|Year : 2020 | Volume
| Issue : 16 | Page : 69-73
Health-seeking behavior of obstetric fistula patients
Ibrahim Garba1, Idris Sulaiman Abubakar1, Mahmoud Kawu Magashi2, Ayyuba Rabiu1
1 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Submission||31-Aug-2019|
|Date of Decision||06-Apr-2020|
|Date of Acceptance||21-May-2020|
|Date of Web Publication||26-Nov-2020|
Dr. Ayyuba Rabiu
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Bayero University, P.M.B. 3011, Kano
Source of Support: None, Conflict of Interest: None
Background: Obstetric fistula (OF) is one of the most dehumanizing diseases on the earth. It is a disease that reduces the female species of humans to a subhuman level where a woman continuously leaks urine and/or feces through her vagina. This birth complication is devastating to our women folks, particularly those living in the rural areas. Objectives: We aimed to look at the health-seeking behaviors of women who suffered from this condition with emphasis of identifying modifiable indices that could lead to reduction and/or eradication of the condition. Methodology: This was a descriptive, cross-sectional study where OF patient's health-seeking behavior was analyzed. All OF patients were recruited during the study period. Results: Fifty-two OF patients were interviewed during the study period. The mean age of the participants was 22.7 ± 7.6 years. Thirty-six participants (69.2%) had no formal education, and more than half of their husbands (57.7%) had no formal education. Majority (82.7%) of the participants were residing in the rural areas. More than half of the respondents (61.5%) had no source of income. Forty-seven (90.4%) attended antenatal care (ANC), and most of them (63.5%) had at least 4 ANC visits. Majority (76.9%) labored for more than 24 h and 35 (67.3%) had delay in reaching health facility. More than one-third (38.5%) were delivered through cesarean section. Forty-two respondents (80.8%) noticed urine leakage 2 days after delivery. Conclusion: Most of the findings here corroborated with the findings of earlier studies except for increased ANC attendance which might be due to increased awareness. The study clearly brought out the need to have deliveries conducted under skilled birth attendants to reduce/eradicate the menace of OF in our communities.
Keywords: Health seeking behavior, Nigeria, obstetric fistula patients
|How to cite this article:|
Garba I, Abubakar IS, Magashi MK, Rabiu A. Health-seeking behavior of obstetric fistula patients. N Niger J Clin Res 2020;9:69-73
| Introduction|| |
The World Health Organization (WHO) defines obstetric fistula (OF) as an “abnormal opening between a women's vagina and bladder and/or rectum through which her urine and/or feces continually leak.” OF is caused by obstetric trauma, whereas nonobstetric fistula (NOF) results from gynecological operations, female genital cutting, genital cancers, and other rare causes of genital fistula. Genital fistula is rare in advanced countries, mainly NOF where it arises as a complication of surgery or radiation therapy for cancer. In developing countries, prolonged labor is the main reported cause of OF. In Nigeria, vesico-vaginal fistula (VVF) sequel to obstructed labor account for as high as 96.5% of cases.
OF is an indicator of poor quality of obstetric care. It is physically and socially disabling obstetric complication that affects many women who are predominantly in developing countries. The WHO estimates that approximately two million girls and women live with fistula worldwide and each year 50,000–100,000 girls and women are affected; however, experts in the field report that the problem is likely to be seriously underestimated considering the fact that the figure is hospital based. In Uganda, an estimated 2.6% of women have experienced OF. A study conducted in Malawi revealed that the prevalence of OF was 1.6 per 1000 women. Three out of every 1000 deliveries in the West African countries develop VVF and about 200,000 women await surgical repair in Nigeria.
Labor becomes obstructed when a woman cannot deliver her baby through the birth canal because of a discrepancy between the size of the fetus and the space available in her pelvis. When labor is obstructed, the presenting part of the fetus (usually the fetal head) is wedged progressively deeper into the pelvis until its further advance is prevented. On the other hand, during uterine contractions, the head of the fetus relentlessly compresses the entrapped soft tissues of the bladder and vagina between the two opposed bony surfaces (the fetal head and the pubic symphysis), eventually shutting off their blood supply. The entrapped tissues die and slough away, creating a fistula between the bladder and the vagina (VVF) or between the rectum and the vagina (recto-vaginal fistula) through which urine or stool respectively leaks in a continuous and unremitting stream.
Most OF patients have common health-seeking behavior. During pregnancy, they do not attend antenatal care (ANC) or may only register for ANC and most of them deliver at home assisted by unskilled birth attendants. It was reported that only 10.9% of OF women from Nigeria attended ANC for the pregnancy which was complicated by the fistula. Although high proportion of women from Niger and Uganda reported they delivered in a health facility (84.2% and 91.3%, respectively); however, 79.1% labored at home for more than 12 h before seeking care due to mode and cost of transportation, distance to the health facility as well as sociocultural influences. There is therefore a compelling indication to study the obstetric health-seeking behavior of OF patients as well as their reasons for that, so as to factor it in educating community on the risk involves to prevent the occurrence of OF. This survey was aimed at identifying the health-seeking behaviors of women who suffered from this condition with emphasis on modifiable indices that could lead to reduction and/or eradication of the condition.
| Methodology|| |
It was a descriptive, cross-sectional survey that was conducted at Laure Madaki Fistula Center of Murtala Muhammad Specialist Hospital, Kano, Kano state, Nigeria. Laure Madaki Fistula Center is one of the fistula centers in Nigeria. Services at the center including surgical operations are free. Surgeries are carried out by the specialist at the center and visiting specialists that come from within and outside the state. The center receives assistance from some nongovernmental organizations. The study population consisted of all OF patients awaiting surgery or recovering from surgery. All OF patients awaiting or recovering from surgery and gave consent to participate in the survey were included.
Ethical clearance was obtained from Research and Ethics Committee of Aminu Kano Teaching Hospital. Participants had explicit explanation of the study, stating clearly that participation was voluntary. All information taken would only be used for the study and confidentially treated. Written informed consent was sought and obtained. Eligible study participants were recruited as they presented to the center until desired sample size was reached. Semistructured questionnaire was used for data collection. The questionnaire included information on bio-data, antenatal booking status, place and duration of labor, pregnancy outcome and circumstances surrounding labor, delivery and subsequent development of fistula. Data collected were entered into a personal computer and analyzed using the Statistical Package for the Social Sciences software version 25.0 for windows (IBM SPSS Inc., IL, Chicago, USA). Quantitative variables were summarized using mean and standard deviations, whereas qualitative variables were presented in percentages and proportions. The results were presented in tables, charts, and graphs. Test of associations was done for categorical data using χ2 test and P < 0.05 was considered significant.
| Results|| |
Fifty-two OF patients were interviewed during the study period (from February 1, 2019, to July 31, 2019). The mean age of the participants was 22.7 ± 7.6 years with age ranged between 13 and 50 years. The median age was 20 years. Close to half of the participants (40.4%) were within the age group of 13–19 years [Table 1]. Thirty-one (59.6%) of them were primiparae. Only a quarter of the respondents (25%) were of high parity (more than three). More than half (55.8%) had no living child [Table 1]. Thirty-six participants (69.2%) had no formal education, and more than half of their husbands (57.7%) also had no formal education [Figure 1]. Majority (82.7%) of the participants were residing in the rural areas [Figure 2]. More than half of the participants (61.5%) had no source of income. Trading was the major occupation of their husbands 39 (75.0%) [Figure 3]. Only 2 (3.8%) participants stayed at their parent's house while pregnant [Table 2].
Forty-seven (90.4%) attended ANC and most of them (63.5%) had at least 4 ANC visits [Figure 4]. However, 51 (98.1%) labored at home. Majority (76.9%) labored for more than 24 h and 35 (67.3%) had delay in reaching health facility [Table 2]. More than one-third (38.5%) were delivered through cesarean section. Majority of the babies delivered (82.7%) were stillborn. Forty-two respondents (80.8%) noticed urine leakage 2 days after the delivery [Table 2].
Even though only six participants (11.5%) were divorced, but more than half of them (55.8%) were not staying in their husband's houses at the time of the survey due to urine leakage [Table 2]. Only five participants or their husbands (9.6%) thought of the possibility of having complications with their pregnancy, and only 3 (5.8%) made monetary arrangements to carter for labor complications during pregnancy. Up to 90.38% attended ANC, but more than ¼ of them had less than four antenatal visits [Figure 4]. Up to 23.08% of the patients spent 12–24 h in labor, whereas 76.92% spent more than 24 h.
There was a statistically significant association between the place of residence and delay in reaching the health facility (χ2 = 5.709, P = 0.017). Similarly, there was a statistically significant association between the place of residence and complication readiness (χ2 = 7.045, P = 0.000). Place of residence was also associated with monetary arrangement for complications (χ2 = 15.211, P = 0.005). Furthermore, husband level of education was significantly associated with complication readiness (χ2 = 12.996, P = 0.005).
| Discussion|| |
The highest frequency of OF is in the <20 years age group which agrees with the previous findings of the study by Kabir etal. conducted more than a decade in the same center in which the highest frequency was recorded in the 10–15 years age. However, while previous study found that the condition was more common in early teenagers (<15 years), in this survey late teenagers are more affected (15–19 years) this further supports the argument that teenage pregnancy is not the cause of OF but unsupervised deliveries. However, it is reasonable enough to have it in mind that girls given out early in marriage would be at risk for obvious reasons if they became pregnant and do not come under the care of a skilled birth attendant during pregnancy, labor and delivery, especially if the need arises for emergency caesarean section.
Most of the respondents in this survey were primiparae (59.6%), this substantiates the findings by Hassan and Ekele in Sokoto which reported 57%. This may be due to similar cultural background between Sokoto and Kano specifically the culture of home delivery in first pregnancy where it is usually unsupervised. However, this finding does not corroborate with the Kaduna study by Lengmang and Degge who found majority (72,7%) were multiparous and the Abakaliki study by Sunday-Adeoye etal. This might be due to overconfidence of having had a successful vaginal delivery in the past, feels that all deliveries will occur without problem. They, therefore, do not present to labor ward for delivery or present very late in labor. This study has proved that OF occurs in both low and high parity women, and therefore, the long time held belief that early marriage is a cause of OF should be reviewed.
Majority (82.7%) of the participants are from the rural areas. This could be due to the paucity of knowledge of OF preventive measures in rural areas. This supports the finding of a cross-sectional study on OF prevention among young women in urban and rural Burkina Faso which demonstrated that women in urban areas were almost three times more likely to have preventive knowledge on OF compared to rural women. It could be due to the lack of awareness as well as nonavailability of emergency obstetrics care services in the rural areas compared to urban. Health facilities are more easily accessible in the urban areas, where there are good roads as well as transportation services compared to rural. Those in urban areas are more likely to anticipate complications during labor and make monetary arrangement in case it arises. These may likely be due to the level of awareness and economy of urban setting which is relatively better than rural.
Most of the patients (69.2%) had no formal education and none among the literate had tertiary level of education. This affirms the previous findings by Kabir etal. in Kano (78.3%) and Lengmang and Degge from Kaduna (69.6%) which is typical characteristics of fistula patients. More than half of the participants' husbands (57.7%) had no formal education too. This is also a social contributor toward the development of OF because educated husbands are unlikely to allow their wives to labor at home. This study had shown that educated husbands were more likely to think of possibility of having complications during pregnancy or labor.
Although most of the respondents were not staying in their husbands' houses due to their health status, but were not divorced. The divorce rate in this study was 11.5%. This corroborates with Abakaliki Study by Sunday-Adeoyeet al. who demonstrated divorce rate of 12.5%. It is much lower than the 27% earlier reported among fistula patients in Sokoto by Hassan and Ekele. This may be due to the increased availability of treatment centers with positive results. Now the fistula patient does not need to travel far away from her locality to get treated and as such does not stay for long with the disease, except where it is complicated.
Most of the respondents (61.5%) had no activity that occupies them to earn something for living. They completely relied on their husbands for survival. Those that are divorced could not engaged in any business or seek employment because of their condition. Wall etal. in a study conducted in Jos (North-Central Nigeria) showed that, overwhelming majority of these women were from poor rural backgrounds.
The proportion of 9.62% of fistula patients that did not book for ANC in this study was eight fold lower than 77.5% earlier reported one and a half decades ago in the same center by Kabir etal. Furthermore, lower than 57.7% reported earlier by Tukur et al. in three states of North-western Nigeria. This may be due to the increase in awareness on the importance of attending ANC during pregnancy.
All the respondents labored at home except one who labored in a health facility. None of the respondents labored for <12 h. Only 23.1% labored for 24 h before decision to go to a health facility was taken, which affirms the earlier findings of 21.1% by Wall et al. This is a typical history of patients with OF complicating prolong obstructed labor. This also shows the importance of emphasizing health facility delivery or delivery under the care of a skilled birth attendant after ANC as a pivot toward preventing OF.
In this study, more than one-third (38,5%) of the patients were delivered through caesarean section, which supports Wall et al. findings of 40.3% cesarean section rate. This finding goes to show that cesarean section will only prevent OF when perform early in obstructed labor and underscores the importance of early presentation to hospital in labor. Others had either spontaneous vaginal delivery or instrumental vaginal (vacuum or forceps) delivery. The stillbirth rate for the pregnancy in which fistula occurred was 82.7% which substantiates the earlier findings of 84.7% by Tukur et al., Slightly lower than the findings of 91.7% by Wall et al. and 87.8% by Ramphal et al.
| Conclusion|| |
In this survey, the major cause of the fistula was prolong obstructed labor. Most of the findings here corroborated with the findings of earlier studies except for increased ANC attendance which might be due to increased awareness on the need for pregnant women to attend ANC. The study also brought out the need to have deliveries conducted under skilled birth attendants to reduce/eradicate the menace of OF in our communities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]