Introduction

Background

Globally, the number of maternal deaths has reduced overtime from over 500,000 to 289,000
women dying from pregnancy related complications but still 99% of these deaths occur in low
income countries (LICs) [1, 2]. For each maternal death, another 15-30 women suffer serious
morbidities one of which is genital fistula, a preventable condition [3]. A fistula is an abnormal
communication between two epithelial surfaces [4, 5]. A genital fistula is an opening from the
urinary tract or rectal wall connecting to the genital tract, through which urine and/or faeces
continually leak. A genital fistula is referred to as an obstetric fistula if it results from the process
of labour or its management [6]. Most of the urogenital fistulas in LICs are due to obstetric
causes mainly following prolonged and neglected obstructed labour [7-9]. The fistula due to
obstructed labour occurs when the baby’s head gets impacted in the birth canal for long, pressing
the bladder or rectum onto the bony pelvis leading to tissue necrosis (death). The dead tissue
eventually sloughs off, creating one or more holes through which urine and/or faeces leak
uncontrollably [7-10]. In most cases the baby dies during the labour process, leaving the woman
incontinent of urine and/or faeces, bearing the sadness of the stillbirth, and often abandoned by
the husband and the society [7]. In addition to the sorrow as well as the shame of loosing a child,
the constant smell of urine and/or faeces that the fistula entails, further humiliates the woman by
driving away the husband, family and friends [11]. Genital fistula among Ugandan women: Risk
Factors, Treatment Outcomes and Experiences of Patients & SpousesJustus Kafunjo Barageine
2015

Obstetric fistula is an injury that occurs during prolonged and obstructed labor causing tissue
damage to organs inside the pelvis and resulting in urine and fecal incontinence or both. obstetric
fistula remains a major public health problem

While obstetric fistula has been virtually eradicated in the developed world, millions of women
and young girls in the developing world are living in poverty as outcasts from their society. lcs
2020. Obstetric fistula is a degrading injury which leaves women incontinent and ostracised by
their community. Pregnant women in rural Ethiopia have little or no access to emergency
obstetric services. If they are among the five percent of women worldwide who will face
obstructed labour, they will be in agonising labour for days and days. They almost always lose
their baby and suffer horrific internal damage – sometimes the bladder is completely destroyed,
sometimes the rectum is also damaged. They leak constantly and are pushed to the edge of their
society, too filthy to be part of village life and considered a curse

It is estimated that More than 2 million women’s live with obstetric fistula in the developing
country, and 50,000 to 100,000 new cases develop in each year [nternational WSH. Annual
report. Bern: Women’s Hope International; 2015]. Sub-Saharan Africa and south Asia are the
regions where the highest obstetric fistula patients exit, which are estimated to be more than 1
million. There are over 6000 new cases per year in these two world regions. The prevalence of
obstetric fistula is 0.29 per 1000 women of reproductive age in the developing world. The
prevalence of obstetric fistula in sub-Saharan Africa and south Asia was 1.6 and 1.2 per 1000
women of reproductive age respectively .Adler AJ,er,al 2013.Women who experience obstetric
fistula suffer constant incontinence of urine or feces or both, with accompanying foul odor,
infection and sometimes infertility. Further complications include nerve damage to the muscles
in the lower legs, and the damage of vaginal tissue shame, anxiety ,social segregation, and other
health and social problems.

The root causes of obstetric fistulas are grinding poverty and the low status of women and girls.
In Ethiopia, poverty and malnutrition in children contributes to the condition of stunting where
the skeleton, and therefore pelvis, do not fully mature. This stunted condition can contribute to
obstructed labour and therefore an obstetric fistula.hamlin 2020 .In Ethiopia, there were nearly
142,387 obstetric fistula patients in 2013. In this setting 10.6 per 1000 women who ever given
birth experiences obstetric fistula in their life . Biadgilign S, et al 2013

In a study conducted in Ethiopia, among the total of 218women with fistula in North West
Ethiopia who were tested with Beck Depression Inventory scale 97.0% of them had depressive
symptoms (Zeleke, et al, 2013).

Low self-esteem, feelings of rejection, depression, stress, anxiety, loss of libido and losses of
sexual pleasure were commonly reported by fistula affected women. Three recent articles

further document the presence of these problems in women with fistulas. In 2007 article on

the health and social problems of women with fistulas in Ethiopia reported 69.2% of fistula
victims were divorced. Depression has a high prevalence in patients with obstetric fistula as a

result of isolation and divorceAssessment of the Role of Counseling Service during Pre and Post
Treatment of Fistula Patients at Addis Ababa Fistula Hospital By: Tirsit Teklewold 2007

. Studies conducted at Addis Ababa Fistula Hospital also reveal that around 96% of the cause of
fistula is obstructed labor In Ethiopia it is estimated that between 26,000 and 40,000 women’s
suffers from obstetric fistula (Muleta, et al, 2007). “Only about 50% of the general population in
Ethiopia has access to primary health care services, and only about 7 % to 10% of all births are
attended by skilled personnel. The median age at first marriage in Ethiopia is 16 years, and 31%
of women are married by age 15. About 12% of the total fertility rate in Ethiopia derives from
births to women aged between 15 and 19 years” (Muleta, et al, 2007 p 46).The girls are given
heavy tasks in the household and are poorly educated. They have no access to any health
institution during pregnancy and in labor are often helped during labor by women of the village
to deliver at home and usually deliver a dead baby after being in labor for days. MULETA 2004
In Ethiopia it is estimated that there are about 39000 women suffering from untreated fistula and
3700 women who develop fistula injuries each year, causing lifelong disabilities and poor quality
of life . (kalembo 2012

The purpose of the study will try to assess their experience on the social impact of women with
fistula problem in Addis Ababa fistula hospital .Thus both before and after treatment fistula
patients will be the case for this study.

Obstructed labour is one of the leading causes of maternal mortality in developing countries

and with it, comes other morbidities, the most devastating being obstetric fistula. It is

estimated that for every maternal death, 20-30 women develop serious obstetric complications

including fistula. These women, apart from surviving the ordeal of obstructed labour, face the

physical and psychosocial challenges of living with obstetric fistula (G. Lewis, WHO press).
Obstetric Fistula in the Developing Countries

Yao Doe | Global Health | Spring 2020

Low self-esteem, feelings of rejection, depression, stress, anxiety, loss of libido and losses of
sexual pleasure were commonly reported by fistula affected women. Three recent articles

further document the presence of these problems in women with fistulas. In 2007 article on

the health and social problems of women with fistulas in Ethiopia reported 69.2% of fistula

victims were divorced. Depression has a high prevalence in patients with obstetric fistula as a

result of isolation and divorce. Assessment of the Role of Counseling Service during Pre and
Post Treatment of Fistula Patients at Addis Ababa Fistula Hospital Tirsit Teklewold 2015

Information from various literature shows that obstetric fistula appears to be linked to certain
social-economic and cultural factors including young age at marriage, poverty and illiteracy,
living in rural areas with lack of emergence obstetric care4,5,12,19. Obstetric fistula has serious
social and economic consequences on the lives of these women. Majority of the women are
abandoned by their spouses who cannot stand the smell of urine. Major risk factors for obstetrics
fistula include early age at pregnancy, short stature, illiteracy, poverty, not attending antenatal
care, and rural place of residence or living far away from a health facility14

Determinants of obstetric fistula in Ethiopia Asrat Atsedeweyn Andargie1 and Abebe Debu2017

statement of the problem

Ethiopia is one of the most underdeveloped countries in the world. Ethiopia is consistently
positioned to the bottom of the annual UNDP Human Development Index. The Ethiopian
population is impoverished and most of the people lead subsistence living. Most of its people
have inadequate healthcare, education and infrastructure. One of the many factors that contribute
to its underdevelopment is health problems with a number of causes. Ruth 2007

typical fistula patients in Ethiopia are young girls who are married in their early teens to farmers,
to illiterate or no education. The girls are given heavy task at home and poorly educated. They
have no access to health institution during pregnancy and labor and helped during labor at home.
Then deliver dead baby after being in a labor for days. Although obstructed labor kills many of
these girls, the survivors develop urogenital fistula because they excluded from their social life
they often whish death derejeB etal 2018
Obstetric fistula victims often experience feelings of powerlessness, physical injury, emotional
breakdown, depression, divorce, erosion of social capital ,and loss of health years [7].women
with fistula problem no longer able to successfully fulfill their societal role of wife and mother,
and are often deserted by husbands and family and stigmatized by society. As one qualitative
study conducted in Pakistan (kohi Goth women hospital)the participant reported family members
including husband and children do not like to spend time with them (Farid, et al, 2013).
Obstetric fistula has devastating effects on women‟s lives.. They have limited employment
opportunities and restricted participation in community activities, as well as frequent
abandonment or divorce by the husband, which make women even more vulnerable UNFPA,
(2006) which can cause many isolate themselves out of shame.

“Some women even contemplate suicide or express constant worry about their future, such as

not being able to have more children, never being able to marry again, or never being

repaired”as cited in Tirstet 2015 (Esegbona, et al, 2012 p.194).

Apart from socio economic consequences, not only does the problem of fistula affect the

productivity of a country, community, and household, it also changes the life of the affected

women forever. As cited by Muleta, 2012 Kelley describes the plight of social rejection

around north Gondor when he suggested first treating the blindness of a blind patient with

fistula, she replied:

“Cure my fistula first. If I am blind people will sit with me and talk to me, but no one will

come near me because I am wet and I smell”

A fistula can usually be repaired with reconstructive surgery. Most women affected by this injury
do not know about the treatment available, however, or they are unable to afford it or to reach the
facilities where it is available. Once a woman has been treated, she may also need counselling
and skills training to help her reintegrate into her community.unfpa
Fistula problem in Ethiopia affect many women’s but it doesn’t get enough attention by
government and concerned organizations there is few studies are done in this area but the
problem affect many parts of the society to fulfill this gap this study will be try to came up with
better reach finding by participants women’s came from different ethnicity to get different
information on the study area .

Poverty is the another barrier to get treatment in the treatment centers many areas in Ethiopia
have transportation problem like distance ,road condition, lack of transport services and social
problem stigmatization this all problems make difficult to them for coming from their area and
take the treatment they can feel discomfort about their situation when they use public transport
but also many of them can’t afford private transport service .

Fistula tends to affect the most marginalized members of the society young, poor, illiterate
women’s living in remote areas in most rural area’s fistula problem considered a sexual
transmitted diseases and viewed as a punishment from god.

In rural areas human labor force is important every member of a society have roles and
responsibilities according to their age, social status but women with fistula problem face
challenges in role performance, Poor role identity in terms of loss of social functioning, key roles
and personal relationships are further consequence of having fistula problem

 Women with living with of are less educated and are of low economic status. They lack
knowledge about of, its causes, treatment and prevention.

 Women with of are less likely to have delivered in the hospital or with the help of a trained
personnel.

 There no treatments for of in the rural areas where these women live and many are not aware
of the availability of treatment at the tamale fistula center.

 Due to financial problems and stigmatization many women do not want to seek treatment.

 Women with of face a lot of challenges with their relationships and self-esteem and many are
abandoned by their husbands and some have lost friends and relatives Bio-psycho-social impacts
and challenges of obstetric fistula on women in northern Ghana

Dr. Michael Wombeogo1, Dr. Thomas Bavo Azongo2, Dr. Vida N. Yakong
Chapter Two: Literature Review

2.1 overview of obstric fistula

Obstetric fi stula was virtually eliminated in Europe and the USA between 1935 and 1950,
because of universal access to safe delivery care. That it is still a public health problem in some
countries shows the enormous gap in maternal health care between high-income and low-income
nations and is a result of the egregious failure of health systems in these regions to provide safe
maternity care. Poor women without timely access to safe intrapartum care are most vulnerable
to obstetric fi stula and the physical and psychological consequences aff ect quality of life.4 Aff
ected women are often abandoned by their husbands and families, and ostracised by their
communities. In many societies, obstetric fi stula is stigmatised. It is not surprising that these
women have been considered as “the most dispossessed, outcast, powerless group of women in
the world”.5and families, and ostracised by their communities. In many societies, obstetric fi
stula is stigmatised. It is not surprising that these women have been considered as “the most
dispossessed, outcast, powerless group of women in the world”.5Burden of obstetric fi stula:
from measurement to action 2015

Obstetric fistula affects nearly 0.3% of all labors, totaling 8000 to 9000 new cases in Ethiopia
alone.These women are affected atanearl yage.The current life expectancy being 55years, there
may be 250,000 women suffering from fistula in Ethiopia. The total number of fistula patients in
the world is estimated to be around 2,000,000. Since 1975, the Addis Ababa Fistula Hospital has
treated more than 20,000 women with vesicovaginal and rectovaginal fistula secondary to child
birth injury. Obstetric fistula and its physical, social and psychological dimension: The etiopian
scenario BirukTafesse,MuluMuleta,AmbayeW.Michael,HailegiorgisAytenfesu 2006

Obstetric fistula remains a major public health problem in developing world where unattended
obstructed labor is common and maternal mortality is unacceptably high. It is a tragedy in
developing world because of illiteracy, poverty, ignorance and lack of health facilities2. An
obstetric fistula is preventable and treatable condition, the untreated condition remains in
developing countries. Ethiopia is one example of developing countries with poor maternal health
care as well as high prevalence of obstetric fistula20. In Ethiopia approximately 26,000 women
living with this disability with an additional 9000 new cases annually11. Typical fistula patients
in Ethiopia are young peasant girls who are married in their early teens to farmers with little or
no education. The girls are given heavy tasks in the household and are poorly educated. They
have no access to any health institution during pregnancy and in labor are often helped during
labor by women of the village to deliver at home and usually deliver a dead baby after being in
labor for days10 Determinants of obstetric fistula in Ethiopia

Asrat Atsedeweyn Andargie1 and Abebe Debu2 2017

in Ethiopia, Uganda, and Nigeria. Fistula surgery is rarely done at private facilities and outside of
the listed centres, and thus underestimating fi stula surgery is unlikely. From 2010 to 2013, on
average, fewer than 2000 women each year had surgery for obstetric fi stula in Ethiopia. Maheu-
Giroux and colleagues2 show that more than 110 000 women in Ethiopia presently have vaginal
fi stula. These data imply that if no new cases occur, it will take at least 55 years to treat the
existing patients in Ethiopia at the current rate. Clearly, Ethiopia has defi ciencies in national
treatment planning— most women will never receive surgical treatment despite living in a
country with one of the world’s best treatment facilities for obstetric fi stula, including a
dedicated fi stula treatment and training facility at Addis Ababa Fistula Hospital. The situation in
other countries is unlikely to be better. Burden of obstetric fi stula: from measurement to action
2015

In Ethiopia, obstetric fistula is still a common health and social problem.6,7 The social
consequences include divorce by husbands, and abandonment and ostracism by affected
women’s families and community. This is due to the uncontrollable leakage of urine and/or feces
and the accompanying smell. Fistula also leaves women with few opportunities to earn a living,
so worsens their poverty.8 Moreover, in nearly every case of fistula, a baby is stillborn, which
may also lead to future inability to conceive. The death of the baby, inability to carry a child, and
the stigma that accompanies fistula results in significant emotional damage.9 Cumulatively, this
keeps victims from complaining about obstetric fistula. As a result, it has been difficult to
determine the exact prevalence of the condition.

Based on accessible statistics in the area, the World Health Organization estimates that more
than two million girls and women worldwide live with obstetric fistula, with an additional
50,000–100,000 new cases occurring every year, the vast majority of whom are in Africa and
Asia.10 Of these, between 26,000 and 40,000 women with obstetric fistula live in Ethiopia.11
http://www.hamlinfistula.org

More than 1500 fistula patients are operated annually at the Addis Ababa Fistula Hospital and
about 400-500 cases at each outreach center. The institution’s activities are not limited to
curative care, prevention and research but also train country postgraduate residents in Obstetrics
and gynecology, and overseas doctors in fistula management. Addis Ababa Fistula Hospital.
http://www.hamlinfistula.org

Nevertheless, 23% of the population in Ethiopia are women of reproductive age [12] and we
found that 2 in every 10 000 women had an untreated fistula. This means that at least 5,000
women in Ethiopia still require fistula surgery and efforts need to focus on improving access to
treatment for these women. Ethiopia is, however, a vast country with many remote and difficult
to access villages. Karen Ballard, Fekade Ayanachew, Jeremy Wright, Habtamu Atnafu
The prevalence of obstetric fistula and symptomatic pelvic organ

prolapse in rural Ethiopia 2016

What is Obstetric Fistu

Obstetric fistula is a medical condition in which a fistula (Hole) developed between cither the
rectum and vaginal or between the bladder and vagina after severe or failed child birth, when
adequate medical care is not available [16]. It is considered as disease of poverty because of its
tendency to occur in women in poor countries who do not have health resources comparable to
developed nations [17

Age, parity and rape the most common cause of VVF in community given marriage at age before
menarche the majority of study in Africa show that 50-80% of women suffering from fistula are
primiparous and this percentage is as high as 85% in Sudan and Ethiopia [13,28] the proportion
of primiparous who suffer from fistula in Asia varies from about 30% in some parts of India to as
high as 85% in Pakistan [26]. Dereje B, Abebe E (2019) Assessment of Obstetric Fistula and
Factors Associated among Women admitted to Jimma Medical Center, South West Ethiopia

A fistula is an opening or a hole between two areas of the body that should normally be
separated. An obstetric fistula, of the kind that occurs in Ethiopia and other developing countries,
is a hole between a woman’s vagina and bladder and/or rectum. This develops over many days of
obstructed labour when the pressure of the baby’s head against the mother’s pelvis cuts off the
blood supply. As a result, the woman is left with a hole between her vagina and bladder (called a
vesicovaginal fistula or VVF) and sometimes between her rectum and vagina (rectovaginal
fistula, RVF). This hole results in incontinence of urine and/or faeces. Many women who
develop obstetric fistula are abandoned by their husbands and ostracised by their communities
because of the offensive smell.Hamlin 2020

In Ethiopia, however, obstetric fistula remains one of the factors contributing to maternal illness
and death as the health care system is still young. The nation’s young, small and illiterate girls
and women who live in the remote part of the country are becoming the victim of this
preventable and curable obstetric complication. As cited Zewdu 2008 De Ridder D, Badlani GH,
Browning A, Singh P, Sombie I, Wall LL. Fistula in the developing country. Available from:
http://www.icsoffice.org/Publications/ICI_4/filesbook/comite-18.pdf OF has been neglected in
Ethiopia and affects the most marginalized group of the population. It is still a problem in
Ethiopia for the fact that the health care system fails to provide accessible and good-quality
family planning as well as basic and emergency obstetric care. Moreover, not all women are
assisted by skilled birth attendant during delivery and the treatment of fistula is not affordable for
many. The social system does not provide a safety net for the susceptible girls and women as. In
Ethiopia, only 6% of the women give birth assisted by skilled birth attendants, 28% of the
mothers have ANC for their pregnancy, 77 infants die per 1,000 births, 871 mothers die due to
birth problems out of 100,000 births annually, and women have a fertility rate of 5.4%. Central
Statistic Agency Measure DHS ORC Macro. Ethiopia demographic and health survey.
Calverton, Maryland: Central Statistic Agency Measure DHS ORC Macro; 2005

The majority of reports concerning fistula came from Africa where early marriage and child
bearing are most common [11]. In Africa a number of studies show that 50-80% of women are
under the age of 20, with the youngest patients being 12 or 13-years-old, when they are given in
marriage [21] and they start bearing of child before physical development is complete this
contribute to CPD [13,21].derJE B

Like many other women in remote areas of poor countries, most women who develop fistula give
birth at home without assistance from skilled birth attendants [22]. Traditional practice of early
marriage contributes to risk of obstetric fistula. In parts of sub-Saharan Africa and south Asia,
where obstetric fistula is most common women are often marry as adolescent, sometimes as
young as ten years of age and may become pregnant immediately before their pelvis are full
developed for child bearing [23]. In Ethiopia and Nigeria, for example our 25% of fistula
patients had become pregnant before the age of 15 and over 50% had become pregnant before
the age of 18 years [23].DEREJE B

cause for fistula

Early childbirth
A woman who is given out in marriage as early as 10 to 16 years of age usually has a small and
narrow pelvis. Early introduction to sexual activities as a result of this marriage leads to early
pregnancy when the growth of pelvis is not complete, this situation causes cephalopelvic
disproportion, a condition when the baby’s head or body is too big to fit through the mother’s
pelvis (Ajuwon, 1997:27) Since the birth canal is too narrow for the baby to come out, a
prolonged and obstructed labours occurs, threatening both the life of the mother and the child at
the same time. The trauma experienced by the woman may damage her birth canal, thus giving
way to reproductive tract infections; this in turn leads to the development of an opening or fistula
between the vagina and the urethra, which allows urine to pass through the vagina uncontrollably
(The safe Motherhood Newsletter, 2005). WHO reports that : “In Ethiopia and Nigeria, for
example, over 25% of fistula patients had become pregnant before the age of 15, and over 50%
had become pregnant before the age of 18” (2006:7). Age at marriage no doubt affects pregnancy
and labour complications VESICO-VAGINAL FISTULA AND PSYCHO-SOCIAL WELL-
BEING OF WOMEN IN NIGERIA (2007) Gbola Fasakin

During her prolonged labor, the mother’s contractions continually push the baby’s head against
her pelvis. Soft tissues caught between the baby’s head and her pelvic bone become compressed,
restricting the normal flow of blood.

Obstetric fistula is a direct result of obstructed labour, one of the major causes of maternal
deaths. This is where the mother’s pelvis is too small for the baby to be delivered without help.
Obstetric fistula happens during a long and obstructed labour. The pressure caused by the
obstructed labour damages the tissue of the internal passages of the bladder and/or rectum. With
no access to a Caesarian section and emergency obstetric care, the woman may be left
permanently incontinent. This means being unable to hold urine or faeces, which leak out
through her vagina. In about 90 per cent of cases, the baby does not survive, which means the
mother has to deal with the devastating internal injuries on top of her loss,UNPFA 2018

Without adequate blood supply, sections of tissue soon die, leaving holes—known as “fistulae”
—between the mother’s vagina and her bladder or rectum. It is these holes that cause
incontinence. If untreated, the woman will uncontrollably leak urine, stool, or sometimes both,
for the rest of her life
Childbirth care is affected by a variety of factors including access, socio-economic resources,
and culture. Obstetric care may be geographically or financially unavailable, home delivery may
be common and preferred over facilities, while timely referral systems for emergency obstetric
care may be lacking, and girls and women may lack decision-making power and agency for
seeking care. Many barriers preventing care for pregnant women and during labor are mirrored
in women with fistula unable to access care. A poor, rural, pregnant woman may be unable to
afford transportation for birth in a medical facility, and may be similarly unable to access
transportation to a facility if she develops a fistula during delivery Bellows, Ben, Rachel Bach,
Zoe Baker, Charlotte Warren. 2015. Barriers to Obstetric Fistula Treatment in Low-income
Countries: A Systematic Review. Nairobi: Population Council

Poverty

women are the most affected by poverty. Although poverty affects men, women and children,
there appears to be a stronger link between women and poverty. They are poorer than men and
have less access to and control over socio-economic resources such as land, livestock and
income. Women have a prominent position in agricultural production, but they lack control over
resources Lesetedi, Gwen N. (2018). A Theoretical Perspective on Women and Poverty in
Botswana.Journal of International Women's Studies, 19(5), 193-208

Poverty is the main indirect cause of obstetric fistulae around the world. As obstructed labor and
obstetric fistulae account for 8% of maternal deaths worldwide[42] and “a 60-fold difference in
gross national product per person shows up as a 120-fold difference in maternal mortality ratio,”
impoverished countries produce higher maternal mortality rates and thus higher obstetric fistula
rates.[43] Furthermore, impoverished countries not only have low incomes, but also lack
adequate infrastructure, trained and educated professionals, resources, and a centralized
government that exist in developed nations to effectively eradicate obstetric fistulae.[44]
WHO puts pervasive poverty to be a root cause of obstetric fistula while emphasizing the fact
that the immediate causes are obstructed labor and lack of prompt access to emergency obstetric

care. WHO also reckons that women who suffer from obstetric fistula tend to be impoverished;
traditional practice of early marnage contributes to a risk of obstructed labor and fistula 2007
ruth

In addition, WHO illustrates that the low status of women, particularly young women just after
marriage, plays a fundamental part in fistula development. Some women are denied access to
care, or actually harmed, due to cultural beliefs and traditional practices; harmful traditional
practices such as female genital cutting or mutilation increase the likelihood of gynecological
and obstetric complications, including prolonged labor and fistula. Although there are few
reliable statistics available, these practices may increase the likelihood of such complications by
up to seven times and may explain as many as 155 of fistula cases in some parts of Africa. ruth
2997

18

According to UNFPA, “Generally accepted estimates suggest that 2.0-3.5 million women live
with obstetric fistulae in the developing world, and between 50,000 and 100,000 new cases
develop each year. All but eliminated from the developed world, obstetric fistula continues to
affect the poorest of the poor: women and girls living in some of the most resource-starved
remote regions in the world.”[45]

Lack of education

High levels of poverty also lead to low levels of education among impoverished women
concerning maternal health. This lack of information in combination with obstacles preventing
rural women to easily travel to and from hospitals lead many to arrive at the birthing process
without prenatal care. This can cause a development of unplanned complications that may arise
during home births, in which traditional techniques are used. These techniques often fail in the
event of unplanned emergencies, leading women to go to hospital for care too late, desperately
ill, and therefore vulnerable to the risks of anesthesia and surgery that must be used on them. In a
study of women who had prenatal care and those who had unbooked emergency births, “the
death rate in the booked-healthy group was as good as that in many developed countries, [but]
the death rate in the unbooked emergencies was the same as the death rate in England in the 16th
and 17th centuries.” In this study, 62 unbooked emergency women were diagnosed with obstetric
fistulae out of 7,707 studied, in comparison to three diagnosed booked mothers out of 15,020
studied.[43] In addition, studies find that education is associated with lower desired family size,
greater use of contraceptives, and increased use of professional medical services. Educated
families are also more likely to be able to afford health care, especially maternal healthcare.[

Lack of healthcare

Even women who do make it to the hospital may not get proper treatment. Countries that suffer
from poverty, civil and political unrest or conflict, and other dangerous public health issues such
as malaria, HIV/AIDS, and tuberculosis often suffer from a severe burden and breakdown within
the healthcare system. This breakdown puts many people at risk, specifically women. Many
hospitals within these conditions suffer from shortages of staff, supplies, and other forms of
medical technology that would be necessary to perform reconstructive obstetric fistula repair.
[citation needed] There is a shortage of doctors in rural Africa, and studies find that the doctors
and nurses who do exist in rural Africa often do not show up for work.[47]

A lack of adequately trained fistula surgeons has long been a barrier to scaling up fistula
treatment. Fistula repair surgeries are difficult to perform, and require special training. There are
simply not enough surgeons to meet the need. Moreover, many women live in countries where it
is not culturally acceptable to be treated by male physicians, and female surgeons are scarce.

Compounding this shortage of surgeons, manbsite 2005y hospitals lack adequate capacity to
keep up with the volume of patients needing care fistula foundation we

Status of women

In developing countries, women who are affected by obstetric fistulae do not necessarily have
full agency over their bodies or their households. Rather, their husbands and other family
members have control in determining the healthcare that the women receive.[16] For example, a
woman's family may refuse medical examinations for the patient by male doctors, but female
doctors may be unavailable, thus barring women from prenatal care.[46] Furthermore, many
societies believe that women are supposed to suffer in childbirth, thus are less inclined to support
maternal health efforts.[47]
rape

Obstetric fistula refers to the rupturing of tissue between the vagina and the bladder or rectum
after prolonged, obstructed labour or, less commonly, violent rape. The condition typically
results in urinary or faecal incontinence.

An estimated two million women have the condition worldwide – most of them in developing
countries. Madagascar is one of the worst hit countries, with around 4,000 women affected every
year.UNPFA2018

Physical consequence

Physical consequence was the core theme shared across most studies, described as loss of body
control and the challenges faced to keep cleanness [13, 16, 19, 24, 28, 29, 32]. Physical
challenges include the emotional and medical problems of fistula which resulted from
incontinence, such as genital sores, smells, wounds, pain, discomfort, exhaustion, and foot drop
[21]. studies indicated that women with the condition were unable to afford hygiene keeping
supplies and to cover medical fees therefore, they use herbs to sooth sores [11, 23]. In order to
control the leak some women restrict themselves from feeding as they used to in pre fistula
period, and this resulted in weight loss [11]. Moreover, in order to prevent the smell, discomfort,
and to stay clean women with obstetric fistula tend to bath repeatedly; and they get bored of the
frequency of washing [13, 32].

Consequences on women’s social and marital relation ship

Most studies included marital and social relationships issues as the main theme [11, 13, 19, 22,
23, 26, 29]. It is a common event that fistula-affected women face divorce as they fail to satisfy
their husband’s sexual needs and/or fail to bear children. As the women become incapable of
performing the family roles expected of them, they were perceived as “useless” beings.
Therefore, they became neglected and abandoned. A woman reported that she was mistreated by
her spouse after the fistula incident, “He left me and threw out all of my belongings” …..ever
since I developed the condition, we have not been together as husband and wife. I have been left
out here to care for the old lady (mother-in-law). Even after repair, different socio-cultural
factors can hinder the acceptability of women who integrated back to the community [13, 26,
31]. A study in Malawi reported that remarriage was not difficult among divorced women with
fistula, as long as the husband knows the problem prior to marriage [31]. However, the report
might not represent all other women with fistula, as it was reported by one participant and also
may not be true for all fistula women living across different countries. Except for this report
from Malawi, the concept of keeping association was also a common theme of all reviewed
papers. Seven (43%) reported the faced discrimination and difficulty in maintaining social
relationships. Unless they got an opportunity to obtain a repair service, women with fistula
would not be considered as a woman and therefore, they lose their power and confidence [11].
Although few reported the presence of supportive husbands, most studies revealed experience of
rejection, neglect and abandonment [8, 23, 24, 27, 31].

Divorce is common in obstetric fistula patient. Due to the onset of obstetric fistula, some
husbands divorce their wives because of bad odour and leakage of the urine that is disgusting to
them. Others divorce their wives because of fistula survivors cannot satisfy them sexually while
others divorce because the obstetric fistula women cannot produce another children in the future
and it may take them years to recover. The Experience of Women with Obstetric Fistula
following Corrective Surgery: A Qualitative Study in Benadir and Mudug Regions, Somalia

Adam A. Mohamed ,1,2 Abiodun O. Ilesanmi,3 and M. David Dairo 2018

Socio-economic consequences Women with fistula are often ostracized by their husbands,
families and the community. In one study in Nigeria, more than half of the women considered
themselves rejected. Many women become divorced because of their situation. In the meta-
analysis by Ahmed and Holtz (2007), random-effect estimate showed a 36% (95% CI, 27%-
46%) (47% with fixed-effect estimate) rate of divorce or separation amongst women with fistula.
Obstetric Fistula in the Developing Countries Yao Doe | Global Health | Spring 2020
Economic incapability

Loss of income source activities as a result of fistula was reported in some of the reviewed
studies [22, 26, 27, 32]. Women with fistula could not get involved in gainful employment or
activities that needed strict hygiene [32]. They also lost business because of the incontinence,
and were self-employed in petty trading where they earned too little income. As a respondent
from a Ghana study stated [32]: “… I used to sell cooked rice but my condition has obliged me
to stop. My sales started dwindling as the news of my urine incontinence was heard”. Therefore,
sometimes they fell into deeper poverty and start to beg for survival [32]. In this way, fistula has
challenged and contributed to disfigure image of women’s health in developing countries.

Mental health consequences

This issue was addressed in few of the studies that reported loss of dignity, lack of support, and
lack of power to seek care. Loss of hope, fear of future life, and feelings of dependency were
stated as mental health problems [13, 22]. This challenges were emerged as the result of different
interrelated problems such as lack of support and family care, physical or economical
incapability to access care, and lack of information or knowledge about fistula care and treatment
[28]. It might also result from the reactions and comments of people with a poor understanding
of the condition [19, 29]. Perceived causes of fistula and social stigma has caused psychological
morbidity to women [19, 23, 27]. Consequences of obstetric fistula in sub Sahara African
countries, from patients’ perspective: a systematic review of qualitative studies

Debrework Tesgera Bashah, Abebaw Gebeyehu Worku & Mezgebu Yitayal Mengistu 2018

Ecological model

Stigmatization

Stigma was also experienced through the behaviours of other people towards women with a
fistula. Relatives and neighbours distanced themselves from the women with a fistula because of
the perceived fear that the condition might be contagious. The stress of living with a fistula was
compounded by worries that there may be no cure for the condition. As a result, some women
contemplated ending their lives. Most women had ever had suicidal ideations and felt their life
was not worthwhile living. Genital fistula among Ugandan women: Risk Factors, Treatment
Outcomes and Experiences of Patients & Spouses Justus Kafunjo Barageine Kampala and
Stockholm 2015

Stigmatization theory

We used stigma theory (II), as described by Goffman [92], and the coping theory by Lazarus
and Folkman [93], to discuss the experiences of women when they live with fistula. Stigma was
used with regard to the way women perceived their lived experiences. We elucidate the central
question of interpreting what is at stake for a stigmatised woman living with a fistula in Uganda.
The paper also explores the way women coped in their daily lives with this stigmatising
condition.

Goffman defines stigma as “an attribute that is significantly discrediting” [92]. Within the social
process, a stigmatised person possesses an “undesirable difference” or “deviance” [92]. Stigma is
a constantly changing social process that occurs when five interrelated components converge:
namely “labelling”, “stereotyping”, “separation”, “status loss and discrimination” and the
playing out of “social and political power” [94]. Discrimination can be individual, structural or
self-imposed [94, 95]. Anthropologically, the concept of stigma remains empty and
decontextualized if not filled with meaning from people’s lived experiences [96]. Stigmatisation
is a pragmatic response to “perceived threats, real dangers, and fear of the unknown” [97] and
can either be enacted or felt. Enacted stigma refers to the unfair treatment of others towards the
stigmatised person, including discriminatory attitudes and acts of discrimination; whereas felt
stigma refers to the stigmatised 14 person’s internal feelings of shame (self-stigma) and fear of
discrimination (perceived stigma) [98]. Genital fistula among Ugandan women: Risk Factors,
Treatment Outcomes and Experiences of Patients & Spouses Justus Kafunjo Barageine Kampala
and Stockholm 2015
Ecological model

The ecological model helps to explain human health behavior by focusing on the nature of
people’s transactions with their physical and sociocultural surroundings.16 There are four
explicit assumptions in the ecological model. First, health is influenced by multiple components
of the physical and social environment, including personal attributes. Second, the environment
itself is multidimensional. Third, interactions between humans and their environment can be
described at varying levels of aggregation (individuals, families, work and cultural organizations,
communities). Fourth, there is feedback across different levels of the environment and groups of
people.17

The model shows that human health behavior is influenced by the interaction between personal,
situational, sociocultural, and environmental factors, including the built environment. Inclusion
of all these types of analysis provides an opportunity to see the influence of intrapersonal (level
of individual knowledge, attitudes, and beliefs about obstetric care) and interpersonal (level of
support from spouses, families, neighbors, and traditional birth attendants) behavioral factors on
women’s health and social circumstances. It also helps to explain the influence of sociocultural
and environmental factors on the occurrence and consequences of fistula. A qualitative study of
the experience of obstetric fistula survivors in Addis Ababa, Ethiopia Gebresilase Y 2014

Objective of the Study

General objectives
The general objective of this study will search out the different social challenges and life
experiences they face that’s related to their health condition by womens affected b y fistula in
Addis Ababa the case of women taking treatment in Addis Ababa fistula hospital
Specific objectives
The specific objectives of the study will be꞉−
1.To explore possible social impacts they face because of their health condition
2.To identify the problems they experience in their area since the occurrence of fistula problem
and when they decide to came to treatment center
3.To identify what they expected after the treatment and when they go back to their area
4.To identify what action they suggested to be done by government and private organizations to
eradicate fistula problem
5. to asses their conditions after treatment from those who take the
Research Question
1 what are the possible social challenges they face because of their health condition by women’s
affected by fistula and taking treatment in Addis Ababa fistula hospital
2 what the problems they face when they decide to came to treatment center to get treatment
3 what are the expectations they have from the treatment and when they go back fo their area
after post treatment
5.Whar are the suggestions they give to government and other concerned body’s to eradicate
fistula
5 what are their experiances post treatment

Significant of the study

The study will attempt to address the social challenges and their life experience of women with
fistula problem in addis ababa in case of women taking treatment in Addis Ababa fistula hospital
For social policy makers :this reaerch will give information for policy makers to consider the
social factors which affect womens with fistula problem
For future Research As it has been indicated in the previous section assessing the social
challenges and other many factors are nor enough address by social implications . Thus, as far as
the future research implication of the study is concerned it may be useful for further implications.
Implication for concerned body in the pervious researches mention that understanding the effect
of fistula in developing countery is so difficult it hide in different cultures, location and society
so this research by identifying the possible social factors affected women in fistula it will be
supportive for government bodies & NGOS in supporting the system.
.
Methodology
Research Design
Under this section I will describe the methods that I will use in the research .additionally
I will discuss the methods of the study I will use in the research process from data collection to
data analysis. research methods are important base of the research . the research design, sampling
technique, data collection methods, and data analysis will discussed in detail. The entire method
techniques will be selected by taking into consideration the research objective .
Research Site
The study will be conduct in Addis Ababa fistula hospital.the selection of the area is because the
center have many fistula patients from different part of the country with difference culture and
different life experience
Research Design
For this research I will use qualitative research design because the method is a type of social
science research that collects and works with non-numerical data that seeks to interpret meaning
from these data that help us to understand social life through the study of targeted populations or
places [Punch, 2013]. It is the observations and interpretations of people’s perception of different
events It focuses on words rather than numbers, this type of research observes the world in its
natural setting, interpreting situations to understand the meanings that people make from day to
day life [Walia, 2015]. Qualitative Research Methodology in Social Sciences and Related
SubjectsMohajan, Haradhan Assistant Professor, Premier University, Chittagong, Bangladesh.
10 December 2018 Online at https://mpra.ub.uni-muenchen.de/85654/
qualitative research approach helps give critical insight that people point to their circumstances
and create a platform to record qualitative data thoroughly, accurately and systematically, using
filed notes, audiotapes, photographs and other suitable means (Hesse & Leavy 2010). So for this
particular study of assessing challenges and social impact of women with fistula , it is important
and reasonable to use this method.from haben
Phenomenological Research
The meaning of the phenomenon is conceptualized in the interior of the individual’s awareness.
Phenomenology is an approach to explore people’s everyday life experience. It is used when the
study is about the life experiences of a concept or phenomenon experienced by one or more
individuals. A phenomenological researcher investigates subjective phenomena [Creswell,
2009]. Qualitative Research Methodology in Social Sciences and Related SubjectsMohajan,
HaradhanAssistant Professor, Premier University, Chittagong, Bangladesh.10 December 2018
Sampling technique
Non-Probability Sampling Design
In this study I will use the purposive sampling technique to get usefull and reach information for
the study. In this type of sampling, the researcher chooses the participants as per own judgment,
keeping back in mind the purpose of the study. It uses the judgment of an expert in selecting
cases or it selects cases with a specific purpose in mind. Dr. Huma Parveen Non-Probability and
Probability Sampling Paper: Communications Research . Also, nurises officials working in
Addiis Ababa fistula hospital who have direct contact with women with fistula problem are
included because the researcher believed that they will able to provide more information. So, I
will selected my informants who could provide valid and reliable data, including women with
fistula problem in trearment time, nurese, health professionals, and post treatment womens who
have fistula problem in previous time.
Research Participants
Participants will be women with fistula problem selected from the Addis Ababa fistula hospital,
women’s who take treatment at data collection time and women’s who was in treatment before
2−5 years before, so I chose patients from Addis Ababa fistula hospital.
Data Collection Tools
Data collection tools allow us to systematically collect information about our objects of study
and about the settings in which they occur. If data are collected haphazardly, it will be difficult to
answer our research questions in a conclusive way (Elmusharaf, 2012. In Qualitative research
data collected from ony relevant groups from the society in other word in qualitative research
data collected from set of society parts it can’t be generalized the set of society parts selected
according to the study focus and objective . This data type is non-numerical in nature and it
describe by words . This type of data can be collected through methods of observations,
interviews, and focus groups.in this study .to acheve the research objective primary data will be
collected through interview an focus group disscution . In this study, interview guide will prepare
for the womens with fistula patients who take treatment at the data collection time in line with
the basic research questions of the study. The questions will first prepare in English and latter
translate in Amharic to make them understandable by all interview participants.
In-depth Interview
In-depth interviewing, also known as unstructured interviewing, is a type of interview which
researchers use to elicit information in order to achieve a holistic understanding of the
interviewee’s point of view or situation; it can also be used to explore interesting areas for
further investigation. This type of interview involves asking informants open-ended questions,
and probing wherever necessary to obtain data deemed useful by the researcher. As in-depth
interviewing often involves qualitative data, it is also called qualitative interviewing. Patton
(1987:113)haben

In-depth interviews are a qualitative research method; their goal is to explore in depth a
respondent’s point of view, experiences, feelings, and perspectives. WORKBOOK E:

CONDUCTING IN-DEPTH INTERVIEWS In-depth interviews can uncover valuable insights,

and enable you to find out “the real story” from the people in the know, Respondents are most
likely to open up on a one-on-one basis and Data can be collected faster than other research
methods—usually within a few weeks.From all this benefits indepth interview is best to collect
primary data so I decide to use indepth interview to collect data from respondants.

I will contact physicaly the research participants by going to Addis Ababa fistula hospital and
explain a bout the aim of the study and by creating mutual understanding ,i will arrange the time
by following their interst.i will use some basic witing quations that can help me to extending the
converstation with particepants to get more use full and reach data for the study This results in
rich background information that can shape further questions relevant to the topic.

Key informants
key informant interviews involve interviewing a select group of individuals who are likely to
provide needed information, ideas, and inshights on a particular subject.
Focus group
Focus group or focus group interview is a qualitative technique for data collection. A focus
group is “a group comprised of individuals with certain characteristics who focus discussions on
a given issue or topic” (Anderson, 1990, p.241) According to Denscombe (2007, p.115), “focus
group consists of a small group of people, usually between six and nine in number, who are
brought together by a trained moderator (the researcher) to explore attitudes and perceptions,
feelings and ideas about a topic”. A focus group interview provides a setting for the relatively
homogeneous group to reflect on the questions asked by the interviewer. Cited in Focus Group
Interview as a Tool for Qualitative Research: An Analysis Rana Muhammad Dilshad 2013

A focus group discussion (FGD) is a good way to gather together people from similar
backgrounds or experiences to discuss a specific topic of interest. The group of participants is
guided by a moderator (or group facilitator) who introduces topics for discussion and helps the
group to participate in a lively and natural discussion amongst them. A focus group discussion is
a form of group interviewing in which a small group – usually 10 to 12 people – is led by a
moderator (interviewer) in a loosely structured discussion of various topics of interest. The
course of the discussion is usually planned in advance and most moderators rely on an outline, or
moderator’s guide, to ensure that all topics of interest are covered. Focus Group Discussion in
Qualitative Research Lokanath Mishra TechnoLEARN Vol. 6: No. 1: p. 1-5, June 2016

Observation
MARSHALL and ROSSMAN (1989) define observation as "the systematic description of
events, behaviors, and artifacts in the social setting chosen for study"cited in
Observation methods are useful to researchers in a variety of ways. They provide researchers
with ways to check for nonverbal expression of feelings, determine who interacts with whom,
grasp how participants communicate with each other, and check for how much time is spent on
various activities (SCHMUCK, 1997) Participant Observation as a Data Collection Method
Barbara B. Kawulich 2005
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