A nurse-delivered mental health intervention for obstetric fistula patients in Tanzania: results of a pilot randomized controlled trial.

BACKGROUND: Obstetric fistula has severe psychological consequences, but no evidence-based interventions exist to improve mental health in this population. This pilot trial evaluated a psychological intervention for women receiving surgical care for obstetric fistula. METHODS: A parallel two-armed pilot RCT was conducted between 2014 and 2016. The intervention was six individual sessions, based on psychological theory and delivered by a nurse facilitator. The study was conducted at a tertiary hospital in Moshi, Tanzania. Women were eligible if they were over age 18 and admitted to the hospital for surgical repair of an obstetric fistula. Sixty participants were randomized to the intervention or standard of care. Surveys were completed at baseline, post-treatment (before discharge), and 3 months following discharge. Standardized scales measured depression, anxiety, traumatic stress, and self-esteem. Feasibility of an RCT was assessed by participation and retention. Feasibility and acceptability of the intervention were assessed by fidelity, attendance, and participant ratings. Potential efficacy was assessed by exploratory linear regression and clinical significance analysis. RESULTS: Eighty-five percent met criteria for mental health dysfunction at enrollment. All eligible patients enrolled, with retention 100% post and 73% at 3 months. Participants rated the intervention acceptable and beneficial. There were sharp and meaningful improvements in mental health outcomes over time, with no evidence of differences by condition. CONCLUSIONS: A nurse-delivered mental health intervention was feasible to implement as part of in-patient clinical care and regarded positively. Mental health treatment in this population is warranted given high level of distress at presentation to care. TRIAL REGISTRATION: ClinicalTrials.Gov NCT01934075.

Experiences of social support among women presenting for obstetric fistula repair surgery in Tanzania.

OBJECTIVE: An obstetric fistula is a childbirth injury resulting in uncontrollable leakage of urine and/or feces and can lead to physical and psychological challenges, including social isolation. Prior to and after fistula repair surgery, social support can help a woman to reintegrate into her community. The aim of this study was to preliminarily examine the experiences of social support among Tanzanian women presenting with obstetric fistula in the periods immediately preceding obstetric fistula repair surgery and following reintegration. PATIENTS AND METHODS: The study used a mixed-methods design to analyze cross-sectional surveys (n=59) and in-depth interviews (n=20). RESULTS: Women reported widely varying levels of social support from family members and partners, with half of the sample reporting overall high levels of social support. For women experiencing lower levels of support, fistula often exacerbated existing problems in relationships, sometimes directly causing separation or divorce. Many women were assertive and resilient with regard to advocating for their fistula care and relationship needs. CONCLUSION: Our data suggest that while some women endure negative social experiences following an obstetric fistula and require additional resources and services, many women report high levels of social support from family members and partners, which may be harnessed to improve the holistic care for patients.

Psychological Symptoms and Social Functioning Following Repair of Obstetric Fistula in a Low-Income Setting.

Objectives Obstetric fistula is a maternal injury that causes uncontrollable leaking of urine or stool, and most women who develop it live in poverty in low-income countries. Obstetric fistula is associated with high rates of stigma and psychological morbidity, but there is uncertainty about the impact of surgical treatment on psychological outcomes. The objective of this exploratory study was to examine changes in psychological symptoms following surgical fistula repair, discharge and reintegration home. Methods Women admitted for surgical repair of obstetric fistula were recruited from a Tanzanian hospital serving a rural catchment area. Psychological symptoms and social functioning were assessed prior to surgery. Approximately 3 months after discharge, a data collector visited the patients' homes to repeat psychosocial measures and assess self-reported incontinence. Baseline to follow-up differences were measured with paired t tests controlling for multiple comparisons. Associations between psychological outcomes and leaking were assessed with t tests and Pearson correlations. Results Participants (N = 28) had been living with fistula for an average of 11 years. Baseline psychological distress was high, and decreased significantly at follow-up. Participants who self-reported continued incontinence at follow-up endorsed significantly higher PTSD and depression symptoms than those who reported being cured, and severity of leaking was associated with psychological distress. Conclusions Fistula patients experience improvements in mental health at 3 months after discharge, but these improvements are curtailed when women experience residual leaking. Given the rate of stress incontinence following surgery, it is important to prepare fistula patients for the possibility of incomplete cure and help them develop appropriate coping strategies.

Development of an intervention to improve mental health for obstetric fistula patients in Tanzania.

Obstetric fistula is a debilitating childbirth injury that has been associated with high rates of psychological distress. Global efforts have helped to link women to surgical repair, but thus far no evidence-based interventions exist to address the psychological needs of these women during the hospital stay. In this paper, we describe the development of a psychological intervention for women in Tanzania who are receiving surgical care for an obstetric fistula. The intervention was developed based on theories of cognitive behavioral therapy and coping models. Content and delivery were informed by qualitative data collection with a range of stakeholders including women with fistula, and input from a study advisory board. The resulting intervention was six individual sessions, delivered by a trained community health nurse. The session topics were (1) recounting the fistula story; (2) creating a new story about the fistula; (3) loss, grief and shame; (4) specific strategies for coping; (5) social relationships; and (6) planning for the future. A trial run of the intervention revealed that the intervention could be delivered with fidelity and was acceptable to patients. A future randomized control trial will evaluate the efficacy of this intervention to address the mental health symptoms of this population.

Prevalence and predictors of exclusive breastfeeding among women in Kilimanjaro region, Northern Tanzania: a population based cross-sectional study.

BACKGROUND: Exclusive breastfeeding (EBF) is a simple and cost-effective intervention to improve child health and survival. Effective EBF has been estimated to avert 13% - 15% of under-five mortality and contribute to reduce mother to child transmission of HIV. The prevalence of EBF for infant less than six months is low in most developing countries, including Tanzania (50%). While the Tanzania Demographic Health Survey collects information on overall EBF prevalence, it does not evaluate factors influencing EBF. The aim of this paper was to determine the prevalence and predictors of exclusive breastfeeding in urban and rural areas in Kilimanjaro region. METHODS: A population-based cross-sectional study was conducted between June 2010 to March 2011 among women with infants aged 6-12 months in Kilimanjaro. Multi-stage proportionate to size sampling was used to select participants from all the seven districts of the region. A standardized questionnaire was used to collect socio-demographic, reproductive, alcohol intake, breastfeeding patterns and nutritional data during the interviews. Estimation on EBF was based on recall since birth. Multivariable logistic regression was used to obtain independent predictors of EBF. RESULTS: A total of 624 women participated, 77% (483) from rural areas. The prevalence of EBF up to six months in Kilimanjaro region was 20.7%, without significant differences in the prevalence of EBF up to six months between urban (22.7%) and rural areas (20.1%); (OR = 0.7, 95% CI 0.5,1.4).In multivariable analysis, advice on breastfeeding after delivery (Adjusted odds ratio, AOR = 2.6, 95% CI 1.5, 4.6) was positively associated with EBF up to six months. Compared to married/cohabiting and those who do not take alcohol, single mothers (AOR = 0.4, 95% CI 0.2, 0.9) and mothers who drank alcohol (AOR = 0.4, 95% CI 0.3, 0.7) had less odds to practice EBF up to six months. CONCLUSION: Prevalence of EBF up to six months is still low in Kilimanjaro, lower than the national coverage of 50%. Strengthening of EBF counseling in all reproductive and child health clinics especially during antenatal and postnatal periods may help to improve EBF rates.