Reducing Barriers to Fistula Care

The Council is working with the EngenderHealth Fistula Care Plus project to reduce barriers to fistula treatment in Uganda and Nigeria.

The Issue

Obstetric fistula is a complication of prolonged obstructed labor that results in a hole between the vagina and the bladder or rectum through which urine or feces leak. It is most common in low-income countries where access to emergency obstetric services is limited. Women may also experience fistula caused by medical procedures or sexual violence. An unrepaired fistula can lead to lifelong ostracism, stigma, and shame for affected women.

While fistula is both preventable and treatable, millions of women worldwide are currently living with fistula, and at least 50,000–100,000 new cases occur every year. Women may not seek treatment for their fistula because they do not know that repair is possible, because of financial or transportation barriers to accessing care, or because of a lack of skilled fistula repair surgeons in their area.

The Progress

The Population Council is partnering with the Fistula Care Plus (FC+) project—a five-year cooperative agreement funded by USAID and managed by EngenderHealth—to design and evaluate interventions to improve access to fistula repair in two countries: Nigeria, and Uganda.

Following a global systematic review and formative research in Nigeria and Uganda, Population Council researchers co-designed a three-pronged intervention targeting financial, transportation, and awareness barriers at community and primary healthcare levels. The intervention model involves leveraging three communications channels for fistula-related messages and screening including mass media and interactive voice response through mobile phones, community outreach agents and primary health center workers to test one screening algorithm for detecting potential fistula cases, and offers a transport voucher for a fistula patient and a companion of her choice to the repair center/camp. The intervention aims to run for at least nine months.  The Council conducted a baseline in selected sites in Ebonyi and Katsina, Nigeria and the Central 1 Sub-Region, Uganda and more recently, carried out midline data collection to explore the implementation process and offered recommendations for intervention adaptation.

Population Council’s baseline analysis show sparse recording of routine data (e.g. referrals) at PHCs, and these facilities have low structural capacity including shortages of staff, drugs, supplies, and equipment in all three sites (Ebonyi and Katsina in Nigeria and Uganda). Primary health center provider surveys suggest low levels of fistula knowledge, including uneven understanding of counseling, management, and referrals. Post-repair client surveys reveal the full range of experiences on a specifically designed barrier checklist and open-ended questions allowed for its content validation. Qualitative analysis of the FGDs and IDIs indicate similar themes as seen during formative research phase and provided more detailed explanations for transportation, financial, awareness, social, cultural, and political barriers to accessing fistula repair. Psychosocial issues—pre-repair and post-repair—though not the focus of the current version of the FC+ barrier intervention, need to be monitored as they play in promoting or deterring access.  Though communities and providers consider traditional healers as barriers to accessing treatment, this sentiment is not consistent across study settings and not always described by women themselves.

The Impact

With appropriate resources, awareness, knowledge, and strong health systems for prevention, treatment, and support, fistula will become a rare event for future generations of women.

Principal Investigator

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Research Publications (12)

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