POG in Press, March 2017 Demographic profile and treatment outcomes of 100 women with obstetric fistula in Niger Alison Heller, Ph.D.1 Keywords: Niger, obstetric fistula, West Africa, stigma Abstract: commonly portrayed. Additionally, it was more difficult for women to access surgical repair and that repair was less successful than women Introduction: Due to high fertility rates, low themselves anticipated. Notably, the quality of access to emergency obstetric care, and the care varied considerably between the four fistula poor quality of that care, obstetric fistula is centers. Long waits combined with poor surgical relatively widespread in Niger. outcomes often resulted in negative social outcomes for women. Methods: Mixed-methods research was carried out over a total of eighteen months with 100 1University of Maryland College Park, women with fistula at four fistula centers in Department of Anthropology, College Park, MD Niger, three in the capital of Niamey and outside the city of Maradi. Introduction Results: The one hundred women who made up the research sample reflect marked diversity in Obstetric fistula, a maternal childbirth ethnicity, age, marital situation, parity, length of injury that results in chronic time living with fistula, and surgical history and incontinence, affects an estimated 1 to outcomes. At the time of initial interviews women 3.5 million women in resource-poor ranged from 15-70 years old (average 1,2 31.0±10.6), but had developed fistula from 13-54 countries. Obstetric fistula is caused years old (average 23.4 ±8.4). Women had lived by prolonged, obstructed labor with fistula between 1 month to 50 years unrelieved by medical intervention such (average 6.7 years ±8.6). At initial interview, as cesarean section. The protracted women waited an average of 5.8 months (±9.9) pressure of the fetal head against a while living at fistula centers, ranging from 2 weeks to 6 years. At the end of the research woman’s pelvic tissues produces an period, only 22 of the 61 women who underwent ischemic injury that leads to fistula surgeries during the research period (36%) formation between the vagina and attained continence. The remaining 39 women bladder and/or between the vagina and (64%) were still incontinent. rectum, resulting in chronic incontinence Conclusions: Women with fistula in Niger’s of urine and/or feces. There has been clinics are more demographically diverse than no need for a specialized fistula hospital Please cite this paper as: Heller A. Demographic profile and treatment outcomes of 100 women with obstetric fistula in Niger. POG in Press. 2017 March; Article 2 [15 p.]. Available from: http://ir.uiowa.edu/pog_in_press/. Free full text article. Corresponding author: Alison Heller, Ph.D., University of Maryland College Park, Department of Anthropology, 1111 Woods Hall, 4302 Chapel Drive, College Park, MD 20742, (301) 405-1423, [email protected] Financial Disclosure: The author received a small research grant from Worldwide Fistula Fund in 2012. Copyright: © 2017 Heller. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1 POG in Press, March 2017 in the United States for over 100 years. of formalized education, rural residence, Yet, due to high fertility rates, low and poverty. However, women with access to emergency obstetric care, and fistula in Niger are also diverse in their the generally-poor quality of that care, age, parity, marital status, and their obstetric fistula is relatively widespread experiences living with fistula. Women in much of sub-Saharan Africa, seeking treatment for their fistulas in particularly in the West African country Niger generally have poor surgical of Niger. Niger has the world’s highest outcomes and experience long wait- total fertility rate of 7.6 births per times at fistula centers. There is, woman3 and is ranked by the United however, a marked diversity in the Nations Development Programme quality of care between fistula centers in 188/188, situating it as the least Niger. developed country in the world.4 This confluence of pronatalism and poverty Materials & Methods results in predictably poor maternal health outcomes. This fieldwork was carried out over the course of one year (2013) plus two In Niger, 1 in 23 women are expected to additional summers (2011, 2014) at four die in their lifetimes from pregnancy- fistula centers. Three centers were related causes.5 For every woman who located in Niger’s capital of Niamey dies from obstetric complications in (l’Hôpital National de Lamordé, Centre Niger, approximately ten more suffer National de Reference des Fistules from severe acute maternal morbidity.6 Obstétricale [CNRFO], and Dimol), and Obstructed labor, the cause of obstetric one was located about 500 miles east of fistula, is the leading cause of maternal the capital in a rural area approximately morbidity in Niger.6 Although there are 20 miles north of the Nigerian border few reliable estimates, Niger is believed (the Danja Fistula Center). Two centers to have one of the highest rates of were state-run (Lamordé and CNRFO) obstetric fistula incidence in the world, and two were privately-funded and run between 700 and 800 new cases per (Danja and Dimol). year.7,8 Although historically inaccessible to women, fistula repair This study adopted a mixed-methods surgeries are becoming more accessible approach to data collection. Information in much of Niger and throughout sub- was gathered on marital and Saharan Africa due to a relatively recent reproductive histories as well as fistula increase in international attention, and treatment-seeking experiences. interest, and funding. Quantitative data were captured through multiple standardized surveys. These This article examines the demographic included a comprehensive demographic and ethnic profile of 100 women seeking survey and a modified version of the treatment at four fistula centers in rural HIV/AIDS Stigma Instrument, or HASI- and urban Niger. Specifically, the P, used to measure fistula-related social 9 findings related to women’s reproductive stigma. Qualitative data were captured and marital histories, as well as their through a breadth of standard clinical experiences, are analyzed. ethnographic methodologies including Women in Niger have similar participant observation, focus groups, demographics with respect to their lack and most-importantly, in-depth Obstetric fistula in Niger 2 POG in Press, March 2017 interviews with one hundred women with external apparatus or technology) and fistula as well as with thirty-eight family did not include clinical diagnoses. As members, husbands, and fistula most people in rural Niger do not professionals. prioritize tracking their or their children’s ages, many do not report them Although attempts were made to include accurately or consistently. When a diverse range of experiences, the inconsistencies arose, ages were sample was not universal. Women were triangulated. purposively sampled based on a range of factors including linguistic abilities, Interviews were voice recorded and familiarity and comfort with researcher, surveys were collected using paper and desire to participate. Clinical forms and recorded and stored in a diagnosis was not an inclusion criterion Microsoft Excel database. Textual data (as Dimol did not have access to such as interview notes and field notes qualified specialists), neither was age were transcribed, systematically coded, nor nationality. Family members, and analyzed using the qualitative husbands, and fistula professionals analysis software package MAXQDA. were purposively sampled based on a range of factors including linguistic Results ability, desire to participate, access (for family members, distance from home to The one hundred women in the study fistula center), and specialized are relatively homogeneous in knowledge (for experts). educational attainment, rural residence, and religion. All of the women identified Interviews and surveys were conducted as Muslim, and all but three came from after comprehensive informed oral rural villages. However, these women consent. This study was approved by also reflect marked diversity in ethnicity, the Institutional Review Board of age, marital situation, parity, length of Washington University in St. Louis, le time living with fistula, and surgical Comité Consultatif National d'Ethique du history and outcomes. The 100 women Niger, and le Ministère des sampled represented six ethnic groups, Enseignements Moyen et Supérieur et and all results are reported by ethnic de la Recherche Scientifique du Niger. identification. All interviews were conducted in Hausa, Zarma, or French by the Compared to many West African author/researcher (all Zarma and some countries, Niger is relatively ethnically Hausa interviews were facilitated by a homogenous, composed of only seven research assistant for translation). main ethnic groups. According to the Although Tuareg, Fulani, Kanuri, and 2010 Nigerien Government census, the Mossinke women were also included in largest ethnic group in Niger is the the research, they were multi-lingual in Hausa, constituting more than half either Hausa or Zarma. (56%) of Niger’s population, followed by the Zarma, or the closely associated Women’s surgical outcomes were ethnic group, the Songhai (21% of the limited to self-reported experiences of population). Both the Hausa and Zarma continence (as defined by the ability to are sedentary farmers, living primarily in hold urine without the use of any the arable southern tier of Niger Obstetric fistula in Niger 3 POG in Press, March 2017 (although the Zarma live predominantly women identified as Hausa). in the west of the country while the Hausa regions are found in the central Table 1 shows the basic demographic and east of Niger). The remainder of characteristics of the 100 women in the Nigerien people are nomadic, semi- sample. At the time of initial interview, nomadic, or historically nomadic women ranged from 15-70 years old, pastoralists, including the Tuareg with an average age of 31.0 (±10.6).