Shout From The Rooftops: "Obstetric Fistula Is Treatable"

Obstetric fistula has gained much attention in Uganda, thanks to raised consciousness on maternal health and achieve the SDGs especially SDG 3.

Get involved for these three reasons:

1. You can raise awareness on the causes of Obstetric Fistula and how to seek treatment
2. You can contribute to your communities’ critical number of those who are willing to support women gaining optimal maternal health and achieving the SDGs
3. You can make it easier for other members of the community to understand, get involved and participate in prevention of fistula

According to www.prb.org, childbearing poses many risks in Uganda, a largely rural country of 25 million people where the average number of children per woman is almost 7.

Trained medical professionals assist an estimated four in 10 births, and roughly 500 women die of childbirth-related complications for every 100,000 live births, according to the 2000/01 Uganda Demographic and Health Survey (UDHS). 

Although some 98 percent of pregnant women receive some level of antenatal care, the survey shows that only 42 percent make the four or more visits recommended by the health ministry. Infant and child deaths are also high. For every 1,000 live births, 88 children die before age 1 and 152 die before age 5.

Most fistula patients in Uganda, like those in other countries, are young and poor with little education and limited access to quality health care, including emergency obstetric care, according to the 2003 Baseline Assessment of Obstetric Fistula in Uganda. Often, patients lack the knowledge that the condition can be repaired and are too ashamed of their condition to seek help. Those who remain untreated may be shunned by their communities and relatives and must find new ways to support themselves.

With little access to healthcare and information about these kinds of risks, young people begin sexual activity and childbearing at an early age. More than half the population (52 percent) is below age 15, and 23 percent of women surveyed at ages 20 to 49 said that by age 15 they were already sexually active, according to the 2000/2001 UDHS. The median age at first sexual intercourse for women ages 20 to 49 was 17 years. 

The UDHS also showed that some 31 percent of teenagers had begun childbearing, an improvement over the 43 percent shown in the 1995 UDHS.

Early marriages, linked to social and religious customs among certain tribes, contribute to the high number of teenage pregnancies, since young brides become mothers soon after marriage. Although the minimum legal age for a woman to get married in Uganda is 18, the latest UDHS shows that 17 percent of women ages 20 to 49 at the time of the survey were married by the time they were 15, and more than half were married by age 1.

Most recent studies revealed that in Uganda, there are 1,900 new cases of obstetric fistula per year. There are between 75,000-100,000 who suffer Obstetric Fistula. 

From the UDHS (2000/01) statistics that gave 500/1,000 women die in childbirth, there has been been a small reduction to 438/1000 (UDHS 2011). 

According to the 2011 Demographic and Health Survey (DHS), 438 women die of birth-related causes for every 100,000 live births in Uganda, and for every woman who dies, six survive with chronic and debilitating ill health (UBOS & ICF International, 2012). Obstetric fistula, a devastating and frequent outcome of prolonged or unattended labor, is an example of this chronic ill health and a significant public health problem in Uganda. Although detailed data about obstetric fistula in Uganda are limited, the 2011 DHS estimated that 2% of Ugandan women aged 15–49 had experienced the condition (UBOS & ICF International, 2012). Obstetric fistula occurs when there has been a gap in maternal health care, preventive services, or community response. Addressing these gaps requires a concentrated and coordinated effort at the national and local levels (WHO, 2006). Surgeons, community leaders, hospital administrators, health care providers, nongovernmental organizations (NGOs), and women needing services are distinct groups with their own needs. Organizing these groups requires leadership, and the Ministry of Health (MOH) is often best placed to provide centralized coordination among the various players to ensure that quality services are available.

Among the women screened and in need of the repair services, for severe rectovaginal  fistula (RVF) whose perennial tears resulting into constantly passing feaces or vesicovaginal fistula (VVF). Fistula,  is a childbirth injury resulting from unsupervised deliveries especially happening out of hospital.It costs between US$400 (about sh1.4 m) to have a fistula repair done; an amount that an average Ugandan woman cannot afford. The surgery lasts between 1-5 hours depending on the complexity of the case.

According to the UDHS 2011 report on the situation of fistula in Uganda, fistula prevalence stands at 4.0% in the western region. 

Globally, UNFPA reports that there are approximately 3.5 million cases of the fistula with up to 100, 000 new cases annually with the majority being in Sub-Saharan Africa and Asia.

In Uganda, UNFPA reports 1,900 new cases of fistula are still occurring every year.

In 2018, UNFPA supported more than 1100 fistula repair surgeries, contributing to 1829 fistula repairs done in Uganda.

Remember you too can get involved.

Get involved for these three reasons:

1. You can raise awareness on the causes of Obstetric Fistula and how to seek treatment
2. You can contribute to your communities’ critical number of those who are willing to support women gaining optimal maternal health and achieving the SDGs
3. You can make it easier for other members of the community to understand, get involved and participate in prevention of fistula

For more follow these links please:

https://chimpreports.com/uganda-to-mark-fistula-day-this-week/

https://www.engenderhealth.org/files/pubs/fistula-care-digital-archive/7/7.4/Uganda_TWG_TB_ENGLISH.pdf

https://www.newvision.co.ug/new_vision/news/1500854/rukungiri-fistula-victims-receive-free-surgery

Violence Against Women and Children And Affects Quality of RMNCAH Outcomes: Analysis of reports from 8 African Countries

Background: Effective and quality RMNCAH outcomes are linked to reduced risk to violence. This study explored negative stereotypes of hegemonic masculinity and the social structures linked to it. An exploration of 8 Sub-Saharan African countries found  country-specific definitive social structures impacting the stereotypes, i.e., Enabling; Restrictive; and Hindering structures.

According to MoH Guidelines on Maternal Nutrition in Uganda (2010), this includes all processes ensuring safer, optimal birth outcomes, maternal wellbeing, nutrition and autonomy for women to have opportunities for self care. Maternal malnutrition, sets in place an intergenerational cycle of maternal nutrition. Which in turn affects pregnancy, lactation, undernourishment in utero, low birth weight babies, stunted growth and adolescent pregnancies. 

 Violence as related to maternal health and nutrition here is all those actions that tend to discriminate against women’s maternal health and nutrition needs. They subsume women and elevate male needs. AT household level these come in the form of: aggression or such actions that are used to deliberately  deny a women or children access to resources that are life promoting, agency, set preservation and autonomy. According to WHO (2002), violence is “the intentional use of force or power, threatened or actual, against oneself, another person, or against a group or community that either results in, or has a higher likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”

Whether men seek consent before sexual intercourse; whether men are conscious of the notion of age of consent; precarious toxic masculinity practices and notion of transgression such as: gender role transgression, perceiving safer sex initiated by women as threats, tendencies for aggression to portray/power posturing, blocking or denying women access to resources (toxic custodianship) and silencing women by shaming feminine voicing ( toxic censorship).  According to Dr Olaro Charles, the Director Clinical and Community Services, “Women who give birth before age 20 are at greatest risk of fistula. Poor nutrition during a girl’s childhood can also cause stunted growth and increase her risk for fistula.”

One of the findings in a study by Kaye (2006) titled “Domestic violence as risk factor for unwanted pregnancy and induced abortion in Mulago Hospital, Kampala, Uganda,” was that pregnancy intentions have many causes: One is to pacify and aggressive male partner who may demand a child (virility) or for the woman to prove her fertility (fecundity). In other words, pregnancy intentions have social pressure causes too, on top of others.

 - d’Oliveira et al (2002) in a study titled “Violence against women in health-care institutions: an emerging problem,” argue that Maternal morbidity and mortality in childbirth also stems from violence committed by health workers in childbearing or abortion services, which affects health-service access, compliance, quality, and effectiveness.

 - The unavailability of formal recording and reporting tools that capture assault women face from their partners in domestic settings make it harder to generate accurate cross cultural estimates of wife assault because only a few countries have attempted a nationwide accounting. But the data that do exist give cause for concern according to Heise of cisas.org. 

 -Enlisting and emancipating women to report violence against them is one way violence will be checked. Whether or not women will participate fully is another matter. There is fear that if they voice, then they will exit their homes, which therefore means they prefer to take up silence and suffering. This has implications. According to (WHO 2013) report titled ‘Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence,’ “Violence against women has consequences to women’s physical, mental and reproductive health. What is new is the growing recognition that acts of violence against women, violates the rights of women and girls, limits their participation in society, and damages their health and well-being. It is a global public health problem that affects approximately one third of women globally.”

Methods: Meta-analysis of data from 2000-2019 of relationship between violence against women and children, is reflected in reports generated during: Trauma Informed Care (TIC); comprehensive RMNCAH strategies such as IMNI, A/PNC, KMC, perinatal death review, and/or integrated maternal and perinatal death surveillance and response (MPDSR) processes; catalyze the well woman agency; enforcement of legal gender equality; religious and traditional support for respect and dignity of women; uptake of gender-specific prevention services; Domestic Violence (DV) reports and HIV Prevention. 170 articles and reports were identified but 80 met inclusion criteria.

Results: Stereotypes of hegemonic masculinity exist in all 8 countries studied. Politics, religion and tradition influence risk reduction, e.g., enforcement of legal gender equality, political commitment and accountable judiciary ensure women can report abuses. Male dominance beliefs; traditions e.g. precarious toxic masculinity, indifference to expectant mother health by males, stigmatization of frequent clinic visits; and gender of breadwinner are linked to violence-related risks. Compared to all 8 countries, Rwanda, Ethiopia and Kenya have a hindering structure promoting significant risk reduction with institutions fostering increased rule of law, political commitment to RMNCAH outcomes, enforcement and risk-reduction consciousness. Uganda and Tanzania have a restrictive structure characterised with legal loopholes, irregular enforcement and ambivalent political commitment to address acts of violence against women and children. In Senegal, South Africa and Nigeria political, religious and traditional factors blatantly backing traditional negative stereotypes of hegemonic masculinity foster violence enabling structures entrenching repressive acts and hate crimes against women and children. In all countries however, Delivery room reception; level of Health Information Management skills; HIV criminalization; affinity and sensitivity to quality health by all people; stigma around attending clinics by males; negotiating for safer sex by women which is circumscribed as a threat to male dominance, subvert or support optimal RMNCAH goals.

 These are precarious male identity and masculinity tendencies that are aggressive, abusive, silence the voice of women and children, use sexual, gender roles to posture and portray power. They are characterized as influencing sexual, gender, agency, autonomy roles. Through sexual roles, males expect and assume they are entitled to sexual intercourse at their will even if it meant without any form of protection. A precarious gender role situates the woman as the submissive kind who should not transgress that expectation. Gender transgression is construed as a threat to male identity and power. By precarious agency is meant that it is only males who are supposed to think on behalf of the family. If women demand things beyond what the male provides, this depicts him as a failed provider. A failed complex means that the man is inadequate and therefore feels threatened. Precarious autonomy, means that it is the males who are independent, get the prestige, respect, recognition and praise for all that is good and not the woman. The woman is dependent and so are all the children. This has implications on age of first sexual debut, how the woman’s input is sought when it does to planning the size of family, money and time set aside for maternal nutrition and self care. Power is derived from authority, economic, social, cultural and leadership positions.

According to the UNICEF’s Maternal And Health Disparities Uganda (2017), these negative and toxic male stereotypes contribute to higher numbers of adolescent pregnancies, higher Maternal Mortality Ratio and Neonatal mortality Rate (NMR).

According to MoH Guidelines on Maternal Nutrition in Uganda (2010), these included: preconception, pregnancy stage, lactation stage and recognising partner affinity to provide safe and optimal birth outcomes. The list included provisions such as: Folic acid; ensuring proper weight gain during pregnancy; Antenatal care; iron and folic acid supplementation; malaria and worm control to prevent anaemia; diet during pregnancy and lactation; Vitamin A Supplementation; Postnatal care and iron and folic acid supplementation; Iodine supplementation; Nutrition counselling and education; Breastfeeding and family planning; Education regarding local practices that negatively affect maternal nutrition; nutrition during emergencies.

Women emancipated and empowered to engage in safer sex negotiations, access to contraceptives, gain contraceptive-use expertise, provide peer education to other women who are contraceptive-use naive and ensure maternal health autonomy.

Conclusions: Safer and optimal birth outcomes are dependent on overarching social, political and economical dispensation. These manifest as: economic autonomy, religion and traditional backing which contribute effectively to overall risk-reduction as far as maternal nutrition and health are concerned. Contexts hindering violence prevail where state-led commitment thrives and these have far reaching benefits e.g., more people demand, access and benefit from RMNCAH outcomes. Effective and quality RMNCAH programming in the countries studied will be effective if it is designed to involve males and addresses hegemonic masculinity practices too. Mortality implementation audits need to be disaggregated to reflect causes of and contributing factors to deaths such as assault to women and lack of male involvement in practices promoting optimal birth outcomes.