Volume 200, Issue 5 , Pages e40-e42, May 2009
Obstetric fistulae in West Africa: patient perspectives
Article Outline
Objective
The objective of this study is to gain insight into the nature of obstetric fistulae in Africa through patient perspectives.
Study Design
At l'Hôpital Saint Jean de Dieu in Tanguieta, Benin, 37 fistula patients underwent structured interviews about fistula cause, obstacles to medical care, prevention, and reintegration by 2 physicians via interpreters.
Results
The majority of participants (43%) thought their fistulae were a result of trauma from the operative delivery. Lack of financial resources (49%) was the most commonly reported obstacle to care, and prenatal care (38%) was most frequently reported as an intervention that may prevent obstetric fistulae. The majority (49%) of the participants requested no further reintegration assistance aside from surgery.
Conclusion
Accessible emergency obstetric care is necessary to decrease the burden of obstetric fistulae in Africa. This may be accomplished through increased and improved health care facilities and education of providers and patients.
Key words: global health, international heath, maternal morbidity, obstetric fistula, obstructed labor
Worldwide, at least 2 million women and girls live with obstetric fistulae and 50,000 to 100,000 have 1 develop yearly.1 Often a direct result of obstructed labor, obstetric fistulae are now rare in countries where women are educated and emergency obstetric care (EmOC) is accessible.2
Comprehensive obstetric fistulae services consist of 3 main components: surgical repair, reintegration, and prevention. In the developing world, it costs approximately $100-$400 to surgically repair a basic obstetric fistula.3 However, associated stigma and subsequent marginalization of these women make reintegration programs important and prevention strategies essential.
Direct dialogue with affected women is imperative for understanding obstacles to timely care and decreasing the burden of obstetric fistulae. Therefore, structured interviews about perceptions of fistula cause, obstacles to medical care, prevention, and reintegration were conducted with fistula patients in West Africa.
Materials and Methods
Our study was conducted at l'Hôpital Saint Jean de Dieu in Tanguieta, Benin. This 231-bed hospital in rural West Africa hosts the Geneva Foundation for Medical Education and Research (GFMER) for fistula repair missions all year. This study was performed during GFMER's Spring 2007 and 2008 missions.
An open-ended questionnaire was created and validated by 2 faculty obstetrician/gynecologists at Albert Einstein College of Medicine (AECOM). The first section included questions about demographics, literacy, prenatal care (PNC), and distance to nearest health care facility (HCF). Detailed descriptions of labor and delivery experiences were recorded.
Information on the people present, days in labor, and number of HCFs visited was elicited. The second section examined perspectives on fistula cause, obstacles to medical care, prevention, and reintegration.
Patients receiving inpatient postoperative care were approached. Secondary to a high rate of illiteracy, questionnaires were administered orally. A physician conducted structured interviews of each patient with the assistance of fluent interpreters. A questionnaire/interview study tool was used and therefore this study was exempt by the AECOM institutional review board.
Results
After being fully informed of the purpose, all 37 patients approached consented to participate in the study. Participants' characteristics are in Table 1. Twenty-five (68%) reported receiving PNC; however, 10 (40%) stated this involved only 1 or 2 visits. Only 1 patient received PNC throughout pregnancy.
TABLE 1. Characteristics
| Sociodemographics | Number (n = 37) | Percentage |
|---|---|---|
| Age (y) | Range = 20-51 | |
| Mean = 30 | ||
| Parity | ||
 1 | 18 | 49 |
| 2 | 9 | 24 |
| 3 | 6 | 16 |
| 4 | 3 | 8 |
| 5 | 1 | 3 |
| Countries of origin | ||
| Burkina Faso | 19 | 51 |
| Benin | 9 | 24 |
| Togo | 8 | 22 |
| Niger | 1 | 3 |
| Literate | 7 | 19 |
| Prenatal care | 25 | 68 |
| Traditional birth attendant | 10 | 27 |
| Distance from HCF | ||
| 0-50 km | 27 | 73 |
| 51-100 km | 6 | 16 |
| < 100 km | 4 | 11 |
| Labor and delivery | ||
| Transferred to second HCF | 12 | 32 |
| Days in first HCF before transfer | 1-2 | |
| Days in labor | 1-6 | |
| Delivery | ||
| Cesarean | 17 | 46 |
| Vaginal | 13 | 35 |
| Operative vaginal | 7 | 19 |
| Perinatal mortality | 35 | 95 |
Despite that some women lived less than 20 km from a HCF, more than three quarters labored between 1 and 3 days before they either delivered at home or were transported to a HCF. Days in labor ranged from 1-6, with the majority of women laboring for 3 days before delivery. Once at the HCF, many continued laboring without timely treatment of their protracted/obstructed labor.
Thirty-two percent required the transfer to a second HCF and, on average, spent 2 days in the first HCF before transfer. They reported being transferred because the HCF did not have the capacity to perform the required operative delivery.
The participants' perspectives on fistula cause, obstacles to medical care, prevention, and reintegration are in Table 2.
TABLE 2. Patient perspectives
| Perceived fistula cause | Number (n = 37) | Percentage |
|---|---|---|
| Delivery trauma | 16 | 43 |
| Lack of intrapartum care | 8 | 22 |
| Fetal size | 4 | 11 |
| Uncertain | 4 | 11 |
| Length of labor | 3 | 8 |
| God | 1 | 3 |
| Witchcraft | 1 | 3 |
| Obstacles to care | ||
| Financial | 18 | 49 |
| Knowledge | 9 | 24 |
| Religion | 5 | 14 |
| Husband | 3 | 8 |
| Distance | 1 | 3 |
| None | 1 | 3 |
| Prevention | ||
| Prenatal care | 14 | 38 |
| Intrapartum care | 13 | 35 |
| Education | 8 | 22 |
| Increased health care facilities | 1 | 3 |
| Religion/prayer | 1 | 3 |
| Uncertain | 1 | 3 |
| Reintegration assistance | ||
| Surgical repair | 18 | 49 |
| Financial support | 8 | 22 |
| Patient education | 7 | 19 |
| Family/village education | 7 | 19 |
| Nothing | 6 | 16 |
Comment
Our results highlight the complex nature of obstetric fistulae in Africa. Accessible EmOC is clearly necessary and we agree this will require increasing HCFs.4 Our results further supported the need to increase EmOC capabilities at existing HCFs4 and to educate providers and patients.5 This was evidenced by only 1 woman reporting distance to a HCF as an obstacle to timely medical care and the apparent failure of providers and patients to recognize the obstetric emergency.
Education therefore should be a central focus of prevention efforts and initiated at the first PNC visit. The majority of our participants received PNC, a finding that has been documented in Zambia, as well.6 However, many attended only 1 or 2 appointments. Women must be encouraged to continue PNC, despite the perception of a normal pregnancy. Provider education should also be enhanced to identify emergencies and ensure timely access to EmOC.
The most commonly reported obstacle to timely intrapartum care was the lack of financial resources. Benin has a yearly per capita income of approximately $1100,7 making transportation to a hospital plus medical care prohibitively expensive. Many countries8, 9 have therefore initiated community health care insurance plans. One unique Beninese insurance plan, Femme pour Femme, is specifically designed to provide transportation and cover medical costs for pregnant women only. Such innovative insurance schemes are crucial to overcoming this substantial obstacle to EmOC.
Many participants reported no need for reintegration assistance, underscoring the high expectation of a successful surgical repair. It is therefore important that fistula repair programs conduct thorough preoperative evaluations and provide comprehensive counseling regarding the potential extensive nature of the surgery and postoperative course. In addition, there is a clear need to increase accessible facilities capable of both repairing fistulae and training local surgeons.
Participants, who did desire reintegration assistance, predominantly sought economic self-sufficiency through financial assistance to start small businesses or employment. Some participants also requested education for family and friends about the nature and cause of fistulae. Specifically, they wanted their village to understand they were not cursed. This is a common belief in many areas in Western Africa, where voodoo is frequently practiced.10 Educational efforts should be implemented specifically targeting these misperceptions.
Multiple, complex factors exist that continue to perpetuate the burden of obstetric fistulae. Despite language barriers and sample size limitations, dialogue with patients is necessary and beneficial. By continuing to use patient perspectives as an investigative tool, we will gain unique insight into the problem and potential solutions.
References
- . Second meeting of the working group for the prevention and treatment of obstetric fistula, November 2002, Addis Ababa. http://www.unfpa.org/upload/lib_pub_file/146_filename_fistula_kgroup02.pdfAccessed March 1, 2007
- . Obstetric fistula: guiding principles for clinical management and programme development. http://www.who.int/making_ pregnancy_ safer / publications/en/Accessed March 1, 2007
- . Obstetric fistula needs assessment report: findings from nine African countries 2003. http://www.unfpa.org/upload/lib_pub_file/356_filename_fistula-needs-assessment.pdfAccessed March 1, 2007
- . Improving emergency obstetric care in Mozambique: the story of Sofala. Int J Gyneacol Obstet. 2006;94:190–201
- . Risk factors for Ostetric fistulae in north-eastern Nigeria. J Obstet Gynaecol. 2007;27:819–823
- . Obstetric fistulae: a study of women managed at the Monze Mission Hospital, Zambia. BJOG. 2007;114:1010–1017
- . http://web.worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS/0,content MDK:20535285∼menuPK:1390200∼pagePK:64133150∼piPK:64133175∼theSitePK:239419,00.htmlAccessed April 24, 2008
- . Low enrollment in Ugandan community health insurance schemes: underlying causes and policy implications. BMC Health Serv Res. 2007;7:105
- . Portals to the World. http://www.loc.gov/rr/international/amed/benin/resources/benin-religion.htmlAccessed April 24, 2008
This research was conducted in Tanguieta, Benin.
PII: S0002-9378(08)02027-9
doi:10.1016/j.ajog.2008.10.014
© 2009 Mosby, Inc. All rights reserved.
Volume 200, Issue 5 , Pages e40-e42, May 2009
