Por debaixo dos panos: um estudo etnográfico com pacientes de fistula obstétrica do hospital Central de Maputo / Under the covers: an ethnographic study with obstetric fistula patients at the Maputo central hospital - Mozambique

Em Moçambique, embora se observe uma redução da mortalidade materna de 1.300mortes/100mil nascimentos em 1990 para 480/100mil em 2012, ela ainda constitui um grave problema de saúde (Pathfinder, 2016). As altas taxas de mortalidade materna estão correlacionadas com a alta prevalência dos casos de Fístula Obstétrica. Estima-se que a cada mulher que morre na gravidez/parto, trinta sofrem de complicações agudas, são doenças crônicas ou incapacitantes (Bergstrom, 2002:16). De acordo com o Ministério da Saúde de Moçambique no ano de 2013 foram realizados cerca de um milhão de partos no país, dos quais surgiram pelo menos dois mil novos casos de Fístula. A Fístula Obstétrica consiste numa comunicação anormal entre a bexiga e a vagina decorrente da destruição dos tecidos da região pélvica por compressão da cabeça do feto durante o trabalho de parto. Causando perda constante de urina e/ou fezes pela vagina, destruição de órgãos do aparelho urinário e em alguns casos a impossibilidade de andar ou de ter filhos. Se não bastasse a dor física decorrente da doença, elas também sofrem com a culpa por perderem o filho, que geralmente morre durante o parto. Sendo abandonadas pelos maridos passam a viver como "deadwomenwalking", isoladas devido ao odor fétido que exalam (Ahmed e Holtz, 2007). Com receio de serem rotuladas escondem esse segredo por debaixo dos panos amarrados na cintura, as capulanas. Outro aspecto relevante é que na sociedade moçambicana a construção social de gênero está baseada na submissão feminina. Esse contexto tem influência direta sobre a vulnerabilidade feminina durante o casamento, gestação e parto, e sobre as práticas preventivas à infecção do HIV e o uso de métodos contraceptivos. Destaca-se ainda a presença de práticas culturais arraigadas que também exercem influência sobre o parto, que tem de ser realizado em casa, por outra mulher e caso haja alguma intercorrência é porque a esposa foi infiel ao marido e está sendo castigada pelos espíritos. Esta pesquisa é uma etnografia da Fístula Obstétrica em Moçambique. Tendo como objetivo analisar, não tanto as questões biomédicas da doença, mas mais substancialmente com o desejo de compreendermos se, e em que medida, o ambiente hospitalar se constitui como um espaço social caracterizado pelas relações de poder e que reproduz as relações de gênero e o controle sob os corpos femininos presentes na sociedade moçambicana.

In Mozambique, although there is a reduction in maternal mortality from 1,300 deaths / 100,000 births in 1990 to 480 / 100,000 in 2012, it is still a serious health problem (Pathfinder, 2016). The high maternal mortality rates are correlated with the high prevalence of Obstetric Fistula cases. It is estimated that for every woman who dies in pregnancy / childbirth, thirty suffer from acute complications, are chronic or disabling diseases (Bergstrom, 2002: 16). According to the Mozambican Ministry of Health in 2013, approximately one million births were performed in the country, the of which resulted in at least two thousand new cases ofFistula.Obstetric Fistula is an abnormal communication between the bladder and the vagina due to the destruction of pelvic tissues by compression of the fetal head during labor. Causing constant loss of urine and / or feces through the vagina, destruction of urinary organs and in some cases the inability to walk or have children. If the physical pain of the disease were not enough, they also suffer from the blame for losing their child, who usually dies during childbirth. Being abandoned by their husbands, they live as dead women walking, isolated due to the foul odor they exude (Ahmed and Holtz, 2007). Afraid of being labeled, they hide this secret under the cloth tied around their waist, the capulanas.Another relevant aspect is that in Mozambican society the social construction of gender is based on female submission. This context has a direct influence on female vulnerability during marriage, pregnancy and childbirth and on HIV prevention practices and the use of contraceptive methods. Also noteworthy is the presence of ingrained cultural practices that also influence the birth, which has to be performed at home, by another woman and if there is any complication, it is because the wife has been unfaithful to her husband and is being punished by the spirits.This research is an ethnography of Obstetric Fistula in Mozambique. Having as its objective to analyze, not so much the biomedical questions of the disease, but more substantially with the desire to understand if, and to what extent, the hospital environment is constituted as a social space characterized by the relations of power and that reproduces the relations of gender and control over the female bodies present in Mozambican society.

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

OBJECTIVE: To identify the barriers faced by women living with obstetric fistula in low-income countries that prevent them from seeking care, reaching medical centres and receiving appropriate care. METHODS: Bibliographic databases, grey literature, journals, and network and organisation websites were searched in English and French from June to July 2014 and again from August to November 2016 using key search terms and specific inclusion and exclusion criteria for discussion of barriers to fistula treatment. Experts provided recommendations for additional sources. RESULTS: Of 5829 articles screened, 139 were included in the review. Nine groups of barriers to treatment were identified: psychosocial, cultural, awareness, social, financial, transportation, facility shortages, quality of care and political leadership. Interventions to address barriers primarily focused on awareness, facility shortages, transportation, financial and social barriers. At present, outcome data, though promising, are sparse and the success of interventions in providing long-term alleviation of barriers is unclear. CONCLUSION: Results from the review indicate that there are many barriers to fistula treatment, which operate at the individual, community and national levels. The successful treatment of obstetric fistula may thus require targeting several barriers, including depression, stigma and shame, lack of community-based referral mechanisms, financial cost of the procedure, transportation difficulties, gender power imbalances, the availability of facilities that offer fistula repair, community reintegration and the competing priorities of political leadership.

Pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa: Scoping Review.

OBJECTIVE: To synthesise the evidence on pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa and to identify the existing knowledge gaps. METHODS: A scoping review of studies reporting on pregnancy and childbirth in women who underwent repair for obstetric fistula in sub-Saharan Africa was conducted. We searched relevant articles published between 1 January 1970 and 31 March 2016, without methodological or language restrictions, in electronic databases, general Internet sources and grey literature. RESULTS: A total of 16 studies were included in the narrative synthesis. The findings indicate that many women in sub-Saharan Africa still desire to become pregnant after the repair of their obstetric fistula. The overall proportion of pregnancies after repair estimated in 11 studies was 17.4% (ranging from 2.5% to 40%). Among the 459 deliveries for which the mode of delivery was reported, 208 women (45.3%) delivered by elective caesarean section (CS), 176 women (38.4%) by emergency CS and 75 women (16.3%) by vaginal delivery. Recurrence of fistula was a common maternal complication in included studies while abortions/miscarriage, stillbirths and neonatal deaths were frequent foetal consequences. Vaginal delivery and emergency C-section were associated with increased risk of stillbirth, recurrence of the fistula or even maternal death. CONCLUSION: Women who get pregnant after repair of obstetric fistula carry a high risk for pregnancy complications. However, the current evidence does not provide precise estimates of the incidence of pregnancy and pregnancy outcomes post-repair. Therefore, studies clearly assessing these outcomes with the appropriate study designs are needed.

Factors associated with loss to follow-up in women undergoing repair for obstetric fistula in Guinea.

OBJECTIVES: To analyse the trend of loss to follow-up over time and identify factors associated with women being lost to follow-up after discharge in three fistula repair hospitals in Guinea. METHODS: This retrospective cohort study used data extracted from medical records of fistula repairs conducted from 1 January 2007 to 30 September 2013. A woman was considered lost to follow-up if she did not return within 4 months post-discharge. Factors associated with loss to follow-up were identified using a subsample of the data covering the period 2010-2013. RESULTS: Over the study period, the proportion of loss to follow-up was 21.5% (448/2080) and varied across repair hospitals and over time with an increase from 2% in 2009 to 52% in 2013. After adjusting for other variables in a multivariate logistic regression model, women who underwent surgery at Labe hospital and at Kissidougou hospital were more likely to be lost to follow-up than women operated at Jean Paul II hospital (OR: 50.6; 95% CI: 24.9-102.8) and (OR: 11.5; 95% CI: 6.1-22.0), respectively. Women with their fistula closed at hospital discharge (OR: 3.2; 95% CI: 2.1-4.8) and women admitted for repair in years 2011-2013 showed higher loss to follow-up as compared to 2010. Finally, loss to follow-up increased by 2‰ for each additional kilometre of distance a client lived from the repair hospital (OR: 1.002; 95% CI: 1.001-1.003). CONCLUSION: Reimbursement of transport was the likely reason for change over time of LTFU. Reducing geographical barriers to care for women with fistula could sustain fistula care positive outcomes.

Rehabilitation experiences after obstetric fistula repair: systematic review of qualitative studies.

OBJECTIVES: To synthesise evidence on women's experiences surrounding rehabilitation and reintegration after obstetric fistula repair in sub-Saharan Africa and explore recommendations from women and health service providers. METHOD: Systematic literature review of qualitative studies surrounding rehabilitation experiences of women in sub-Saharan Africa who have undergone obstetric fistula repair. Using a pre-defined search strategy, seven databases, relevant source publications and grey literature were searched for primary qualitative studies. Data from ten studies were collected, and thematic analysis based on the framework approach was used to analyse the findings. RESULTS: The most important rehabilitating factor for women was fulfilment of social roles. Health service perspectives were more frequent than women's perspectives. Counselling and health education were the most common recommendations from both perspectives. CONCLUSION: Little qualitative evidence is available on rehabilitation after obstetric fistula repair in sub-Saharan Africa. Counselling services and community health education are priorities. Further research should emphasise women's perspectives to better inform interventions aimed at addressing the physical and social consequences of obstetric fistula.

Good clinical outcomes from a 7-year holistic programme of fistula repair in Guinea.

OBJECTIVES: Female genital fistula remains a public health concern in developing countries. From January 2007 to September 2013, the Fistula Care project, managed by EngenderHealth in partnership with the Ministry of Health and supported by USAID, integrated fistula repair services in the maternity wards of general hospitals in Guinea. The objective of this article was to present and discuss the clinical outcomes of 7 years of work involving 2116 women repaired in three hospitals across the country. METHODS: This was a retrospective cohort study using data abstracted from medical records for fistula repairs conducted from 2007 to 2013. The study data were reviewed during the period April to August 2014. RESULTS: The majority of the 2116 women who underwent surgical repair had vesicovaginal fistula (n = 2045, 97%) and 3% had rectovaginal fistula or a combination of both. Overall 1748 (83%) had a closed fistula and were continent of urine immediately after surgery. At discharge, 1795 women (85%) had a closed fistula and 1680 (79%) were dry, meaning they no longer leaked urine and/or faeces. One hundred and fifteen (5%) remained with residual incontinence despite fistula closure. Follow-up at 3 months was completed by 1663 (79%) women of whom 1405 (84.5%) had their fistula closed and 80% were continent. Twenty-one per cent were lost to follow-up. CONCLUSION: Routine programmatic repair for obstetric fistula in low resources settings can yield good outcomes. However, more efforts are needed to address loss to follow-up, sustain the results and prevent the occurrence and/or recurrence of fistula.