Psychosocial Burden of Obstetric Fistula Among Women in South-South Nigeria
Nelson Daberechi Egwu1, Adebayo Babafemi Charles Daniyan2,
Regina Ejemot-Nwadiaro3, Andrew Okpe4
1.Department of Obstetrics and Gynaecology, National Obstetric Fistula Centre, Abakaliki, Nigeria. 2. Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Abuja, Nigeria. 3. Department of Public Health, University of Calabar, Calabar, Nigeria. 4. Department of Obstetrics and Gynaecology,
University of Calabar Teaching Hospital, Calabar, Nigeria.
ABSTRACT
Background: Obstetric fistula, a medical and psychosocial problem, is a source of misery for women in low- and middle-income countries. This study was aimed at identifying the psychosocial impact of obstetric fistula among women in Cross River State of Nigeria. Methodology: It was a descriptive cross-sectional study carried out among women seeking treatment for obstetric fistula in 3 hospitals in Cross River State, Nigeria. A combined purposive, proportionate and consecutive sampling technique was used to select 210 participants. Ethical approval was obtained. An interviewer-administered questionnaire was used to obtain information on the demographics, obstetric characteristics and psychosexual problems experienced by the women. Data was analyzed with SPSS version 20. Chi-square was used to compare categorical variables. A P-value of less than 0.05 was considered significant. Results: The mean age of the women was 33.7+16.6 years. The commonest psychosocial problem encountered by the participants was depression which was experienced by 175 (83.3%) women. Other problems included social discrimination in 151 (71.9%) women, sleep disturbance in 143 women (68.1%), loss of libido in 138 women (65.7%), loss of job/means of livelihood in 86 women (41.0%), extreme poverty (34.3%), ostracism in 54 women (25.4%) and divorce/marital separation in 27 women (12.9%). Conclusion: Obstetric fistula has enormous psychosocial burden on the women affected, the commonest problem being depression. Beyond urinary continence, the goals of treatment should include social rehabilitation, re-integration, psychotherapy and mental well-being. A collaborative approach is recommended to achieve these.
Keywords: Burden; Obstetric Fistula; Psychosocia; South-South Nigeria
Correspondence
Adebayo Babafemi Charles Daniyan
Department of Obstetrics and Gynaecology,
University of Abuja Teaching Hospital, Abuja
babafemidaniyan@yahoo.com
+2348033803982
BACKGROUND
Obstetric fistula continues to be a source of misery for women in the low- and middle-income countries (LMICs) of the world.1,2 It is both a medical and a psychosocial problem.2,3 The condition is extremely distressing for the affected women because the uncontrollable leakage of urine or faeces causes feeling of shame, embarrassment, rejection, guilt, regrets, loss of dignity and low self-esteem.4 It also disrupts social, marital and sexual relationships, leaving the women depressed, ostracized, abandoned, divorced and financially dependent.4 It is commonly seen in young, poor and uneducated women who lack access to quality obstetric care.2 There are an estimated 2 million of such women globally, with about 150,000 residing in Nigeria.5
Obstetric fistula usually results from prolonged obstructed labour when there is sustained pressure by the fetal skull against the maternal pelvic bones.6 This compromises blood flow to the soft tissues of the vagina and bladder or rectum which are trapped in-between, leading to ischemia necrosis. Subsequently, the affected tissues slough off leaving a defect in the vagina through which urine or faeces leak.7,8 Recently however, increasing numbers of cases are seen due to poorly-performed Caesarean sections.9,10,11 These are as a result direct undetected injury to the bladder intraoperatively or accidental inclusion of the bladder in the closure of a very low uterine incision.12
While the medical aspect of the problem has been extensively studied and is largely amendable to surgical repair, the same cannot be said of the equally weighty social problems that plague these women. Hence they continue to suffer myriads of unidentified and untreated social and psychosexual problems after a successful surgery and short follow-up. This study was therefore carried out to identify the psychosocial impact of obstetric fistula among women in Cross River State, South-South Nigeria. The findings will form a basis for advocating a more wholistic and multidisciplinary care that emphasizes long-term follow-up and social rehabilitation.
METHODOLOGY
Study Area
The study was carried out in the University of Calabar Teaching Hospital (UCTH), Calabar, General Hospital, Calabar and General Hospital Ogoja, all in Cross River State, South-South geopolitical zone of Nigeria. Calabar is the capital of Cross River State. The three hospitals have dedicated obstetric fistula units where women with obstetric fistula are admitted, operated on and managed until they are discharged.
Study Design
It was a cross-sectional descriptive study.
Study Duration
The study was carried out over a period of six (6) months.
Study Population
The study population comprised all the patients who presented for treatment of obstetric fistula in the three hospitals.
Sample Size Determination
The minimum sample size for this descriptive cross-sectional study was determined using the Cochran’s formula, 2018, which is expressed as:
Sample Size, N = Z1-α/22P(1-P)
d2
where, N = the desired minimum sample size
Z1-α/2= Standard normal variate, at 5% type 1 error (p<0.05), it is 1.96 and at 1% type 1 error (p<0.01), it is 2.58
d= absolute error or precision, at 95% confidence level, it is 0.05
In rural areas of sub-Saharan Africa, about 124 cases of fistula develop per 100,000 deliveries (Sheheta, 2012). This gives a Prevalence rate, P of 0.124%.
Therefore, N = 1.962 X 0.124 (1-0.124)
0.052
N = 3.84 X 0.1086/0.0025 = 167
To account for non-response bias, the sample size will be increased by 10% which is approximately 17. Therefore, the minimum sample size is 184.
Sampling Technique
Using purposive sampling, the three hospitals in Cross River State providing obstetric fistula repairs were selected for the study. These were General Hospital, Ogoja, General Hospital, Calabar and University of Calabar Teaching Hospital, Calabar. Proportional sampling using institutional data of patient load was used to arrive at a sampling ratio of 14: 3: 2 among the three hospitals respectively giving quotas of 136 patients for General Hospital, Ogoja, 29 for General Hospital, Calabar and 19 for University of Calabar Teaching Hospital, Calabar. Using consecutive sampling, all eligible, consenting women who met the inclusion criteria were recruited in each hospital with the above quota as minimum. A total of 210 women were recruited.
Data Collection
Women who met the inclusion criteria were informed about the study. A diagnosis of obstetric fistula was made based on history of involuntary leakage of urine or faeces from the vagina following delivery and physical examination finding of a communication between the vagina and the bladder or rectum. After obtaining informed consent, a semi-structured interviewer-administered questionnaire was used to obtain information on the socio-demographic characteristics, obstetric characteristics of participants, events of labour, pregnancy outcome, symptoms, signs, complications and psychosexual impact of obstetric fistula.
Data Analysis
All the questionnaires were reviewed by the investigator for completeness. Data obtained was cleaned and analyzed with SPSS version 20 (SPSS Inc. Chicago, USA). The frequencies, percentages, means, standard deviations and of the socio-demographic characteristics, obstetric characteristics and other relevant information were presented in tables. Socio-demographic, obstetric and other factors associated with the outcome variables were assessed using inferential statistics, which includes the use of chi-square to compare categorical variables. A P-value of less than 0.05 was considered significant.
Ethical Consideration
Prior to the commencement of the study, ethical approval was obtained from the Health Research Ethics Committee, Cross River State Ministry of Health, Calabar. A written informed consent was obtained from the participants before administration of questionnaires for data collection. All the information obtained was kept confidential. Other ethical principles of autonomy, respect for persons, beneficence and non-maleficence were upheld.
RESULTS
The sociodemographic characteristics are shown in Table 1. The mean age of the women was 33.7+16.6 years. Fifty-nine women (28.1%) were aged between 30 and 39 years, 135 (64.3%) had no formal education and 168 (80%) were farmers. Eighty-one women (38.6%) were grandmultipara at the time of developing the fistula and 80 (38.1%) had no living child.
The psychosocial burden is shown in Table 2. The commonest psychosocial problem encountered by the participants was depression which was experienced by 175 (83.3%) women. Other problems included social discrimination in 151 (71.9%) women, sleep disturbance in 143 women (68.1%), loss of libido in 138 women (65.7%), loss of job/means of livelihood in 86 women (41.0%), extreme poverty (34.3%), ostracism in 54 women (25.4%) and divorce/marital separation in 27 women (12.9%).
DISCUSSION
The study identifies the psychosocial problems faced by women with obstetric fistula, a scourge with an easily recognizable medical but huge and hidden psychosocial components. The condition continues to ravage women in different parts of Nigeria. The mean age of the women
Table 1: Socio-demographic Characteristics of Participants
studied was 33.7+16.6 years and the largest age group was 30-39 years. This finding is similar to that of a study done in Abakaliki in 2017 where the mean age of the women was 36.4 years and most (40%) of them were aged 26-35 years.13 It however differs from findings in a study done in Kano in 2004 where majority (72.5%) of the fistula patients were between 10-20 years14 and another in Ile-Ife in 2017 where most (52.1%) of the women were aged 15-24 years with mean age of 24.8 years.15 These figures suggest that fistula patients in the South-South and South East are older than those in the North-West and South-West geopolitical zones.
Table 2: Psychosocial Problems of Women with Obstetric Fistula
The commonest psychosocial problem identified among the women was depression which was experienced by 83.3% of them. Traumatic childbirth experience, delivery of a stillbirth coupled with leaking of urine or faeces with myriads of medical and psychosocial problems can result in varying degrees of depressive illness in these women. A study in Kano in 2022 shows that about two-thirds (61.7%) of the vesico-vaginal fistula patients suffer from moderate depression while 35% of them reported mild depression and 2.3% severe depression.16 Occurrence of depression among women living with obstetric fistula is well documented in other studies.17-20 Nweke and Igwe in 2017 identified numerous psychosocial problems like poor social support, helplessness, sadness, suicidal thoughts, feelings of worthlessness, social withdrawal, shame, stigmatization andfear of divorce. They advocated collaboration with psychologists and psychiatrists in the treatment of these women.13
Other problems identified included social discrimination in 71.9% of the women, sleep disturbance/distortion (68.1%), loss of libido (65.7%), loss of job/means of livelihood (41.0%), extreme poverty (34.3%), ostracism (25.4%) and divorce/marital separation (12.9%). This shows that the apparent clinical presentation of involuntary leakage of urine or faeces in women with obstetric fistula may just be a tip of the iceberg as there are equally serious problems requiring attention. The systematic review by Nduka et al identified harrowing experiences such as stigma, economic deprivation, feeling of hopelessness, loss of identity, loss of marriage and inability to carry out social functions among Nigerian women living with obstetric fistula.20 Another study showed that women who have been successfully repaired still suffered varying degrees of stigmatization, shame, discrimination, economic dependence, marital disharmony and ostracism from both family and community members.3 This is worrisome and calls for development of policies to ensure complete rehabilitation of these women.
Sexual dysfunction is associated with obstetric fistula as seen in this study. Possible reasons for this are lack of spousal support, painful intercourse, incontinence, reduced vaginal capacity or a combination of these.21 A study showed that sexual function and quality of life improved following surgical repair.22 Generally however, women have been shown to experience sexual problems following surgery because of narrowed vagina, reduced desire, inadequate lubrication dyepareunia and anorgasmia.21, 23, 24 Sexual function is an important aspect of the quality of life of a women with enormous impact on social and marital relationships. These women should therefore benefit from extensive counselling and treatment to ensure optimal sexual health during their rehabilitation.
Separation and divorce are other psychosocial problems among women living with obstetric fistula as seen in this study.20, 25 Obstetric fistula has enormous consequences on marriage and social relationships.25 This is due to rejection and perceived failure to perform social roles such as sexual satisfaction of the spouse and childbearing.25 Marital separation has even been reported among women who had successful repair due to continued stigmatization by the spouse and family members.3 A study done in Jos Nigeria showed that women who had living children and those with some level of formal education are less likely to suffer separation and divorce.26 To protect social and marital relationships therefore, spousal counselling and re-integration at the family and community levels should be incorporated into the care of these women.3
CONCLUSION
In conclusion, obstetric fistula has enormous psychosocial burden on the women affected, the commonest problem being depression. Beyond achieving urinary continence, the goals of treatment should include social rehabilitation, re-integration, psychotherapy and mental well-being. A collaborative approach is recommended to achieve these.
Conflicts of Interests: None declared.
Funding: None.
REFERENCES