Barriers and facilitators to preventive interventions for the development of obstetric fistulas among women in sub-Saharan Africa: a systematic review

Demand and supply analysis for maternal and child health services at the primary healthcare level in Nigeria

BACKGROUND

The low demand for maternal and child health services is a significant factor in Nigeria's high maternal death rate. This paper explores demand and supply-side determinants at the primary healthcare level, highlighting factors affecting provision and utilization.

METHODS

This qualitative study was undertaken in Anambra state, southeast Nigeria. Anambra state was purposively chosen because a maternal and child health programme had just been implemented in the state. The three-delay model was used to analyze supply and demand factors that affect MCH services and improve access to care for pregnant women/mothers and newborns/infants.

RESULT

The findings show that there were problems with both the demand and supply aspects of the programme and both were interlinked. For service users, their delays were connected to the constraints on the supply side. On the demand side, the delays include poor conditions of the facilities, the roads to the facilities are inaccessible, and equipment were lacking in the facilities. These delayed the utilisation of facilities. On the supply side, the delays include the absence of security (fence, security guard), poor citing of the facilities, inadequate accommodation, no emergency transport for referrals, and lack of trained staff to man equipment. These delayed the provision of services.

CONCLUSION

Our findings show that there were problems with both the demand and supply aspects of the programme, and both were interlinked. For service users, their delays were connected to the constraints on the supply side.

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.

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.

Quality of life and its predictive factors among women with obstetric fistula in Ethiopia: A cross-sectional study

Objective

Living with obstetric fistulas is detrimental to the quality of life of women with fistulas. This study aimed to assess the quality of life and predictive factors among women with obstetric fistula in Ethiopia.

Methods

A cross-sectional study was employed on consecutively selected 478 women. Linear regressions were used for data analysis.

Results

The mean quality of life in physical, psychological, social, and environmental health domains and the overall quality of life were 40.59 ± 1.58, 38.10 ± 1.78, 29.59 ± 1.97, 34.21 ± 1.65, and 44.61 ± 3.99 respectively. Repair outcome without urinary inconsistence (β = 5.2; 95% CI = 0.72, 9.64), self-esteem (β = 1.3; 95% CI = 0.96, 1.57), negative attitude (β = 5.1; 95% CI = 1.86, 8.33), waiting treatment (β = -8.4; 95% CI = -15.54, -1.10), and low intention (β = 4.7; 95% CI = 1.52, 7.93) were predictors of the quality of life in physical domain. Repair outcome without urinary inconsistence (β = 5.9; 95% CI = 1.73, 9.99), self-esteem (β = 1.8; 95% CI = 1.47, 2.11), negative attitude (β = -6.4; 95% CI = -9.60, -3.25), fathers at primary school (β = 12.5; 95% CI = 0.08, 24.82), living only with parents (β = 4.9; 95% CI = 0.99, 8.90), time of care-seeking (β = -0.01, 95% CI = -0.02, -0.002), and duration lived with fistula (β = -5.4; 95% CI = -9.12, -1.68) were predictors of psychological domain. Dead birth (β = -5.2; 95% CI = -9.86, -0.51), self-esteem (β = 1.1; 95% CI = 0.72, 1.43), and living only with parents (β = 5.5; 95% CI = 0.30, 10.69), and living only with husband (β = 7.8; 95% CI = 2.01, 13.55) were predictors of social domain. Living in rural (β = -6; 95% CI = -9.22, -2.79), women at secondary school (β = 14.1; 95% CI = 3.67, 24.48), self-esteem (β = 1.3; 95% CI = 0.99, 1.55), negative attitude (β = -5.1; 95% CI = -7.97, -2.29) were predictors of quality of life in environmental domain. Repair outcome without urinary inconsistence (β = 8.3; 95% CI = 0.62, 16.02), self-esteem (β = 2.1; 95% CI = 1.34, 2.79), and living only with parents (β = 2.9; 95% CI = 1.06, 4.76) were significant predictors of the overall quality of life.

Conclusions

The quality of life of women with obstetric fistula was low. Repair outcomes, self-esteem, negative attitudes, rural residence, living with parents, and time of care-seeking were significant predictors of quality of life. Urgent measures should be taken to address these factors to improve the quality of life of women with fistula.

The Predictors of Intent to Prevent Obstetric Fistula Recurrence Among Women with Fistula in Ethiopia: A Facility-Based Cross-Sectional Study

Background

Obstetric fistula recurrence predisposes to a decreasing success rate of fistula repair and accounts for the continued incidence of obstetric fistulas in low-income countries. Evidence has revealed that there are women’s intent gaps in the prevention of obstetric fistula recurrence. Assessments of predictors of intent to prevent obstetric fistula recurrence among women with fistula are scarce.

Objective

This study assessed the intent to prevent obstetric fistula recurrence and its predictive factors among women with obstetric fistula in Ethiopia.

Methods

Facility-based cross-sectional study was conducted from April 01, 2019, to August 01, 2019, with consecutively selected 478 women with fistulas in five fistula treatment centers in Addis Ababa and Oromia regions. Data were collected using an interviewer-administered structured questionnaire and analyzed using SPSS 23 software. Simple and multiple linear regression models were fitted for data analysis.

Results

Mean score of intent to prevent obstetric fistula recurrence among women with obstetric fistula was 27.72 ± 5.06. Living in a rural setting (β =−2.27; 95% CI: −3.62, −0.93), being married (β =1.71, 95% CI: 0.56, 2.85), having one previous repair (β =2.14, 95% CI: 0.19, 4.08), high self-esteem (β =1.42, 95% CI: 0.09, 2.74), psychological health (β =0.05, 95% CI: 0.26, 3.79), living with fistula ≥5 years (β =1.82, 95% CI: 0.44, 3.21), high knowledge of risk factors (β =3.12, 95% CI: 1.99, 4.25), and a positive attitude (β =2.33, 95% CI: 1.12, 3.54) were significant predictors of the intent to prevent obstetric fistula recurrence.

Conclusion

Intent to prevent obstetric fistula recurrence among women with obstetric fistula was low. This indicates an urgent need to create awareness among women with an obstetric fistula on the risk factors of obstetric fistula recurrence, attitudinal changes towards prevention of obstetric fistula recurrence, and the availability of prevention measures.

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.

'I can't leave everything in the hands of my husband': Economic constraints and gender roles in care-seeking in post-Ebola Guinea

The 2014-2016 Ebola epidemic in West Africa had enduring effects on health systems and healthcare utilisation. This study explores the intersection of economic constraints and gender roles in Guinea to understand delays in care-seeking post-Ebola. In-depth interviews (n = 45) and focus group discussions (n = 24) were conducted with mothers, male heads of household, grandmothers, and health workers in rural and urban areas in Basse-Guinée and Guinée Forestière. A thematic analysis identified salient themes related to gender and economic constraints on health care-seeking. Participants, particularly men, emphasised the high cost of seeking care, which led to delays as women secured funds. Men's engagement in care-seeking included providing funds and permission, picking up medication, and giving appointment reminders. As principal actors when 'navigating' the healthcare system, women were intimately involved in economic decisions and responsible for securing funds for services - even when lacking direct financial control. Essentialist descriptions of men as 'providers' and women as 'navigators', therefore, masked nuances in care-seeking and economic responsibilities. Programmes must acknowledge men's engagement in care-seeking and address both the economic barriers women face when seeking care and their economic roles. Greater attention to the complex intersection of economic constraints and gender roles could address care-seeking delays.

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.

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 the awareness of vaginal fistula among women of reproductive age: findings from the 2018 Nigerian demographic health cross-sectional survey

INTRODUCTION

Involuntary leakage of urine and or stool per vaginam (vaginal fistula) after childbirth remains a public health challenge in Africa and South East Asia. To the best of our knowledge, there is no previous national data that examined the awareness of vaginal fistula among women in Nigeria.

AIM

To determine the prevalence of awareness of urinary/faecal incontinence due to vaginal fistula, and the associated risk factors among women with no previous experience of incontinence.

METHODS

We used a cross-sectional study, the 2018 Nigerian Demographic Health Survey, to analyse awareness of vaginal fistula among women with no previous leakage of urine or stool. The primary outcome was childbirth experience, and other variables were demographics, access to information and reproductive or sexual history. The descriptive, univariate and multivariable models were presented.

RESULTS

Of 26 585 women interviewed, 50 (0.2%) who had experienced fistula were excluded from the risk factor analysis. The mean age of women with childbirth experience was 32.8±8.6 years, while that of women without childbirth experience was 20.3±6.2 years. The prevalence of vaginal fistula awareness was 52.0%. Factors associated with the awareness include the following: childbirth experience (adjusted OR (AOR)=1.14; 95% CI, 1.01 to 1.30); age of 20-24 years (AOR=1.36; 95% CI, 1.18 to 1.56) and older; currently working (AOR=1.35; 95% CI, 1.22 to 1.49) and ownership of a mobile phone (AOR=1.16; 95% CI, 1.05 to 1.27). Other associated factors include the following: having at least secondary education; wealth quintiles, ethnicity, regional location, religion, access to radio, newspaper and internet; age up to 17 years at first sex; history of previous termination of pregnancy and use of contraception.

CONCLUSION

A significant number of young women with no childbirth experience had low level of awareness. We recommend vaginal fistula awareness programmes that will target women at risk of vaginal fistula and the inclusion of other useful questions to improve the quality of information in future surveys.

Barriers and facilitators systematic reviews in health: A methodological review and recommendations for reviewers

BACKGROUND

Systematic reviews cataloguing the barriers to and facilitators of various outcomes are increasingly popular, despite criticisms of this type of review on philosophical, methodological, and practical grounds. The aims of this review are to appraise, analyze, and discuss the reporting and synthesis practices used in recently published barriers and facilitators reviews in health services research.

METHODS

All English-language peer-reviewed systematic reviews that synthesized research on barriers and facilitators in a health services context were eligible for inclusion. We searched 11 databases over a 13-month period (1 November 2017-30 November 2018) using an exhaustive list of search terms for "barrier(s)," "facilitator(s)," and "systematic review."

RESULTS

One hundred reviews were included. We found a high degree of variation in the synthesis practices used in these reviews, with the majority employing aggregative (rather than interpretive) approaches. The findings echo common critiques of this review type, including concerns about the reduction of complex phenomena to simplified, discrete factors. Although several reviews highlighted the "complexity" of barriers and facilitators, this was usually not analyzed systematically. Analysis of the subsample of reviews that explicitly discussed the barriers and facilitators approach revealed some common issues. These tended to be either conceptual/definitional (eg, ideas about interrelationships and overlap between factors) and methodological/practical (eg, challenges related to aggregating heterogeneous research).

CONCLUSION

Barriers and facilitators reviews should (a) clearly operationally define "barrier" and "facilitator," (b) explicitly describe how factors are extracted and subsequently synthesized, and (c) provide critical reflection on the contextual variability and reliability of identified factors.

Obstetric fistulas in Uganda: scoping review using a determinant of health approach to provide a framework for health policy improvement

Background

The uneven global and national distribution of obstetric fistulas suggests a complex network of determinants contributing to fistula development. This study aims to create an understanding of the determinants of obstetric fistula in Uganda and to give a framework for health policy improvement.

Methods

A scoping review of existing literature was performed, searching the PubMed/MEDLINE database, Ugandan Demographic and Health Surveys, and official sources of Ugandan statistics. Data was analysed using the model for the determinants of health by Dahlgren and Whitehead.

Results

Obstetric fistulas are associated with different personal lifestyle factors, certain social and community networks, as well as poor working and living conditions. Malnutrition, early childbearing, limited female empowerment, lack of awareness of childbearing risks, low socioeconomic status, and long distances to emergency obstetric care play a part. Certain regions of Uganda are in particular associated with obstetric fistula, where an accumulation of determinants is notable.

Conclusion

Analysis using the model of Dahlgren and Whitehead shows that obstetric fistulas are associated with determinants at different levels of society. Poverty and low education link these in a web that is disproportionately hard to escape from for the poorest women. This inequity asks for co-operation between ministries to dismantle the environment for obstetric fistula.

Obstetric fistula in southern Mozambique: a qualitative study on women's experiences of care pregnancy, delivery and post-partum

BACKGROUND

Obstetric fistula is still common in low- and middle-income countries (LMIC) despite the on-going shift to increased facility deliveries in the same settings. The social behavioural circumstances in which fistula, as well as its consequences, still occur are poorly documented, particularly from the perspective of the experiences of women with obstetric fistula. This study sought to describe women's experiences of antenatal, partum and post-partum care in southern Mozambique, and to pinpoint those experiences that are unique to women with fistula in order to understand the care-seeking and care provision circumstances which could have been modified to avoid or mitigate the onset or consequences of fistula.

METHODS

This study took place in Maputo and Gaza provinces, southern Mozambique, in 2016-2017. Qualitative data were collected through in-depth interviews conducted with 14 women with positive diagnoses of fistula and an equal number of women without fistula. All interviews were audio-recorded and transcribed verbatim prior to thematic analysis using NVivo11.

RESULTS

Study participants had all attended antenatal care (ANC) visits and had prepared for a facility birth. Prolonged or obstructed labour, multiple referrals, and delays in receiving secondary and tertiary health care were common among the discourses of women with fistula. The term "fistula" was rarely known among participants, but the condition (referred to as "loss of water" or "illness of spillage") was recognised after being prompted on its signs and symptoms. Women with fistula were invariably aware of the links between fistula and poor birth assistance, in contrast with those without fistula, who blamed the condition on women's physiological and behavioural characteristics.

CONCLUSION

Although women do seek antenatal and peri-partum care in health facilities, deficiencies and delays in birth assistance, referral and life-saving interventions were commonly reported by women with fistula. Furthermore, weaknesses in quality of care, not only in relation to prevention, but also the resolution of the damage, were evident. Quality improvement of birth care is necessary, both at primary and referral level. There is a need to increase awareness and develop guidelines for prevention, early detection and management of obstetric fistula, including early postpartum treatment, availability of fistula repair for complex cases, and rehabilitation, coupled with the promotion of community consciousness of the problem.