Insights from birthing experiences of fistula survivors in North-central Nigeria: Interplay of structural violence.

Obstetric Fistula is an abnormal opening between the vagina and rectum resulting from prolonged and obstructed labour. Studies indicate that delays in accessing maternal care and home birth contribute to the development of fistula. Survivors are usually women of low socioeconomic status residing in rural locations. This study explores the birthing experiences of 15 fistula survivors through a narrative inquiry approach at a repair centre in North-central Nigeria. Using structural violence as a lens, it describes the role of social, political and health systems in the inequitable access to care for women. For women opting for home births, preference for home delivery was mainly due to lack of finances, poor health systems and cultural practices. Rural location inhibited access as women seeking facility delivery faced transfer delays to referral centres when complications developed. Inequitable maternal health services in rural locations in Nigeria are inherently linked to access to health care, and these contribute to the increased incidence of fistulae. Structural intervention is a health policy priority to address poor health systems and achieve universal health coverage to address maternal health issues in Nigeria.

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.

Coping with a Disruptive Life Caused by Obstetric Fistula: Perspectives from Malawian Women.

Background: The main symptom of obstetric fistula is urinary and or fecal incontinence. Incontinence, regardless of the type is debilitating, socially isolating, and psychologically depressing. The objective of this study was to explore the strategies that women with obstetric fistula in Malawi use to manage it and its complications. Methods: A subset of data from a study on experiences of living with obstetric fistula in Malawi was used to thematically analyze the strategies used by women to cope with their fistula and its complications. The data were collected using semi-structured interviews. Nvivo 10 was used to manage data. Results: Participants used two forms of coping strategies: (1) problem-based coping strategies: restricting fluid intake, avoiding sexual intercourse, using homemade pads, sand, corn flour, a cloth wreathe and herbs, and (2) emotional-based coping strategies: support from their families, children, and through their faith in God. Conclusion: Women living with incontinence due to obstetric fistula employ different strategies of coping, some of which conflict with the advice of good bladder management. Therefore, these women need more information on how best they can self-manage their condition to ensure physical and emotional comfort.

Effects of surgical repair of obstetric fistula on severity of depression and anxiety in Ethiopia.

BACKGROUND: The surgical repair of fistula can address the physical symptoms, but may not end the psychological challenges that women with fistula face. There are a few studies that focus on women with this condition in Ethiopia. Hence, the aim of this study was to determine the effects of surgical repair of obstetric fistula on the severity of depression and anxiety in women with obstetric fistula in Ethiopia. METHOD: The study employed a longitudinal study design to investigate the changes in 219 women with obstetric fistula admitted to six fistula management hospitals in Ethiopia. The data were collected on admission of the patients for obstetric fistula surgical repair and at the end of six-month post repair. A structured questionnaire was used to obtain socio-demographic information and medical history of the respondents. Depression and anxiety symptoms were measured using the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) scales. The data was entered using Epi-Data software and then exported to SPSS for further analysis. The Mann-Whitney-U test, the Kruskal-Wallis test and Paired t-test were performed to measure the change in psychological symptoms after surgical repair. RESULT: Though 219 respondents were interviewed pre-obstetric fistula surgical repair, only 200 completed their follow up. On admission, the prevalence of depression and anxiety symptoms were 91 and 79% respectively. After surgical repair, the prevalence rate was 27 and 26%. The differences in the prevalence of screen-positive women were statistically significant (P < 0.001). CONCLUSION: The study concluded that the severity of depression and anxiety symptoms decrease post-obstetric fistula surgical repair. However, a woman with continued leaking after surgery seems to have higher psychological distress than those who are fully cured. Clinicians should manage women with obstetric fistula through targeted and integrated mental health interventions to address their mental health needs.

Contraceptive knowledge, use and intentions of Malawian women undergoing obstetric fistula repair.

OBJECTIVES: Unintended pregnancy contributes to morbidities, such as obstetric fistula. Furthermore, after fistula repair, women should avoid pregnancy for a year to prevent its breakdown. Our study objective was to evaluate the contraceptive knowledge, practices and intentions of women undergoing obstetric fistula repair at a centre in Malawi. METHODS: This cross-sectional study used a standardised survey to examine the contraceptive knowledge, practices and intentions of women undergoing obstetric fistula repair in Lilongwe, Malawi, between September 2011 and November 2014. Log binomial models were used to examine correlates of prior and planned contraceptive use. RESULTS: The analysis included 569 women, of whom 61.3% had heard of, and 38.7% had used a modern method of contraception. Women aged 20-49 years, married, with secondary education or higher and with living children were significantly more likely to report prior use of a modern contraceptive method. Of the 354 women who still had reproductive potential (premenopausal women who had not undergone sterilisation) and answered questions on future contraceptive use, less than half (41.6%) planned to use a modern method of contraception after fistula repair. Planned modern contraceptive use was significantly associated with being currently married and having secondary education or higher. CONCLUSIONS: Contraceptive knowledge, prior use and planned future use were low in our study population. To increase contraceptive use among women undergoing obstetric fistula repair, interventions in the postoperative period must seek to increase their family planning knowledge and access to contraceptive methods.

Mental health screening in women with severe pelvic organ prolapse, chronic fourth-degree obstetric tear and genital tract fistula in western Uganda.

INTRODUCTION AND HYPOTHESIS: High levels of mental health dysfunction have been identified in women with genital tract fistula. The aim of this study was to use the General Health Questionnaire-28 (GHQ-28) to screen women in western Uganda with severe pelvic organ prolapse, chronic fourth-degree obstetric tear and genital tract fistula for risk of mental health dysfunction. METHODS: Women undergoing surgery for severe pelvic organ prolapse, chronic fourth-degree obstetric tear, and genital tract fistula were interviewed using the GHQ-28 to screen for the risk of mental health dysfunction. RESULTS: A total of 125 women completed the GHQ-28, including 22 with pelvic organ prolapse, 47 with fourth-degree obstetric tear, 21 with genital tract fistula, and 35 controls. Nearly all women with these serious gynaecological conditions were positive for the risk of mental health dysfunction. In the domain assessing symptoms of severe depression, women with fourth-degree obstetric tear and genital tract fistula scored higher than women with pelvic organ prolapse. CONCLUSIONS: A significant risk of mental health dysfunction was identified in women with severe pelvic organ prolapse and chronic fourth-degree obstetric tear. These rates are similar to the high rates of mental health dysfunction in women with genital tract fistula. Identification and management of mental health dysfunction in women with these conditions should be a priority.

Psychological Symptoms and Social Functioning Following Repair of Obstetric Fistula in a Low-Income Setting.

Objectives Obstetric fistula is a maternal injury that causes uncontrollable leaking of urine or stool, and most women who develop it live in poverty in low-income countries. Obstetric fistula is associated with high rates of stigma and psychological morbidity, but there is uncertainty about the impact of surgical treatment on psychological outcomes. The objective of this exploratory study was to examine changes in psychological symptoms following surgical fistula repair, discharge and reintegration home. Methods Women admitted for surgical repair of obstetric fistula were recruited from a Tanzanian hospital serving a rural catchment area. Psychological symptoms and social functioning were assessed prior to surgery. Approximately 3 months after discharge, a data collector visited the patients' homes to repeat psychosocial measures and assess self-reported incontinence. Baseline to follow-up differences were measured with paired t tests controlling for multiple comparisons. Associations between psychological outcomes and leaking were assessed with t tests and Pearson correlations. Results Participants (N = 28) had been living with fistula for an average of 11 years. Baseline psychological distress was high, and decreased significantly at follow-up. Participants who self-reported continued incontinence at follow-up endorsed significantly higher PTSD and depression symptoms than those who reported being cured, and severity of leaking was associated with psychological distress. Conclusions Fistula patients experience improvements in mental health at 3 months after discharge, but these improvements are curtailed when women experience residual leaking. Given the rate of stress incontinence following surgery, it is important to prepare fistula patients for the possibility of incomplete cure and help them develop appropriate coping strategies.

Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: a qualitative study.

BACKGROUND: Obstetric fistula affects a woman's life physically, psychosocially, and economically. Although surgery can repair the physical damage of fistula, the devastating consequences that affect a woman's quality of life may persist when she reintegrates into her community. This qualitative study assessed long-term outcomes among women who underwent obstetric fistula repair in Malawi. We explored three domains: overall quality of life before and after repair, fertility and pregnancy outcomes after repair, and understanding of fistula. METHODS: In-depth interviews were conducted in Chichewa with 20 women from seven districts across Central Malawi. All women were interviewed 1 to 2 years after surgical repair for obstetric fistula at the Fistula Care Centre in Lilongwe, Malawi. Interviews were independently coded and analyzed using content analysis. RESULTS: About half of women were married and nine of 20 women reported some degree of urinary incontinence. With the exception of relationship challenges, women's concerns before and after repair were different. Additionally, repair had resolved many of the concerns women had before repair. However, challenges, both directly and indirectly related to fistula, persisted. Improvements in quality of life at the individual level included feelings of freedom, confidence and personal growth, and improved income-earning ability. Interpersonal quality of life improvements included improved relationships with family and friends, reduced stigma, and increased participation with their communities. Nearly half of women desired future pregnancies, but many were uncertain about their ability to bear children and feared additional pregnancies could cause fistula recurrence. Most women were well informed about fistula development but myths about witchcraft and fear of delivery were present. Nearly all women would recommend fistula repair to other women, and many were advocates in their communities. CONCLUSIONS: Nearly all women believed their quality of life had improved at the individual and interpersonal levels since fistula repair, even among women who continued to have urinary incontinence. Contrary to other studies, women reported they were welcomed back by their communities and had limited challenges when reintegrating. Despite the overall improvements in quality of life, many continued to have relationship problems and were concerned about future fertility. These issues need to be further explored in other studies.

'As a man I felt small': a qualitative study of Ugandan men's experiences of living with a wife suffering from obstetric fistula.

The effects of obstetric fistula surpass the individual woman and affect husbands, relatives, peers and the community at large. Few studies have documented the experiences of men who live with wives suffering from fistula. In this study, our objective was to understand how fistula affects these men's lives. We conducted 16 in-depth interviews with men in central and western Uganda. We used thematic narrative analysis and discuss our findings based on Connell's theory of hegemonic masculinity. Findings show that the men's experiences conflicted with Ugandan norms of hegemonic masculinity. However, men had to find other ways of explaining their identity, such as portraying themselves as small men but still be responsible, caring husbands and fathers. The few individuals who married a second wife remained married to the wife with the fistula. These men viewed marriage as a lifetime promise before God and a responsibility that should not end because of a fistula. Poverty, love, care for children and social norms in a patriarchal society compelled the men to persevere in their relationship amidst many challenges.

Psychological Symptoms Among Obstetric Fistula Patients Compared to Gynecology Outpatients in Tanzania.

BACKGROUND: Obstetric fistula is a childbirth injury prevalent in sub-Saharan Africa that causes uncontrollable leaking of urine and/or feces. Research has documented the social and psychological sequelae of obstetric fistula, including mental health dysfunction and social isolation. PURPOSE: This cross-sectional study sought to quantify the psychological symptoms and social support in obstetric fistula patients, compared with a patient population of women without obstetric fistula. METHOD: Participants were gynecology patients (N = 144) at the Kilimanjaro Christian Medical Center in Moshi, Tanzania, recruited from the Fistula Ward (n = 54) as well as gynecology outpatient clinics (n = 90). Measures included previously validated psychometric questionnaires, administered orally by Tanzanian nurses. Outcome variables were compared between obstetric fistula patients and gynecology outpatients, controlling for background demographic variables and multiple comparisons. RESULTS: Compared to gynecology outpatients, obstetric fistula patients reported significantly higher symptoms of depression, post-traumatic stress disorder, somatic complaints, and maladaptive coping. They also reported significantly lower social support. CONCLUSION: Obstetric fistula patients present for repair surgery with more severe psychological distress than gynecology outpatients. In order to address these mental health concerns, clinicians should engage obstetric fistula patients with targeted mental health interventions.

[Social integration of women operated for obstetric urogenital fistula]. / Intégration sociale des femmes opérées de fistule urogénitale obstétricale.

OBJECTIVE: To study the social integration of women supported in the urology department of the University Hospital of Point G for obstetric urogenital fistula. PATIENTS AND METHOD: Prospective study conducted over a period of 13 months from June 2008 to June 2009 in the Department of Urology at the University Hospital of Point G. The study included all patients who have been operated on at least twice for obstetric fistula genitourinary. Records of surgical, medical records and tracking sheets for each patient were the media database. RESULTS: Situation before treatment: before surgical treatment, 76.92% of patients were rejected by their spouses. The family attended the patient in 84.62% of cases. Situation after treatment: after treatment, 90.31% of women with fistula lived in the matrimonial home or family. The resumption of business activity was announced by 11.2% of patients. Among the women, 93.7% participated in housework. The number of patient intervention ranged from two to five. Healing (fistula closed and no sphincter dysfunction) was complete in 50% of cases. Among the women, 11.54% had sphincter dysfunction after closure of the fistula, which makes a total of fistula closed more than 61% after at least two attempts. CONCLUSION: The urogenital fistulas are not a fatal disease but is a real handicap for women who suffer to conduct a socio-cultural and economic mainstream. Generally excluded from the ongoing operations of the company, these women are more integrated after successful surgical treatment of the fistula.

An accountable fistula management treatment plan.

An accountable fistula management treatment plan focuses on combining effective medical and nursing treatment with effective and efficient pouching technique and equipment to ensure patient comfort. Small bowel fistula following abdominal surgery can provide challenges in patients' medical and nursing management. This article describes a case study of the successful medical and nursing management of a patient post-abdominal surgery. Within days of surgery a small bowel fistula formed within an abdominal wound. Medical management involved the use of total parenteral nutrition, electrolyte balance management, nil orally and Sandostatin medication. The nursing interventions comprised accurate intake and output measurement, effective and efficient pouching systems and appropriate psychological care. The medical and nursing interventions provided during the healing process are outlined together with the assessment and evaluation of a new innovative wound management pouch. This system proved invaluable in the successful containment of a high small bowel effluent and skin preservation. In an attempt to share best practice a pictorial guide is provided to demonstrate the correct application of the pouching system and technique. This article provides details of an accountable fistula management treatment plan which resulted in the successful spontaneous closure of the small bowel fistula coupled with excellent cost-effectiveness and patient comfort.

Foreign-body granuloma of the penis in sexually active individuals (penile paraffinoma).

BACKGROUND: The practice of insertion of foreign bodies in the penis is well documented, but the clinical characteristics of penile foreign-body granuloma (FBG) and social motivation of the patients has not been studied in large groups. OBJECTIVE: The aim of this study was to evaluate the clinical and epidemiological profile of patients with penile insertion of foreign bodies and assess the significance of social motivation. METHODS: Twenty-five heterosexual male patients, who visited our clinic from 1990 to 2005, were retrospectively studied. All of them had implanted two different types of foreign bodies in their penis and had tattoos in the same area. Twenty-five male patients with genital tattoos served as clinical controls. RESULTS: The age of peak incidence of patients with penile FBG was 28 years. The youngest patient was 19 years. Twenty-three (23 of 25, 92%) of the patients were from gipsy origin, and two men were of Bulgarian origin. All the patients had risky social behaviour (prisoners and beggars). The motivation of 20 (20 of 25, 80%) of the patients was to enlarge the penile size. Fifteen (15 of 25, 60%) wanted to increase the feelings of the sexual partners. The majority of the patients (23 of 25, 92%) had injection of fatty substances, and 2 (2 of 25, 8%) had undergone implantation of a plastic pellet. In 14 cases (14 of 25, 56%), the insertion of mineral oil was complicated by formation of fistulas and wide ulcers with histological features of FBG. CONCLUSION: The reported cases represent an example of the detrimental effects of the insertion of foreign bodies in the penis. Immediate measurements should be performed to prevent severe outcomes.

Mental health screening in women with genital tract fistulae.

There is little information regarding the mental health status of women with genital tract fistulae in developing countries. The aim of this prospective observational study was to screen women at Dhaka Medical College Hospital, Bangladesh (December 2003 to June 2004), and Addis Ababa Fistula Hospital, Ethiopia (June to July 2004), with genital tract fistula for mental health dysfunction. Women presenting to the above institutions were screened using the General Health Questionnaire (GHQ-28) prior to fistula surgery. As the women were illiterate, the questionnaire was completed with the assistance of a medical officer, nurse or interpreter. The female staff members acted as controls. Sixty-eight women with fistulae and 28 controls completed the GHQ-28. Sixty-six of the 68 women with fistulae screened positive to probable mental health dysfunction compared with 9 of the 28 controls. We conclude that women with genital tract fistula are at high risk of mental health dysfunction. If the high rates of positive screening are confirmed on psychiatric evaluation, then the management of women with genital tract fistulas must include routine psychological/psychiatric assessment and treatment.

Syrinx extending from conus medullaris to basal ganglia: a clinical, radiological, and pathological correlation.

A 41-year-old woman with a history of birth injury to the brachial plexus suffered several delayed episodes of neurological deterioration. Magnetic resonance imaging studies revealed a syrinx extending from the conus medullaris into the brainstem and rostrally into both internal capsules. She died of an acute exacerbation of chronic respiratory failure. Autopsy demonstrated syringomyelia and syringobulbia with cavity extension bilaterally along the corticospinal tracts into the internal capsules. Islands of glial tissue in the subarachnoid space around the medulla caused obstruction of the subarachnoid space at the foramen magnum. These were probably the result of birth injury to the cerebellum. A detailed clinico-pathological correlation is provided to explain her neurological deficits. The pathogenesis of syrinx formation is discussed in terms of a late manifestation of birth trauma.

The perilymph fistula syndrome defined in mild head trauma.

Neurological and neuro-otological studies were carried out on 102 adults with mild cranio-cervical trauma productive of positional vertigo and perilymph fistula as confirmed by laboratory tests, and by the finding of perilymph fistula at tympanotomy in the surgically managed group. In this patient group, all other neurological and neuro-otological diagnoses were excluded, e.g. epilepsy, cerebral palsy, multiple sclerosis, retardation; and for the neuro-otological group those with a history of ototoxicity, labyrinthitis, Meniere's disease, chronic ear infections, or developmental or familial disorders. Emphasis in this study was on mild trauma: fewer than half of the sample had been rendered unconscious in the injury of record, and a third of the cases were of whiplash type, with no loss of consciousness (LOC) and no remembered headstrike. These concomitant lesions comprise the perilymph fistula syndrome (PLFS) with a unique profile of neurological, perceptual, and cognitive deficits resembling a post-concussion injury. A complete description of the clinical picture is given, including psychological, cognitive and diagnostic tests, and the outcome of bedrest vs. surgical management. PLFS can arise from minor trauma, fistula are frequently bilateral (71/102), a mild sensorineural hearing loss is of variable occurrence (53%), secondary hydrops is not uncommon, and women appear more vulnerable than men for developing the syndrome. As based upon combined laboratory techniques and clinical symptomology, fistula were correctly predicted in 61 of 65 laser-operated ears. The positional vertigo component of PLFS was in all cases managed according to a special physical therapy program utilizing exercises for vestibular symptom habituation. Even when diagnosed late, a good-to-excellent outcome was achieved in 70% of treated patients.