Research Article

Why the Poor Care-Seeking Behavior for Vesico-Vaginal Fistula Repair/Rehabilitation Care Among Patients Attending Vvf Centers in Northwestern Nigeria? Healthcare Givers’ Perspectives

Uzoma K Ndugbu^1*, Chizoba Elsie Madukwe² and Chidimma Jane Ezennia¹

¹Department of Public Health, Federal university of Technology, Owerri, Nigeria

²Department of Post Basics, Pediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria

Corresponding author: Uzoma K Ndugbu, Department of Public Health, Federal University of Technology, Owerri, Nigeria. Tel: +2348032654963, E-mail: kizykn@gmail.com

Citation: Ndugbu UK, Madukwe CE, Ezennia CJ (2019) Why the Poor Care-Seeking Behavior for Vesico-Vaginal Fistula Repair/Rehabilitation Care Among Patients Attending VVF Centers in Northwestern Nigeria? Healthcare Givers’ Perspectives. J Midwifery Women’s Health Nurs Pract 2019: 43-50.

Received Date: 19 August, 2019; Accepted Date: 23 August, 2019; Published Date: 29 August, 2019

Abstract

Background: Vesico-vaginal fistula has continued to be a public health problem threatening maternal healthcare, as almost 200,000 Nigerian women suffer from this abnormal tear between the bladder and the vagina. Given its accompanying complications, repair and rehabilitation from such condition is most needed and encouraged.

Aim: The study was aimed at assessing the perspectives of health care providers on factors contributing to poor care-seeking for fistula repair/ rehabilitation services.

Methods: A descriptive cross-sectional design was used. Respondents were selected through convenient sampling. Forty-five (45) health care providers were selected to participate in the study. A structured interview schedule was used to collect data. Statistical analysis was performed with the SPSS, with data was expressed as descriptive summary measures.

Results: A total of 45 respondents were interviewed. We found the factors enhancing poor seeking care behavior to include: lack of permission from husband/family, no knowledge that repair services exist, psychological depression, societal stigmatization, transportation challenges, money for the treatment, myths and misconception on obstetric fistula and poor health systems.

Conclusion: As a public health problem with a ‘near miss maternal death’ nature, there is need for a more broad and participatory integrated intervention that not only would take on a physical approach (surgery/or reconstructive surgery) and social integration towards offering repair and rehabilitative care.

Keywords: Healthcare Givers; Obstetric Fistula; Vesico-Vaginal Fistula; Fistula Repair; Fistula Rehabilitation; Nigeria

Introduction

A fistula is an abnormal relation that begins to exist between two epithelial cavities. It is a childbirth complication; hence, it is called obstetric fistula. It can either be by way of hole developing between the vagina and the rectum (recto-vaginal fistula) or between the vagina and the bladder (vesico-vaginal fistula) [1]. In both cases, there are attendant medical and societal complications. Most cases of obstetric fistula occur from pressure necrosis from prolonged obstructed labor [2,3], others could be as a result of gynecological cases like abdominal or vaginal hysterectomy, anterior colporrhaphy, ruptured uterus, Gishiri cut and complicated caesarean section, insertion of corrosive substances into the vagina, straddle injury [1,4]. A high number of women are living with obstetric fistula, particularly vesico-vaginal fistula, with an incidence estimated at 2.11 per 1000 births; a preventable disease prevalent among the less privileged and marginalized of the population, predominantly in sub-Saharan Africa and South Asia [5]. The truth is that, the true incidence and prevalence of vesico-vaginal fistula in the communities are not easy to be known. Yet, between 100,000 to 1,000,000 of Nigerian women are living with vesico-vaginal fistula, especially in the northern part of Nigeria though existent in the southern part [3,6]. However, an obstetric fistula is treatable by surgery, and there have been a number of such surgeries in designated repair and rehabilitation centers, especially in the northern part of Nigeria [7,8]. Even though, some of the specialist centers undertaking the fistula repairs and rehabilitation are lacking in manpower [9,10] there has been a noticeable poor care seeking behavior among those with vesico-vaginal fistula owing to ignorance, cultural beliefs and practices, financial constraints, transportation, societal stigmatization, psychological depression, and misinformation [11-15]. Surely, the burden of vesico-vaginal fistula on affected women, who given to factors captured by several studies, who are seeking repair care, delay to seek such care and may not seek such care is such that; they are exposed to morbidities like valval dermatitis, valval amenorrhea, dyspareunia, misuse atrophy, genitourinary diseases, contractures, renal failure, psychological depression and high divorce consequences [4,5,9,16-21]. Often times, the healthcare providers point of view as the regards the knowledge, attitude and practice (KAP) dispositions are rarely brought to limelight in evaluating care impacts; and this is wrong. This study therefore looked at how the healthcare providers understand the factors leading to poor care-seeking behaviors to repair and rehabilitation services for women with vesico-vaginal fistula.

Materials and Methods

This was a quantitative descriptive cross-sectional study. The study population were healthcare givers at Aminu Kano Teaching hospital, Kano and intervention facilitators/care givers working in the fistula repair and rehabilitation centers in Kano, Katsina, Sokoto and Kaduna (Laure fistula center, Bubbara ruga fistula center, Maryam Abacha Women & children hospital, and Gambo Sawaba General Hospital). A total of 45 respondents participated in the study over a period of one year from June 2018 and June 2019. Data were collected using a structured questionnaire. Data collection instrument was pre-tested in Lusaka province. The interview took 30-45 minutes. The proposal was approved by the Research Ethics Committee of the Federal University of Technology, Owerri, Nigeria. Privacy, anonymity and confidentiality were maintained and participation in the study was purely voluntary. Collected data were securely kept in a locked cupboard and only accessible to the researcher.

Data was entered in a computer and analyzed using SPSS version 20 computer statistical package. The demographic variables were summarized using descriptive summary measures and inferential statistics: expressed as mean (standard deviation) for continuous variables and percentages/proportions for categorical variables.

Results

Majority of the respondents were aged 31 to 40 years (42.2%) while those aged above 50 years were 3 (6.7%). Majority of the respondents were females (66.6%) while males were (33.3%). Majority of the respondents (26.7%) were VVF coordinators while (11.1%) representing the medical doctors was the least respondents, after registered nurses (24.4%), registered midwives (22.2%) and theatre nurse (20%) respectively. A greater number of the respondents (64.4%) had their work area in surgical wards and an appreciable number (35.6%) at the Obstetrics and gynecological ward. About their years of experience with vesico-vaginal fistula, quite a reasonable number (46.7%) of the respondents have been attending to patients for between five to eight years. Majority of the respondents (51.1%) were married while (44.4% & 4.4%) were single or divorced respectively (Table 1,2).

Variable	Frequency	Percentage
Age
20-30 years	18	40%
31-40 years	19	42.20%
41-50years	5	11.10%
Above 50 years	3	6.7
TOTAL	45	100%
Sex
Females	30	66.60%
Males	15	33.30%
TOTAL	45	100%
Occupation
Medical Doctor	5	11.10%
VVF coordinator	12	26.70%
Registered Midwife	10	22.20%
Registered Nurse	11	24.40%
Theatre Nurse	9	20%
TOTAL	45	100%
Work Area
Surgical Ward	29	64.40%
Obstet. & Gynecological Ward	16	35.60%
TOTAL	45	100%
Years of work experience
0 - 4years	18	40%
5-8 years	21	46.70%
>8 years	6	13.30%
TOTAL	45	100%
Marital Status
Single	20	44.40%
Married	23	51.10%
Divorced	2	4.40%
TOTAL	45	100%

Table 1: Demographic Data (n=45)

Variable	Percentage
Lack of knowledge that repair/ rehabilitation services exist
Establishment of more fistula centers in local communities in order to bring awareness and improve access to afflicted women on the condition and where to seek care services	75%
Involvement of men and ‘gatekeepers’ (influential people in the society like chiefs, community leaders, community-based volunteers, religious leaders, journalists, human rights’ activists, local government officials and NGOs) to aid in creating the awareness of the availability and possibility of fistula repair and rehabilitation	62%
Possibly have side by side ANC clinics, fistula centers so as to educate all pregnant women who visit the Antenatal clinics on obstetric fistula and fistula care services	28.20%
Psychological complications
Target families of afflicted women and give them information on obstetric fistula and advocacy visits to communities to talk on the condition’s amenability to cure	69%
Families to be taking those afflicted women for fistula repair/rehabilitation exercises	51.10%
Loss of dignity
Scale-up interaction and psycho-social support for afflicted women and their relatives by providing follow-up social and physical reintegration	92%
Inaccessible transport system
Transport fare reimbursement for those who seek fistula care services using their own resources	70%
Government to ensure accessible road networks	81%
Keeping fistula repair and rehabilitation center at the local communities	40%
Financial constraints
Government to eradicate poverty, and provide free fistula repair and rehabilitation services	100%
Educate men not to abandon their wives after sustaining a fistula so as to support their wives financially. Women economic socio-empowerment.	100%
Cultural barriers and misconception
Sensitize the communities that fistula is not a curse. It is a most dehumanizing condition that afflicts women as a result of prolonged labor, but it is CURABLE.	100%
Engaging cultural leaders towards discouraging early marriages and Gusshiri cut, gender inequality and demeaning patriarchy.	98%
Poor health systems
Train surgeons on how to repair afflicted women since successful surgical repair do depend, amidst others, on surgeon’s skill, surgical technique and post-operative management	90.20%
Adequate staffing of humane and approachable personnel, and equipment like partographs, drugs, electricity to ensure basic, comprehensive, prompt and sufficient care.	90%

Table 2: Health care provider views (n=45)

Discussion

In the interview, participants were asked to deliberate on factors leading to poor care-seeking attitude to vesico-vaginal fistula repair and rehabilitation services and provide their views. Regarding lack of knowledge that repair and rehabilitation services exist, it has been pointed out how lack of awareness of the availability of obstetric fistula repair and rehabilitation care are frequently mentioned barrier to seeking care by those affected [8]. Such that, most of the women affected are unaware of the warning signs of difficult labor, need for care; and most when they know would still wait on their husband’s permission to access such care [8,18]. Hence, a greater number of the respondents (75%) are of the view that more obstetric fistula centers are to be established in local community’s order to create awareness and improve access to repair and rehabilitation care for women affected by the condition. This will equally assist fistula patients to have access to skilled birth attendance and care [5]. We had more than half of the respondents (62%) believing that involving men and ‘gate-keepers’, that is, influential people in the community can greatly aid in creating the needed knowledge, attitude and care- seeking practice for fistula repair and rehabilitation for concerned persons. Surely, it has been stated elsewhere [4,5] how community participation can influence public health education and choice of positive behaviour. However, a lower percentage of the participants (28.2%) expressed that possibly having obstetric fistula clinics side by side antenatal clinics could aid in educating pregnant mothers on fistula repair and rehabilitation care. The healthcare givers who expressed this view did so with some reservations, considering that ANC is noticeably underutilized [22]. About the psychological complications barrier to seeking fistula repair and rehabilitation care, the participated made submissions. For more than half of them (69%), the advocacy visits and seminars need to get to and involve households or relatives of women with fistula condition to let them know of the condition’s amenability to cure. It has been highlighted that most of the patients of vesico-vaginal fistula suffer greatly from unnecessary and avoidable psychological complications; most painfully from husbands, families and friends [5,3]. Taking the cultural context into consideration, an appreciable number (51.1%) of the participants expressed the need for a close ‘male’ involvement in the repair and rehabilitation exercises of women with fistula. This they maintained would boost the afflicted woman’s self-esteem, sense of belongingness, and dissipate the dehumanizing sense of been rejected by all [3,23].

Also, there is an often-cited factor of a loss of dignity, either as human beings or as women. Indeed, the tragic event outcome of vesico-vaginal fistula - obstructed labor complex in Nigeria is adverse fetal outcome, that is, high stillbirth, high birth asphyxia, neonatal sepsis and neonatal mortality [3,8,18]. Thus, a greater number of the participants (92%) are in agreement that there scaled-up interactions and psycho-social support for the women affected and their families. This will go a long way to providing social and physical reintegration. Part of this support could be reconstruction of neo-vagina for the inoperable patients to enable them remarry or special entrepreneurial trainings to assist the after the treatment. Most studies on obstetric fistula have harped on the impact of misconceptions and cultural attitudes on care-seeking for fistula patients, especially in Nigeria [1-5,18]. About this, the participants (100%) maintained that there is need to sensitize the communities about the fact that fistula is a ‘curse’ from God. It is a most dehumanizing condition that afflicts women as a result of prolonged labor, and it is curable. Such sensitization should begin from households to public places, palaces of traditional rulers, schools, mosques, churches, markets and during weddings [5,3]. One of the participants maintained that, a law be enacted against stigmatization of afflicted women based on misconceptions; to relieve them of feelings of unwantedness. After all, culture and society are responsible in the way women emerged vesico-vaginal patients. Again, an appreciable number (98%) expressed the view that engaging cultural custodians, community heads towards discouraging early marriages, Gushiri cuts, gender inequality, and demeaning patriarchy. It has been observed that seeking husband’s permission constitutes one of the delay reasons for seeking fistula care for afflicted women [5].

Transportation challenges play an important role in women with fistula in not seeking fistula repair services [23,24]. In the views expressed by the participants, quite a number (70%) spoke for the introduction of transport fare reimbursement initiative as part of government provision of support for maternal health; for patients who seek care. This, no doubt, will have some impact in mobilizing affected women to seek care, as it is often the case that lack of accessible roads, or delay in transporting patients to facilities has worsened conditions or discouraged seek for care [3,18]. Also, (81%) of the respondents harped on the need for government to create and ensure accessible road networks to health facilities to not only encourage access and utilization, but also to manage emergencies. (40%) of the respondents suggested establishing fistula repair and rehabilitation centers in the communities. This they argued takes care of the limiting accessibility problem. And truly, it has stated elsewhere that having the fistula centers in the rural areas can greatly enhance access and patronization; and so discourage care seekers who would otherwise consult traditionalists for reasons of proximity and road advantage [3,6,9]. Expectedly, financial constraint is a huge factor delaying or discouraging seeking care for fistula repair and rehabilitation. If, for no reason but the fact that those so affected as abandoned by family and friends [2,4,9,25]. Not surprising then, (100%) of the participants in the current study talked about Government providing free fistula repair and rehabilitation care services. It is worthy of mention that with government and international donor’s support, there have been free fistula repair and rehabilitation services been given free of charge in Nigeria [5,7-9]. However, more needs to be done in terms of eradicating poverty and women economic empowerment. Also, all the respondents (100%) are agreed that abandoning the affected women in their condition can, and do take a toll on their economic disposition to seek care; and so, submit that partners, husbands or families of affected women be encouraged not to abandon them. Studies have shown how difficult it is for such abandoned women can access fund or bargain money for their up keep [5,3,26].

Furthermore, poor health system has been identified as encouraging delay in seeking fistula repair and rehabilitation care [9,23-27]. About this, majority of the participants (90.2%) believed that training surgeons is very important to scale-up the health system delivery. This finds agreement with stated concerns of how successful VVF surgery is dependent, amidst other things, on surgeon’s skill, technique and post-operative management [3,5,18]. In fact, as a result of poor health systems, many designated fistula care health facilities have very few specialists to attend to many patients [9]. This of course, could discourage attendance, and hence encourage patronage of unskilled personnel [5,8,18]. Yet, a successful repair, and subsequent rehabilitation restores patient’s dignity, self-esteem, and improves the quality of life [24,25]. Equally, a majority of the respondents (90%) agreed that adequate staffing of approachable and humane personnel’s and equipment can greatly encourage care seeking for fistula repair and rehabilitation. Indeed, this understanding may have been influenced by reports that most fistula patients attribute delay to accessing prompt care at health facilities as resulting from unfriendly attitude of healthcare providers [5]. Truth is, in many health facilities, drugs are out of stock, equipment are obsolete, patients are given list of drugs and materials for caesarean section to procure outside the health facility and incessant power outage that delays sterilization of instruments and surgery; which may delay time of relieving obstruction and worsening complications [4,5,28].

Conclusion

This study has shown that involving ‘gatekeepers’ as a way of community participation, educating women and families on fistula causes and amenability to cure, encouraging families involvement in care-seeking for fistula services; scaling up of psycho-social support; adopting transport fare refund strategy; training of more personnel and equipping health facilities; establishing fistula care clinics in rural communities; eradicating poverty; provision of free fistula care and rehabilitation services and women empowerment are sure ways to go towards addressing the poor care-seeking behaviour among VVF patients, especially those of Northwestern Nigeria.

Implications of The Study

This study on the healthcare givers’ perspectives on why there is poor care-seeking behaviour among VVF women despite being limited in scope as it is healthcare givers based has implications. First, to the best of the authors’ knowledge there is no healthcare givers’ perspective study on why VVF patients’ delay in accessing care services. Second, the study shows how the input of this often not included sector of healthcare delivery impact evaluation; can be most beneficial. Third, this study goes to indicate the transforming power of a healthy choice that must begin with the individual, and then the community. Finally, we believe that encouraging prompt and sustained seeking of care for repair and rehabilitation; must begin by reducing the occurrence of VVF. This can be done by preventing obstructed labor.

Reference

NORCAL Publications