The experiences of women and young girls living with obstetric fistula in developing countries: a systematic review
Authors: Tanywe Asahngwa , Matchawe Chelea 
Published: December 2014

Executive summary

Background
Obstetric fistula is a medical condition whereby an abnormal opening occurs between the vagina and the rectum or bladder. It is caused by several delays during obstructed labor without timely medical intervention, typically a caesarean section to relieve the pressure. While obstetric fistula affects women at all ages, the risk is higher among very young mothers between the ages of 14 and 20, who live in very poor conditions in rural settings. Obstetric fistula inflicts a significant health, economic, physiological, socio-cultural and psychological burden on the sufferers.

Objectives
To present the best available evidence on the experiences of women and young girls living with obstetric fistula in developing countries using a qualitative approach to evidence synthesis.

Review questions:

Inclusion criteria

Types of participants

This review considered studies with a focus on the social, cultural and economic consequences on women and young adolescents of child bearing age suffering from obstetric fistula living in developing parts of the world such as Latin America, Asia and Africa.

Phenomena of interest

The experiences of women and young adolescent girls living with obstetric fistula with a particular focus on the support, management, surgical intervention, social reintegration and relationships of these women.

Context

Women and young girls living with obstetric fistula in community and hospital settings.

Types of studies

This review considered qualitative studies with approaches such as phenomenology, ethnography, grounded theory, ethnomethodology, phenomenography, behavioral studies, knowledge attitudes and practice, narrative and critical, interpretative or feminist analysis studies that illuminate the experiences of women and young girls suffering from obstetric fistula and was limited to studies conducted in developing countries.

Search strategy
A three-step search strategy was used to identify published and unpublished studies. MEDLINE and CINAHL were initially searched, and text words in titles, abstracts and index terms were analyzed. Identified keywords and index terms were used to search for studies across all include databases. Finally, the reference lists of all studies included for appraisal were searched for additional papers. Due to the lack of resources for translation, only studies published in English were considered. Papers published from 1990 onwards were considered as those published before this year were deemed not to reflect the current reality of the topic.

Methodological quality
Studies that met the inclusion criteria were assessed by two independent reviewers for methodological validity using the standardized critical appraisal tools of the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI).

Data collection
Data was extracted using a standardized data extraction tool of JBI-QARI.

Data synthesis
Using the JBI-QARI degrees of credibility assessment, the findings of included studies were categorized, synthesized and further meta-synthesized.

Results
From the seven included studies, 61 findings were derived, and grouped into seven categories which were finally meta-synthesized into three synthesized findings:

Synthesized finding 1
The negative impact of obstetric fistula on marital and sexual relationship includes divorce, abandonment, neglect and interruption of sexual activities. Furthermore, some women suffer from infertility, difficulty in conceiving and loss of pregnancy, thereby depriving them from performing their roles as wives and mothers irrespective of their marital status.

Synthesized finding 2
Women with obstetric fistula suffer from urine incontinence, bad odor, body depreciation, stigma, loss of societal roles, depression, mental illness, desperation, the desire to commit suicide, drop in economic activities and loss of financial viability.

Synthesized finding 3
Women with obstetric fistula experience a variety of challenges regarding treatment in hospitals such as fear and uncertainty about treatment, wrong diagnosis, difficulty in seeing a doctor and poor quality service delivery. However, successful fistula surgery restored the dignity of women living with obstetric fistula and enhanced their social reintegration.

Conclusions
Women living with obstetric fistula have a variety of negative experiences regarding treatment and social relationships. Health professionals and decision makers need to acknowledge the negative experiences of women living with obstetric fistula and understand that interventions to combat fistula has to go beyond biomedicine to include psycho-social factors.

Implications for practice

The experiences of women and young girls must be understood by clinicians, policy makers and Non- Governmental Organizations and integrated in programs to combat fistula.

Implications for research

Further high-quality qualitative studies are needed to address the experiences of women and young girls who underwent unsuccessful surgical repairs and those who still suffer from social rejection despite successful surgical repairs.