Contributors for the obstetric fistula
The findings of this study revealed that the possible contributors for the obstetric fistula were multidimensional and included sociocultural, non-use of services during pregnancy and delivery, and the three delays.
Socio-cultural contributors
Early marriage and early childbirth were the main socio-cultural contributors of obstetric fistula in this study. Majority (19/24) were married below 18 years and 15/24 had their first child before 18 years of age. More than half (14/24) were teenagers (13–19) during the time of delivery when the fistula happened.
Non-use of services during pregnancy and childbirth:
Ten out of 24 never had antenatal care (ANC) visits at all, and 9 out of 24 had inadequate ANC (< 4 ANC visits) during their pregnancy for which the fistula had encountered. The main reason for not attending ANC at least once was the unavailability of a nearby health facility (6/10), followed by a lack of information on the importance of ANC (3/10). Similarly, 10 out of 24 gave their birth at home attended by family members of traditional unskilled attendants and the rest went to the health facility after facing a long duration of labor and facing problems. The major reasons were similar to that of ANC, lack of nearby health facility, lack of transportation, and lack of sufficient information about the complications of delivery and problems of home delivery, including the occurrence of fistula.
The three delays:
Delay in making a decision (first delay), not timely reaching the health facility (second delay), and not receiving care timely after reaching facility (third delay) are the known contributors of obstetric complications, including fistula. Likewise, in this study, about 14 out of the 24 made their decision on place of delivery and for the rest either husband (8/24) or the parents (2/24) made decisions. Even for those, who gave birth at a health facility, it was reported that they went after home delivery failed. The other problem was lack of transport; 8 of the 14 facility deliveries traveled on foot and the rest 2 were by traditional caring (‘Karezza’) by people, and for 9 of them it took more than 2 hours to reach the health facility as there is no nearby facility.
As a result, the majority of them (10 out of 14 facility deliveries) reached the health facility after 24 hours of the start of labor, and the rest 4 reached within 18–24 hours. Overall, 21 out of the 24 mothers had prolonged labor (≥ 24 hours). While 6 of the 14 facility deliveries received care and gave birth within one hour of arrival, 4 of the rest had given birth after 12 hours of arrival.
Consequences of obstetric fistula
Physical consequences
The qualitative in-depth interview findings revealed that women affected by obstetric fistula face various physical challenges. The most commonly mentioned were pain (18/24), body weakness (16/24), and numbness of legs (6/24). As a result of these problems, most of them responded that they were not able to carry out routine daily activities such as farming (14/24), difficulty to sit and defecate properly (12/24), and difficulty of washing and changing closes regularly, including putting on underwear (7/24).
A 35 years old mother, who was para 7 and have lived with the fistula for 4 years expressed her filling as,
…..after having the fistula, because of the high pain at the site of the injury and numbness of my left leg, I can’t stand and walk; I can’t take and eat my food; I can’t even take and drink water. I depend only on my family. Painful! Painful!...
Psycho-social Consequences
The majority of the respondents reported that they have been affected by a variety of psycho-social problems that range from not participating in social events to the level of suicidal ideation. Most of them responded that because of the foul-smelling fluid liking continually, they can’t go for recreation with their peers (19/24), no one won't be with them or near them (stigma and discrimination) (18/24), and can’t attend social events (14/24) such as coffee ceremonies, ‘Ikub,’ “Idir,’ visiting birthing mothers, visiting sick relatives, attending funeral programs (death of relatives), religious ceremonies and wedding ceremonies.
A 26 years old mother, who faced fistula during her first birth at the age of 18 and lived with fistula for 8 years, expressed her feeling by crying as,
“…because of the bad odor leaking, I can’t go with my peers for recreation as before, I can’t go market, even I can’t join my neighbors for coffee. This is what worries me day and night….” She cried.
She continued saying,
…while I am at home, most of the time I hate myself for making my families suffer from carrying for me; I wish dying. Thanks to this hospital now I have some hope.
The other commonly mentioned psychosocial problem was the husband’s rejection or divorce (11/24). As most of them explained, most community members, including husbands, do not know that fistula can happen to any woman and can be repaired. As a result, the husbands reject their wives and look for another healthy woman.
30 years old and par 5 mothers living with the fistula said,
…people like us when we are healthy and beautiful. Let alone other people, even husbands like us when we wash and look clean and beautiful. No one wants to be near to a woman with fistula; she smells…
Another 35 years old and par 6 mothers, living with the fistula for the last 1 year, expressed her filling by crying as,
“…my husband ignored me saying, ‘I have to look for a healthy and clean woman;’ a girl, my relative, living with me before also left me. I am alone now; I prefer to die rather than living with this foul-smelling leakage and hated by every people.” She cried.
A 36 years old mother, who faced fistula during her first birth at the age of 16, and lived with the fistula for the last 20 years added,
…my husband used to love me very much; he usually says, ‘I can’t live without you;’ I do the same. But, after I faced this problem, he ignored me saying, ‘you are not healthy and no more important to me;’ and he has married and now living with another healthy woman; but, I remained with my problem and he never asked me at least. I am left alone with nothing; I don’t even have a single hen. Thanks to my father that I am alive till today……
The other Psycho-social problems reported by about one-third (8/24) of the respondents were being ashamed of looking at other’s hands, considering themselves as dependents on their families, and making family suffer from their care. As a result of this, they suffer from worrying day and night, lack of sleep, stress, and headache. And about one in four (6/24) had a history of the feeling of hopelessness and suicide ideation.
Socio-economic Consequences
Women with fistula face either indirect or direct socio-economic problems. The leading socio-economic consequence mentioned by the majority (18/24) was the inability to carry out routine activities to support their family. This is followed by not able to engage in income-generating activities to earn money (e.g daily laborer, collecting coffee) (14/24) and difficulty to travel to market for trading, selling, or buying, to fulfill the demand of the family members (12/24).
About a third (8/24) reported that the direct cost of treatment and transportation is beyond what they can afford. The same number (8/24) reported that the foul-smelling fluid linkage needs frequent changing of closes, more than four times a day, and frequent washing by using soap of good odor. This incurs the big cost of buying closes and soap regularly, which most of them can’t able to do.
A 35 years old par 7 mothers, who lived for 4 years with the fistula said,
…individuals can get broken bones; but, this can heal and they can start working to earn money to support the family. But, fistula is non-curing and I can’t work to earn money. Simply looking for support from others …
Coping strategies for the challenges of obstetric fistula
About half (12/24) of the women affected with obstetric fistula used keeping themselves at home to make it secrete and hiding not to be seen by others as a coping stray. This is with the fear that their peers will laugh or tease them. A significant number (10/24) used to sit and simply cry and pray to God/Allah as coping strategies.
35 years old women, who were para 1 and have lived with obstetric fistula for 5 years reflected,
…I have already decided not to be seen by any person. I don’t want to be laughed at. So, I never go out of my home even for coffee. I have told to my children to say, ‘she is sleeping’ and send back whenever someone is coming to visit me…
25 years old women, who were para 4 and have lived with obstetric fistula for 1 year added,
…I can’t go market, I can’t go church, I can’t join my peers for social events; because, I don’t want my peers to laugh at me. Why this happened only to me? This is what God has done to me. So, I always keep myself hide and cry to God. Now, God helped me and I am a good hand of Doctors…
61 years old women, who were para 7 and have lived with obstetric fistula for 16 years supplemented,
…my husband ignored me. He took me and left with my family. But, still, I can’t live with them in the same room, but in a separate room, because of the bad-smelling. When I try to collect coffee, I do it separately; I can’t go with other people. I can’t visit sick relatives or when relatives die; if I go, I will remain in the kitchen in order not to be seen by people or not to smell to them.
About a third (8/24) has left their homes and moved to their families (father and mother). The same number reported that they use multiple closes (wearing 3–4 closes at once as a diaper) to prevent fluid linkage and changing very frequently. About a fourth (6/24) reported that they use perfumes or soaps with good odor.