Obstetric fistulas predominantly affect women in developing countries who lack access to quality maternal health care.
A recent systematic review suggested that there are approximately one million women with fistula in sub-Saharan Africa and South Asia and more than 6,000 new cases per year in these regions. We therefore know there is a problem and largely we know what needs to be done to ‘fix’ the problem (effective surgical repair) However, do we know what is preventing women living in these countries from receiving the life-changing fistula treatment that they need?
This article focuses on the fascinating paper written by Zoe Baker et al in Tropical Medicine and International Health (August 2017)1 looking at exactly this question. Click here to read the article in full.
Zoe Baker and her team could find no pre-existing systematic review that focused on barriers to fistula treatment. Instead, recent systematic reviews have concentrated on fistula prevalence, clinical outcomes associated with fistula repair, rehabilitation after fistula treatment and prevention strategies.
Her aim was to identify and understand what was preventing these women accessing and receiving the fistula repair surgery that they needed. She performed an extensive search of journal databases, publishers’ pages and organisational websites written in either French or English. Articles written between 1980 and 2016 discussing obstetric fistula and mention of barriers to treatment were initially flagged (almost 6,000 articles). Further screening and analysis of these articles identified only 139 that specifically discussed barriers to obstetric fistula repair.
In the articles that Zoe Baker’s team analysed, the following barriers were identified (on average 4-5 barriers were mentioned per article). These barriers broadly aligned with the Three Delays Model previously described by Thaddeus and Maine2.
Delay in seeking care
Social barriers were most frequently mentioned (in 66% of sources) Issues such as stigma, and embarrassment, particularly where women live in isolation and face abandonment by their husbands. These issues prevent women from seeking care.
Cultural factors include male dominance where the men control the money and access to health care. Women can have negative associations with hospitals and a preference for traditional medicine.
Lack of awareness (56% of sources) – many women do not know what a fistula is, that it is treatable or where to get treatment. If they don’t understand what it is and that it can be cured, they do not seek help.
Psychosocial barriers which Include depression, loss of dignity and self-worth and anxiety. Not cited as frequently as other barriers, but these factors may inhibit a woman’s initiative to seek treatment.
Financial barriers (in 64% of sources) – the procedure is too costly.
Delay in reaching an adequate healthcare facility
Transportation Barriers – often women come from remote, rural areas while most fistula services exist in urban centres. Transportation can be costly or sometimes non-existent. The women may experience too much pain to travel or be turned away from public transportation due to their condition.
Delay in receiving adequate care once at the facility
Facility related shortages were another barrier (mentioned in 65% of sources) eg. shortages of doctors/trained surgeons and other personnel, as well as shortages of supplies and basics such as electricity.
Lack of political leadership. Political leaders fail to recognise the importance of maternal health and fistula repair and therefore do not fund these sufficiently. This can be particularly true in countries with competing health priorities that seem more acute eg. civil war, political insecurity and corruption.
The four most cited barriers were social, facility shortages, financial issues and awareness of fistula as a health issue that was potentially curable. Interventions to counter these barriers are being introduced but their effectiveness can be difficult to assess. However, raising awareness though radio campaigns, providing free fistula repair (as occurs in Hamlin facilities), establishing new – particularly rural facilities – with increased numbers of trained community workers are all hopes for the future.
Zoe Baker and her team conclude that a greater commitment is needed to address the barriers-to-care experienced by women living with fistula. To achieve success, solutions targeting multiple barriers such as a combination of increasing fistula awareness and reducing financial barriers, facility shortages and psychosocial barriers may be more effective than those that focus on facility shortages alone. Most importantly, strategies to reduce stigma and improve community support will empower women with the knowledge and means to seek treatment.
Click here to see how Hamlin Fistula Ethiopia is addressing multiple barriers to deliver a world class obstetric fistula prevention, treatment and rehabilitation program.
Author: Felicity Gallimore – Obstetrician and Hamlin Fistula Ethiopia (Australia) volunteer.