By Elly Arnoff, Program Associate – Evaluation & Research, EngenderHealth
Women with fistula are often among the most impoverished and marginalized members of society. Obstetric fistula is a rupture between the vagina and bladder and/or rectum that occurs when a woman has a prolonged labor or obstructed delivery, and does not access emergency obstetric care in a timely manner. After, the infant is often stillborn and the woman is left with incontinence – chronic leakage of urine and/or feces. In many places, women with fistula are also rejected by their family, friends and communities, further marginalizing them and exacerbating existing barriers to accessing care and treatment services. The barriers to accessing fistula repair must be addressed holistically and in an integrated manner so more women can live fistula-free. Through a research to action approach, the Fistula Care Plus (FC+) project at EngenderHealth is breaking down barriers to fistula prevention and treatment at both the community and provider levels!
In 2014, FC+ partnered with the Population Council to conduct a literature review on barriers affecting women’s access to fistula services in low-income countries. The study identified numerous barriers that women often face and categorized these as psychosocial, cultural, awareness, social, financial, transportation, facility shortages, and quality of care factors. Building on this, FC+ project and Population Council conducted formative, qualitative research in 2015 to better understand the specific barriers faced in Nigeria and Uganda and identify enabling factors that can alleviate the most salient barriers. Through interviews and focus group discussions with women with fistula, family members, and community stakeholders, the study found that within communities there was considerable lack of understanding on how fistula occurs. One fistula client in Uganda describes,
“It took a period of about two months to notice this condition because I had never heard about it, that it can happen to a person.”
Amongst primary care providers, there was also a substantial lack of knowledge on where to access fistula treatment. Additionally, the cost of transportation for women to seek services was cited as a considerable constraint. One fistula client in Nigeria explains,
“It was just the lack of money that hindered me from seeking care for eight years. We were looking for traditional treatment because of lack of money to come here…yes no money to come here. My husband hadn’t, and his father hadn’t, my father had to sell some things for us to come here.”
Findings from these studies informed the design of a comprehensive information, screening and referral intervention aimed at reducing the awareness, financial and transportation barriers that impede women’s access to fistula treatment in Nigeria and Uganda. The intervention utilizes one question for fistula screening, a transportation voucher to enable positively screened women to travel to and from the fistula treatment facility for free, and multiple communication channels for fistula messaging, screening and referral. Primary health care providers (doctors, midwives, nurses, and community health care workers), who are often the first point of contact for women suffering from incontinence related to fistula, will be trained to identify potential fistula clients for referral and to facilitate free transportation to appropriate treatment facilities. At the community level, outreach agents will circulate targeted messages about fistula symptoms and available treatment services; and a free hotline service, which will be widely advertised by community agents, radio messages, and through flyers, will screen women for fistula via their mobile device using interactive voice response technology. Positively screened women from each of the channels will receive a voucher for free transportation to and from the fistula treatment facility as well as case-management support from either the community agent or primary health care provider.
The intervention is being piloted by FC+ in two sites in Nigeria and one site in Uganda. Population Council is conducting a third phase of implementation research to assess the effects of this intervention. At the Fourth Global Symposium on Health Systems Research in Vancouver, Canada, EngenderHealth’s FC+ Deputy Director, Dr. Vandana Tripathi, presented this barrier research initiative at a session entitled, “Getting there: working within existing health systems to overcome barriers to maternal and reproductive health care.” The panel included speakers from Population Council, Johns Hopkins School of Public Health, and London School of Hygiene and Tropical Medicine and discussed broadly how social, cultural, economic, political, gender, and trust barriers can be overcome in maternal and reproductive health care in African countries, such as Kenya, Nigeria, Swaziland, and Uganda, and South Asian countries, such as Bangladesh, India, and Pakistan.