Barriers to obstetric fistula treatment in low-income countries: A systematic review

This condition can lead to lifelong ostracism, stigma, and shame for women affected by it. Obstetric fistula is both preventable and treatable, but women in these countries experience delays in seeking repair due to various factors, including awareness of their condition, resources necessary for seeking care, lack of skilled fistula surgeons, and long hospital waiting times. According to UNFPA (2012) estimates, 2 to 3.5 million women are currently living with fistula worldwide, with at least 50,000 to 100,000 new cases occurring every year. The true number of women with fistula may be higher, as untreated patients who never reach a medical facility are more difficult for researchers to identify, and sampling biases are hard to verify. This review aims to identify and understand the barriers affecting women's access to fistula repair, to inform the design of possible interventions that may be effective in addressing these barriers. A three-stage search protocol was developed using key terms to identify relevant papers. The first stage reviewed titles and abstracts identified from bibliographic databases as well as grey literature searches with explicit inclusion and exclusion criteria. In the second stage, full articles from the first phase were reviewed in parallel by two reviewers who then discussed any discrepancies and agreed on the standardization of the extracted data. The third stage included a qualitative review of references in key articles, expert inquiry, and data extraction from relevant sources. A total of 3,921 articles were identified in the electronic database search, with 30 added from a review of the grey literature and 21 from the expanded search. A total of 110 studies were included in the systematic review. The 110 articles were further categorized by nine barriers, which correspond with Thaddeus and Maine's (1994) Three Delays Model. The articles were further categorized into five types: articles featuring barriers to treatment as their primary focus; articles identifying factors perceived as barriers; articles briefly mentioning barriers; reviews, needs assessments or annual reports; and articles focusing on interventions that aim to remove barriers to treatment. Interventions were analyzed in further detail to ascertain which barriers they targeted and their effectiveness during their study period. From the articles included in this systematic review, it is consistently observed that obstetric fistula is directly linked to poverty, income inequality, gender disparities, discrimination, and poor education. Previous interventions may have achieved increased access to fistula treatment by removing the barriers preventing one or more of the three delays in seeking maternal healthcare. Community-based models identifying women who are disempowered and stigmatized can address the first barrier of limited awareness and knowledge. Transportation and healthcare financing models that successfully refer women with fistula to a surgical center are critical for overcoming the second barrier that prevents women from reaching a medical facility. Provider empathy and respectful care, strong surgical skills, and prioritized registration at facilities ensure that the third delay, appropriate care at a facility, is reduced for women seeking fistula repair services. While barriers to fistula treatment may be easily identified, reducing their effects is difficult and requires sustained interventions that may target several barriers. There are few scientific studies of fistula prevalence and few studies of population-based strategies to improve fistula treatment. The results presented in this review identify current evidence gaps that must be addressed in research, for generating information for planning and implementing future interventions to improve access to fistula treatment in low-income regions. Obstetric fistula is a maternal morbidity with devastating effects on a woman's life, persisting in low-income countries but virtually eliminated from the morbidity burden in high- and middle-income countries. UNFPA (2012) estimates 2 to 3.5 million women currently suffer untreated fistula worldwide; and at least 50,000 to 100,000 women develop a fistula every year. There is uncertainty, however, about the prevalence estimate because of the rarity of diagnosis and a lack of high-quality studies. Because women living with fistula are predominantly poor, geographically and socially isolated, and with little political power, identifying these women for accurate prevalence or incidence data is difficult. A recent systematic review found an aggregate prevalence of 0.29 cases per 1,000 women of reproductive age and incidence of 0.09 new cases per 1,000 recently pregnant women each year, suggesting no more than one million women worldwide currently living with fistula (Adler et al. 2013). That study, however, likely missed women who never reached a hospital or who are isolated from their communities. The uncertainty in these estimates and difficulty in measuring the extent of the problem underscore the difficulties in mounting an effective response for fistula's treatment and prevention. Obstetric fistula is both preventable and treatable. In recent years, various initiatives have been established to prevent and repair fistula but women experience delays in