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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 224-228  

Associated factors for obstetric fistula among young women and its possible effects on their mental well-being


1 Department of Public Health, American International University-Bangladesh, Bangladesh
2 Management Information System, Directorate General of Health Services, Bangladesh
3 Department of Surgery, Kushtia Medical College, Kushtia, Bangladesh
4 Department of Medicine, Tairunnessa Memorial Medical College and Hospital, Gazipur, Bangladesh
5 MIS (Management Information System), National Institute of Preventive and Social Medicine, Dhaka, Bangladesh

Date of Submission14-Jun-2019
Date of Decision15-Oct-2019
Date of Acceptance12-Sep-2019
Date of Web Publication3-Jun-2020

Correspondence Address:
Shirmin Bintay Kader
Department of Public Health, American International University of Bangladesh, Dhaka
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_171_19

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  Abstract 


Context: Obstetric fistula is the most frequently found complication in the obstetric care facility in Bangladesh. In addition to physical illness, this life-long complication is also associated with the declined mental status of the sufferer. Aims: The aim of the study was to find the associated factors in the occurrence of obstetric fistula and their effect on the mental health status of women of the reproductive age group. Settings and Design: This was a cross-sectional study. Subjects and Methods: A total of 108 women aged between 15 and 35 years were interviewed with a semi-structured questionnaire to explore their sociodemographic, obstetric, and mental status domain. Statistical Analysis Used: The frequencies of the different variables were analyzed using SPSS 20 software, and the Chi-square test was done to observe the associations. Results: The average age of the participants was 23 years. Over 40% of women had their first delivery between the ages of 16–18 years and the same percentage of them had never taken antenatal checkup during their pregnancy. Obstetric fistula was found in nearly 45% of the women after their first delivery. Over two-thirds of the women were found to have a severe depression after the incident. Despite being common in the younger age group, patients older than 25 years were more prone to the severity of depression. Conclusions: The present study strongly supports the association of having obstetric fistula with reduce mental health ranging from having moderate-to-extreme depression.

Keywords: Bangladesh, mental wellbeing, obstetric fistula


How to cite this article:
Kader SB, Rahman MM, Tulsan SK, Podder V, Pial RH, Saha M. Associated factors for obstetric fistula among young women and its possible effects on their mental well-being. Med J DY Patil Vidyapeeth 2020;13:224-8

How to cite this URL:
Kader SB, Rahman MM, Tulsan SK, Podder V, Pial RH, Saha M. Associated factors for obstetric fistula among young women and its possible effects on their mental well-being. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Sep 27];13:224-8. Available from: http://www.mjdrdypv.org/text.asp?2020/13/3/224/285756




  Introduction Top


Obstetric fistula is an emerging global health problem and is significantly more prevalent in resource-limited countries than in high-resource countries.[1],[2] It has been defined as an “abnormal opening between a women's vagina and bladder and/or rectum through which her urine and/or feces continually leak.” Women living in low-income countries with a lack of access to quality maternal health care are predominantly affected and have been associated with lifelong ostracism, stigma, and shame and with sexual, fertility, and future childbearing issues, in addition to incontinence. According to the World Health Organization (WHO), approximately 50,000–100,000 women are affected each year by this condition worldwide, and 2 million young women remain untreated without having any treatment in Asia and sub-Saharan Africa.[3] However, the actual number of affected women may be higher than approximated, as untreated patients are difficult to trace and they may have poor access to a health-care facility.[4] Obstetrics fistula results from prolonged pressure during obstructive labor (hence named so). Any kind of disproportionate placement of the fetus when obstructs through the maternal pelvis during the course of vaginal delivery can damage the soft tissues between the vagina and bladder and/or rectum. The dead tissues create the fistula as it sloughs away, leaving women incontinent of urine and/or feces.[5] Prevention and treatment of this condition are contributory to achieving Sustainable Development Goal 3, which is improving maternal health.[6] This condition can be prevented by assessing the labor progression from the very beginning. If progression is not up to the mark, obstructed labor ensues, and an emergency cesarean delivery is needed. However, health-care facilities and access to cesarean delivery are poorly available in rural areas as compared to urban.[7] Despite increasing health facility-based deliveries in Bangladesh, rural people are less likely than urban people to avail facility-based delivery (8.2% vs. 31.0%) and to receive cesarean section (5.0% vs. 15.5%). Past studies have identified several potential barriers to have emergency C-section in the rural areas leading to home delivery, such as long distance from a health facility and with poor transportation, costs of care, including informal charges or expenses, opportunity costs from time lost, perceived low-quality care in facilities, or sociocultural barriers to professional health seeking (stigma, fear, inability for women to travel alone, or seen by male doctors and social norm).[8],[9] The other causes of developing obstetric fistula are an iatrogenic injury that might be sustained during the delivery period; for example, cesarean section to overcome the obstructed labor situation by health-care provider itself can lead to a fistula.[10] Some other causes of obstetric fistula are accidents, sexual abuse, and rape.[11]

Along with physical problems, psychological problems were also evident in patients with vesicovaginal fistula (VVF). Affected women also reported an intramarital relationship problem and ill-behavior from relatives and neighbors, which consequently had decreased their quality time with family members. Even religious practices were found to be affected as a result of repeated filthy clothes.[12] The lower socioeconomic condition has been attributed to limiting access of women to health-care facilities for reproductive health care. In Bangladesh, the poor literacy rate among rural women acts as an additional contributing factor to having less usage of reproductive health services.[13]

The grief of VVF patients can be preliminarily divided into five major implications: physical, psychological, social, religious practice, and financial factors. It has been identified that current health-care delivery in Bangladesh only considers physical illness of patients with VVF, and there is no provision of psychological support to alleviate psychiatric illness of the patients and to encourage patients toward rehabilitation. In-depth review of the literature revealed that there is a paucity of studies regarding the mental well-being of obstetric fistula patients. Hence, a knowledge gap is present which needs to be addressed as an important public health problem. Therefore, this study was conducted to assess this largely neglected, unexplored problem emphasizing the associated factors regarding obstetric fistula among women aged 15-35 years and their overall mental health status, especially depression.


  Subjects and Methods Top


A cross-sectional analytical study was conducted at the fistula ward in Dhaka Medical College and Hospital, Bangladesh, using the face-to-face interview technique. The inclusion criteria were female patients with VVF, aged between 15 and 35 years, and who were admitted to the fistula ward. The exclusion criteria were seriously ill, mentally unstable, and noncooperative women. Data were collected between July 2015 and December 2015. For this study, while keeping in mind about the time constraints, the final sample size was determined to 108.

Data collection instrument

Data were collected with a semi-structured interviewer-administered questionnaire with both open- and closed-end questions. The questionnaire was divided into three domains, namely sociodemographic domain, obstetric status domain, and mental status domain. The sociodemographic domain was developed using standard questions for taking sociodemographic data such as age, education, and residence. The mental status domain questions were formed using the Bangla version of the standard Beck Depression Inventory (BDI)-II questionnaire,[14] and for obstetric status, regular routine questions were developed regarding obstetric history. At first, the questionnaire was prepared in English and then was translated into Bangla.

Data collection method

Data were collected by face-to-face interviews with the respondents through an interviewer-administered questionnaire. A rapport was built with the participants before beginning the interview, by adequate listening to their grief and providing assurance to their ongoing treatments. The participants were well informed regarding the purpose of the study before proceeding for the interview. Depression scale was measured using the depression scale questionnaire and informal interviewing of the participants.

Data processing and analysis

Each questionnaire had been validated for completion and consistency every day and stored after giving an appropriate identification number. The data were then entered into standard analysis program (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. IBM Corp., Armonk, NY) following the preentry checking. The frequency of variables and mean was calculated. Linear regression was performed to see the likelihood of depression among different groups. Depression was measured according to the BDI scale score. All these data were analyzed with the help of SPSS version 20.0.

Ethical issues

Ethical Approval for the study was obtained from the AIUB Research Committee. Permission was taken from the director of Dhaka Medical College and hospital to perform the study over there. Written informed consent was obtained from the study subjects. Privacy and confidentiality were strictly limited to the purpose of this study. Respondents were adequately counseled that involving in this study will not hamper their treatment and will not cause any harm to them or their children.


  Results Top


Sociodemographic domain

Of the 108 respondents, the majority (68.5%) of them belonged to 16–25 years of age, 71.3% had literacy, 77.7% were married and the rest (22.3%) were either separated or divorced, 97.2% belonged to Muslim community, and 78.7% were unemployed. The mean age for the respondents was 23.36 (standard deviation ± 5.02) years, and the mean family income was 4410 Bangladeshi taka (BDT; equivalent to US $52). The majority (53%) of the respondents had completed their primary education, 14% completed their secondary level education, and 28.7% were illiterate, whereas 4.6% said that they had received informal education. About 79% of the patients were unemployed, 9% worked as a maidservant, 1% non governmental organization worker, 4% garment workers, and 7% had some other jobs. The sociodemographic data of the participants indicated that most of them belonged to a poor socioeconomical background [Table 1].
Table 1: Sociodemographic domain of the participants of the study

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Obstetric domain

Most respondents (80.6%) reported their age of marriage below 18 years and their age of first delivery (41.7%) between 16 and 18 years (legal age of marriage for girls in Bangladesh is 18 years). Most of the respondents (41.7%) never had an antenatal checkup (ANC) for their first delivery. The number of children per women was mostly (44.4%) one, with a mean number 1.93. Approximately 45% were between 19 and 21 years of age during their first delivery, and the second-highest group, 41.7%, belonged to 16–18 years during their first delivery. Only 10.2% of the respondents said that their age was between 22 and 24 years at the time of their first delivery [Table 2].
Table 2: Obstetric characteristics

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Depression status

This study was conducted to assess the overall mental health status (especially depression) of the VVF patients and their sociodemographic variables. The depression level of the respondents was determined using the BDI-II scale. Patients were found to suffer from moderate (9.3%), severe (69.4%), and extreme (21.3%) depression [Table 3].
Table 3: Distribution of respondents according to the Beck Depression Inventory score (severity of depression)

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The respondents' age and current marital status were found to have a statistically significant relationship with depression (P< 0.05) [Table 4]. [Table 4] shows that patients older than 25 years were suffered more from moderate and severe depression than patients younger than 25 years. However, patients younger than 25 years were more prone to have extreme depression than patients older than 25 years [Figure 1].
Table 4: Relationship of different variables with the severity of depression

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Figure 1: Relation of respondents' age with the severity of depression

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Obstetric fistula has a shattering effect, as the consequences of this condition are severe than any other diseases. In addition to physical illness, the continuous smell of urine and feces makes the affected persons more distressful. Often, they found themselves abandoned from their own family and unbearable to pursue normal life due to the prevailing misconceptions. An informal interview was conducted before proceeding with a structured interview and during the moments of rapport building with the participants. This informal interview stimulated them to unfold miserable life stories without hesitation. One of the respondents, Khadija, said ”It is a very sorrowful event of my life that, I am suffering from a condition that occurred as a result of delivering a baby. And now my husband is asking me to leave his house and leave behind my child. He claimed that I am useless as my body smelt of urine throughout the day, and I will not able to make him happy sexually anymore.”

Morium said

”Along with this irritation of having uncontrolled urination, I am facing the rejection from everybody surrounding me. I took several medications, even underwent surgery. But the condition remained the same. When my husband realized that it is an untreatable disease and will remain for whole life, he gave me a divorce. I used to be very friendly, but now most of the time I don't talk with anyone.”


  Discussion Top


The reproductive health issue is the major health problem faced by women in Bangladesh due to a poor health system, lack of awareness, and negligence. VVF is the most prevalent case in obstetrical wards at every hospital in Bangladesh. The present study not only highlights the factors associated with obstetric fistula but also the effect of this disease on their mental health, especially depression. Different studies found that around 33% of the affected women suffered from depression, 18% got divorced, and 53% had a feeling of abandoned from society.[15],[16] However, in our findings, we have found that 69.4% among the respondents were severely depressed, which is more than double compared to the early study. It might be due to the small sample size and recruitments of the patients from tertiary hospital in our study where they came with much more complications and they were away from their families due to prolong hospitalization. A qualitative study conducted in rural Tanzania reflected our findings, which broadly represented several aspects of depression resulted from social isolation, separation from spouse, inability to earn, disrupted sex life, etc.[17] As per the WHO, obstructive fistula can be prevented by delaying the age of marriage, delaying the age of first pregnancy, and timely access to obstetric care.[3] In our study, of the total participants, the majority (68.5%) belonged to the age group of 16–25 years (mean age was 23.24 years). Approximately 72% of the respondents were literate, ranging between primary and secondary education. Over 80% of the respondents reported that they had their first baby before 18 years. An Ethiopian study found similar findings where the mean age of the first marriage and delivery was 14.7 years and 17 years, respectively.[15] In our study, nearly 42% of the participants reported that their first delivery was at the age of 16–18 years; 2.8% had their first baby born before they were 16 years old. Moreover, 41.7% of the respondents did not avail any antenatal checkup, with only 2% reported being taking full antenatal checkup.

Women who are affected by VVF tend to suffer more from depression than any other gynecological patients, as evident in our study. A similar response was obtained in another qualitative study representing various parameters of depression among women living with VVF.[16] The severity of depression was found more in the case of older (25 years or more) patients compared to women younger than 25 years old. However, patients younger than 25 years were more prone to have extreme depression. Based on marital status, 37% of the married women had an increased chance of depression for their physical condition than those who are divorced or separated. Our study has established an association of early age marriage and marital status of the participants with the depression. Although the Ethiopian study found an association of depression with the older age group, the other associations support our findings.[15]


  Conclusions Top


The purpose of this study was to explore the mental health status of women suffering from VVF and its associated factors. The study findings support the association of obstetric fistula with moderate-to-extreme depression. The study also shows different factors associated with obstetric fistula along with sociodemographic characteristics of the participants. As there is a paucity of research on this unique association, further long-term studies are imperative to explore this vicious obstetric complication to prevent and treat this condition among women of the reproductive age group in Bangladesh. The study will help health-care providers and policy-makers to understand the current problem and improve reproductive health as well as maternal health in Bangladesh. Moreover, it will also help to raise awareness regarding rehabilitation and psychological support for the affected women.

Acknowledgments

The authors would like to thank the American International University of Bangladesh for giving Ethical Committee Clearance and Dhaka Medical College and Hospital for giving permission to collect the data from the fistula ward.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Donnay F, Ramsey K. Eliminating obstetric fistula: Progress in partnerships. Int J Gynaecol Obstet 2006;94:254-61.  Back to cited text no. 1
    
2.
Wall LL, Arrowsmith SD, Briggs ND, Browning A, Lassey A. The obstetric vesicovaginal fistula in the developing world. Obstet Gynecol Surv 2005;60:S3-51.  Back to cited text no. 2
    
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Obstetric Fistula. World Health Organization. 10 facts on obstetric fistula [Internet]. World Health Organization; 2018. Available from: https://www.who.int/features/factfiles/obstetric_fistula/en/.  Back to cited text no. 3
    
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Baker Z, Bellows B, Bach R, Warren C. Barriers to obstetric fistula treatment in low-income countries: A systematic review. Trop Med Int Health 2017;22:938-59.  Back to cited text no. 4
    
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Amodu OC, Salami BO, Richter MS. Obstetric fistula policy in Nigeria: A critical discourse analysis. BMC Pregnancy Childbirth 2018;18:269.  Back to cited text no. 6
    
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Neuman M, Alcock G, Azad K, Kuddus A, Osrin D, More NS, et al. Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: Cross-sectional analysis of data from Bangladesh, India and Nepal. BMJ Open 2014;4:e005982.  Back to cited text no. 7
    
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Parkhurst JO, Rahman SA, Ssengooba F. Overcoming access barriers for facility-based delivery in low-income settings: Insights from Bangladesh and Uganda. J Health Popul Nutr 2006;24:438-45.  Back to cited text no. 8
    
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Hilton P. Trends in the aetiology of urogenital fistula: A case of 'retrogressive evolution'? Int Urogynecol J 2016;27:831-7.  Back to cited text no. 10
    
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Uddin M, Faruk O, Khanam M, Uddin MK. Psychometric Evaluation of the Bangla Beck Scale for Suicide Ideation. Bangladesh Psychological Studies 2013;23:85-97.  Back to cited text no. 12
    
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Amin R, Shah NM, Becker S. Socioeconomic factors differentiating maternal and child health-seeking behavior in rural Bangladesh: A cross-sectional analysis. Int J Equity Health 2010;9:9.  Back to cited text no. 13
    
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Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Archives of General Psychiatry 1961;4:561-71.  Back to cited text no. 14
    
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Kelly J. Ethiopia: An epidemiological study of vesico-vaginal fistula in Addis Ababa. World Health Stat Q 1995;48:15-7.  Back to cited text no. 15
    
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Kabir M, Iliyasu Z, Abubaker IS, Umar UI. Medico-social problems of patients with vesicovaginal fistula in Murtala Mohammed specialist hospital, Kano. Ann Afr Med 2004;2:54-7.  Back to cited text no. 16
    
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Mselle LT, Moland KM, Evjen-Olsen B, Mvungi A, Kohi TW. “I am nothing”: Experiences of loss among women suffering from severe birth injuries in Tanzania. BMC Womens Health 2011;11:49.  Back to cited text no. 17
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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