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Obstetric fistula in southern Mozambique: a qualitative study on women’s experiences and perspectives
Centro de Investigação em Saúde de Manhiça (CISM).
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health).ORCID iD: 0000-0002-2475-2560
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health).
Department of Public Health Sciences, Karolinska Institutet.
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Obstetric fistula is still common in low- and middle-income countries (LMIC) despite the on-going shift to increased facility deliveries in the same settings.  The social behavioural circumstances in which fistula, as well as its consequences, still occur are poorly documented, particularly from the perspective of the experiences of women with obstetric fistula. This study sought to describe women’s experiences of antenatal, partum and post-partum care in southern Mozambique, and to pinpoint those experiences that are unique to women with fistula in order to understand the care-seeking and care provision circumstances which could have been modified to avoid or mitigate the onset or consequences of fistula. 

Methods: This study took place in Maputo and Gaza provinces, southern Mozambique, in 2016-2017.  Qualitative data were collected through in-depth interviews conducted with 14 women with positive diagnoses of fistula and an equal number of women without fistula. All interviews were audio-recorded and transcribed verbatim prior to thematic analysis using NVivo11.

Results: Study participants had all attended antenatal care (ANC) visits and had prepared for a birth facility. Prolonged or obstructed labour, untimely multiple referrals, and delays in receiving secondary and tertiary health care were common among the discourses of women with fistula. The term “fistula” was rarely known among participants, but the condition (referred to as “loss of water” or “illness of spillage”) was recognised after being prompted on its signs and symptoms. Women with fistula were invariably aware of the links between fistula and poor birth assistance, in contrast with those without fistula, who blamed the condition on women’s physiological and behavioural characteristics.

Conclusion: Although women sought antenatal and childbirth care in health facilities, delays and deficiencies in the provision of the most appropriate care possible, such as referral and caesarean section, were evident in their discourses. While women with fistula were minimally aware of the causes of their condition, those without fistula cited discriminatory attributions, reflecting the outsider’s perspectives of fistula. There is a need to increase awareness and reinforce preventive obstetric measures, early detection and prompt management of obstetric fistula.

Keywords [en]
obstetric fistula, women’s experiences, quality of care, Mozambique.
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-380579OAI: oai:DiVA.org:uu-380579DiVA, id: diva2:1300581
Available from: 2019-03-29 Created: 2019-03-29 Last updated: 2019-03-29
In thesis
1. ‘How good is good?’: Studies of facility-based childbirth care in southern Mozambique, from the perspectives of women and health providers
Open this publication in new window or tab >>‘How good is good?’: Studies of facility-based childbirth care in southern Mozambique, from the perspectives of women and health providers
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Despite the large shift toward facility-based childbirths occurred during the last 15 years in several low resource settings, including in Mozambique, the burden of maternal mortality and morbidity remain considerable. Obstetric fistula is one of the most devastating of all maternal morbidities which still prevalent and is entirely avoidable.

The aim of this thesis was to evaluate and explore the provision of childbirth care, focusing on obstetric fistula as one of its complications, in a rural Mozambican setting of high facility delivery rate.

The four studies constituting this thesis were implemented in Maputo and Gaza provinces, southern Mozambique, between April 2016 and March 2017. We included 4385 women having given birth up to 12 months the study identified from a cohort of women of reproductive age (12-49 years). We identified women with constant urine leakage, assess them clinically, confirm the diagnosis and estimate the incidence of obstetric fistula. In-depth interviews with selected women with and without fistula (n=28), were used to describe the women’s experiences of maternal care and pinpoint those experiences that are unique to women with fistula. During the same cross-sectional survey (n=4385) we also assessed the women’s experiences of care and satisfaction with care during childbirth. We complemented the women’s survey with a survey among 175 health workers of the study area to assess their perception of their work context.

The incidence of fistulae was 1.1 per recently pregnant women (95% CI 0.14-2.16). Delays in receiving definite care at referral hospitals despite having reached the primary health facility in time, were reported by the women who had fistulae. Women without fistula, blamed the fistula condition on women’s physiological and behavioural characteristics. Most (92.5%) of the 4358 women interviewed reported to be satisfied with care during childbirth and would recommend a family member to deliver in the same facility. Women who gave birth in primary level facilities tended to be more satisfied than those gave birth in hospitals, and presence of a companion had a positive influence on the satisfaction, irrespective of age, education and socio-economic background. Health workers rated highly the items on all dimensions of context when asked to evaluate their work context using the Context Assessment for Community Health (COACH) tool, although still above the scale midpoint, the organizational resources dimension had the lowest score.

This thesis demonstrates a high incidence of obstetric fistula despite a high coverage of facility-based childbirths in a rural context where services are generally perceived as adequate by childbearing women and health providers. To reduce maternal morbidity by fistula, major interventions are needed to improve the quality of childbirth care, including complication recognition and decision-making for referral, health facility preparedness as well as to improve the health providers’ work environment.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. p. 84
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1561
Keywords
Facility-based childbirth, Obstetric fistula, Satisfaction with care, Health providers, Context assessment, Mozambique
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-380580 (URN)978-91-513-0619-3 (ISBN)
Public defence
2019-05-20, Rudbecksalen, Rudbeck entréplan C11, Dag Hammarskjölds väg 20, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2019-04-26 Created: 2019-03-29 Last updated: 2019-06-18

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