Consequences of obstetric fistula in sub Sahara African countries, from patients’ perspective: a systematic review of qualitative studies

The database searches used specified key terms to identify studies for potential inclusion in the review. The literature was searched through search engines Google, Google scholar, and Hinari, using Pub- Med data bases and citation tracking.

CoCoPopS protocol was formulated to identify articles Co: obstetric fistula impact/challenge; Co: developing world/sub-Saharan Africa; Pop: women with obstetric fistula; and S: primary qualitative and/or mixed method studies.

The terms were; “Obstetric fistula”,“vesicovaginal fistula”, “Rectovaginal fistula”, “Urogenital fistula”, “challenges of fistula”, “Consequences of fistula”, “Psychosocial experience” of women were key words used to search relevant papers and the search protocol was as follows:

“Obstetric fistula” [MeSH Terms] OR “Obstetric fistula” [All Fields] OR“VVF” [MeSH Terms] OR “Vesico-vaginal Fistula[MeSH Terms]OR” “Rectovaginal Fistula” [MeSH Terms] OR “RVF” [MeSH Terms] OR “Urogenital fistula” [MeSH Terms] AND “Consequence” [MeSH Terms] OR“Consequence” [All Fields] OR “Challenges” [All Fields] OR “Lived experience” [All Fields] AND “Africa” [All Fields] OR “sub-Sahara Africa” [All Fields]. There were no language restrictions except for articles which did not have the “translate” option. As a result, one article was found in French and was excluded due to the irrelevance of its objective with the review objective. Predominantly, the review was based on a selection of published literature. Three steps were used to select papers for review. First, relevant titles and abstracts were identified from databases. In the second stage, screening and retrieving of full text articles were conducted. In the final step, after identifying papers that potentially meet the inclusion criteria, data extraction from relevant selected articles and qualitative reviews of the articles were done. Analysis was restricted to studies intended to explore the consequences of obstetric fistula on women with the condition.

For studies that have an abstract identified in the database searches, the abstracts were reviewed to determine whether or not they should be included by using the following criteria for the inclusion and exclusion of papers.

Physical consequence was the core theme shared across most studies, described as loss of body control and the challenges faced to keep cleanness [13, 16, 19, 24, 28, 29, 32]. Physical challenges include the emotional and medical problems of fistula which resulted from incontinence, such as genital sores, smells, wounds, pain, discomfort, exhaustion, and foot drop [21]. studies indicated that women with the condition were unable to afford hygiene keeping supplies and to cover medical fees therefore, they use herbs to sooth sores [11, 23]. In order to control the leak some women restrict themselves from feeding as they used to in pre fistula period, and this resulted in weight loss [11]. Moreover, in order to prevent the smell, discomfort, and to stay clean women with obstetric fistula tend to bath repeatedly; and they get bored of the frequency of washing [13, 32].

Most studies included marital and social relationships issues as the main theme [11, 13, 19, 22, 23, 26, 29]. It is a common event that fistula-affected women face divorce as they fail to satisfy their husband’s sexual needs and/or fail to bear children. As the women become incapable of performing the family roles expected of them, they were perceived as “useless” beings. Therefore, they became neglected and abandoned. A woman reported that she was mistreated by her spouse after the fistula incident, “He left me and threw out all of my belongings” …..ever since I developed the condition, we have not been together as husband and wife. I have been left out here to care for the old lady (mother-in-law). Even after repair, different socio-cultural factors can hinder the acceptability of women who integrated back to the community [13, 26, 31]. A study in Malawi reported that remarriage was not difficult among divorced women with fistula, as long as the husband knows the problem prior to marriage [31]. However, the report might not represent all other women with fistula, as it was reported by one participant and also may not be true for all fistula women living across different countries. Except for this report from Malawi, the concept of keeping association was also a common theme of all reviewed papers. Seven (43%) reported the faced discrimination and difficulty in maintaining social relationships. Unless they got an opportunity to obtain a repair service, women with fistula would not be considered as a woman and therefore, they lose their power and confidence [11]. Although few reported the presence of supportive husbands, most studies revealed experience of rejection, neglect and abandonment [8, 23, 24, 27, 31].

Loss of income source activities as a result of fistula was reported in some of the reviewed studies [22, 26, 27, 32]. Women with fistula could not get involved in gainful employment or activities that needed strict hygiene [32]. They also lost business because of the incontinence, and were self-employed in petty trading where they earned too little income. As a respondent from a Ghana study stated [32]: “… I used to sell cooked rice but my condition has obliged me to stop. My sales started dwindling as the news of my urine incontinence was heard”. Therefore, sometimes they fell into deeper poverty and start to beg for survival [32]. In this way, fistula has challenged and contributed to disfigure image of women’s health in developing countries.

This issue was addressed in few of the studies that reported loss of dignity, lack of support, and lack of power to seek care. Loss of hope, fear of future life, and feelings of dependency were stated as mental health problems [13, 22]. This challenges were emerged as the result of different interrelated problems such as lack of support and family care, physical or economical incapability to access care, and lack of information or knowledge about fistula care and treatment [28]. It might also result from the reactions and comments of people with a poor understanding of the condition [19, 29]. Perceived causes of fistula and social stigma has caused psychological morbidity to women [19, 23, 27].

Keeping strict hygiene, washing with scented soap, the use of pieces of old cloth as a sanitary pad, and the use of herbs for cleaning, were reported as common coping mechanisms [22, 26, 32]. In some cases, ineffective practices for coping such as isolation, hiding, drinking a lot and eating less or changing feeding habits were undertaken [19]. Which may result in to other health problems such as depression and malnutrition [23, 27]. Women were used to discuss among themselves as a means for getting relief and those who got training tended to accept the reality in order to cope in a better way and keep themselves busy doing hand crafts [22].

Limited geographical coverage of the reviewed literatures might affect the transferability of the findings. Most of the included researches were conducted in facility settings, which mean that the voice of those women remaining at home, with perhaps more challenges, was lacking. The search strategy has not included subscription databases such as MEDLINE, EMBASE, and Scopus.