Tools for self-management of obstetric fistula in low- and middle-income countries: a qualitative study exploring pre-implementation barriers and facilitators among global stakeholders

Abstract

Background: Obstetric fistula, a debilitating maternal morbidity, occurs in contexts with poor access to and quality of emergency obstetric care, predominantly in sub-Saharan Africa. As many as two million women and girls suffer from fistula, which results in urinary incontinence, vulnerability to stigma for women and families, and economic consequences for the household and the healthcare system. Surgical repair, the gold standard for treatment, remains inaccessible to many and success is not guaranteed. Non-surgical, user-controlled fistula management options are not readily accessible, although some technologies, like insertable devices, have been found to have some level of feasibility and acceptability and provide short-term control over incontinence. As evidence for the effectiveness of tools to support self-management grows, the determinants of their implementation within various contexts remain unknown. The purpose of this qualitative study was to explore with key stakeholders, prior to implementation, those factors that could influence successful implementation of an innovation for self-management of obstetric fistula in a LMIC. Methods: Stakeholders were purposefully identified from sectors that address the needs of women with obstetric fistula in sub-Saharan Africa: clinical care, academia, international health organizations, civil society, and government. Twenty-one key stakeholders were interviewed about their perceptions of innovations for fistula self-management and their implementation. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analysis of transcripts from recorded interviews. Analyses were carried out within Nvivo v.12. Deductive coding focused on constructs within the CFIR, then inductive coding identified additional constructs relevant for implementation. Results: Potential facilitators to implementation included a clear tension for change for low-cost, accessible innovations for self-management and a relative advantage over existing tools. The development of partnerships and identification of champions could also support implementation. Barriers included the lack of evidence identifying the optimal beneficiary and the need for educational strategies that encourage acceptability among clinical providers. Inductive coding revealed an additional relevant construct of sustainability. Conclusions: Effectiveness and implementation of non-surgical tools for fistula self-management should be further examined in LMICs. Future research could inform comprehensive fistula care to reduce vulnerability to stigma and improve quality of life.