Abstract
AbstractConsidered the most severe of maternal morbidities, obstetric fistula is a debilitating childbirth injury that results in complete incontinence with severe physical and psychosocial consequences.The primary intervention for women with obstetric fistula is surgical repair, and success rates for repair are reported between 80% and 97%. However, successful treatment is commonly defined solely by the closure of the fistula defect and often fails to capture women who continue to experience urinary incontinence after repair. Residual incontinence post-fistula repair is both underreported and under-examined in the literature. Through a novel mixed-method study that examined clinical, quantitative, and qualitative aspects of residual incontinence post-repair, this chapter draws on in-depth interviews with women suffering with residual incontinence and fistula surgeons, participant observation, and a desk review of fistula policies and guidelines to argue that an inadequate model of fistula treatment that neglects follow-up care exists. We found that obstetric fistula policy has been determined in large part over the years by international development agencies and funding organizations, such as international nongovernmental organizations (INGOs). We argue that the neglect in follow-up care is evident in fistula policy and can be traced to a donor-funded treatment model that fails to prioritize and fund follow-up care as an essential component of fistula treatment, instead focusing on a “narrative of success” in fistula treatment. As a result, poor outcomes are underreported and women who experience poor outcomes are largely erased from the fistula narrative. This erasure has limited the attention, resources, research, and dedicated to residual incontinence, leaving out women suffering from residual incontinence largely without alternative treatment options.
Highlights
In the calm before the afternoon storm, the regional referral hospital in central Uganda was uncharacteristically quiet
Uganda struggles with severe health worker shortages and an inadequate distribution of health workers, with the majority of health workers located in urban areas despite a predominantly rural population. Compounding this are the low wages––the major complaint during the national doctors’ strike––poor morale, inadequate training, and low-staff competence, all of which result in poor quality of care, which recent studies have shown is even more pronounced in rural health facilities (Kruk et al, 2016)
This chapter draws on qualitative results from a community-led project with a Ugandan nongovernmental organization (NGO) that provides fistula treatment and reintegration services, including psychosocial counseling, safe motherhood and sexual health and reproductive rights education, and income generating skills training
Summary
In the calm before the afternoon storm, the regional referral hospital in central Uganda was uncharacteristically quiet. Missing were the long lines of women waiting for care—the norm in maternity wards throughout Uganda— along with the chaotic bustle of the hospital grounds that I had grown accustomed to It was four days into a national doctors’ strike, in which doctors were protesting appallingly low wages and a chronically underfunded healthcare system. Other women started leaking immediately following surgery; this screening was the first time a healthcare worker had explained that they were experiencing residual incontinence rather than a failed closure. In both circumstances, the women had either not received follow-up care or returned for follow-up but were still confused about their prospects for treatment. This erasure shapes treatment possibilities and research priorities, leaving out women still in need of additional treatment
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