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Journal club

This is one of the stories from the September 2012 issue of International News. Kathryn Siddle selected two papers published during 2011 that give interesting insights into the experiences of women suffering obstetric fistulae, and  reviewed them while undertaking a final year elective spent at a fistula unit in Tanzania.

Use the table below to access other stories in this issue.

Editorial In their own words: 12 stories of obstetric fistulae
The problem of obstetric fistulae: a personal view Provision of fistula services and programmes
Update on the FIGO/RCOG and partners competency-based fistula manual The problem of continuing urinary incontinence after obstetric vaginal surgery
Creating a balanced narrative about women living with fistulae Moving beyond incontinence
Vesicovaginal fistulae in Nepal Vesicovaginal fistula repairs at Aberdeen Women’s Centre in Sierra Leone
Vesicovaginal fistulae in Bangladesh Vesigovaginal fistula repair in Tanzania
transportMypatient: overcoming the barrier of transport costs Obstetric fistula surgery in Uganda

 

“I am nothing”: experiences of loss among women suffering from severe birth injuries in Tanzania

Lilian T Mselle, Karen Marie Moland, Bjørg Evjen-Olsen, Abu Mvungi and Thecla W Kohi
BMC Women’s Health 2011;11:49.

In Tanzania, there are 2000–3000 new cases of obstetric fistulae each year with only approximately 1000 repairs taking place, leaving many women living with this condition. This research was designed to look at the physical, cultural/social and emotional/psychological effects of living with obstetric fistulae, and how it affects women’s identity and their role in rural Tanzania.

This cross-sectional study contained both qualitative and quantitative components and was conducted between October 2008 and February 2010 over three sites: Comprehensive Community Based Rehabilitation in Tanzania disability hospital in Dar es Salaam, Bugando Medical Centre in Mwanza and Mpwapwa district in the Dodoma region.

The qualitative study consisted of semi-structured interviews with 16 women, two focus group discussions with six women in each, and one focus group discussion of six husbands. The quantitative element comprised a closed-ended questionnaire completed by 151 women, which was analysed using SPSS.

In the analysis of the lived experiences from women affected by obstetric fistulae, four themes emerged: loss of body control, loss of social role as a woman, loss of integration in social life and loss of dignity and self-worth.

One woman described the loss of body control because of smell, wounds, pain and discomfort : ‘when you wake up all clothes are wet: when you work it flows on its own’. This often led to the use of plastic shopping bags to prevent the urine dribbling down their legs, but which also caused painful skin wounds.

A ‘shattered sex life’ and inability to attend to daily commitments contributed to the loss of the social role as a woman and wife. One woman said ‘since I got this problem, we have not slept together … and this is the most painful thing’ and a husband portrayed the sex as ‘distasteful and unpleasant all the way through’, with some husbands describing their relationship as like brother and sister, not husband and wife.

The loss of integration in social life frequently disrupted marriages and led to rejection by their husbands and other family members. One woman explained ‘because I am leaking urine, I am useless, I have no value … my husband left me because I am leaking urine and I would not bear a child for him’. Frequently, fistulae led to infidelity by the husband, or a divorce/separation. Husbands felt pressure from the community to divorce their wives as ‘the community will isolate the whole family’. Even within families, women distanced themselves, ‘at times even sitting with her children is difficult. She has turned into one who hides and runs away from others, sits alone.’ Some women were not allowed to cook for the family as ‘they see it as dirt’.

The loss of dignity and self-worth women experience results from increased dependence on others, especially regarding economic activities. The feelings of uselessness and self-contempt were powerfully expressed: ‘I am nothing, I feel like a child’.

The research concludes that obstetric fistulae represent a major physical, emotional and social problem for the women affected and suggests improved access to social and economic development and education for girls and women, with better access to quality obstetric care. It also recommends education of society regarding fistula occurrence and management, as well as family counselling to help these affected women receive the support they need.

Waiting for attention and care: birthing accounts of women in rural Tanzania who developed obstetric fistula as an outcome of labour

Lilian T Mselle, Thecla W Kohi, Abu Mvungi, Bjørg Evjen-Olsen and Karen Marie Moland
BMC Pregnancy and Childbirth 2011;11:75.

This mixed method study of birth experiences by women who subsequently developed fistulae was designed to identify barriers to accessing adequate care during labour and delivery and was conducted between October 2008 and February 2010. To the authors’ knowledge at the time of writing, such a study has never before been carried out in Tanzania.

This is mainly a qualitative study, based on 16 interviews with women suffering from obstetric fistulae at the Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) disability hospital in Dar es Salaam, but with a quantitative component taking the form of 151 questionnaires completed by patients with fistulae from both CCBRT and Bugando Medical Centre in Mwanza.

Broadly, the authors describe four categories of delay in obstructed labour: deciding where to give birth, struggling to reach a health facility, waiting at the health facility and receiving unskilled care.

When deciding where to give birth, almost all women had wanted to give birth in a health facility, but for only 7% was the eventual decision left to them. The husband or mother-in-law had the final say in around 60% of cases, and mostly chose home births, for reasons such as convenience, custom and cost. Lack of decision-making power, distance to a health facility and income poverty led many women to labour at home. The family commonly called upon traditional birth attendants (TBAs), with one woman reporting ‘in our village, there is a TBA, she is the one who harmed us’. With the decision-making power often lying with the husband, women had to wait after the onset of labour for him to return (frequently from farming) to decide how to proceed.

It took two or more days to reach the final place of delivery for 51% of the women, with the authors suggesting lack of trust in the healthcare system or birthing culture as the reason for this. Public transport was the means of transport for 43% of the women and 20% walked or were carried. One woman with no transport described: ‘I had very strong labour pains and after about two hours walk, I felt like something had ruptured in the womb. I started bleeding and we had to stop and rest before I could continue walking.’

The women interviewed perceived that the substandard care in the health facilities arose from negligence by healthcare providers. Many lacked support during the birth process; often being left to push alone. One woman had her mouth covered by one nurse, while others applied fundal pressure to her abdomen.

The authors describe poor monitoring and referral routines following consistent reports that the women were left for many hours or even days before the decision to refer them to a higher-level facility was made. One woman pushed for 48 hours at a dispensary before a doctor attended and delivered the head, and then, unable to deliver the body, transferred her to a hospital.

Overall, the delays resulted in 85% of the births being stillbirths. The authors conclude that delays in receiving adequate care after arrival at health facilities were the most central finding in the women’s accounts. Until this is improved, lack of trust in professional care will continue to cause delays prior to arrival in the health facility. The authors recommend governmental strengthening of existing health services, making them ‘available, accessible, acceptable and of adequate quality’ for rural Tanzanian women.

Kathryn Siddle, Final year elective student, School of Medicine, Cardiff University