like the limited number of fistula specialist doctors, poor funding, withdrawal from seeking help, long distance, and discrimination limit patients' access to support services and adequate fistula care. The study highlighted that community involvement in fistula care, adequate funding, training, and retraining of professionals will boost support services for fistula patients.

CONCLUSION

The study recommends the adoption of a multidisciplinary approach in the management of obstetric fistula patients including the involvement of not only medical personnel but also social workers, families, groups, and community leaders.

The economic consequences of obstetric fistula: A systematic search and narrative review

BACKGROUND

Obstetric fistula develops from obstructed labor and is a devastating condition with significant consequences across several domains of a woman's life. This study presents a narrative review of the evidence on the economic consequences of obstetric fistula.

METHODS

Three databases were searched, and search results were limited to English language papers published after 2003. Search results were reviewed for relevance based on title and abstract followed by full text review using specific inclusion and exclusion criteria. Bibliographies of papers were also scanned to identify relevant papers for inclusion. Data were extracted under three categories (defined a priori): the economic consequences of having the condition, the economic consequences of seeking care, and the macroeconomic impacts.

RESULTS

The search returned 517 unique papers, 49 of which were included after screening. Main findings identified from the studies include women losing their jobs, becoming dependent on others, and losing financial support when relationships are lost. Seeking care was economically costly for families or unaffordable entirely. There were no studies describing the impact of fistula on national economies.

CONCLUSION

Economic consequences of obstetric fistula are multifaceted, pervasive, and are intertwined with the physical and psychosocial consequences of the condition. Understanding these consequences can help tailor existing fistula programs to better address the impacts of the condition. Further research to address the dearth of literature describing the macroeconomic impact of obstetric fistula will be critical to enhance the visibility of this condition on the health agendas of countries.

Measuring the cost-effectiveness of treating rectovaginal and vesicovaginal fistulas: A multicenter global study by the Fistula Foundation

OBJECTIVE

Surgery for obstetric fistula is a highly effective treatment to restore continence and improve quality of life. However, a lack of data on the cost-effectiveness of this procedure limits prioritization of this essential treatment. This study measures the effectiveness of fistula surgeries using disability-adjusted life years (DALYs) averted.

METHODS

In 2021 and 2022, the Fistula Foundation funded 20 179 fistula surgeries and related procedures at 143 hospitals among 27 countries. We calculated DALYs averted specifically for vesicovaginal fistula and rectovaginal fistula procedure types (n = 13 235 surgeries) by using disability weights from the 2019 Global Burden of Disease study. We based cost calculations on direct treatment expenses, including medical supplies, health provider fees, and preoperative and postoperative care. We measured effectiveness using data on the risk of permanent disability, country-specific average life spans, and treatment outcomes.

RESULTS

The total treatment cost was $7.6 million, and a total of 131 433 DALYs were averted. Thus, the cost per DALY averted-the cost to restore 1 year of healthy life-was $58. For this analysis, we took a cautious approach and weighted only surgeries that resulted in a closed fistula with restored continence. We calculated DALYs averted by country. Limitations of the study include data entry errors inherent in patient logs and lack of long-term outcomes.

CONCLUSION

The current study demonstrates that obstetric fistula surgery, along with having a significant positive impact on maternal health outcomes, is highly cost-effective in comparison with other interventions. The study therefore highlights the benefits of prioritizing fistula treatment as part of the global agenda for maternal health care.

Impact of Beyond Fistula programming on economic, psychosocial and empowerment outcomes following female genital fistula repair: A retrospective study

OBJECTIVE

To retrospectively assess changes in economic status, psychosocial status and empowerment among women who participated in Beyond Fistula reintegration programming following fistula repair.

METHODS

We conducted a retrospective study among 100 Beyond Fistula program participants capturing sociodemographic characteristics, obstetric and fistula history, program participation, and our primary outcomes: economic status, psychosocial status, and empowerment via quantitative survey at two time points: before program participation and currently. Data were collected from November 2020 to July 2021 from 2013 to 2019 program participants. We compared outcomes across these two time points using paired t tests or McNemar's tests.

RESULTS

The proportion of individuals owning property (28.0% vs. 38.0%, P = 0.006), having a current source of income (19.0% vs. 56.0%, P < 0.001), and saving or investing income (11.0% vs. 37.0%, P < 0.001) increased significantly from pre- to post-programming. We also identified statistically significant increases from pre- to post-programming in self-esteem (5.0 [IQR 4.0-5.0] vs. 5.0 [IQR 5.0-5.0], P < 0.001), reintegration (53.0 [IQR 43.0-69.0] vs. 65.0 [IQR 51.0-72.0], P < 0.001) and level of input into household economic decision making (2.0 [SD 1.0] vs. 2.3 [SD 1.0], P = 0.004).

CONCLUSION

Beyond Fistula programming likely improved economic status, psychosocial status, and empowerment of participants. Post-surgical interventions incorporating a holistic approach can advance recovery through supporting psychosocial and economic wellbeing and should be offered to women undergoing genital fistula repair.

Journey for a cure: Illness narratives of obstetric fistula survivors in North Central Nigeria

Obstetric fistula is a life transforming event resulting in embodied biographical disruption. Survivors suffer myriad long-term physical and emotional consequences. This paper is an account of a narrative inquiry, conducted with 15 fistula survivors in North-central, Nigeria, who described how their identities had been transformed by their condition. A narrative therapeutic approach, using Frank's 'chaos, restitution and quest' typology, was used to map their recovery narratives. 'Chaos', described by Frank as the opposite of restitution, dominated, with women losing hope of recovery. Women's shift towards 'restitution' began with treatment, but inadequate health-care access often delayed this process. In their quest narratives, women's life and identify changes enabled them to derive meaning from their experience of obstetric fistula within the context of their own lives. The findings highlight socio-structural factors raising the risk of obstetric fistula, which in turn causes biographical disruption and hampers sufferers' treatment and recovery. Rehabilitation should include income-generating skills to bring succour to survivors, particularly those whose incontinence persists after repairs.

Obstetric fistula repair failure and its associated factors among women who underwent repair in sub-Saharan Africa. A systematic review and meta-analysis

BACKGROUND

Obstetric fistula repair failure can result in increased depression, social isolation, financial burden for the woman, and fistula care programs. However, there is limited, comprehensive evidence on obstetric fistula repair failure in Sub-Saharan African countries. This systematic review and meta-analysis aimed to determine the pooled prevalence of obstetric fistula repair failure and associated factors among women who underwent surgical repair in Sub-Saharan African countries.

METHODS

To identify potential articles, a systematic search was done utilizing online databases (PubMed, Hinari, and Google Scholar). The Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA) guideline was used to report the review's findings. I2 test statistics were employed to examine study heterogeneity. A random-effects model was used to assess the pooled prevalence of obstetric fistula repair failure, and the association was determined using the log odds ratio. Publication bias was investigated using the funnel plot and Egger's statistical test at the 5% level of significance. Meta-regression and subgroup analysis were done to identify potential sources of heterogeneity. The data were analyzed using STATA version 17 statistical software.

RESULTS

A total of 24 articles with 9866 study participants from 13 Sub-Saharan African countries were included in this meta-analysis. The pooled prevalence of obstetric fistula repair failure in sub-Saharan Africa was 24.92% [95% CI: 20.34-29.50%]. The sub-group analysis by country revealed that the highest prevalence was in Angola (58%, 95% CI: 53.20-62.80%) and the lowest in Rwanda (13.9, 95% CI: 9.79-18.01%). Total urethral damage [OR  =  3.50, 95% CI: 2.09, 4.91], large fistula [OR = 3.09, 95% CI: (2.00, 4.10)], duration of labor [OR = 0.45, 95% CI: 0.27, 0.76], and previous fistula repair [OR = 2.70, 95% CI: 1.94, 3.45] were factors associated with obstetric fistula repair failure.

CONCLUSION

Women who received surgical treatment for obstetric fistulas in Sub-Saharan African countries experienced more repair failures than the WHO standards. Obstetric fistula repair failure was affected by urethral damage, fistula size, duration of labor, types of fistula, and history of previous repairs. Therefore, we suggest policy measures specific to each country to provide special attention to the prevention of all risk factors, including poor nutrition, multiparty, obstructed labor, and maternal age, which can result in conditions like large fistulas, urethral damage, and repeat repair, in order to reduce obstetric fistula repair failure.

Training and capacity building in obstetric fistula repair: A scoping review

BACKGROUND

An ongoing barrier to sustainable obstetric fistula (OF) care is the lack of trained fistula surgeons. Despite a standardized training curriculum, data regarding OF repair training remain limited.

OBJECTIVES

To assess the availability of literature on the case numbers or training duration required for OF repair competency and whether these data are stratified by trainee background or repair complexity.

SEARCH STRATEGY

A systematic search of MEDLINE, Embase, and OVID Global Health electronic databases and gray literature.

SELECTION CRITERIA

All English sources from all years from low- and middle-income and high-income countries were eligible. Identified titles and abstracts were screened and full-text articles were reviewed.

DATA COLLECTION AND ANALYSIS

Data collection and analysis included a descriptive summary organized by training case numbers, training duration, trainee background, and repair complexity.

RESULTS

Of the 405 sources retrieved, 24 were included in the study. The only concrete recommendations were in the International Federation of Gynecology and Obstetrics 2022 Fistula Surgery Training Manual, which proposes 50 to 100 repairs (Level 1), 200 to 300 repairs (Level 2), and trainer discretion for Level 3 competency.

CONCLUSIONS

More case- or time-based data, particularly if stratified by trainee background and repair complexity, would be useful at the individual, institutional, and policy level for fistula care implementation or expansion.

Factors associated with reintegration trajectory following female genital fistula surgery in Uganda

BACKGROUND

A female genital fistula, primarily caused by prolonged obstructed labor or after cesarean delivery in resource-limited countries, affects 500,000 to 2,000,000 women worldwide. Fistula is preventable with timely access to high-quality obstetrical care. Access to surgical repair of a female genital fistula has greatly increased over time. However, research surrounding postrepair reintegration, the process of returning to an individual's normal life, remains limited, and further efforts are needed to understand the factors shaping women's ability to rebuild their relationships and lives following repair.

OBJECTIVE

This study aimed to characterize the 12-month reintegration trajectory after female genital fistula repair by participant sociodemographic and clinical characteristics.

STUDY DESIGN

This study analyzed quantitative survey and medical record data of women (N=60) participating in a longitudinal cohort study assessing recovery after genital fistula repair in Uganda, with baseline and 4 quarterly follow-up assessments in 12 months. The primary outcome of reintegration was assessed using a 19-item postfistula repair reintegration instrument (range, 0-100) where a higher score represents better reintegration. Predictors of interest included parity and living children, quality of life, depressive symptoms at baseline, self-esteem, stigma, trauma, physical symptoms, and social support. We described participant baseline characteristics using means and proportions and estimated a series of mixed-effects linear regression models, including interactions of characteristics with time to understand how these characteristics influence reintegration trajectory in the 12 months after repair.

RESULTS

The participants' physical and psychosocial morbidities at baseline were high; more than 80% of participants reported fistula-related physical symptoms, 82% of participants described their general health as poor, and measures of self-esteem, overall social support, and overall quality of life were low. The mean reintegration score at baseline was 33 (standard deviation, 20), which increased to 78 (standard deviation, 19) at 12 months after fistula repair. The participant sociodemographic characteristics statistically associated with reintegration included any living children (β, 1.08; 95% confidence interval, -0.08 to 2.23). Moreover, psychosocial factors significantly affected reintegration with steeper trajectories for women with depressive symptoms (β, 0.89; 95% confidence interval, 0.02-1.75) or women experiencing internalized stigma (β, 0.05; 95% confidence interval, -0.00 to 0.11) and less steep for those with higher self-esteem (β, -0.11; 95% confidence interval, -0.24 to 0.01), overall social support (β, -0.06; 95% confidence interval, -0.12 to -0.01), and partner support (β, -0.21; 95% confidence interval, -0.35 to -0.07).

CONCLUSION

Understanding the prominent factors associated with differences in reintegration trajectories across the year after genital fistula surgery has the potential to inform interventions that mitigate challenges and improve women's postrepair recovery experiences.

Successful surgical closure and continence rate of obstetric fistula in Africa: systematic review and meta-analysis

Background

A female genital fistula is an abnormal connection between a woman's reproductive tract and her urinary tract or rectum. While numerous studies have aimed to determine the success rate of obstetric fistula closure in different health settings, there remains a significant scarcity of data on closure success rates and incontinence rates for various types of fistulas at the regional and sub-regional levels. The success rate reflects the continent's healthcare setup in regard to the World Health Organization standards. Thus, this study aims to determine the success of surgical closure and the continence rate of obstetric fistula in Africa.

Methods

This systematic review and meta-analysis review includes studies conducted up to February 2023. Search engines like EMBBASE, Medline, Google, PubMed, Google Scholar, African Journals Online, and ScienceDirect databases were utilized to find articles. The Joanna Briggs Institute critical evaluation checklist was used to evaluate the quality of our review, which was conducted in accordance with PRISMA criteria. Heterogeneity was indicated by a p-value for I2 statistics of less than 0.05. Publication bias was assessed using the Egger regression asymmetry test. Data were entered into Microsoft Excel and analyzed using STATA 16.

Result

This review includes 85 studies. A total of 24 countries from East, West, Central, North, and Southern African sub-regions were included. The overall pooled estimated rate of successful obstetric fistula closure is 86.15 (95% CI: 83.88-88.42). Moreover, the pooled estimated rate of successfully closed vesico-vaginal fistulas but with ongoing or residual incontinence (wet) was revealed as 13.41% (95% CI: 11.15-15.68). The pooled estimated rate of successfully closed rectovaginal fistulas and combined VVF and RVF are 91.06% (95% CI: 86.08-96.03) and 62.21% (95% CI: 48.94-75.49), respectively.

Conclusions

The rate of successful obstetric fistula closure in Africa is 86.15, which is higher than the WHO target. However, the surgical closure rate of a combined VVF and RVF is 62.2%, which is significantly lower than the WHO target.

North-central Nigerian women's experiences of obstetric fistula risk factors and their perceived treatment services: An Interpretive Description

BACKGROUND

An obstetric fistula also known as vesico vaginal fistula (VVF), or recto-vaginal fistula (RVF) is an abnormal opening between the urogenital tract and intestinal tract caused by prolonged obstructed labour; when the head of the baby presses on the soft tissues in the pelvis leading to loss of blood flow to the women's bladder, vagina, and rectum. This can cause necrosis of the soft tissues resulting in debilitating fistula formations.

AIM

This study aimed to uncover North-central Nigerian women's experiences of obstetric fistula and their perceived treatment services.

DESIGN

Qualitative, interpretive descriptive methodology underpinned by symbolic interactionism involving face-to-face semi-structured interviews was used to explore North-central Nigerian women's experiences of obstetric fistula and their perceived treatment services.

SAMPLE

A purposive sample of 15 women who had experienced obstetric fistula at a repair Centre in North-central Nigeria were eligible.

RESULTS

Four themes emerged from North-central Nigerian women's experiences of obstetric fistula and their perceived treatment services i) I was left alone in the room ii) Waiting for the one vehicle in the village iii) I never knew about labour until that very day iv) and We kept following the native doctors and sorcerers.

CONCLUSION

The findings from this study highlighted the depth of women's experiences from the devastating complication of childbirth injury in North-central Nigeria. Analysis of insights from women's voices directly affected by obstetric fistula demonstrated that in their views and experiences the themes identified were majorly responsible for their fistula status. Thus women need to raise their collective voices to resist oppressive harmful traditions and demand empowerment opportunities that will improve their social status. Government should improve primary healthcare facilities, train more midwives and subsidise maternal care for antenatal education and birth services spending for childbirth women may result in improved childbirth experiences for women in rural and urban communities.

TWEETABLE ABSTRACT

Reproductive women call for increased accessibility to healthcare services and the provision of more midwives to mitigate obstetric fistula in North-central Nigerian communities.

Health-seeking experiences of women with obstetric fistula: a qualitative study at two fistula centres in Ghana

OBJECTIVES

The study explored the health-seeking experiences of women with obstetric fistula from the onset of the condition until surgical treatment was obtained. It also describes their interactions with health staff and traditional healers.

DESIGN

Exploratory, descriptive qualitative study.

SETTING

Two secondary-level health facilities in the northern and central regions of Ghana; data collection took place in 2018-2019.

PARTICIPANTS

A purposive sample of 37 women who had experienced fistula resulting from childbirth and were awaiting fistula repair at the two fistula centres in Ghana was obtained.

DATA ANALYSIS

Thematic analysis was used to analyse the data.

RESULTS

Health-seeking experiences and behaviours of women with obstetric fistula were identified. Six major themes were generated: attribution and perceptions of fistula; competing alternatives/multiple sources of care; limited awareness and access to care; financial barriers; psychosocial challenges, and abuse by healers. The results indicate that the health-seeking experiences of women with obstetric fistula were characterised by long delays in care-seeking. The major themes and subthemes are presented with quotes from participants.

CONCLUSION

The women experienced winding pathways of treatment-seeking due to lack of awareness and incorrect attribution. The major barriers to health-seeking included poverty, challenges with transportation and inadequate repair centres. Increased awareness of obstetric fistula and access to repair centres could shorten the suffering women go through while awaiting fistula treatment. Improved awareness of obstetric fistula and establishment of more fistula centres would be beneficial.

Variability and awareness of obstetric fistula among women of reproductive age in sub-Saharan African countries: A systematic review and meta-analysis

BACKGROUND

Obstetric fistula among women of reproductive age is a significant public health issue in developing countries, including Sub-Saharan Africa. However, the pooled awareness of obstetric fistula among women of reproductive age in Sub-Saharan Africa and its variation between countries have not yet been studied. Hence, the review aims to assess variability and awareness of obstetric fistula among women of reproductive age in Sub-Saharan African Countries.

METHOD

Articles were searched using different electronic databases, such as PubMed, Web of science, science direct (Scopus), Google scholar, and HINARI and manual search without regard to publication date. A random-effects model was used to ascertain the pooled prevalence of obstetric fistula awareness among women of reproductive age in Sub-Saharan Africa. Publication bias was checked by using funnel plot and Egger's test at a 5% level of significance. I2 test statistics was performed to evaluate heterogeneity among included studies. In addition, to identify the possible reason for the potential heterogeneity between the studies, sub-group and meta-regression analyses were conducted. A sensitivity analysis was performed to determine the impact of individual research on the overall results. The data were extracted by using Microsoft excel and analyzed using statistical software STATA/SE version 17.

RESULT

A total of 22 studies with 79,693 women of reproductive age were included in this systematic review and meta-analyses. In Sub-Saharan Africa, the pooled prevalence of awareness towards obstetric fistula among women of reproductive age was 40.85% (95% CI: 33.48, 48.22%). Analysis of the subgroups by specific countries revealed significant variation. The highest awareness of obstetric fistula was found among Tanzanian women of reproductive age (61.10%, 95% CI: 55.87-66.33%), whereas the lowest awareness was found in research from the Gambia (12.80%, 95% CI: 12.20-13.40%).The likelihood of obstetric fistula awareness were lower by a factor of 0.424 among studies with sample sizes greater than 3542 (β = -0.424 (95% CI: -0.767 to 0.081), p -value <0.05).

CONCLUSION

According to the current review, there is a low level of awareness about obstetric fistula among women of reproductive age in sub-Saharan Africa, and the results of the sub-group analysis by country showed wide variations. Therefore, we emphasize the need for country-specific public health initiatives to raise awareness about obstetric fistula among women of reproductive age, which could reduce the risk of delayed treatment.

Women's views on obstetric fistula risk factors and prevention in north-central Nigeria: an interpretive descriptive study

OBJECTIVE

Obstetric fistula, also known as vesicovaginal fistula or rectovaginal fistula, is an abnormal opening between the vagina and rectum caused by prolonged obstructed labour that causes substantial long-term harm to women. It is most prevalent in low resource settings and although preventative measures have been proposed, they have not, to date, taken women's own views into account. The objective of this study was to explore the views of North Nigerian women on obstetric fistula risk factors and prevention.

DESIGN

This study was conducted using Interpretive Description methodology, which is a qualitative approach underpinned by Symbolic Interactionism. A semistructured questionnaire was used to explore the views of 15 women living with obstetric fistula about risk factors and prevention of the condition. Data were collected in one-to-one in-depth interviews conducted between December 2020 and May 2021. All interviews were audio-recorded and transcribed verbatim, and a thematic approach to data analysis was employed.

SAMPLING AND SETTING

The setting for this study was a fistula repair centre in north-central Nigeria. The sample was formed of a purposively selected 15 women who had experienced obstetric fistula at a repair Centre in north-central Nigeria.

RESULTS

Four core themes emerged from women's views on obstetric fistula risk factors and prevention: (1) Women's autonomy, (2) Economic empowerment, (3) Infrastructure/transportation and (4) Provision of skilled healthcare services.

CONCLUSION

The findings from this study highlight previously unknown women's views on obstetric fistula risk factors and prevention in north-central Nigeria. Analysis of insights from women's voices directly affected by obstetric fistula demonstrated that in their views and experiences, giving women autonomy (decision-making power) to choose where to birth safely, economic empowerment, enhancement of transportation/infrastructure and provision of skilled healthcare services may mitigate obstetric fistula in Nigeria.

Identifying Opportunities for Prevention of Adverse Outcomes Following Female Genital Fistula Repair: Protocol for a Mixed-Methods Study in Uganda

Background

Female genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000-2 million women in lower-resource settings. Vesicovaginal fistula causes urinary incontinence. Other gynecologic, neurologic and orthopedic morbidity may occur during fistula development. Women with fistula are stigmatized; limit engagement in social, economic, or religious activities; and report high psychiatric morbidity. Improved global surgical access has reduced fistula consequences yet post-repair risks impacting quality of life and well-being include fistula repair breakdown or recurrence and ongoing or changing urine leakage or incontinence. Limited evidence on risk factors contributing to adverse outcomes hinders interventions to mitigate adverse events, protecting health and quality of life after surgery. This study seeks to identify predictors and characteristics of post-repair fistula breakdown and recurrence (Aim 1) and post-repair incontinence (Aim 2), and to identify feasible and acceptable intervention strategies (Aim 3).

Methods

This mixed-methods study incorporates a prospective cohort study of women with successful vesicovaginal fistula repair at approximately 12 fistula repair centers and affiliated care sites in Uganda (Aims 1-2) followed by qualitative inquiry among key stakeholders (Aim 3). Cohort participants will have a baseline visit at the time of surgery followed by data collection at 2 weeks, 6 weeks, 3 months and quarterly thereafter for 3 years. Primary predictors to be evaluated include patient-related factors, fistula-related factors, fistula repair-related factors, and post-repair behaviors and exposures, collected via structured questionnaire at all data collection points. Clinical exams will be conducted at baseline, 2 weeks post-surgery, and for outcome confirmation at symptom development. Primary outcomes are fistula repair breakdown or fistula recurrence and post-repair incontinence. In-depth interviews will be conducted with cohort participants (n ~ 40) and other key stakeholders (~ 40 including family, peers, community members and clinical/social service providers) to develop feasible and acceptable intervention concepts for adjustment of identified risk factors.

Discussion

Participant recruitment is underway. This study is expected to identify key predictors that can directly improve fistula repair and post-repair programs and women's outcomes, optimizing health and quality of life. Furthermore, our study will create a comprehensive longitudinal dataset capable of supporting broad inquiry into post-fistula repair health.

Trial Registration

ClinicalTrials.gov Identifier: NCT05437939.

Social support among women with genital fistula in Uganda

Resulting from prolonged obstructed labour, iatrogenic and traumatic aetiologies, female genital fistula in low-resource settings causes a significant physical and psychosocial burden. Social support is an important mechanism to build resilience to health challenges. This study aimed to understand the role of emotional, informational and tangible social support for Ugandan women affected by fistula. Thirty-three participants who had had fistula surgery 6-24 months prior to the study were recruited from Mulago Hospital in Kampala, Uganda. Data from in-depth interviews (n = 16) and 4 focus group discussions were analysed thematically using a social support framework. Various individuals were key providers of social support across the different domains. They included family, friends, community organisations, and other women affected by fistula. Social support was critical in helping women cope with fistula, access fistula care, and post-repair recovery. Women relied heavily on tangible and emotional support to meet their physical and psychological needs. Support-enhancing interventions for women and their families, particularly those offering emotional and tangible support, may be a promising strategy for improving the experiences and quality of life of women affected by fistula.

Understanding Healthcare-Seeking Pathways and Dilemmas Among Women with Obstetric Fistulas in Ethiopia: A Qualitative Inquiry

Background

Obstetric fistula is a public health problem with a damaging effect on the health of women around the world. The path to medical care is an integral part of women's experience of illness that may have an impact on their health. Studies have addressed the experiences of patients after fistula repair, but fistula victims' care-seeking pathways and dilemmas are still poorly understood in low-income countries, particularly Ethiopia.

Objective

This study aimed to explore the care-seeking pathways and dilemmas among women with fistulas in Ethiopia.

Methods

An exploratory phenomenological study was carried out from April 1 to August 1, 2019, through in-depth interviews and supplementary informant interviews. Data were obtained from 21 purposively selected women with fistulas who survived with morbidity for one and more years and 12 supplementary interviewees at fistula treatment centers in Oromia Region and Addis Ababa. Data were analyzed assisted by ATLAS. ti 8.4 software.

Results

Respondents gave their testimony that most of the women with fistulas first sought care from traditional care places and finally from fistula treatment centers. The reasons for care-seeking path dilemmas were a wrong perception about fistula, its causes, and treatment; families' pressure and lack of decision-making power on where to seek treatment, and a lack of knowledge on where modern treatments are available for fistula. They received psychological, companionship, and transport support from a family and a community; referral and counseling support from health care providers during their care-seeking pathways.

Conclusion

A myriad of reasons inhibits the right care-seeking pathways among women with fistulas. Communities and women with fistula awareness creation on the right places for fistula treatment and psychological support programs are required. Additionally, developing and implementing tactics for community-level screening programs for targeted victims and early admission to treatment centers can minimize the tragic sequela of the fistula.

Interventions for treating obstetric fistula: An evidence gap map

Obstetric fistula is prevalent in low- and middle-income countries, with between 50,000 and 100,000 new cases each year. The World Health Organization aims to eradicate it by 2030 but a clear idea of the extant evidence is unavailable. This evidence map compiled evidence on treatments for obstetric fistula to identify potential knowledge gaps. The protocol for this work was published on the Open Science Framework (DOI: 10.17605/OSF.IO/H7J35). A survey was developed, piloted and distributed online through organisations with an interest in obstetric fistula and snowballing. Results informed the evidence map framework. Searches were run on MEDLINE, Embase, CENTRAL, Global Index Medicus and ScanMedicine on 16 February 2022 to identify potentially eligible systematic reviews, randomised controlled trials, cohort studies and case-control studies. Forward and backward citation chaining was undertaken on relevant systematic reviews and included studies. Studies were screened, coded and assessed for risk of bias by a single reviewer, with a second checking a proportion. The evidence map results were compared to survey results. Thirty-nine people responded to the survey, half of which were clinicians. Of 9796 records identified, 37 reports of 28 studies were included in the evidence map. Many included studies were at some risk of bias; for observational studies, this was predominantly due to lack of controlling for confounders. Most studies (71%) assessed surgical interventions alone. Reporting on other intervention types was limited. Regarding outcome measures most important to survey respondents, 24 studies reported on cure/improvement in obstetric fistula and 20 on cure/improvement in urinary incontinence. Reporting on quality of life, faecal incontinence and sexual function was limited. There is currently little robust evidence to guide patients and practitioners on the most effective treatment option for obstetric fistula. Further research is required to address evidence gaps identified.

Validation of an ovine vesicovaginal fistula model

INTRODUCTION AND HYPOTHESIS

A representative, large animal model of vesicovaginal fistulas is needed for the training of surgeons and for the development of new surgical techniques and materials for obstetric fistula repair.

METHODS

The safety, feasibility, and reproducibility of vesicovaginal fistula creation were studied in 4 adult female sheep. A 1-cm fistula was created between the vagina and the bladder through a transvaginal approach. The defect was allowed to heal for 8 weeks and the animals were then euthanized. The primary outcome was the fistula patency. Secondary outcomes were fistula size, urogenital dimensions, urodynamic evaluation, histology (inflammation, vascularization, collagen deposition) and biomechanical characteristics of the fistula edge (stress at break, maximum elongation, and stiffness).

RESULTS

The transvaginal creation of a vesicovaginal fistula was safe. All animals survived the surgical procedure and follow-up period, without complications. Three of the four animals demonstrated a patent vesicovaginal fistula after 8 weeks. Baseline data are provided of the urogenital dimensions and the urodynamic, histological, and biomechanical characteristics of the model.

CONCLUSIONS

The ewe is a safe, feasible, and reproducible model for vesicovaginal fistulas. The model can help to study new techniques and materials to boost surgical innovation for vesicovaginal fistula repair.

Prevalence and factors associated with the awareness of obstetric fistula among women of reproductive age in The Gambia: a multilevel fixed effects analysis

Background

An obstetric fistula is an inappropriate connection between the vagina, rectum, or bladder that results in faecal or urine incontinence. Young women from rural areas with poor socioeconomic situations and education are the majority of victims, which restricts their access to high-quality healthcare. Obstetric fistulas can have devastating effects on the physical health of affected women if they are not promptly treated. Inadequate awareness of the symptoms delays recognition of the problem, prompt reporting, and treatment. Women with poor awareness of the disorder are also more likely to develop complications, including mental health issues. Using data from a nationally representative survey, this study investigated the prevalence and factors associated with the awareness of obstetric fistula among women of reproductive age in The Gambia.

Methods

This study used population-based cross-sectional data from the 2019–2020 Gambia Demographic and Health survey. A total of 11823 reproductive-aged women were sampled for this study. Stata software version 16.0 was used for all statistical analyses. Obstetric fistula awareness was the outcome variable. Multilevel logistic regression models were fitted, and the results were presented as adjusted odds ratios (aOR) with statistical significance set at p < 0.05.

Results

The prevalence of obstetric fistula awareness was 12.81% (95%CI: 11.69, 14.12). Women aged 45–49 years (aOR = 2.17, 95%CI [1.54, 3.06]), married women (aOR = 1.39, 95%CI [1.04, 1.87]), those with higher education (aOR = 2.80, 95%CI [2.08, 3.79]), and women who worked as professionals or occupied managerial positions (aOR = 2.32, 95%CI [1.74, 3.10]) had higher odds of obstetric fistula awareness. Women who had ever terminated pregnancy (aOR = 1.224, 95%CI [1.06, 1.42]), those who listened to radio at least once a week (aOR = 1.20, 95%CI [1.02, 1.41]), ownership of a mobile phone (aOR = 1.20, 95%CI [1.01, 1.42]) and those who were within the richest wealth index (aOR = 1.39, 95%CI [1.03, 1.86]) had higher odds of obstetric fistula awareness.

Conclusion

Our findings have revealed inadequate awareness of obstetric fistula among women of reproductive-age in The Gambia. Obstetric fistulas can be mitigated by implementing well-planned public awareness initiatives at the institutional and community levels. We, therefore, recommend reproductive health education on obstetric fistula beyond the hospital setting to raise reproductive-age women's awareness.

Sub-Saharan African women's views and experiences of risk factors for obstetric fistula: a qualitative systematic review

Background

Obstetric fistula used as synonymous with VVF in this study, is an abnormal communication/hole between the urinary tract and the genital tract or the gastrointestinal tract and the genital tract, resulting from prolonged obstructed labour. VVF may cause sufferers to experience chronic urinary/faecal incontinence, and the stigma of continuing foul odour. VVF is primarily caused by prolonged obstructed labour, which is brought about by a range of causes. Recently, it has been proposed that women’s groups and fistula survivors should suggest interventions to reduce or prevent the incidence of obstetric fistula.

Objective

The objective of this review was to synthesise what is reported about women’s views and experiences of the risk factors underlying the causes of VVF.

Methods

A systematic approach outlined in the Joanna Briggs Institute Manual for Evidence synthesis was followed for this review, articles published since the last 11 years from 2011 to 2021 were selected against several criteria and critically appraised using JBI Critical Appraisal Checklist for qualitative studies.

Results

Nine studies were retained for inclusion in this review and the data were then synthesised into five themes: (1) Cultural beliefs and practices impeding safe childbirth, (2) Lack of woman’s autonomy in choices of place to birth safely, (3) Lack of accessibility and social support to safe childbirth, (4) Inexperienced birth attendants and, (5) Delayed emergency maternal care (childbirth).

Conclusions

This review highlights the complexity of risk factors predisposing women to the known causes of VVF. It also illuminates the absence of women’s voices in the identification of solutions to these risks. Women are most directly affected by VVF. Therefore, their knowledge, views, and experiences should be considered in the development and implementation of strategies to address the issue. Exploring women’s views on this issue would enable the identification of gaps in maternity care provision, which would be of interest to community and health service leaders as well as policymakers in Sub-Saharan Africa.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05013-2.

Rectovaginal Fistula Management in Low-Resource Settings

Rectovaginal fistula (RVF) is an abnormal connection between the rectum and vagina that affects women globally. In low- and middle-income countries (LMIC), RVF is most commonly due to obstetric complications such as prolonged labor or perineal tears, female genital mutilation and trauma such as sexual violence or iatrogenic surgical injuries. Women affected by this condition suffer from debilitating physical symptoms, social isolation, economic disempowerment, psychological trauma, low self-esteem, and loss of role fulfillment. Lack of accessible, high-quality, and effective healthcare is a major barrier to timely and safe obstetric care and to care for subsequent complications such as RVF. Additionally, social, cultural, financial, and systemic barriers put women at risk of acquiring fistula and contribute to delays in seeking and receiving care. Literature evaluating RVF repair in those able to access care offers limited information about management and outcomes. It is difficult to ascertain which surgical techniques are used. To reduce the burden of this often-preventable disease, appropriate investment in healthcare infrastructure to strengthen maternal care in LMICs is paramount. Furthermore, more standardized reporting of severity and treatment approach along with outcome data are critical to improving the quality of care for patients impacted by RVF.

Exploring awareness of obstetric fistula in Eastern and Northern Nigeria: perceived causes, symptoms, and availability of treatment services

Background

Evidence suggests that there are approximately two female genital fistula cases per 1000 women of reproductive age in sub-Saharan Africa. It is estimated that more than 200,000 women are affected by fistula in Nigeria, primarily due to obstetric causes. Awareness has been indicated as a risk factor for the development of obstetric fistula. This study explored the awareness of obstetric fistula such as causes, symptoms, and availability of and access to treatment services in southeastern and northwestern Nigeria.

Methods

An exploratory qualitative study design was used to conduct this research in Kano and Ebonyi states in northern and eastern Nigeria, respectively. A total of six (6) focus group discussions were conducted with three categories of participants: women who were successfully repaired and discharged (n = 2), community-married men (n = 2), and women (n = 2). Forty-four (44) In-depth interviews were conducted three categories of participants: 18 with women with fistula who were either awaiting repair or had been repaired; 6 family member caregivers accompanying fistula patients, and 20 health service providers at fistula repair centers. We developed a data analysis plan based on the emerging themes. The transcripts and field notes were imported into QSR Nvivo version 11 and coded accordingly. Content and thematic analysis was run by inductively drawing themes based on the elicited information from participants.

Results

There was lack of knowledge of obstetric fistula and its causes among married men and women in the community, caregivers, and some patients were unaware of what caused their fistula for years. In this study, none of the community men and women nor caregivers correctly identified the causes and symptoms of a fistula or knew where to seek treatment. Knowledge about fistula was more common among women who had undergone repairs. Some repaired women attributed the cause of fistula to the providers who attended to them during delivery.

Conclusions

Findings reveal a widespread lack of awareness of obstetric fistula onset and awareness of the availability of repair services at the community level. There is an urgent need to explore multi-pronged strategies for increasing awareness of obstetric fistula and available treatment services among women and other community members.

Factors associated with surgical repair success of female genital fistula in the Democratic Republic of Congo: Experiences of the Fistula Care Plus Project, 2017-2019

Objective

We sought to document outcomes and factors associated with surgical success in hospitals supported by the Fistula Care Plus Project in the Democratic Republic of Congo (DRC), 2017–2019.

Methods

This was a retrospective cohort study analysing routine repair data on women with Female Genital Fistula. Univariate and multivariate analyses were conducted to determine factors associated with successful fistula repair.

Results

A total of 895 women were included in this study, with a mean age of 34 years (±13 years). The majority were married or in union (57.4%) and living in rural areas (82.0%), while nearly half were farmers (45.9%). The average duration living with fistula was 8 years (±7). Vesicovaginal (70.5%) and complex (59.8%) fistulas were the most common fistula types. Caesarean section (34.7%), obstructed labour (27.0%) and prolonged labour (23.0%) were the main aetiologies, with the causal deliveries resulting in stillbirth in 88% of cases. The vaginal route (74.9%) was the primary route for surgical repair. The median duration of bladder catheterization after surgery was 14 days (interquartile range [IQR] 7–21). Multivariate analysis revealed that Waaldijk type I fistula (adjusted odds ratio [aOR]:2.71, 95% confidence interval [CI]:1.36–5.40), no previous surgery (aOR:2.63, 95% CI:1.43–3.19), repair at Panzi Hospital (aOR: 2.71, 95% CI:1.36–5.40), and bladder catheterization for less than 10 days (aOR:13.94, 95% CI: 4.91–39.55) or 11–14 days (aOR: 6.07, 95% CI: 2.21–15.31) were associated with better repair outcomes.

Conclusion

The Fistula Care Plus Project in the DRC recorded good fistula repair outcomes. However, further efforts are needed to promote adequate management of fistula cases.

Awareness of obstetric fistula and associated factors among women in reproductive age group attending public hospitals in southwest Ethiopia, 2021

BACKGROUND

Obstetric fistula occurs in all developing countries but it is confined to the "fistula belt" across the northern half of Sub-Saharan Africa from Mauritania to Eritrea and in the developing countries of the Middle East and Asia. Ending obstetric fistula is critical to achieving Sustainable Development by 2030. So creating awareness on obstetrics fistula among women in the reproductive age group have a crucial role in reducing morbidity, mortality, and social stigma.

OBJECTIVE

To assess awareness on obstetric fistula and its associated factors among reproductive-age women attending governmental hospitals in southwest Ethiopia, 2021.

METHODS

An Institutional based cross-sectional study design was conducted among 413 women. The sample size was estimated by using a single population proportion formula. The collected data were coded and entered into EPI-data version 3.1 then exported to SPSS version 24 for descriptive and inferential analysis. Adjusted odds ratio (AOR) along with 95% confidence level was estimated to assess the strength of the association and variables with a p-value < 0.05 were considered to declare the statistical significance in the multivariable analysis in this study.

RESULTS

In this study, a total of 400 clients have participated in the study. The mean ages of participants were 30.26 (SD ± 8.525) years old. Education of women who cannot read and write are 85% less likely to have good awareness than women who are above the secondary level of education [AOR = 0.162; 95% CI (0.081-0.364)]. While Women who have primary education level are 83% less likely to have good awareness than women who are above the secondary level of education [AOR = 0.170; 95% CI (0.085-0.446)]. In addition, This study shows women who have not heard about obstetric complications are 54% less likely to have awareness of obstetric fistula than those who heard about obstetric complications [AOR = 0.458; 95% CI (0.368-0.643)].

CONCLUSION

This study identifies that the educational level of women, history of pregnancy, distance to the nearby health institution, and awareness of obstetrics complications were the factors associated with awareness of reproductive age women on obstetrics fistula. Hence, increasing awareness on obstetric fistula plays a key role in averting this problem.

What factors affect patients' ability to access healthcare? An overview of systematic reviews

OBJECTIVES

This overview aims to synthesise global evidence on factors affecting healthcare access, and variations across low- and middle-income countries (LMICs) vs. high-income countries (HICs); to develop understanding of where barriers to healthcare access lie, and in what context, to inform tailored policies aimed at improving access to healthcare for all who need it.

METHODS

An overview of systematic reviews guided by a published protocol was conducted. Medline, Embase, Global Health and Cochrane Systematic Reviews databases were searched for published articles. Additional searches were conducted on the Gates Foundation, WHO and World Bank websites. Study characteristics and findings (barriers and facilitators to healthcare access) were documented and summarised. The methodological quality of included studies was assessed using an adapted version of the AMSTAR 2 tool.

RESULTS

Fifty-eight articles were included, 23 presenting findings from LMICs and 35 presenting findings from HICs. While many barriers to healthcare access occur in HICs as well as LMICs, the way they are experienced is quite different. In HICs, there is a much greater emphasis on patient experience; as compared to the physical absence of care in LMICs.

CONCLUSIONS

As countries move towards universal healthcare access, evaluation methods that account for health system and wider cultural factors that impact capacity to provide care, healthcare finance systems and the socio-cultural environment of the setting are required. Consequently, methods employed in HICs may not be appropriate in LMICs due to the stark differences in these areas.

Toward a complete estimate of physical and psychosocial morbidity from prolonged obstructed labour: a modelling study based on clinician survey

Introduction

Prolonged obstructed labour often results from lack of access to timely obstetrical care and affects millions of women. Current burden of disease estimates do not include all the physical and psychosocial sequelae from prolonged obstructed labour. This study aimed to estimate the prevalence of the full spectrum of maternal and newborn comorbidities, and create a more comprehensive burden of disease model.

Methods

This is a cross-sectional survey of clinicians and epidemiological modelling of the burden of disease. A survey to estimate prevalence of prolonged obstructed labour comorbidities was developed for prevalence estimates of 27 comorbidities across seven categories associated with prolonged obstructed labour. The survey was electronically distributed to clinicians caring for women who have suffered from prolonged obstructed labour in Asia and Africa. Prevalence estimates of the sequelae were used to calculate years lost to disability for reproductive age women (15 to 49 years) in 54 low- and middle-income countries that report any prevalence of obstetric fistula.

Results

Prevalence estimates were obtained from 132 participants. The median prevalence of reported sequelae within each category were: fistula (6.67% to 23.98%), pelvic floor (6.53% to 8.60%), genitourinary (5.74% to 9.57%), musculoskeletal (6.04% to 11.28%), infectious/inflammatory (5.33% to 9.62%), psychological (7.25% to 24.10%), neonatal (13.63% to 66.41%) and social (38.54% to 59.88%). The expanded methodology calculated a burden of morbidity associated with prolonged obstructed labour among women of reproductive age (15 to 49 years old) in 2017 that is 38% more than the previous estimates.

Conclusions

This analysis provides estimates on the prevalence of physical and psychosocial consequences of prolonged obstructed labour. Our study suggests that the burden of disease resulting from prolonged obstructed labour is currently underestimated. Notably, women who suffer from prolonged obstructed labour have a high prevalence of psychosocial sequelae but these are often not included in burden of disease estimates. In addition to preventative and public health measures, high quality surgical and anaesthesia care are urgently needed to prevent prolonged obstructed labour and its sequelae.

Obstetric and Gynecologic Genitourinary Fistulas

Urinary incontinence shortly after childbirth or gynecologic surgery can be the result of obstetric or iatrogenic fistula formation. This can be a confusing and challenging diagnosis for medical providers. While the number of iatrogenic fistula cases is rising worldwide, obstetric fistulas are an issue uniquely particular to resource poor settings. Appropriate treatment of genitourinary fistulas spans beyond surgical intervention of leakage, and includes re-integration into the community, widespread education and counseling, and battling social stigma and cultural biases. Current and future research must focus on rigorous, unified efforts to set evidence-based practices to help the millions of women affected.

Function and disability status among women with fistula using WHODAS2.0: A descriptive study from Rwanda and Democratic Republic of Congo

OBJECTIVE

To assess function and disability among women in Rwanda and Democratic Republic of Congo living with fistula and identify characteristics associated with higher disability scores.

METHODS

Women presenting for fistula care were recruited. Eligible participants underwent a physical examination to classify fistula type and completed the WHO Disability Assessment Schedule 2.0 questionnaire to ascertain the impact of fistula on function across six domains: cognition, mobility, self-care, getting along, life activities, and participation. Disability scores were calculated (where 0 = no disability and 100 = complete disability). Participants were grouped according to no, low, or high disability status; results were examined to determine the domains most affected.

RESULTS

Among 69 participants, fistula type included: vesicovaginal (59.4%), ureterovaginal (14.5%), total absence of proximal urethra (11.6%), and rectovaginal (14.5%). Median disability score was 43.0/100 (interquartile range 26.0-67.0); 83% exhibited high disability status. Life activities and participation in society domains were most affected. Women with rectovaginal fistula reported the lowest scores, and those with total absence of proximal urethra reported the highest scores.

CONCLUSION

WHO Disability Assessment Schedule 2.0 represents a simple, robust measure of global disability status, aligns with research efforts to estimate maternal disability, and may inform health needs and resource allocation for this population. In this study, disability was common, varied by fistula type, and affected physical, mental, and social domains.

Measuring barriers to fistula care: investigating composite measures for targeted fistula programming in Nigeria and Uganda

BACKGROUND

Accessing surgical repair poses challenges to women living with female genital fistula who experience intersectional vulnerabilities including poverty, gender, stigma and geography. Barriers to fistula care have been described qualitatively in several low- and middle-income countries, but limited effort has been made to quantify these factors. This study aimed to develop and validate composite measures to assess barriers to accessing fistula repair in Nigeria and Uganda.

METHODS

This quantitative study built on qualitative findings to content validate composite measures and investigates post-repair client surveys conducted at tertiary hospitals in Northern and Southern Nigeria and Central Uganda asking women about the degree to which a range of barriers affected their access. An iterative scale development approach included exploratory and confirmatory factor analyses of two samples (n = 315 and n = 142, respectively) using STATA 13 software. Reliability, goodness-of-fit, and convergent and predictive validity were assessed.

RESULTS

A preliminary 43-item list demonstrated face and content validity, triangulated with qualitative data collected prior to and concurrently with survey data. The iterative item reduction approach resulted in the validation of a set of composite measures, including two indices and three sub-scales. These include a Financial/Transport Inaccessibility Index (6 items) and a multidimensional Barriers to Fistula Care Index of 17 items comprised of three latent sub-scales: Limited awareness (4 items), Social abandonment (6 items), and Internalized stigma (7 items). Factor analyses resulted in favorable psychometric properties and good reliability across measures (ordinal thetas: 0.70-0.91). Higher levels of barriers to fistula care are associated with a woman living with fistula for longer periods of time, with age and geographic settings as potential confounders.

CONCLUSIONS

This set of composite measures that quantitatively captures barriers to fistula care can be used separately or together in research and programming in low- and middle-income countries.

Factors associated with delay in seeking treatment among women with pelvic organ prolapse at selected general and referral hospitals of Southern Ethiopia, 2020

Background

Pelvic organ prolapse (POP) is the descent of the vaginal wall, cervix, uterus, bladder, and rectum downward into the vaginal canal. Its prevalence is higher among women in developing countries because women are more prone to risk factors. In Ethiopia, women with prolapse seek treatments at advanced stages of prolapse; hence, surgical management has been widely practicing. Therefore, it was found to be very important to conduct research that assesses factors hindering early treatments in Southern Ethiopia. This study aimed to find out factors associated with the delay in seeking treatment of pelvic organ prolapse among patients at selected general and referral hospitals of Southern Ethiopia.

Methods

Cross-sectional study design was employed in 123 participants of seven randomly selected General and Referral Hospitals of Southern Ethiopia from February 01 to April 30, 2020, by using a structured questionnaire. Pre-trained two midwives in each center were deployed to collect data. Physicians performed diagnosis and physical examination. Data were entered and coded using EPI INFO version 7 and exported into SPSS version 25 for analysis. Bivariate and multivariable logistic regression analyses were performed. The goodness of fit was assessed by using the Hosmer and Lemeshow goodness test.

Results

In this study, out of 123 clinically diagnosed POP cases, nearly half of them were stage III, and over one-third were stage IV. Therefore, 84.6% (104 participants) of the respondents were delayed for the treatment of POP. The mean length of delay for POP treatments was 36.41 ± 3.95 months. After adjusting for covariates, lack of supports [AOR (Adjusted Odds Ratio) = 5.2 (95% CI 1.4–19.5)], low-income [AOR = 5.8 (95% CI 1.1–19.66)], and fear of social stigma [AOR = 4.7 (95% CI 1.2–18.59)] were significant factors for delayed treatments.

Conclusions

Most of the POP patients were delayed for POP treatments. Factors like lack of support, low-income, and fear of losing social value/stigma were associated with treatment delay. Screening for the POP cases, educating (making awareness) the community about this devastating disease to facilitate early treatment and to avoid social stigma, and raising access to treatment by making the nearby hospitals equipped with facilities to treat POP are recommended.

Grant Report on mCARE: Mobile-Based Care for Children with Autism Spectrum Disorder (ASD) for Low- and Middle-Income Countries (LMICs)

In low- and middle-income countries, especially in Bangladesh, Autism Spectrum Disorder (ASD) may be considered an anathema, and social-cultural-financial constraints mean that there are few facilities available for treatment for ASD children. The revolution in the use of the mobile phone (~80%) by the majority of people in Bangladesh in recent years has created an opportunity to improve the overall scenario in the treatment or remote monitoring process for children with ASD. In this grant project, we planned and developed a mobile phone-based system to remotely monitor children with ASD and help their treatment process both at the caregiver and care practitioner ends. In developing mCARE, we utilized a Remote Experience Sampling Method to design, build, deploy, and study the impact of mobile based monitoring and treatment of children with ASD in Bangladesh. We developed a mobile application using the Experience Sampling Method (ESM). A caregiver routinely reported the behavioral and milestone parameters of their children with ASD. The care practitioners monitored the longitudinal data that helped them in decision-making in a particular patient’s treatment process. The Value Sensitive Design (VSD) was used to make this mobile application more user friendly with consideration of the local economic, social, and cultural values in Bangladesh.

Integrated mental health screening for obstetric fistula patients in Mali: From evidence to policy

BACKGROUND

Obstetric fistula significantly impacts women's mental health and well-being. Routine screening for mental health in fistula repair programs can be a gateway to link patients to services, and can produce routine data to inform programmatic investments. This study observed the integration of a mental health screening program into an obstetric fistula repair program in Mali, with two specific objectives: 1) to describe the social and mental health well-being of women presenting with obstetric fistulas in Mali, and 2) to document the impact of the mental health screening pilot on policy change in Mali.

METHODS

Seven fistula repair campaigns were conducted between June 2016 and May 2017. All individuals presenting for fistula repair completed a mental health assessment at intake, including a depression screener (PHQ-9) and an assessment of psycho-social impacts of fistula. The depression screener was repeated three months following inpatient discharge. Findings were shared with stakeholders in Mali and impacts on policy were documented.

RESULTS

Of 207 women who presented for fistula repair, 167 patients completed the mental health assessment at surgical intake, and 130 patients repeated the screener at 3-month follow-up. At intake, 36.5% of women had moderate or severe depression, decreasing to 16.9% at follow-up. The mean depression score differed significantly by timepoint (9.14 vs. 6.72, p <0.001). Results were shared in a report with stakeholders, and consultations with the Mali Ministry of Health. As a result of advocacy, mental health was a key component of Mali's National Fistula Prevention and Treatment Strategy (2018-2022).

CONCLUSION

The high prevalence of depression in Malian fistula patients underscores a need for more robust mental health support for patients after surgery. Data on mental health from routine screening informs community reintegration strategies for individual patients, elevates the overall quality of care of fistula repair programs by addressing patients' holistic health needs, and contributes to evidence-informed decision-making and data-driven policy change within the larger health system.

Women's experiences of fistula-related stigma in Uganda: a conceptual framework to inform stigma-reduction interventions

Fistula-related stigma is common. The absence of a unifying conceptual framework prevents a nuanced understanding of the nature of fistula-related stigma, comparison across contexts and the ability to contrast with other stigmas. It also hinders intervention development. We conducted in-depth interviews or focus groups with 60 women who had undergone fistula surgery 6-24 months prior at Mulago Hospital in Kampala, Uganda in 2014. Transcripts were analysed for experiences and consequences of enacted, anticipated and internalised stigma. Narratives revealed experiences with enacted stigma, including gossip, verbal abuse and social exclusion. Women also anticipated and feared stigma in the future. Internalised stigma reports revealed shame and low self-esteem: self-worth reduction, feeling disgraced and envisioning no future. Consequences included social isolation, changes to normal activities, non-disclosure and poor mental health. Refining stigma theory to specific conditions has resulted in a more nuanced understanding of stigma dimensions, manifestations, mechanisms and consequences, permitting comparison across contexts and populations and the development of stigma-reduction interventions. These lessons should be applied to fistula, acknowledging unique features: concealability, the potential for treatment, lack of community awareness and the social consequences of stillbirth. Reducing fistula-related stigma requires timely surgery and supportive care, stigma-reduction interventions and addressing the complex societal structures that perpetuate fistula.

Reflections on Identity: Narratives of Obstetric Fistula Survivors in North Central Nigeria

Obstetric fistula is a condition that affects women and can lead to identity changes because of uncontrolled urinary and/or fecal incontinence symptom experiences. These symptoms along with different emerging identities lead to family and community displacement. Using narrative inquiry methodology that concentrates on the stories individuals tell about themselves; interviews were conducted for 15 fistula survivors to explore their perception of identities of living with obstetric fistula. Within a sociocultural context, these identities consist of the "leaking" identity, "masu yoyon fitsari" (leakers of urine) identity, and the "spoiled" identity, causing stigmatization and psychological trauma. The "masu yoyon fitsari" identity, however, built hope and resilience for a sustained search for a cure. Identity is a socially constructed phenomenon, and the findings reveal positive community involvement which reduces obstetric fistula stigmatization and improves women's identity. Sexual and reproductive health issues remain of grave concern within a contextualized societal identity of women's role.

Use of interactive voice response technology to address barriers to fistula care in Nigeria and Uganda

BACKGROUND

The use of digital health technologies has expanded across low-resource settings, including in programs seeking to improve maternal health care seeking and service usage. However, there has been limited use of these technologies for screening and referral within maternal health, and many interventions have relied on SMS tools, which may have limited impact in settings with low female literacy. Digital health technologies have the potential to increase access to care for chronic maternal morbidities, such as obstetric fistula, and for women facing stigma, geographic isolation, and other sociocultural barriers to care seeking. This study documented the process of developing and implementing an innovative fistula screening and referral hotline using interactive voice response (IVR) technology, and described the service usage results and stakeholder perspectives associated with the hotline.

METHODS

The IVR hotline was introduced within the context of a broader Fistula Treatment Barriers Reduction Intervention implemented by the USAID-funded Fistula Care Plus project in Ebonyi and Katsina states in Nigeria and Kalungu district in Uganda. The intervention used three communication pathways to disseminate fistula information and conduct fistula screening: trained community agents, trained primary health care providers, and the IVR hotline paired with mass media messaging. All positively-screened women were eligible to receive vouchers for free transportation to an accredited fistula treatment center. Quantitative and qualitative data on intervention implementation and use across all three communication pathways were gathered during intervention implementation, at baseline, midline, and endline; as well as through ongoing program monitoring. This study presents findings specifically on service usage and stakeholder perspectives related to the IVR hotline.

RESULTS

Over a period of ten to twelve months of implementation, depending on the intervention area, a total of 566 women completed the IVR hotline screening process. Across the areas, 415 (73%) hotline callers screened positive for fistula symptoms. Hotline users and implementation partners reported positive impressions of the hotline, particularly the ability to preserve anonymity in seeking information and referral for fistula symptoms. Challenges to hotline use included limited mobile phone ownership and poor cellular network connectivity, affecting operability by women and community agents.

CONCLUSIONS

Implementation of the fistula screening hotline suggests that IVR-based interventions may be useful in expanding access to health services for stigmatized conditions, particularly in settings where literacy is limited. In the current context, such IVR tools require pairing with community and health system partners to complete referral and support clients. Further program experience and evaluation research is required to understand the options for integrating the IVR hotline or other interventions similarly using mobile technologies for screening and referral into broader digital health platforms that are sustained by national health systems or commercial business models.

Treatment-seeking for vaginal fistula in sub-Saharan Africa

BACKGROUND

There is dearth of data regarding the treatment-seeking practice of women living with vaginal fistula. The paper describes the health-seeking behaviour of fistula cases in the sub-Saharan Africa (SSA) where the burden of the problem is high.

METHODS

The data of 1,317 women who ever experienced fistula-related symptom were extracted from 16 national Demographic and Health Surveys carried out in SSA between 2010 and 2017. The association between treatment-seeking and basic socio-demographic characteristics was analysed via mixed-effects logistic regression and the outputs are provided using adjusted odds ratio (AOR) with 95% confidence intervals (CI).

RESULTS

Among all women who had fistula-related symptom, 67.6% encountered the problem soon after delivery, possibly implying obstetric fistula. Fewer identified sexual assault (3.8%) and pelvic surgery (2.7%) as the underlying cause. In 25.8% of the cases clear-cut causes couldn't be ascertained and, excluding these ambiguous causes, 91.2% of the women possibly had obstetric fistula. Among those who ever had any kind of fistula, 60.3% (95% CI: 56.9-63.6%) sought treatment and 28.5% (95% CI: 25.3-31.6%) underwent fistula-repair surgery. The leading reasons for not seeking treatment were: unaware that it can be repaired (21.4%), don't know where to get the treatment (17.4%), economic constraints (11.9%), the fistula healed by itself (11.9%) and feeling of embarrassment (7.9%). The regression analysis indicated, teenagers as compared to adults 35 years or older [AOR = 0.31 (95% CI: 0.20-47)]; and women without formal education compared to women with formal education [AOR = 0.69 (95% CI: 0.51-0.93)], had reduced odds of treatment-seeking. In 25.9% of the women who underwent fistula-repair surgery, complete continence after surgery was not achieved.

CONCLUSION

Treatment-seeking for fistula remains low and it should be improved through addressing health-system, psycho-social, economic and awareness barriers.

Research in Obstetric Fistula: Addressing Gaps and Unmet Needs

Although obstetric fistula has likely plagued women since the beginning of time, very little research proportionally exists. This article summarizes the most substantial research on the topic and delineates research gaps and future needs. Existing research demonstrates that access to care is the underlying cause of obstetric fistula and that the first attempt at closure holds the highest chance at success, ranging between 84% and 94%. For simple cases, 10 days of a catheter is sufficient, although what constitutes as simple is unclear. Circumferential fistulas are at high risk for ongoing urethral continence. Psychosocial programs are helpful for all women, but those who are "dry" tend to reintegrate into society, whereas those still leaking need additional support. Prenatal care and scheduled cesarean delivery are recommended to avoid another fistula. Gaps in research include accurate prevalence and incidence, interventions to improve access to care, surgical technique, especially for complex cases, and ways to prevent ongoing incontinence, among many others. In all areas, more rigorous research is needed.

Is there a relationship between female genital mutilation/cutting and fistula? A statistical analysis using cross-sectional data from Demographic and Health Surveys in 10 sub-Saharan Africa countries

OBJECTIVES

Literature on associations between female genital mutilation/cutting (FGM/C) and fistula points to a common belief that FGM/C predisposes women to developing fistula. This study explores this association using nationally representative survey data.

DESIGN

A secondary statistical analysis of cross-sectional data from Demographic and Health Surveys was conducted to explore the association between FGM/C and fistula.

SETTING

Sub-Saharan Africa.

PARTICIPANTS

Women aged 15-49 years in Burkina Faso (n=17 087), Chad (n=17 719), Côte d'Ivoire (n=10 060), Ethiopia (n=14 070), Guinea (n=9142), Kenya (n=31 079), Mali (n=10 424), Nigeria (n=33 385), Senegal (n=15 688) and Sierra Leone (n=16 658).

MAIN OUTCOME MEASURES

Fistula symptoms.

RESULTS

Multivariate logit modelling using pooled data from 10 countries showed that the odds of reporting fistula symptoms were 1.5 times (CI 1.06 to 2.21) higher for women whose genitals were cut and sewn closed than those who had undergone other types of FGM/C. Women who attended antenatal care (ANC) (adjusted odds ratio (AOR) 0.51, CI 0.36 to 0.71) and those who lived in urban areas (AOR 0.62, CI 0.44 to 0.89) were less likely to report fistula symptoms than those who did not attend ANC or lived in rural areas.

CONCLUSIONS

Severe forms of FGM/C (infibulation) may predispose women to fistula. Contextual and socioeconomic factors may increase the likelihood of fistula. Multisectoral interventions that concurrently address harmful traditional practices such as FGM/C and other contextual factors that drive the occurrence of fistula are warranted. Promotion of ANC utilisation could be a starting point in the prevention of fistulas.

Removing barriers to fistula care: Applying appreciative inquiry to improve access to screening and treatment in Nigeria and Uganda

A research-to-action collaboration sought to understand and respond to barriers to female genital fistula treatment in Nigeria and Uganda. This was guided by appreciative inquiry, a participatory approach for transformative programing with four phases: (1) inquire, (2) imagine, (3) innovate, and (4) implement. Through this process, partners designed and refined a treatment barrier reduction intervention using multiple communication channels to disseminate a consistent fistula screening algorithm and provide transportation vouchers to those screening positive. Partnership between an implementation organization, a research institution, and local community partners enabled data-driven design and patient-centered implementation to address specific barriers experienced by women.

Time to recovery from obstetric fistula and determinants in Gondar university teaching and referral hospital, northwest Ethiopia

BACKGROUND

Obstetric fistula is an abnormal connection between the vagina and rectum and/or bladder, which leads to continuous urinary or fecal incontinence. It is a serious problem in the world poorest countries, where most mothers give birth without any medical care. In most cases obstetric fistula is preventable and can be treated successfully, if it is carried out by a competent surgeon with a good follow-up of postoperative care. However, there remains to explore more on the duration of obstetric fistula recovery and determinant factors. The aim of this study was to estimate the average recovery time of obstetric fistula and to identify its determinants in Gondar University teaching and referral hospital, northwest Ethiopia.

METHOD

A retrospective follow up study was conducted at Gondar University teaching and referral hospital. A total of 612 fistula cases were included in the study and simple random sampling technique was applied to select the study subjects. Kaplan-Meier and log rank test were computed to explore the data. Weibull regression survival model with univariate frailty was done to identify the determinant factors of time to recovery.

RESULTS

Of 612 fistula patients, 539(88.07%) were recovered. The Average (median) recovery time was 5.14 (IQR = 3.14, 9.14) weeks. Using Antibiotic (AHR = 1.49, 95% CI = 1.11-2.01), having history of antenatal care (ANC) (AHR = 1.95, 95% CI = 1.39-2.73), being literate (AHR = 2.23, 95% CI = 1.62-3.06), duration of bladder catheterization (AHR = 0.93, CI = 0.90-0.95) and being multiparous (AHR = 1.51, 95% CI = 1.17-1.96) were a significant predictors of the rate of recovery. Also, underweight (AHR = 0.45, 95% CI = 0.30-0.68), overweight (AHR = 0.56, 95% CI = 0.41-0.76), being obese (AHR = 0.41, 95% CI = 0.21-0.80), having extensive fistula (AHR = 0.82, 95% CI = 0.73-0.91), large fistula (AHR = 0.42, 95% CI = 0.23-0.78), medium width (AHR = 0.62, 95% CI = 0.43-0.91) and large width (AHR = 0.42, 95% CI = 0.23-0.78) were statistically significant predictors of the rate of recovery from fistula patients.

CONCLUSION

The average recovery time from obstetric fistula patients was 5.14 weeks. Small Length and width of fistula, patients' educational status (literacy), antibiotic use, history of antenatal care visits, normal BMI, short period catheterization and being multiparous were the significant determinate variables which shorten the recovery time of obstetric fistula.

Feasibility and acceptability of the menstrual cup for non-surgical management of vesicovaginal fistula among women at a health facility in Ghana

OBJECTIVE

To assess the feasibility of the menstrual cup for short-term management of urinary leakage among women with vesicovaginal fistula (VVF).

METHODS

A repeated measures design compared volume of leakage with and without the cup via a 2-hr pad test among women with VVF seeking surgical repair at a health facility in Ghana. Subsequently a gynecological exam was administered to assess safety outcomes, followed by a questionnaire to assess acceptability and perceived efficacy. A paired t-test was used to analyze reduction of leakage in ml, and percent reduction was reported. Study limitations include observer bias while evaluating adverse outcomes and the possibility of social desirability bias during questionnaire administration that might overestimate the effect of the cup and women's acceptability.

RESULTS

Of the 32 patients screened, 11 were eligible (100% consent rate). At baseline, mean (±SD) leakage in ml was 63.2 (±49.2) (95% CI: 30.2-96.3) over two hours, while the mean leakage over two hours of use of the cup was 16.8 (±16.5) (95% CI: 5.7-27.9). The mean difference of 46.4 (±52.1) ml with use of the cup (95% CI: 11.4-81.4) was statistically significant (p = 0.02). With the cup, women experienced an average 61.0% (±37.4) (95% CI: 35.9-86.2) leakage reduction, a difference 10/11 users (91.0%) perceived in reduced leakage. One participant, reporting four previous surgical attempts, experienced a 78.7% leakage reduction. Acceptability was high-women could easily insert (8/11), remove (8/11), and comfortably wear (11/11) the cup and most (10/11) would recommend it. No adverse effects attributable to the intervention were observed on exam, although some women perceived difficulties with insertion and removal. Data collection tools were appropriate with slight modification advised.

CONCLUSION

A larger trial is warranted for a more robust evaluation of the menstrual cup for management of urinary leakage due to VVF among women who have not yet accessed surgery or for whom surgery was not successful.

Estimating the cost and cost-effectiveness for obstetric fistula repair in hospitals in Uganda: a low income country

In Africa, about 33 000 cases of obstetric fistula occur each year. Women with fistula experience debilitating incontinence of urine and/or faeces and are often socially ostracized. Worldwide, Uganda ranks third among countries with the highest burden of obstetric fistula. Obstetric fistula repair competes for scarce resources with other healthcare interventions in resource-limited settings, even though it is surgically efficacious. There is limited documentation of its cost-effectiveness in the most affected settings. We therefore sought to assess the cost-effectiveness of surgical intervention for obstetric fistula in Uganda so as to provide appropriate data for policy-makers to prioritize fistula repair and reduce women's suffering in similarly burdened countries. We built a decision-analytic model from the perspective of Uganda's National Health System to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery vs a competing strategy of no surgery for Ugandan women with fistula. Long-term disability outcomes were assessed based on a lifetime Markov state-transition cohort and effectiveness of surgery. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula and mortality rates among the general population in Uganda were based on published sources. The cost of providing fistula repair surgery in Uganda was estimated at $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the lifetime disability burden from 8.53 DALYs to 1.51 DALYs, yielding a cost per DALY averted of $54. The results were robust to variations in model inputs in one-way and probabilistic sensitivity analyses. Surgery for obstetric fistula appears highly cost-effective in Uganda. In similar low-income countries, governments and non-governmental organizations need to prioritize training and strengthening surgical capacity to increase access to fistula surgical care, which would be an important step towards achieving universal health coverage.

Obstetric fistula policy in Nigeria: a critical discourse analysis

BACKGROUND

In 2012, Nigeria's Federal Ministry of Health published its National Strategic Framework for the Elimination of Obstetric Fistula (NSFEOF), 2011-2015. The framework has since lapsed and there is no tangible evidence that the goal of eliminating obstetric fistula was met. To further inform future policy directions on obstetric fistula in Nigeria, this paper explores how the NSFEOF conceptualized obstetric fistula and its related issues, including child marriage and early childbearing.

METHODS

A critical discourse analysis of the policy was performed. We examined four policies in addition to the strategic framework: the Nigerian constitution; the Marriage Act; the Matrimonial Causes Act; and the National Reproductive Health Policy. We used the three phases of critical discourse analysis: textual analysis, analysis of discourse practice, and analysis of discursive events as instances of sociocultural practice.

RESULTS

The analysis demonstrates that, despite its title, the policy document focuses on reduction rather than elimination of obstetric fistula. The overall orientation of the policy is downstream, with minimal focus on prevention. The policy language suggests victim blaming. Furthermore, the extent to which subnational stakeholders in government and civil society were engaged in decision-making process for developing this policy is ambiguous. Although the policy is ostensibly based on principles of social justice and equity, several rhetorical positions suggest that the Nigerian constitutional environment and justice systems make no real provisions to protect the reproductive rights of girls in accordance with the United Nations' "2030 Agenda for Sustainable Development."

CONCLUSION

This analysis establishes that the Nigerian constitution, justice environment and the obstetric fistula policy itself do not demonstrate clear commitment to eradicating obstetric fistula. Specifically, a clear commitment to eradicating obstetric fistula would see the constitution and Marriage Act of Nigeria specify an age of consent that is consistent with the agenda to prevent obstetric fistula. Additionally, a policy to end obstetric fistulas in Nigeria must purposefully address the factors creating barrier to women's access to quality maternal healthcare services. Future policies and programs to eliminate obstetric fistulas should include perspectives of nurses, midwives, researchers and, women's interest groups.

"Poverty is the big thing": exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda

BACKGROUND

Women living with obstetric fistula often live in poverty and in remote areas far from hospitals offering surgical repair. These women and their families face a range of costs while accessing fistula repair, some of which include: management of their condition, lost productivity and time, and transport to facilities. This study explores, through women's, communities', and providers' perspectives, the financial, transport, and opportunity cost barriers and enabling factors for seeking repair services.

METHODS

A qualitative approach was applied in Kano and Ebonyi in Nigeria and Hoima and Masaka in Uganda. Between June and December 2015, the study team conducted in-depth interviews (IDIs) with women affected by fistula (n = 52) - including those awaiting repair, living with fistula, and after repair, and their spouses and other family members (n = 17), along with health service providers involved in fistula repair and counseling (n = 38). Focus group discussions (FGDs) with male and female community stakeholders (n = 8) and post-repair clients (n = 6) were also conducted.

RESULTS

Women's experiences indicate the obstetric fistula results in a combined set of costs associated with delivery, repair, transportation, lost income, and companion expenses that are often limiting. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly among all fistula care centers or camps due to funding shortages. In Uganda, experienced transport costs indicate that women spend Ugandan Shilling (UGX) 10,000 to 90,000 (US$3.00-US$25.00) for two people for a single trip to a camp (client and her caregiver), while Nigerian women (Kano) spent Naira 250 to 2000 (US$0.80-US$6.41) for transportation. Factors that influence women's and families' ability to cover costs of fistula care access include education and vocational skills, community savings mechanisms, available resources in repair centers, client counseling, and subsidized care and transportation.

CONCLUSIONS

The concentration of women in poverty and the perceived and actual out of pocket costs associated with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Findings recommend innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers.

Reasons for delay in decision making and reaching health facility among obstetric fistula and pelvic organ prolapse patients in Gondar University hospital, Northwest Ethiopia

Background

Obstetric fistula and pelvic organ prolapse remain highly prevalent in sub-Saharan Africa, where women have poor access to modern health care. Women having these problems tend to stay at home for years before getting treatment. However, information regarding the reasons contributing to late presentation to treatment is scarce, especially at the study area.

The objective of this study was to assess the reasons whywomen with obstetric fistula and pelvic organ prolapse at Gondar University Hospital delay treatment.

Method

A hospital based cross-sectional study was conducted among 384 women. Delay was evaluated by calculating symptom onset and time of arrival to get treatment at Gondar University Hospital. Regression analysis was conducted to elicit predictors of delay for treatment.

Result

Of the total 384 participants, 311 (80.9%) had pelvic organ prolapse and 73(19.1%) obstetric fistula. The proportion of women who delayed treatment of pelvic organ prolapse was 82.9% and that of obstetric fistula 60.9%. Fear of disclosing illness due to social stigma (AOR = 2; 1.03, 3.9) and lack of money (AOR = 1.97; 1.01, 3.86) were associated with the delay of treatment for pelvic organ prolapse,while increasing age (AOR =1.12; 1.01, 1.24) and divorce (AOR = 16.9; 1.75, 165.5) were were responsible for delaying treatment forobstetric fistula.

Conclusion

A large numberof women with pelvic organ prolapse and obstetric fistula delayed treatment. Fear of disclosure due to social stigma and lack of moneywere the major factors that contributed to thedelay to seek treatment for pelvic organ prolapse,while increasing age and divorce were the predictors for delaying treatment for obstetric fistula.