Complicating causality: patient and professional perspectives on obstetric fistula in Nigeria

Abstract

Obstetric fistula, a preventable maternal morbidity characterised by chronic bladder and/or bowel incontinence, is widespread in Nigeria. This qualitative, multi-site study examined the competing narratives on obstetric fistula causality in Nigeria. Research methods were participant observation and in-depth interviews with 86 fistula patients and 43 healthcare professionals. The study found that both patient and professional narratives identified limited access to medical facilities as a major factor leading to obstetric fistula. Patients and professionals beliefs regarding the access problem, however, differed significantly. The majority of fistula patients reported either delivering or attempting to deliver in medical facilities and most patients attributed fistula to a lack of trained medical staff and mismanagement at medical facilities. Conversely, a majority of health professionals believed that women developed obstetric fistula because they chose to deliver at home due to women’s traditional beliefs about womanhood and childbirth. Both groups described financial constraints and inadequate transport to medical facilities during complicated labour as related to obstetric fistula onset. Programmatic insights derived from these findings should inform fistula prevention interventions both with healthcare professionals and with Nigerian women.

Résumé

La fistule obstétricale, une morbidité maternelle évitable se caractérisant par l’incontinence chronique urinaire et/ou intestinale, est répandue au Nigéria. Cette étude qualitative multi-sites a examiné les fils narratifs concurrents sur la causalité de la fistule obstétricale au Nigéria. Les méthodes employées pour les recherches étaient : observation des participants et entretiens approfondis avec 86 patientes présentant une fistule et 43 professionnels médicaux. L’étude a conclu que les fils narratifs tant des patients que des professionnels identifiaient l’accès limité aux établissements médicaux comme un facteur d’envergure aboutissant à la fistule obstétricale. En revanche, les croyances des patientes et des professionnels concernant le problème d’accès différaient considérablement. La plupart des patientes présentant une fistule ont dit avoir accouché ou avoir tenté d’accoucher dans des établissements médicaux, et la plupart des patientes attribuaient la fistule au manque de personnel médical formé et à la mauvaise gestion de ces établissements. En revanche, la plupart des professionnels de la santé estimaient que les femmes développaient une fistule obstétricale parce qu’elles choisissaient d’accoucher chez elles en raison de leurs croyances traditionnelles concernant la féminité et l’accouchement. Les deux groupes ont décrit les contraintes financières et le transport inadéquat jusqu’aux installations médicales durant les cas de travail compliqué comme des éléments liés à l’apparition de la fistule obstétricale. Les aperçus pour les programmes découlant de ces conclusions devraient éclairer les interventions de prévention de la fistule, tant avec des professionnels de la santé qu’avec les femmes nigérianes.

Resumen

La fístula obstétrica, una morbilidad materna evitable que se caracteriza por incontinencia urinaria o intestinal crónica, está muy extendida en Nigeria. En este estudio cualitativo multicéntrico se analizaron relatos divergentes sobre la causalidad de la fístula obstétrica en Nigeria. Los métodos que se utilizaron para este estudio fueron la observación de los participantes y entrevistas exhaustivas con 86 pacientes afectadas con fístula obstétrica y 43 profesionales sanitarios. En el estudio se observó que en los relatos de los participantes, tanto las pacientes como los profesionales sanitarios coincidían en que una de las causas principales de fístula obstétrica era el acceso limitado a las centros médicos. Sin embargo, las pacientes y los profesionales tenían opiniones muy diferentes en cuanto al motivo de no poder acceder a los centros sanitarios. La mayoría de las pacientes con fístula obstétrica indicaron que habían tenido el parto o lo habían intentado tener en centros médicos y atribuían su enfermedad a la falta de personal médico cualificado y la gestión inadecuada de los centros sanitarios. Por el contrario, la mayoría de los profesionales de la salud creían que las mujeres desarrollaban una fístula obstétrica porque preferían tener el parto en casa siguiendo prácticas tradicionales sobre la maternidad y el parto. Ambos grupos destacaron que una de las causas de la fístula obstétrica eran las limitaciones económicas y el transporte inadecuado para llegar a los centros sanitarios durante partos complicados. Estos resultados y su significado programático deberían tenerse en cuenta a la hora de elaborar futuros programas dirigidos a profesionales sanitarios y mujeres nigerianas para evitar los casos de fístula obstétrica.

Keywords:

• Nigeria
• obstetric fistula
• patient perspectives
• professional perspectives

Acknowledgements

The trust and time given to us by both the women living with obstetric fistula and the hard-working healthcare professionals who were asked deeply personal and sometimes problematic questions cannot be overstated. Research assistance was Universities of Uyo and Calabar in Nigeria. We express our gratitude for the hospitality and guidance provided by university colleagues and administration.

Funding

This work was supported by the Fulbright Commission [award-id 34134264].

Notes

1. The remaining two Zones, South-West and North-East, were not visited due to time and security constraints.

2. While 95 patients were interviewed, nine of their recordings were impossible to understand due to disturbances during the interview, and were not included in the final analysis.

3. This finding differs from the ‘fistula victim’ typically presented in most African obstetric fistula surgical literature. Several recent obstetric fistula studies in Africa, however, challenge this common causal narrative of obstetric fistula (Hannig n.d.; Heller 2013; Landry et al. 2013). This study’s finding may also reflect the ethnographic methods used for this study, participant observation and in-depth interviewing, which purposefully call attention to what is different, rather than what is a common in global health research (Adams, Burke, and Whitmarsh 2014.).

4. The gishiri or ‘salt’ (in Hausa) cut refers to the removal of an area in or around a woman’s vagina during obstructed labour. Some Hausa reportedly believe that gishiri results ‘from an imbalance in body chemistry’ that causes a growth to develop across the vagina (Wall 2012, 264). This growth prevents the baby from being born. Typical treatment involves using a sharp implement to remove the gishiri, which can injure the bladder or urethra and potentially create a fistula (Tukur, Jido, and Uzoho 2006; Wall 2012).