Barriers and facilitators to preventive interventions for the development of obstetric fistulas among women in sub-Saharan Africa: a systematic review

Abstract

BackgroundObstetric fistula is a debilitating childbearing injury that results from poorly managed obstructed labour, leading to the development of holes between the vagina and bladder and/or rectum. Effects of this injury are long-lasting, as women become incontinent and are often marginalised from their communities. Despite continuous occurrence of this injury in lower-income countries, it is preventable, as evidenced in high-income countries. This systematic review aims to identify and understand barriers and facilitators to interventions aimed at the prevention of obstetric fistulas in sub-Saharan African women.MethodsElectronic databases and grey literature were searched. We included studies written in English that discussed interventions to prevent obstetric fistulas implemented in sub-Saharan Africa, and their associated barriers and facilitators. Quality of the studies was assessed, and data including: country of implementation, preventive interventions, and barriers and facilitators to the interventions were extracted. They were then categorised based on the Three Phase Delay Model.ResultsOur search yielded 537 studies, of which 18 were included from sub-Saharan countries including Ethiopia, Nigeria, and Zambia. The most noted barrier to prevention addressed the first phase of delay: the decision to seek care, particularly lack of awareness of the dangers of unsupervised labours. The most noted facilitator addressed the decision to seek care and the quality of care received at a facility, through partnerships between health facilities and governments, and other organisations that provided both financial and resource support.ConclusionDespite being categorised by the three phases of the delay model, barriers and facilitators were found to play a role in multiple phases. The topic of obstetric fistula needs to be researched more extensively, particularly the effectiveness of preventive interventions.Electronic supplementary materialThe online version of this article (10.1186/s12884-018-1787-0) contains supplementary material, which is available to authorized users.

Factors associated with the awareness of vaginal fistula among women of reproductive age: findings from the 2018 Nigerian demographic health cross-sectional survey

“…Urinary or faecal incontinence among women is a devastating medical morbidity that is mostly caused by prolonged obstructed labour. 1 The delay in relieving the obstructed labour is usually due to lack of access to essential maternity services. 1 According to Thaddeus and Maine, 2 the three delay models used to describe obstetric obstacles leading to maternal death are as follows: (i) delay in decision to seek appropriate medical help for an obstetric emergency; (ii) delay in reaching an appropriate obstetric facility and (iii) delay in receiving adequate care at the facility.…”

Reporting and synthesis practices in barriers and facilitators reviews: a methodological systematic review

“…[57] "Some facilitators and inhibitors were not exclusive to one theme example, continuity of older people's values, beliefs and persona identity, and factors related to organisational culture." [58] Interrelationship among identified factors [26,49,51,52,54] "Our findings also suggest that many, if not, most barriers must b understood through their interrelationships versus conceiving the as singular, independent entities. […] The notion of barriers as constellations -as composed of interconnected, evolving, and contextualized impediments to adherence -could be helpful for further reflection.…”

“…Howe to minimise this risk the search terms did not include 'facilitators barriers' and issues were extracted irrespective of the specific terminology used." [24] Issues regarding applying factors to pre-defined framework [33,42,47,51,52] "[I]t was challenging to decide where specific barriers from the studies we reviewed would best fit with pre-defined framework domains. For example, due to the limited information provided in some studies, it was unclear at times where a barrier would fit w the [Consolidated Framework for Implementation Research] subdomains; this applied in trying to determine the role of an individ involved in engagement, as studies did not always provide suffic detail to code this barrier into an "opinion leader" versus a forma appointed "champion."…”

“…More specifically, barriers-limite finances, limited education and aware-ness, and location of serv -were also found to be interlinked." [52] [17,18,34,42,51,[57][58][59] "Some articles presented findings related to multiple barriers and perspectives, and these were categorized under multiple themes categories, while not necessarily mutually exclusive [emphasis added], provide an analytical framework from which to consider immigrant women's barriers to cervical cancer screening." [57] "Some facilitators and inhibitors were not exclusive to one theme example, continuity of older people's values, beliefs and persona identity, and factors related to organisational culture."…”

Measuring barriers to fistula care: investigating composite measures for targeted fistula programming in Nigeria and Uganda

“…Understanding the layered barriers and intersectional vulnerabilities of poverty, gender, stigma, and geography faced by women in need of fistula care is useful in better targeting fistula services and designing programs to reduce obstacles to care seeking and treatment [ 6 ]. In sub-Saharan Africa, qualitative studies over the last decade have explored multiple barriers faced by women living with fistula [ 5 , 7 – 12 ].…”