Title: The psycho-social impact of obstetric fistula and available support for women residing
in Nigeria: a systematic review
Version: 3 Date: 09 Jan 2022
Reviewer's report:
REVIEWER’S COMMENTS
This is an interesting and important secondary analysis of literature; as it makes a significant
contribution by synthesising the studies on the psychosocial impact of obstetric fistula in
Nigeria; highlighting paucity of research and gaps for future research consideration as well as
area for policy enactment and implementation. However, there is a general lack of focus, and
logical flow that impacts on clarity all through the manuscript. For instance, your paragraph
structure needs to be restructured and organised around a single and/or similar idea/s, to aid
clarity better.
MAJOR ISSUES
1. Title- rephrase to include intervention/support, in line with the aim of your study
2. Background:
Address flow and coherency
- First paragraph should start with the ‘what is OF’, move paragraph to 2 to be the first
- Focus is not too clear on psychosocial impact and interventions – too much information on
prevalence, and why the high prevalence etc. The background should include a brief overview
on what are the psychosocial impacts, and why this is of importance etc. This should then lead
into why the study
3. Method
- Search strategy- did you include ‘psychosocial support/psychosocial intervention’ as key
words? This could potentially improve visibility of  published literature on this for you in your
review
- Quality appraisal- some of your articles were quantitative studies and mixed methods; you
only mentioned using CASP for qualitative research, why? What quantitative and mixed method
quality appraisal tool did you use to appraise their quality? How did you assess the quality
of a quantitative study against qualitative or mixed method study? Could this potentially be a
limitation?
4. Results
a. Address word choice and sentence structure for clarity of meaning all through your write up
e.g  The Psycho-social Impact of Obstetric Fistula of Women Living in Nigeria
line 1..” Factors such as loss of marriage (divorce), depression, stigma, low self-esteem,
discrimination, abandonment, social isolation, ostracization, feelings of worthlessness, suicidal
thoughts, loss of identity, helplessness, sadness and loneliness were reported in the selected
studies”
Rephrase statement and split it up (as it is too long) and join with linking word.
Consider –“ Reported impact include, loss of marriage etc” OR Impacts were loss of
marriage….etc
b. Presentation of results- not orderly which impacts upon clarity. Consider discussing together
related impacts ( see **)
For instance
- Paragraph 2 – describe loss of marriage and paragraph 4- abandonment and isolation.
**This could be merged or the paragraphs follow each other
**The information in the last paragraph could be merged with others. They were not well linked
into each other. For instance,
Helplessness and sadness were identified as the psycho-social impact of obstetric fistula in only
three studies (34,35,37).
**Can be included in your discussion on depression as these are symptoms of depression
“Furthermore, two studies (35,37) reported that women with obstetric fistula were
excommunicated while two studies (19,34) indicated that women who were diagnosed with
obstetric fistula were called names like ‘witch’ and ‘barren woman’”.
**This could be included in your discussion on stigmatisation, as these are evidences of
stigmatisation
However, shame was reported in seven studies (3,9,34,35,36,37).
**Could be included in discussion on stigmatisation
“Respondents in Nsemo (34) were also reported to be lonely”.
Also, four studies acknowledged the poor socio-economic status of the women due to their
condition (3,34,35,37).
**These two could be added to the paragraph on abandonment and isolation
Four studies (3,19,35,37) reported perinatal loss among the respondents. However, only one
study (35) specified perinatal loss in about 85% of the respondents.
**Not sure how this fits in as a psychosocial impact, as this is a medical outcome during the
index labour. However, it could be merged with the discussion on worthlessness?
5. Discussion
General comment; not well focused. Discussion in a ‘nut shell’ is your results explained in the
light of literature. However you discussion did not do this well enough. Similar ideas were not
grouped together and analysed with other literature. There were issues around repetitions as
a result. Again you made reference to what you did not discuss in your results. For instance
consider the paragraphs below (note suggestions in highlighted comments)
- Paragraph 2-
“Furthermore, the high rate of divorce and separation recorded among women with obstetric
fistula could be attributed to their inability to have sex with their partners. The disabilities
acquired by women with obstetric fistula deprives them of sexual pleasure. According to findings
from the studies included in this review (34,35), women experienced inactive sexual lives due
to incontinence. This review also reveals that some husbands of women with obstetric fistula
refused to touch them which caused these women to wallow in sadness over secondary infertility
that accompanies obstetric fistula (34)”
**There was no link with sex in your results. To discuss this here, you need to include this in
your results.
This review also reveals that some husbands of women with obstetric fistula refused to
touch them which caused these women to wallow in sadness over secondary infertility that
accompanies obstetric fistula (34).
**There was no link of ‘sadness to secondary infertility’ in your results. To discuss this here,
you need to include this in your results.
**Consider splitting this paragraph as it is too long
Paragraph 3
This present review also revealed that women living with obstetric fistula experience all forms
of stigma and discrimination due to their incontinence. Consequently, they are unable to attend
community or social gatherings and mostly restrict themselves to their homes
**Your stigma and discrimination was not link to restrictions of movements outside their homes.
To discuss this here, you need to include this in your results.
**Correct spelling of Goffman
**Quote included within the paragraph (check other paragraphs and consider taking quotes out
to results section)
“ A respondent in one of the included studies for this present review (37) stated: “I attend funerals
because everyone is expected to do so but I am always quick to leave before everyone notices
my problem. Those who know my problem would be staring at me with “talking eyes” of which
that makes me feel very uncomfortable”.
**Not necessary here would have been better positioned in results
Psycho-social Support for Obstetric Fistula Women
“Women with obstetric fistula presented high levels of psychological and social suffering which
highlights the necessity of psycho-social support made available for the care of these affected
women”
**Repetition in sentence, rephrase and delete “made available for the care of these affected
women”
“This present review showed that women varied in their levels of support.”
**Do you mean ‘The review revealed that women received varied levels of support’
Paragraph 7
“Equally important, the quality of life of women with obstetric fistula is negatively affected
by the physical damage and social segregation experienced by these women. According to
the disability adjusted life years (DALY) evaluation of maternal health burden, women living
with obstetric fistula lose most of their years of life due to disability (48,68). Most of the
women with obstetric fistula in this review were mostly young, hardly acquired formal education
and were poor. Also, obstetric fistula prevents women from gaining employment and are
mostly abandoned by families. As a result, these women are socially marginalised. The social
marginalisation of women with obstetric fistula have been reported in other studies as well
(48,69,70). Following this, these affected women become helpless as revealed in this review”
**Repetition of what you have written about employment and social marginalisation in above
paragraph is related to what you have written in paragraph 5. Can you merge the ideas and delete
repetitions
6. Conclusion
This needs to be strengthened to include the gap in psychosocial support your review evidenced
had been lacking
MINOR ISSUES
1. Abstract
Method-
“Both qualitative and mixed method studies published between the year 2000 and 2020, that
studied women living in Nigeria who have experienced obstetric fistula and reported the psycho-
social consequences of obstetric fistula, were set as inclusion criteria
**Rephrase to read
**The inclusion criteria was set as articles published between 2000-2020, on the psychosocial
consequences of obstetric fistula in Nigeria
Conclusion
“Promotion of adequate emergency obstetrical services in Nigeria should be encouraged”
**This was not discussed so delete, rather include a key finding statement for instance
** “There is a need for a more holistic approach for management of obstetric fistula”