Sociocultural values are the foundation of African community life. These values are transmitted from generation to generation, often implicitly, without a deep understanding of the people involved. Thus, our exploratory qualitative research on barriers to the social reintegration of obstetric fistula patients allowed us to identify two types of barriers.
Ignorance about urogenital fistula causes
Cultural practices during childbirth and lack of awareness about possible consequences of early pregnancy and childbirth at home create the perfect conditions for the occurrence of fistula. Among communities included in our study, childbirth is interpreted as a natural process that does not require medical attention. In any case, medical assistance is not mandatory. To ensure that the pregnancy progresses well, the woman carries out prenatal consultations, and in these stages, she can do it alone. Her status as a married woman takes away her rights to decide about her health care, but nevertheless, as far as the monitoring of the pregnancy is concerned, those who can decide about her health are not necessarily against it, because on one hand it is free of charge and on the other hand it is just an assistance and a monitoring without interventions.
When it comes to the delivery stage, the decision to go to the health center is taken by the family-in-law (who is supposed to provide financially if needed). For many of the fistula-bearing women we interviewed, delivery was begun at home in the presence of elderly women who were supposed to be in control. The reasons for this practice were the cultural beliefs such as “delivery will proceed normally without the need for outside intervention if the woman is loyal to her husband and her new family” and the closure of health centers due to insecurity. These women were often married around the age of 13 to 16 and had their pregnancies at the origin of the fistula in this age range. In the communities of women we reached, urogenital fistulas were largely unknown and perceived as a punishment from God or a curse. The fact that they did not know this pathology contributed creates the propagation of harmful beliefs and behaviors that stigmatize and exclude the bearer. Attitude and perception associated to religion was also registered as a barrier to living in community.
The smells linked to the permanent leakage of urine are considered very unbearable for those around them (when they express themselves) or lead to denigrating behavior even without verbalizations. In some cases, the carrier herself feels uncomfortable remaining “in the middle of the community” with her disease.
Also, needing assistance when you’re supposed to be the caregiver leads to exclusion, low self-esteem, or violence. We have grouped the roots causes of social exclusion in a diagram representing a problem tree.
The solution requires putting ourselves in the position of the community view to generate sustainable actions
Social exclusion when one has acquired a urogenital fistula as revealed during our study is the reflection of an intersectionality of gender-based violence causes which are due to a woman’s role and decision-making power.
As the world struggles to give decision-making power to women, in our remote communities, this power is taken away from women to protect them. Indeed, the fathers we approached justify early arranged marriages as a necessary way to prevent pregnancies of unknown or unwanted fathers, or the extreme poverty of families. In a context of recurrent security conflicts, the belief that arranged marriages consolidate community ties and alliances favor the perpetuation of these practices and undermines the application of sexual and reproductive health rights of populations. Women and girls are those who are martyr to help the whole community.
From an inclusive perspective and to manage the problem in all its complexity, the root causes of fistula and fistula-related social stigma must be addressed through solutions generated with the participation of communities. There is an identified need to reinforce the community understanding on obstetric fistulas and women’s sexual and reproductive health rights. Social reinsertion of women with obstetric fistulas requires education on women’s sexual and reproductive health rights that is centered on socio-cultural values and deconstructs damaging beliefs.