The psycho-social impact of obstetric fistula and available support for women residing in Nigeria: a systematic review

Obstetric fistula is the constant leakage of urine, faeces or both due to injury caused during childbirth [1‐3]. Obstetric fistula occurs when a woman’s pelvis is too narrow for the foetus to pass through, and the labour prolongs due to lack of access to emergency obstetric care to discharge the obstruction [4]. During prolonged labour, the foetal head exerts a long consistent pressure on the pelvis which disturbs the circulation of blood in the soft tissues surrounding the woman’s vagina, rectum and bladder [4, 5]. The United Nations Population Fund (UNFPA) estimated that Nigeria accounts for 12,000 new cases annually with a current estimated total of 150,000 cases [6]. The actual prevalence of obstetric fistula may be higher due to the under-reporting of cases in Sub-Saharan Africa [7].

Obstetric fistula affects a woman’s physical, economic, psychological and social life [1, 8]. Women living with obstetric fistula suffer urogenital and kidney infection, severe skin irritation and genital lacerations due to incontinence [7, 9]. Aside these, their quality of life is also deeply affected as they face discrimination and stigma from family, friends and the community at large [7, 9]. As a result, they become isolated and are unable to be involved in family, religious and social gatherings [3, 7]. Separation and divorce are also common among women living with obstetric fistula, leaving them lonely [3, 4, 7].

Most women with obstetric fistula lose their source of income due to their incontinence and become an economic burden to their families [1, 10]. This pushes them to poverty, leaving them in bitterness, trauma, depression and suffering disappointment [9]. The lack of support and care from families and the community, the physical and economic incapacity alongside social stigma accompanied with obstetric fistula has affected the quality of life of the affected women and led to multiple suicide attempts [1, 11].

Nonetheless, with the use of adequate and standard resources and effective surgical practice, obstetric fistula can be treated with a closure rate of 80–90% [12]. Sadly, due to lack of resources and skilled surgeons in Nigeria, most affected women are bound to live with the condition for a long time or throughout the course of their lives [2, 12, 13]. Also, other factors such as poor transport system, poor access to perinatal care which are factors that arise where these women live, could prevent them from seeking surgery [14]. Furthermore, given the severe psycho-social consequences of obstetric fistula, studies have shown that surgical repair is not enough in the care of obstetric fistula [11, 15]. Psycho-social support for these women is also needed to reintegrate them into the community.

The mental health impact of living with obstetric fistula is now well recognised and reported [8, 16, 17]. The WHO has recommended the inclusion of psychosocial support in the care of obstetric fistula [18]. However, there is dearth of evidence reporting the psycho-social interventions addressing the impact of obstetric fistula on women living in Nigeria [6, 8]. Also, much attention has not been directed towards the psycho-social outcomes of obstetric fistula even when the evidence base suggests severe psychological and social outcomes for women with obstetric fistula [1, 8, 12, 19, 20]. Some studies have reviewed the general consequences of obstetric fistula [20, 21] but this review shed more light on the psychosocial impacts. This study aimed to review the existing literature on the psycho-social impact of obstetric fistula and the interventions, appraise the available evidence related to psycho-social support for obstetric fistula women living in Nigeria. Synthesising the existing evidence can potentially identify the gaps in the available literature and identify areas for further consideration.

A total of 620 studies were identified from the electronic searches (n = 610) and hand searches (n = 10). Twenty articles passed the title and abstract screening. However, only 8 articles met the inclusion and exclusion criteria after a thorough full-text screening and was included in the review. The study selection process is shown in the PRISMA flow diagram in Fig. 1.

According to five of the included studies, [3, 7, 9, 26, 27], women with obstetric fistula were faced with either divorce or separation from their spouse. This is similar across several regions in Nigeria as reported in the results. This is probably because as women become incontinent, they are unable to satisfy the sexual urges of their husbands and produce children. Also, they become incapable of performing womanly roles in their households. In Nigeria as well as other African countries, women are expected to be married into families, perform household chores, and produce children [32, 33]. Hence, women unable to produce offspring are not seen as real women and are exempted from community gatherings of women and mothers [32]. Evidence suggests that women who had children before the development of obstetric fistula lived better lives compared to women with obstetric fistula with no children [34, 35]. According to some respondents in one of the selected studies [29], women with obstetric fistula lived with the fear of losing their husbands because they had no children. Most men stay with their wives who had developed obstetric fistula because of their children. These findings are consistent with studies conducted in other developing countries like Kenya [15, 36], Somalia [5], Tanzania [11, 17, 37, 38], Uganda [37, 39, 40], Malawi [12], Ethiopia [41] and Ghana [42].

This present review also revealed that women living with obstetric fistula experience all forms of stigma and discrimination due to their incontinence.. These findings corroborate with findings from studies conducted in Malawi [35], Tanzania [11] and Kenya [15]. In the African setting, infertile and childless women are regarded as a failure to womanhood which attracts stigma to the women in question [43]. Findings from this present review also reveal that these affected women are still discriminated and stigmatised even after undergoing a successful obstetric fistula repair surgery. Similar reports are seen in Kenya [15] and Ethiopia [44]. Also, this present review showed that some of these affected women self-stigmatised. Self-stigmatisation by women with obstetric fistula was also observed in a Ugandan setting [1]. It is possible that those who self-stigmatise do so from general societal norms on personality, character and sickness [45]. Likewise, family members of women with obstetric fistula were reported to be subjected to stigma from this present review. This shows the experiences of stigma by not only the women with obstetric fistula but also the close relations including the spouse. According to Goffman [45], due to stigma by association, an individual may react by ending an existing relationship with the source of the stigma, which is the woman with obstetric fistula in this case. In addition, most cultural norms expect control over bladder and bowel movement, thus the loss of control can attract shame, social isolation and loss of dignity [46‐48]. This possibly explains why most women in this present review were socially isolated. Further, evidence suggests a low knowledge and awareness of obstetric fistula in Nigeria [9, 49]. Therefore, people’s actions and reactions towards women with obstetric fistula due to lack of knowledge can result in social isolation of these affected women.

The negative socio-cultural and family experiences Nigerian women with obstetric fistula undergo, leads to the change in the identity of these women. According to Charmaz [50], the comorbidity of obstetric fistula ruptures the social body of the individual, thus such individual undergoes reconstruction on several magnitudes. This present review reveals the different identities women with obstetric fistula are labelled with. Due to incontinence, loss of marriage and inability to perform social activities, women with obstetric fistula lose their identity and roles as wives and women in the community. The several identities identified are in phases. Women with obstetric fistula especially in the Northern region of Nigeria are labelled with the leaking identity which is also known as “mai yoyo” in native Hausa language [3]. However, most women with obstetric fistula transition from the leaking identity to the spoilt identity when they realise how different they have become from other women in the society [3]. At this point, they no longer see themselves as alike to others which are explained by the role identity theory [51]. Hence, these women feel vulnerable, worthless and incomplete. Additionally, some of these women are called names by the members of the community and even family members as reported in this present review. These findings are supported by previous findings from a study in Malawi [12]. This possibly explains why affected women prefer to stay away and isolate themselves from the society.

Also, in some cases, women with obstetric fistula become ostracised as they have lost their cultural identity as revealed in this review. Thus, these women suffer psychological trauma like those observed in Ghana [42], Ethiopia [44], Kenya [15, 36] and Uganda [1], as they cannot live their normal lives with their families. Furthermore, Nigerian women living with obstetric fistula are revealed to suffer from foot drop which make them unable to walk properly without help. As a result, these women are unable to perform their regular activities including activities that bring in income. This was also reported in Ethiopia [44] and Uganda [1, 39]. These women are unable to be gainfully employed and record a decrease in sales of their goods due to incontinence. According to the disability adjusted life years (DALY) evaluation of maternal health burden, women living with obstetric fistula lose most of their years of life due to disability [11, 52]. Most of the women with obstetric fistula in this review were mostly young, hardly acquired formal education and were poor, and obstetric fistula prevented them from gaining employment. As a result, these women are socially marginalised. The social marginalisation of women with obstetric fistula have been reported in other studies as well [10, 11, 53]. Thus, they become poor and beg to survive. This explains the poor socio-economic status observed among these women in this review.

Nigerian women with obstetric fistula are subjected to numerous adverse experiences including lack of support, social stigma and economic incapability which exposes them to various mental health issues such as depression, hopelessness, feelings of worthlessness and loss of dignity as revealed in this present review. Similarly, high rates of depression have been reported in other countries in Sub-Saharan Africa including Niger [54], Tanzania [55] and Kenya [56] which affects their health-seeking behaviour. A study conducted in Ethiopia revealed that nearly all women living with obstetric fistula were depressed when compared to almost two-thirds of patients diagnosed with advanced pelvic organ prolapse [57]. Further, a Tanzanian study reported significant higher rates of depression and post-traumatic stress disorder (PTSD) among women with obstetric fistula compared to other women with other reproductive conditions [17]. Evidence has shown that depression is more common among older women, divorcees and abandoned women living with obstetric fistula [56, 57]. As a result, these women are filled with the thoughts of ending their life of misery. Suicidal thoughts have been reported among women with obstetric fistula in Ethiopia [58] and Niger [54].

This review highlights that beyond the clinical and physical outcomes, obstetric fistula women are faced with severe psychosocial outcomes. Hence, psychosocial support is needed to enable full recovery, even after successful repair surgery. Existing psychosocial interventions for obstetric fistula are limited in Nigeria. There is a need for the introduction of more rehabilitation and reintegration programs across the country. This will greatly contribute to the National Strategic Framework for the elimination of obstetric fistula policy goal in Nigeria, as well as the UN Sustainable Development Goal (SDG) 3 by promoting healthy lives and wellbeing of the affected women [70]. Also, more research is needed to evaluate the impact of psycho-social interventions in obstetric fistula care. Focusing on the psycho-social outcomes of obstetric fistula on women in Nigeria would impact other aspects of the SDG goals such as gender equality and women’s empowerment alongside decreasing poverty.