Obstetric fistula and safe spaces: discussions of stigmatised healthcare topics at a fistula centre.

Obstetric fistula can have major psychosocial repercussions for women and their families, which are often hidden as a result of stigmatisation. We investigated how the sexual function of women with vesicovaginal fistula differs before and after fistula repair at the Fistula Care Centre in Lilongwe, Malawi. Structured interviews and physical examinations were conducted with 115 women from the central region of Malawi. The average age of participants was 32 years and the majority lived in rural communities. Patients were more responsive than expected to discussing how genital modification, gender-based violence, marital relationships and traditional medicine impact their sexual function. Of the 115 participants interviewed, 107 (93%) reported stretching their labia and 42 (37%) were coerced into sexual activities before surgery. Before repair, 56 (49%) women reported husbands being unfaithful. 12 (10%) had new cowives after surgery. 38 (33%) used traditional medicine to enhance their sexual function before surgery. We conclude that specialised centres providing care for women, such as a fistula centre, might offer a unique space in which women can more comfortably discuss stigmatised subjects. This suggests that such issues should be incorporated into services where appropriate.

Social Experiences of Women with Obstetric Fistula Seeking Treatment in Kampala, Uganda.

BACKGROUND: Obstetric fistula is a preventable and treatable condition predominately affecting women in low-income countries. Understanding the social context of obstetric fistula may lead to improved prevention and treatment. OBJECTIVES: This study investigated social experiences of women with obstetric fistula seeking treatment at Mulago Hospital in Kampala, Uganda. METHODS: A descriptive study was conducted among women seeking treatment for obstetric fistula during a surgical camp in July 2011 using a structured questionnaire. Descriptive statistics were computed regarding sociodemographics, obstetric history, and social experience. FINDINGS: Fifty-three women participated; 39 (73.58%) leaked urine only. Median age was 29 years (range: 17-58), and most were married or separated. About half (28, 47.9%) experienced a change in their relationship since acquiring obstetric fistula. More than half (27, 50.94%) acquired obstetric fistula during their first delivery, despite almost everyone (50, 94.3%) receiving antenatal care. The median years suffering from obstetric fistula was 1.25. Nearly every participant's social participation changed in at least one setting (51, 96.23%). Most women thought that a baby being too big or having kicked their bladder was the cause of obstetric fistula. Other participants thought health care providers caused the fistula (15, 32.61%; n = 46), with 8 specifying that the bladder was cut during the operation (cesarean section). Knowing someone with obstetric fistula was influential in pursuing treatment. The majority of participants planned to return to family (40, 78.43%; n = 51) and get pregnant after repair (35, 66.04%; n = 53). CONCLUSION: Study participants experienced substantial changes in their social lives as a result of obstetric fistula, and there were a variety of beliefs regarding the cause. The complex social context is an important component to understanding how to prevent and treat obstetric fistula. Further elucidation of these factors may bolster current efforts in prevention and holistic treatment.

Obstetric Fistula "Disease" and Ensuing Care: Patients' Views in West-Africa.

We explored obstetric fistula patients' real-life experience of care in modern Health System. Our aim was to analyze how these women's views impacted their care uptake and coping. We conducted 67 in-depth interviews with 35 fistula patients or former patients in 5 fistula repair centers within referral hospitals in Mali and Niger. Perceptions of obstetric fistula influenced the care experience and vice versa. Obstetric fistula was viewed as a severe chronic disease due to length of care process, limitation of surgery and persisting physical and moral suffering. We highlight the opportunity to build on patients' views on obstetric fistula trauma and care in order to implement an effective holistic care process.

Community awareness about risk factors, presentation and prevention and obstetric fistula in Nabitovu village, Iganga district, Uganda.

BACKGROUND: Obstetric fistula is a worldwide problem that is devastating for women in developing countries. The cardinal cause of obstetric fistula is prolonged obstructed labour and delay in seeking emergency obstetric care. Awareness about obstetric fistula is still low in developing countries. The objective was to assess the awareness about risk factors of obstetric fistulae in rural communities of Nabitovu village, Iganga district, Eastern Uganda. METHODS: A qualitative study using focus group discussion for males and females aged 18-49 years, to explore and gain deeper understanding of their awareness of existence, causes, clinical presentation and preventive measures for obstetric fistula. Data was analyzed by thematic analysis. RESULTS: The majority of the women and a few men were aware about obstetric fistula, though many had misconceptions regarding its causes, clinical presentation and prevention. Some wrongly attributed fistula to misuse of family planning, having sex during the menstruation period, curses by relatives, sexually transmitted infections, rape and gender-based violence. However, others attributed the fistula to delays to access medical care, induced abortions, conception at an early age, utilization of traditional birth attendants at delivery, and some complications that could occur during surgical operations for difficult deliveries. CONCLUSION: Most of the community members interviewed were aware of the risk factors of obstetric fistula. Some respondents, predominantly men, had misconceptions/myths about risk factors of obstetric fistula as being caused by having sex during menstrual periods, poor usage of family planning, being a curse.

Vaginally inserted herbs causing vesico-vaginal fistula and vaginal stenosis.

A 32-year-old woman developed a vesico-vaginal fistula and vaginal stenosis following insertion of herbs into her vagina by a traditional doctor to "melt" her uterine myomata. She underwent successful trans-abdominal repair of her fistula and passive dilatation of her vagina was recommended for the vaginal stenosis. The emerging importance of traditional treatments as a cause of vesico-vaginal fistula is highlighted. The role of quality improvement through research and strict regulation to maximise the benefits of traditional treatment and minimise complications is also emphasised.

Depression among women with obstetric fistula in Kenya.

OBJECTIVE: To establish the prevalence of depression and describe associated factors among fistula patients attending an obstetric fistula surgical camp in Kenya. METHODS: A cross-sectional study was conducted focusing on obstetric fistula patients attending a national fistula camp held in August 2008 at Kenyatta National Hospital, Nairobi, Kenya. A structured questionnaire was used to obtain sociodemographic data and medical histories for all consenting patients before surgery. Depression measures were obtained using the Patient Health Questionnaire-9. RESULTS: Of the 70 women interviewed, 2 (2.9%) and 12 (17.1%) reported a history of psychiatric illness and suicidal ideations, respectively. Depression was present in 51 (72.9%) patients, with 18 (25.7%) meeting criteria for severe depression. Depression was significantly associated with women older than 20 years of age (P=0.01), unemployment (P=0.03), lack of social support following fistula (P=0.04), and living with fistula for over 3 months (P=0.01). CONCLUSION: Women with obstetric fistula are predisposed to high levels of depression. A holistic management approach, including mental health care and family support, is recommended.

Contributing factors of Vesico-Vaginal Fistula (VVF) among Fistula Patients in Dr.Abbo's National Fistula et Urogynecology Centre - Khartoum 2008

"Background: Vesico-vaginal Fistula (VVF) is defined as an abnormal communicating tract extending between the bladder (vesico-) and the vagina resulting in continuous involuntary discharge of urine into the vaginal vault. Vesico-vaginal fistula is still a persisting scourge in the developing countries; including Sudan in which new cases of obstetric fistula were estimated to occur every year"" #he ob$ectives of this work were to study the contributing factors of vesico-vaginal fistula in Sudanese patients"" Methods: the design was descriptive; cross-sectional; community-based study"" A total of 2 patients with vesicovaginal fistula presented to the Fistula (entre in )Khartoum Teaching hospital from July to August 2 ;; were investigated using an administrated; semi-structured questionnaire"" Results: The study revealed that 44""2of patients were 1;-24 years old; "";were teenagers when married (1; yrs old)"" While 7of the patients were illiterates; 62"";were married to illiterate husbands"" (; "";) were poor; (4 ""4) were from western regions of Sudan"" The study showed that labor was responsible for 9 ""4of VVF of whom 9""6were primiparous; 42""6delivered at home"" It was found that 4 ""4of the total deliveries were by forceps as long as 27""7were emergency caesarian sections"" (3""2) of the deliveries were attended by traditional birth attendants and ""3of cases stayed in labor for more than 24 hours; as long as 3""2were not in regular antenatal care"" Conclusion:The vesico-vaginal fistula in Sudan resulted mainly from obstructed labor"" the victim was mostly a young woman; a primigravida; who was poor; illiterate; not on regular antenatal care et being in labor more than 24 hours"" Most deliveries were carried at home; attended by traditional Birth Attendants in most cases"" the deliveries were mostly assisted by forceps; or conducted as emergency caesarian sections"" To prevent VVF; the study suggested raising awareness of women at bearing age; improve transportation; besides inclusion of the issue in the curricula of schools and universities"""

Prevention of obstetric urogenital fistulae: some thoughts on a daunting task.

Significant obstetric-related pelvic floor injury is still all too common in many areas of the world. Vesicovaginal fistula formation typically results from obstructed labor in the setting of limited medical resources for the patient. Many people have dedicated their time and even their lives to repairing these types of pelvic floor injuries, which certainly can impact in a positive way on the quality of life of these suffering women. However, it is time to consistently combine surgical repair initiatives with education, training, and prevention strategies, as well as outcomes research in order to improve on these efforts. It is only through committed initiatives with all of these elements that we may be able to ultimately decrease the prevalence of these types of pelvic floor sequelae.

Humanitarian ventures or 'fistula tourism?': the ethical perils of pelvic surgery in the developing world.

The vesico-vaginal fistula from prolonged obstructed labor has become a rarity in the industrialized West but still continues to afflict millions of women in impoverished Third World countries. As awareness of this problem has grown more widespread, increasing numbers of American and European surgeons are volunteering to go on short-term medical mission trips to perform fistula repair operations in African and Asian countries. Although motivated by genuine humanitarian concerns, such projects may serve to promote 'fistula tourism' rather than significant improvements in the medical infrastructure of the countries where these problems exist. This article raises practical and ethical questions that ought to be asked about 'fistula trips' of this kind, and suggests strategies to help insure that unintended harm does not result from such projects. The importance of accurate data collection, thoughtful study design, critical ethical oversight, logistical and financial support systems, and the importance of nurturing local capacity are stressed. The most critical elements in the development of successful programs for treating obstetric vesico-vaginal fistulas are a commitment to developing holistic approaches that meet the multifaceted needs of the fistula victim and identifying and supporting a 'fistula champion' who can provide passionate advocacy for these women at the local level to sustain the momentum necessary to make long-term success a reality for such programs.

Fitsari 'dan Duniya. An African (Hausa) praise song about vesicovaginal fistulas.

The vesicovaginal fistula from prolonged obstructed labor is a condition that is no longer seen in the affluent, industrialized world, yet it continues to exist in epidemic proportions in sub-Saharan Africa, where several million women are estimated to suffer from this condition. The unremitting urinary incontinence that is produced by a fistula causes these women to become social outcasts. The problem is particularly acute in Nigeria, where the Federal Ministry of Women's Affairs estimates that there may be as many as 800,000 unrepaired fistula cases. Because of the social stigma attached to their condition, fistula victims have often been subjected to major psychosocial trauma. Finding ways to help such patients reintegrate into social networks is an important part of their treatment. When fistula patients meet one another, they realize that they are not alone in their suffering. This article describes the use of a "praise song" by a group of Nigerian fistula patients as a vehicle for building group identity as part of a "sisterhood of suffering." A transcription and translation of a Hausa praise song about vesicovaginal fistulas is presented, along with a commentary on the text that sheds new light on a problem that is unfamiliar to most Western obstetrician-gynecologists.

Ethiopia: an epidemiological study of vesico-vaginal fistula in Addis Ababa.

A 10% sample was drawn from 3000 records on vesicovaginal fistulae operations performed at the Addis Ababa Fistula Hospital for Poor Women with Childbirth Injuries and their content were analyzed. In 88% of the cases under review the operation was classified as successful. The results of this study underline the tremendous maternal health gains which can be achieved by appropriate obstetric care in case of obstructed labour. It also reinforced the need for early detection and referral of high risk births among the very young mothers who are likely to experience an obstructed labour, the loss of the child, vesico-vaginal fistulae and possibly a ruptured uterus. In the absence of likely increases in the availability of transport, the building of waiting homes at maternal clinics is encouraged so that women can await delivery in the vicinity of a referral centre. There is a need for increased attendance of delivery by trained personnel as well as for continuing education for both staff and traditional birth attendants. It is further recommended to train former patients as helpers for the dedicated care which needs to be extended to the unfortunate, and often stigmatized victims.

PIP: Vesicovaginal fistula (VVF) associated with obstructive labor is highly prevalent throughout many developing countries with poor access to health services. Prevalence of the condition is highest among young primigravida. The Addis Ababa Fistula Hospital for Poor Women with Childbirth Injuries was opened in 1975 and cares for approximately 500 fistula patients per year. There is open access to the facility, in which women are treated with respect and dignity. Upon completion of the operation to correct her fistula, each woman is given sufficient means to return home. She also receives a fistula card which contains essential information for her future obstetric and gynecological care. A sample of 309 records was drawn randomly from the total of 3000 records of vesicovaginal operations performed at the hospital during the period 1983-88, and analyzed. The women were of average age 22.4 years in the range of 9-45 years. 82% travelled at least 700 kilometers for treatment, walking an average of twelve hours and spending an average of 34 hours in a bus. More than 50% of the women were rejected by their husbands after the fistulae developed, leaving them without means. In 52% of cases, admission occurred within six months of fistula development, although 4% of women came only 10-20 years after developing their fistulae. 88% of cases reviewed were cured completely, 6% continued to suffer from urinary stress incontinence, and in 6% of cases the operation failed to produce the desired results. These results demonstrate the enormous maternal health gains which can be achieved with appropriate obstetric care in the case of obstructed labor. They also reinforce the need for early detection and referral of high-risk births among very young mothers who are likely to experience an obstructed labor, child loss, VVF, and possibly a ruptured uterus. Unless transport can be made readily available to women with VVF, waiting homes should be built at maternal clinics so that women can await delivery in the vicinity of a referral center. Trained personnel need to be more often in attendance during delivery, while staff and traditional birth attendants should receive continuing education. It is further recommended that former patients be trained to help provide care to women with VVF.

Epidemiology of vesico--vaginal fistulae in northern Nigeria.

A comparative study of vesico-vaginal fistulae cases and controls was carried out at two tertiary hospitals in Maiduguri, Nigeria. The fistulae cases were significantly shorter in height, younger in age at marriage and had a higher divorce rate. Prolonged labour, traditional surgical practice of "gishiri cut" and ignorance were identified as the commonest causes of the fistulae. The health and socio-economic consequences to the patient are discussed. Patients are considered to have brought shame to themselves and their families and quite often lose the support of the husband. It is recommended that maternity services be firmly integrated and given a higher priority in primary health care. In the long-term increase in the literacy level of females is desirable.

Vesicovaginal fistula in Nigerian children.

Of 80 cases of vesicovaginal fistula in children less than thirteen years of age in Northern Nigeria, 48 were due to labour, 12 to the traditional practice of gishiri cutting, and 20 to other causes including congenital abnormalities, coitus, infections, and trauma. Preventive measures include improved socioeconomic status of the community, education, and reevaluation of the role of females in society.

Epidemiological determinants of vesicovaginal fistulas.

Between 1969 and 1980 1443 patients with vesicovaginal fistulas were operated on in Ahmadu Bello University Hospital in Northern Nigeria. They have been studied in relation to their obstetric, social and environmental background. The preventable nature of the lesion was explored particularly with respect to age, parity and obstructed labour, and to traditional practices including 'gishiri cutting', which alone accounts for 13% of all the fistulas. Vesicovaginal fistulas are still a major cause for concern in many developing countries; measures for prevention include universal education and improved status of women in society as well as improved and accessible medical services.

PIP: Obstetric history, social and environmental background of 1443 patients with vesicovaginal fistulas, corrected at the Ahmadu Bello University Hospital in Northern Nigeria were analyzed. This is the largest series reported, covering 1969-1980, from an area where fistulas are both common and socially devastating. Data were obtained from a 54-part questionnaire including residence, delivery referral, etiology of lesions and operative details. Prolonged obstructed labor caused 83%, and a folk treatment called "gishiri cutting" accounted for 13% of the fistulas. Gishiri means cutting the anterior vagina with a sharp instrument, to relieve or prevent obstructed labor, or to treat dyspareunia, infertility, amenorrhea, dysuria, backache or other complaints. The Hausa, Fulani and Kanuri tribes made up 76%, 12% and 2.6% respectively of the total group. Women over 30 years had a greater incidence of vesicovaginal fistula alone, rather than fistula with tear or rectovaginal fistula, and a greater likelihood of the characteristic gishiri scar, a clean cut often involving the urethra and/or midvaginal region. Another traditional treatment, packing the vagina with caustic or local medicines, was also reported. The other social correlate was the high proportion of young (33% under 16) or primiparous (52%) women with fistulas. These were more often severe, and the group included more rectovaginal fistulas. These reflect the higher incidence of obstructed labor in young, immature women (6% 13 years or less). The only other factor associated with fistulas was the lower educational level of these women compared to that of all women giving birth in the area. Most of these lesions are preventable by later marriage, eradication of harmful traditional treatments, and education about referral to medical care.