Experiences and Consequences of Stigmatization on Women Living with Obstetric Fistula within the Greater Banjul Area of The Gambia

Experiences and Consequences of Stigmatization on Women Living with Obstetric Fistula within the Greater Banjul Area of The Gambia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Experiences and Consequences of Stigmatization on Women Living with Obstetric Fistula within the Greater Banjul Area of The Gambia Fatou Khan, Thomas Senghore This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7302806/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Background Motherhood should be a time of expectation and enjoyment. However, for women, particularly in developing countries, the reality of motherhood is often unattractive. These women experience lots of morbid situations during the normal life-enhancing process of reproduction. Obstetric fistula is an abnormal opening between the vagina and the bladder or rectum, referred to as Vesico-Vaginal Fistula (VVF), Recto-Vaginal Fistula (RVF), respectively, resulting in nonstop and unremitting urinary or faecal incontinence. Obstetric fistulas are both a health and social concern. The resulting stigmatization affects the woman’s body image and psychosocial well-being. This study aimed to explore the experiences and consequences of stigma on women living with obstetric fistula within the Greater Banjul area of the Gambia. Methods A descriptive phenomenological method was used. Participants were recruited using purposive sampling. A sample size of 12 participants was recruited. Participants were recruited in the EFSTH and Bafrow Medical Centre. Data was collected through in-depth interviews using an interview guide. Inductive analysis was employed, and results were presented in themes. Results The findings of this study reveal that women experience various types of stigmatizations: Internalized stigma (self-devaluation, low self-esteem, and lack of self-confidence), insecurity, anticipated stigma (fear of being humiliated by others), and enacted stigma (verbal abuse from people, disrupted sex, sexual dissatisfaction). The consequences of these stigmatizations on the survivors were adapting to new routines, self-isolation, fear of being divorced or physically abused by a partner, and psychological trauma. Conclusion The study showed that women with obstetric fistula experience different forms of stigma, which exposes them to several negative psychosocial consequences. Therefore, there is a need for timely management of these conditions to avoid stigmatization and the negative consequences on the victims. Additionally, education and sensitization of survivors and their family members in the communities will help reduce the stigma attached. Experience Stigmatization Obstetric fistula Women Background Motherhood should be a time of expectation and joy. However, for women, particularly in developing countries, the reality of motherhood is often unattractive [ 1 ]. These women experience lots of morbid situations during the normal and life-enhancing process of reproduction [ 1 ]. One of these morbid experiences is obstetric fistula. Obstetric fistula is an abnormal opening between the vagina and the bladder, referred to as Vesico-Vaginal Fistula (VVF), and/or between the vagina and rectum, called Recto-Vaginal Fistula (RVF), resulting in nonstop and unremitting urinary or faecal incontinence [ 5 , 10 ]. This morbidity is a result of prolonged obstructed labour, which has not been treated on time by caesarean section [ 10 ]. The effect of obstetric fistula is multidimensional, having negative experiences and consequences. The experiences grossly affect her body image, expression of sexuality, and ability to socialize for fear of stigmatization [ 6 ]. According to the World Health Organization [ 2 ], each year between 50,000 and 100,000 women worldwide are affected by obstetric fistula, and there are more than 2 million women with the condition in sub-Saharan Africa and South Asia. They further stated that the development of obstetric fistula is directly linked to one of the major causes of maternal mortality: obstructed labour, poor obstetric care, and lack of timely intervention [ 2 ]. Obstetric fistula can have a detrimental impact on women's physical, psychosocial, and economic well-being [ 1 ]. Survivors of obstetric fistula often experience a sense of powerlessness, physical injury, emotional breakdown, depression, divorce, erosion of social capital, and loss of healthy years [ 13 ]. Abandonment by their husbands and stigmatization by the community [ 3 ]. Social isolation and abandonment can result in low self-esteem, depression, and prolonged emotional trauma [ 10 ]. A study done in The Gambia revealed a prevalence rate of obstetric fistula is 0.5 to 2.05 per 1000 [ 9 , 7 ]. Although stigmatization is a commonly reported social consequence among women with obstetric fistula, there is inadequate knowledge on how it is exactly experienced by women with obstetric fistula [ 8 ]. Having a deeper understanding of the consequences centered on lived experiences from the southern Ethiopia setting related to the consequences of the condition, including social isolation, stigma, and economic hardship [ 4 , 10 ]. In The Gambia, contrary to Southern Ethiopia, obstetric fistula is under-researched, and there is no research has been done to assess the experiences and the consequences of the stigmatization of women living with obstetric fistulas. Therefore, this study aimed to explore the experiences and socioeconomic consequences of stigmatization among women living with obstetric fistula in the Greater Banjul area of The Gambia. The purpose of this study is to investigate the experiences and consequences of obstetric fistula among women who receive care in West Coast Region I of the Gambia. The findings will be utilized to provide recommendations and support policy formulation and implementation to enhance the quality of life of women affected by obstetric fistula, and aid in their reintegration into their communities. As no prior research has been conducted on this topic in the Gambia, this study will contribute to the existing knowledge and improve the quality of life of fistula survivors by promoting their empowerment and integration into society. Methodology A phenomenological research method was used in this study. This study was conducted at Edward Francis Small Teaching Hospital (EFSTH) and The Gambia Foundation for Research on Women's Health, Productivity and the Environment (BAFROW) Medical Centre. These are the two institutions that provide services to obstetric fistula survivors. EFSTH is the main government referral and teaching hospital in The Gambia with about 547 beds. The hospital has ten departments under its purview: (Polyclinic, Psychiatric (Tankatanka), Ndemban clinic, Medical, Surgical, ICU, Domestic, laboratory, Pharmaceutical, and Obstetrics and Gynaecology. The Obstetrics & Gynaecology department serves as the main unit for the care and management of obstetric and gynecological complications, including obstetric fistula identification, diagnosis, and repairs. Likewise, BAFROW is an NGO established in July 1991 and was registered as a charitable trust in 1992. The civil society organization’s main areas of focus are on women's social empowerment, health, environmental issues, and economic welfare. The organization runs a Medical Centre (BAFROW Medical Centre), which provides clinical care, including surgical treatment of obstetric fistulas. The Centre, in collaboration with UNICEF, The Gambia, runs a programme that helps to integrate OF victims back into society. Study population The study population comprises women with obstetric fistula who were registered at the obstetric fistula clinics in EFSTH and BAFROW Medical Centre. Inclusion and Exclusion Criteria Women with obstetric fistula who have registered at the service Centers and can be interviewed irrespective of all ages, marital status, tribes, religions, nationalities, and are willing to take part in the study. Any woman who was not mentally fit and those who were not willing to participate were excluded from the study. Sampling method Participants were sampled purposively from the two hospitals. The hospitals’ obstetric fistula registers were viewed, and those who were registered (discharged or on the waiting list for surgery) were recruited to take part in the study. Using phone contact on the register, those already discharged were called by phone to determine their willingness to participate, and an appointment was made for a meeting to be held either at their home or at the hospital where they were registered. Those admitted at the time of recruitment were met at the Gynae Ward of the EFSTH to determine their willingness. There were no patients admitted at BAFROW during the data collection period, and therefore, participants were called to the clinic for data collection. Sample size and justification Due to the limited number of patients with fistula registered at the two study sites, a sample of 12 participants was recruited. This was deemed sufficient because quality is driven by exploration, and to understand a phenomenon being studied, a small sample size is sufficient. Other similar studies have used similar sample sizes, and saturation principles were followed [ 3 , 1 ]. Data collection tool The data were collected using a Key Informant Interview (KII) and focus group discussions (FGD). One interview guide was used to collect information from both the KII and FGD participants. The KII interview was done individually, and the following sections were explored: participant biographic data, forms of stigma experience, and the consequences of living with OF. In the FGD, the participants were asked the same questions, and participants were put into two groups of three and interviewed. This guide was developed by the researchers and used to answer the research objectives and to suit the research setting. The credibility and trustworthiness of the tool, a phase validity, was validated by the authors of the tool. For the current researcher to ascertain credibility and trustworthiness, a reflexive journal was kept to write the researcher’s thoughts, attentive listening to the interviewed data, probing and asking relevant questions related to the topic were done, and followed by further exploration of questions until data was saturated. Data collection procedure The data collection procedure took place at the clinic where participants were recruited for those who were admitted at the time of recruitment and those who opted to be interviewed at the clinic. The participants who were discharged at the time of recruitment were called to arrange the interview. Following that, some who could not come to the hospital or clinic were followed to their homes and interviewed. While those in the FGD similarity, were called and meetings were arranged at the hospitals where they were interviewed in two groups. However, those in the KII who opted out either did not allow the researcher to visit them in their homes or could not come to the hospital were excluded. Two sets of interviews were conducted; in the KII interview, the participants’ information was read to participants who could not read English and understand, or ask a question. For those who can read in English and understand it was given to them to read and ask questions or clarification if they have any. Following their understanding and willingness to participate, a consent form was issued for them to sign or thumbprint. FDG interview, the same participant information was read to them to determine their understanding and clarification if there were any. Subsequently, they signed or thumb-printed the consent form if they agreed to partake in the study. Focus group discussion (FGD) Two FGDs were carried out. A group of three women of different ages and ethnicities was recruited. An enclosed room was identified where these group discussions took place, as a sensitive issue was discussed. The participants were reassured that the collected audio data would not be shared for any reason. Rules were set as each member was given a number and only asked to talk when asked. The FGD guide focused on the forms of stigma experienced and the consequences of living with fistula. Each FDG lasted for about 1–2 hours and was audio-recorded with permission from the participants and coded accordingly. The participants had some emotional flashbacks, which were very emotional; however, these feelings were resolved by positively reassuring them of their condition. Key informant Three KIIs were conducted in the hospital and three at-home settings. For those who had the interview in the hospital, a room was provided for the interview, while for those at home, the participant provided a safe and calm place to be interviewed. Participants were selected purposely, and their questions were based on the forms of stigma experiences and consequences of living with obstetric fistula. The interview lasted for about 35–45 minutes, and the interview was recorded with the participant's permission and coded accordingly. Negative sentiments from emotional flashbacks were positively reassured about their condition. Analysis procedure The audio-recorded data was translated from the local languages to English. The English transcripts were used for analysis. The process was guided by a thematic analysis approach that was both realistic and inductive (Burnard et al., 2008). This method was used to analyze the transcribed interview using a matrix table. The participant's responses were grouped to form meaning units within the text. A meaning unit contains information or text that relates to the research objectives (Burnard et al., 2008). After the meaning units were grouped, initial codes were assigned to each meaningful unit, which was then followed by a process during which sub-themes from the initial codes were created. Finally, these sub-themes were condensed into four themes: internalized, anticipated, and enacted stigmatization and the consequences of stigmatization. Results Table 1 presents the identification and interview methods of the participants. A total of 12 women diagnosed with obstetric fistula were interviewed. Table 1 Demographic and Fistula Characteristics (n = 12) Variable n % Age 18–35 5 42 36–70 7 58 Marital Status Married 8 67 Divorce 2 17 Remarried 1 8 Widow 1 8 Fistula Occurrence 1st Pregnancy 6 50 2nd Pregnancy 1 8 3rd Pregnancy 2 16 4th Pregnancy 1 8 5th Pregnancy 2 16 The majority were between the ages of 36 to 70 (58%) and were still married at the time of the study (n = 8). In half of the participants (n = 6, 50%), obstetric fistula occurred in the first pregnancy. The summary of participants’ characteristics is presented in Table 1 . Forms of stigmatization experiences Table 2 below shows the different types of stigma experienced by the study participants and their consequences. The sub-themes that emerged from the women's experiences were feelings of self-devaluation or worthlessness, insecurity, fear of being humiliated, sexual dissatisfaction, disruptive sex life, and verbal harassment (gossiping & backbiting). Whereas the themes experienced were internalized, anticipated, and enacted. The consequences of these stigmas were adapting to new routines, self-isolation, and anxiety. Table 2 Themes and sub-themes on women's experiences living with fistula Research Objectives Themes Sub-theme Types of stigma experienced identified Internalized Stigma Feeling of worthlessness Insecurity Anticipated stigma Fear of being humiliated Enact stigma Gossip, verbal abuse Sexual dissatisfaction Destructive sex life Consequences of stigma Coping mechanism Adaptation of a new routine Self-Isolation Psychological concern Fear of the unknown (anxiety) Depression From the experiences described, several themes emerged regarding the types of stigma experienced by these women. The first identified experience was the Internalized/ perceived stigma. Many participants expressed experiences of worthlessness or felt devalued due to their condition. Many of the participants reported feeling guilty that they aren't worth anything in society, as they cannot engage in any meaningful activities without people knowing their condition. One of the participants expresses this in the following quotation “I always have the belief that people around me always talk bad about me that I don’t want. This has made me develop low self-esteem about myself. This has also made me lose my self-confidence and pride in society.” (Participant 12, Age 27) Many of the study participants stated it was difficult for them to execute their religious rites because of their disorder. They said they believe that they cannot perform their religious activities, such as praying, touching the holy Quran or joining the religious gathering, as they would want to. They expressed that they felt unclean as a result of uncontrolled leakage of urine and or faeces, as lamented by one of a participant in the following quote: “... since I have no control over my urine, faeces or flatus, my ablution doesn’t remain intact for a long time, and sometimes while praying before I even finish, I will pass gas or leak urine. I’m always afraid that my prayers will be invalid ....” (Participant 9, Age 45). Another participant reported: “I do not go to the mosque or Madrassa because I am afraid to defile these places and I may be humiliated by the person next to me…” (Participant 4, Age 70). Anticipated stigma refers to the degree of fear in which individuals expect that others will stigmatize them if they know about the demeaning attribute or characteristic they presented or have. In this type of stigmatization, women fear being humiliated or backbiting, verbally abused, or discriminated against. In Anticipated stigmatization, the sub-themes identified are as follows in subsequent paragraphs and quotations: Most of the participants in the study had experienced some degree of anticipated stigma as they were fearful that others would degrade, humiliate, or isolate them if people discovered their conditions. “I am always afraid that someone will know I have this problem, and if that happens, they may humiliate me in front of my husband's family members, who may use this as a tool to always say bad words to me….” (Participant 7, Age 35). Women shared a variety of experiences such as sexual dissatisfaction, disruptive sex life, abandonment/ divorce, verbal harassment, and avoiding social contact. These were expressed as: “ My husband always finds it difficult to have sexual intercourse with me because I am Continuously leaking either faces or urine….” (Participant 6, Age 36) Some women in this study reported that they have been gossiped at when they go out within their community, including in marketplaces. This has caused them to stay home and not interact with other community members. Many women reported experiencing verbal abuse by other women when they went to gatherings. They are often called "wetting women" or "smelling women". One participant further expresses that although this condition is against the social norms of their community, it was not their making. As highlighted in the quote below: “I am always hearing people talking badly about my condition, which has made me always dissociate myself from people, and for others not to humiliate me in front of my peers, but people should know this thing can happen to anyone (Participant 6, Age 36). Another woman stated that she always heard negative comments from her neighbors whenever she went out. As reported in the following quote: “The dirty woman is coming or has just passed, doesn’t she take bath to prevent this bad odor or use body spray” (Participant 3, Age 18) Another worrying concern was their disrupted sex life as they reported that they were seldom displeased with sexual intercourse, and they tried to dodge it because of the excretion of either urine /faces or flatus during copulation. “ Lacking control over my urine, faeces, and flatus, to be candid, this disease destroyed my entire life. It’s very unpleasant or uncomfortable to be suffering from such filth, as I cannot have any smooth sexual intercourse or sexual relationship with my husband, which has affected me negatively” (Participant,5 Age 45). On the other hand, only a few participants testified that their partners accepted them with their fistula as they (husbands) believed that they are partially responsible for the development of the disorder as expressed by a participant in the following quotes: “My husband used to tell me not to be sad about this problem because the problem has occurred because of me wanting children. If you were not pregnant for me this problem would not have happened. There were instances where other people would tell him many things like, “Why are you keeping this cursed woman? Why can’t you marry another woman? There are many clean women around and so but he used to tell them, “I found my wife in good condition before I married her, so if I accept the situation, no one can make me change my decision towards her.” (Participant 3, Age 18). Some of the women were divorced because of disruptive sexual relations with their partners. These divorced women reported that they had a very troubled relationship with their husbands. One of the women lamented that, if she had not gotten married and become pregnant, she wouldn't have had the fistula. She further stated that even after receiving surgical repair, she cannot get married because of the fear of having the fistula recur. This was expressed in the following quote: “In my previous marriage, I always had problems with my sexual relationship with my husband, and this has been the number one reason I was divorced. however, now that I have the repair, I am still afraid to get married and have babies” (Participant 6, Age 35) Another participant testified that, although she is not divorced, her husband doesn't have any sexual intercourse with her since she had the fistula. She narrated that: “After the delivery of my son, I had both air (flatus) and water (urine)coming out of my private parts all the time. Since then, my husband and I haven't had any sexual contact….” (Participant 7, Age 35) Consequences of obstetric fistula The consequences of obstetric fistula for participants in this study were an adaptation to a new routine, self-isolation, or withdrawal. Fear of the unknown or being divorced results in depression and anxiety, stemming from stigma. These coping mechanisms were expressed as follows; Adaptation of new routines has been reported by most of the participants. Many reported hiding their condition by frequently washing and changing cloth pads as well as frequently showering and applying deodorant to themselves, which has become part of their daily routine activities. As a result, they said they worked tirelessly to hide their disorder from others or adjust to maintain proper hygiene, which is so demanding for them. These were lamented in the quote below; “I have to get lots of clothes, as I cannot afford a sanitary pad. I use these clothes every time and change them frequently as I visit the toilet. I do it every time to avoid getting wet. Also, to avoid bad smells coming from me I have to take a bath five to six times in the day just to clean myself and apply spray, which I feel is very difficult…” (Participant 9, Age 50) In some instances, stated by a participant stated that she has to completely avoid social gatherings such as weddings/naming ceremonies, funeral ceremonies, markets, and any other social places, which in her mind could potentially lead her to involuntarily disclose her problem. This is revealed by a respondent in the quotation below: “I could not manage to stay in a group; I have to be honest. Because it can happen that I am putting on a cloth pad, which could be wet or stained. If it is not thick enough, I may leak urine, which means I have exposed myself to people; everyone will laugh at me or point fingers at me. Also, because of this, I need to frequently take baths to keep myself clean and odor free, and I find this to be a burden”. (Participant 2, Age 38) Another coping method reported was social isolation, as most of the participants reported that they were withdrawn from their community. In addition, a participant stated that they are not treated as clean women when they go to a gathering, and this has made them self-isolated because they cannot stand the harassment of being pointed at as “wetting women”. This comment was expressed as follows; “I don’t go anywhere, even our next-door house or compound, because if I go out, they may say I'm leaking or wet. Maybe they may even say I always urinate on myself and sometimes they gossip against me which I always notice when I pass by”. This has made me always want to be alone in my house without anyone.” (Participant 1, Age 18) The findings from this study also revealed that they are always in constant fear that something bad might happen to them because of the obstetric fistula. Their main concerns were the chance of them being divorced or abused by their partners because they could not fulfil their marital obligations, and they think they are useless in this relationship. This concern has been stated by this participant: “ I always feel that someday something bad will happen to my marriage or I will be beaten by my husband if I refuse to have sexual intercourse with him because of this problem.’ (Participant 11, Age 36) Another participant gave the following response: “I try to hide my problem so that nobody notices I am suffering from fistula and because of that, I bear whatever my husband does to me as he sometimes beats or slaps me when we get into an argument.” (Participant 8, Age 45) Depression and anxiety have been reported by many of the participants as psychological problems affecting them while living with an obstetric fistula. Almost all the participants have reported that they have gone through various stressful situations in their marital relationships. This affected them negatively, both emotionally and mentally. “No one can live like this, and you don’t feel bad . Sometimes I tell myself if I had not gotten pregnant, I would have not got this problem and the worst is when I cannot think of anything positive for myself because where will I go and not be ashamed” (Participant 2, Age 38). Additionally, another participant also reported that she sometimes feels so sad that when she eats food, it tastes like sand to her. She sometimes has suicidal ideations. However, she further lamented that these thoughts are quickly cleared from her mind because of her religious belief in God, and she believes that one day her condition will be resolved. Her quote is found below: “ Sometimes, I want to commit suicide because I am tired of this condition. But because I believe in God and I am a Muslim, killing myself will not help solve the problem, so I bear with it until the end.” (Participant 3, Age 18). Discussion This study aimed to explore the experience and consequences of women living with obstetric fistula. The findings of the study revealed that these women experienced three types of stigma with several consequences resulting from the Obstetric Fistula. Types of stigma experienced In this study, women with obstetric fistula experience a distinct form of stigma, which is internalized or perceived stigma, in which they hold negative beliefs and feelings towards themselves and fear humiliation if their condition is disclosed. This is in line with a study done by Changole et al. [ 3 ] and Animut et al. [ 10 ] on women's experience of obstetric fistula in Malawi and Ethiopia, respectively. This, they said, can result in self-discrimination, shame, dejection, insecurity, and feelings of guilt and inferiority without any basis for justification [ 10 ]. Furthermore, the findings of this study show that women also experienced anticipated stigma. This refers to the degree of fear, in which individuals expect that others will stigmatize them if they know about the demeaning attribute or characteristic they have. In this study, women anticipated that they would be humiliated by their friends and relatives because of the obstetric fistula. This is in line with the study conducted by Ahmed and Thorsen [ 1 ] in Khartoum, Sudan, and Huraissa, Koricha, and Dadi [ 11 ] in Ethiopia, who reported that their participants were also manifesting similar thoughts. Similarly, according to Changole et al. [ 3 ] in their study on women's experiences of obstetric fistula in Malawi, reported that all their participants experienced more anticipated stigma because of the fear they expected from others due to their genitourinary abnormalities. Huraisaa, Koricha, and Dadi [ 11 ] equally reported that women with obstetric fistula also experience anticipated stigma, which refers to the expectation of discrimination or prejudice in the future. As a result of these, the victims will always be in constant fear of being humiliated by others. The implication of such behavior on the participant will cause the victims to be stigmatized, as they will always be in constant fear. These fears can be reduced if timely interventions are available for victims. Also, enacted stigma refers to the experience of discrimination due to a stigmatizing condition. This can manifest in the form of gossiping or verbal abuse towards the affected individuals. Ahmed and Thorsen [ 1 ], Huraisaa et al [ 11 ], reported that women had experienced enacted stigma, being constantly subjected to name-calling that degraded them. The study findings also show that the women experienced sexual dissatisfaction and had a disrupted sex life. This finding is in line with a study by Bashah et al. [ 4 ], where their result reveals that almost all the participants reported disrupted sex life and sexual dissatisfaction. Another study, a systematic review by Bashah et al [ 6 ], Animut et al. [ 10 ] in Ethiopia, showed that women with obstetric fistula had disrupted sexual relationships, which led to divorce. However, the finding from Dannis et al. [ 12 ] reveals that despite the disrupted sexual life, their participants were not divorced and instead were supported by their husbands/ family members. This present study also found that regardless of the participant leaking either or both urine and feces, many were in their marital relationship. Therefore, the implications for enacting stigma are numerous, as the survivors are frequently discriminated against both emotionally and psychologically. Consequences of obstetric fistula The consequences of obstetric fistula for participants in this study were numerous. One significant consequence was the need to adapt to new routines. The women in the study reported frequently washing and changing pads, showering, and applying deodorant. Similar findings have been reported in other studies [ 6 , 10 , 3 ]. Strategies for addressing internalized stigma, such as identifying coping resources, building resilience, and treating health problems, are important mechanisms [ 11 ]. For example, preventing and promptly treating fistula cases can reduce the impact on victims. According to previous research, women with obstetric fistula may resort to self-isolation as a coping mechanism due to the shame associated with their disorder [ 1 , 11 ]. These studies have reported that these women often impose isolation on themselves or limit contact with family and friends. Depression and anxiety are major consequences shown in this study. A study conducted in Ethiopia reported that women experienced a stressful situation that affected them both emotionally and psychologically [ 13 ]. The consequence of living with an obstetric fistula causes depression and anxiety, which limits the survivor's involvement in productive engagements. Conclusion The study highlights the stigma experienced by women with obstetric fistulas, which includes internalized, anticipated, and enacted stigma. The consequences of these stigmas were adapting to a new routine, depression, and anxiety, emphasizing the need for creating awareness and advocating for prevention and prompt treatment of survivors. The recommendations include further studies to explore the outcome of treatment, nationwide studies to understand fistula-related stigma, and education and sensitization of women and their communities to prevent stigma. Creating awareness, advocating for prevention and prompt treatment of survivors, and educating and sensitizing women and their communities to prevent stigma are crucial. Further studies are required to explore the outcome of treatment, nationwide studies to understand fistula-related stigma, and strategies and policies should be put in place to help women with obstetric fistula. The study's limitations include not exploring the causes of obstetric fistula, not comparing experiences before and after repair, and limited generalizability due to the study's design setting. Despite the study's limitations, it contributes to the body of knowledge on obstetric fistulas in the Gambia and highlights the need for concerted efforts to address the issue. The strength of the study is that it is the first to explore the life experiences and consequences of women with obstetric fistula within the Greater Banjul Area of the Gambia. Abbreviations BAFROW Gambia Foundation for Research on Women’s Health, Productivity and the Environment EFSTH Edward Francis Small Teaching Hospital FGD Focus Group Discussion FG Focus Group FF Face to Face GBoS Gambia Bureau of Statistics NGO Non-Governmental Organization OF Obstetric Fistula RePubiC Research and Publication Committee RVF Recto- Vaginal Fistula UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund VVF Vesico-Vaginal Fistula WHO World Health Organization Declarations Ethics approval and consent to participate Ethical and scientific approval was received from the Gambia Government/MRC Joint Ethics Committee and the Research and Publication Committee (RePubliC) of the School of Medicine and Allied Health Sciences, respectively, with approval number EFSTH_REC_2022_086. Permission to conduct the study was also obtained from EFSTH and BAFROW Medical Centre. Written informed consent was sought from the participants, and the purpose of the research was well explained before obtaining consent. Participants were assured of confidentiality and privacy. Participation was voluntary, and individuals could choose to leave at any time or not participate at all. This study was performed in line with the tenets of the Declaration of Helsinki. Consent for publication Participants provided consent for publication and participation Availability of data and materials Data will be made available upon request Competing interests No competing interests Funding There was no funding for this study Authors' contributions All authors contributed to the manuscript and read and approved the final manuscript. Acknowledgements We would like to thank the participants, EFSTH, and BAFROW Medical Centre administrations. 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Consequences of obstetric fistula in sub-Saharan African countries, from patients’ perspective: a systematic review of qualitative studies. BMC women's health. 2018 Jun 20; 18(1):106. UNFPA. Zero Fistula Gambia Campaign to empower women and bring hope to communities 2022 Online: https://gambia.unfpa.org/en/news/zero-fistula-gambia-campaign-empower-women-and-bring-hope-communities Wall LL. Tears for my sisters: the tragedy of obstetric fistula. JHU Press; 2018 Jan 15. https://books.google.gm/books?id=COdFDwAAQBAJ&lpg=PR7&ots=p-hXnlCOYg&dq=Tears%20for% 20My%20Sisters%3A%20The%20Tragedy%20of%20Obstetric%20Fistula%3B%20&lr&pg=PR10#v=onepage&q&f=false Bizunesh T. Tamirat, Situational Analysis of Obstetric Fistula in The Gambia, WHO Report 2007 Animut M, Mamo A, Abebe L, Berhe MA, Asfaw S, Birhanu Z. “The sun keeps rising but darkness surrounds us”: a qualitative exploration of the lived experiences of women with obstetric fistula in Ethiopia. BMC women's health. 2019 Feb 26; 19(1):37. Hurissa BF, Koricha ZB, Dadi LS. Challenges and coping mechanisms among women living with unrepaired obstetric fistula in Ethiopia: A phenomenological study. PLoS ONE. 2022 Sep 29; 17(9): e0275318. Dennis AC, Wilson SM, Mosha MV, Masenga GG, Sikkema KJ, Terroso KE, Watt MH. Experiences of social support among women presenting for obstetric fistula repair surgery in Tanzania. International journal of women's health. 2016 Sep 6:429-39. Gebrselassie YT. A qualitative study of the experience of obstetric fistula survivors in Addis Ababa, Ethiopia. International journal of women's health. 2014 Dec 8:1033-43. Additional Declarations No competing interests reported. Supplementary Files PARTICIPANTINTERVIEWGUIDE.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 Aug, 2025 Submission checks completed at journal 08 Aug, 2025 First submitted to journal 08 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7302806","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498810365,"identity":"71b74411-627d-459a-8f7a-22fd6b9e58a5","order_by":0,"name":"Fatou Khan","email":"data:image/png;base64,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","orcid":"","institution":"The Gambia College","correspondingAuthor":true,"prefix":"","firstName":"Fatou","middleName":"","lastName":"Khan","suffix":""},{"id":498810366,"identity":"fe302720-dc38-4eaf-a809-1fe4e12f3fe9","order_by":1,"name":"Thomas Senghore","email":"","orcid":"","institution":"University of the Gambia","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Senghore","suffix":""}],"badges":[],"createdAt":"2025-08-05 16:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7302806/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7302806/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88870971,"identity":"216518c5-fae3-476c-a892-1bdd2e2c3434","added_by":"auto","created_at":"2025-08-12 09:19:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":682538,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7302806/v1/2abe5687-5250-492a-a43b-856c43774a65.pdf"},{"id":88870544,"identity":"6b3ae4bc-7454-4a17-980c-e8c526581847","added_by":"auto","created_at":"2025-08-12 09:11:23","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":196975,"visible":true,"origin":"","legend":"","description":"","filename":"PARTICIPANTINTERVIEWGUIDE.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7302806/v1/bc9850940d91d7c1055e48ec.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Experiences and Consequences of Stigmatization on Women Living with Obstetric Fistula within the Greater Banjul Area of The Gambia","fulltext":[{"header":"Background","content":"\u003cp\u003eMotherhood should be a time of expectation and joy. However, for women, particularly in developing countries, the reality of motherhood is often unattractive [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These women experience lots of morbid situations during the normal and life-enhancing process of reproduction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. One of these morbid experiences is obstetric fistula. Obstetric fistula is an abnormal opening between the vagina and the bladder, referred to as Vesico-Vaginal Fistula (VVF), and/or between the vagina and rectum, called Recto-Vaginal Fistula (RVF), resulting in nonstop and unremitting urinary or faecal incontinence [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This morbidity is a result of prolonged obstructed labour, which has not been treated on time by caesarean section [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe effect of obstetric fistula is multidimensional, having negative experiences and consequences. The experiences grossly affect her body image, expression of sexuality, and ability to socialize for fear of stigmatization [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. According to the World Health Organization [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], each year between 50,000 and 100,000 women worldwide are affected by obstetric fistula, and there are more than 2\u0026nbsp;million women with the condition in sub-Saharan Africa and South Asia. They further stated that the development of obstetric fistula is directly linked to one of the major causes of maternal mortality: obstructed labour, poor obstetric care, and lack of timely intervention [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eObstetric fistula can have a detrimental impact on women's physical, psychosocial, and economic well-being [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Survivors of obstetric fistula often experience a sense of powerlessness, physical injury, emotional breakdown, depression, divorce, erosion of social capital, and loss of healthy years [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Abandonment by their husbands and stigmatization by the community [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Social isolation and abandonment can result in low self-esteem, depression, and prolonged emotional trauma [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA study done in The Gambia revealed a prevalence rate of obstetric fistula is 0.5 to 2.05 per 1000 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although stigmatization is a commonly reported social consequence among women with obstetric fistula, there is inadequate knowledge on how it is exactly experienced by women with obstetric fistula [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Having a deeper understanding of the consequences centered on lived experiences from the southern Ethiopia setting related to the consequences of the condition, including social isolation, stigma, and economic hardship [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn The Gambia, contrary to Southern Ethiopia, obstetric fistula is under-researched, and there is no research has been done to assess the experiences and the consequences of the stigmatization of women living with obstetric fistulas. Therefore, this study aimed to explore the experiences and socioeconomic consequences of stigmatization among women living with obstetric fistula in the Greater Banjul area of The Gambia.\u003c/p\u003e\u003cp\u003e The purpose of this study is to investigate the experiences and consequences of obstetric fistula among women who receive care in West Coast Region I of the Gambia. The findings will be utilized to provide recommendations and support policy formulation and implementation to enhance the quality of life of women affected by obstetric fistula, and aid in their reintegration into their communities. As no prior research has been conducted on this topic in the Gambia, this study will contribute to the existing knowledge and improve the quality of life of fistula survivors by promoting their empowerment and integration into society.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eA phenomenological research method was used in this study. This study was conducted at Edward Francis Small Teaching Hospital (EFSTH) and The Gambia Foundation for Research on Women's Health, Productivity and the Environment (BAFROW) Medical Centre. These are the two institutions that provide services to obstetric fistula survivors. EFSTH is the main government referral and teaching hospital in The Gambia with about 547 beds. The hospital has ten departments under its purview: (Polyclinic, Psychiatric (Tankatanka), Ndemban clinic, Medical, Surgical, ICU, Domestic, laboratory, Pharmaceutical, and Obstetrics and Gynaecology. The Obstetrics \u0026amp; Gynaecology department serves as the main unit for the care and management of obstetric and gynecological complications, including obstetric fistula identification, diagnosis, and repairs.\u003c/p\u003e\u003cp\u003eLikewise, BAFROW is an NGO established in July 1991 and was registered as a charitable trust in 1992. The civil society organization\u0026rsquo;s main areas of focus are on women's social empowerment, health, environmental issues, and economic welfare. The organization runs a Medical Centre (BAFROW Medical Centre), which provides clinical care, including surgical treatment of obstetric fistulas. The Centre, in collaboration with UNICEF, The Gambia, runs a programme that helps to integrate OF victims back into society.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy population\u003c/h2\u003e\u003cp\u003eThe study population comprises women with obstetric fistula who were registered at the obstetric fistula clinics in EFSTH and BAFROW Medical Centre.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eInclusion and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eWomen with obstetric fistula who have registered at the service Centers and can be interviewed irrespective of all ages, marital status, tribes, religions, nationalities, and are willing to take part in the study. Any woman who was not mentally fit and those who were not willing to participate were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eSampling method\u003c/h3\u003e\n\u003cp\u003e Participants were sampled purposively from the two hospitals. The hospitals\u0026rsquo; obstetric fistula registers were viewed, and those who were registered (discharged or on the waiting list for surgery) were recruited to take part in the study. Using phone contact on the register, those already discharged were called by phone to determine their willingness to participate, and an appointment was made for a meeting to be held either at their home or at the hospital where they were registered. Those admitted at the time of recruitment were met at the Gynae Ward of the EFSTH to determine their willingness. There were no patients admitted at BAFROW during the data collection period, and therefore, participants were called to the clinic for data collection.\u003c/p\u003e\n\u003ch3\u003eSample size and justification\u003c/h3\u003e\n\u003cp\u003eDue to the limited number of patients with fistula registered at the two study sites, a sample of 12 participants was recruited. This was deemed sufficient because quality is driven by exploration, and to understand a phenomenon being studied, a small sample size is sufficient. Other similar studies have used similar sample sizes, and saturation principles were followed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eData collection tool\u003c/h3\u003e\n\u003cp\u003eThe data were collected using a Key Informant Interview (KII) and focus group discussions (FGD). One interview guide was used to collect information from both the KII and FGD participants. The KII interview was done individually, and the following sections were explored: participant biographic data, forms of stigma experience, and the consequences of living with OF. In the FGD, the participants were asked the same questions, and participants were put into two groups of three and interviewed. This guide was developed by the researchers and used to answer the research objectives and to suit the research setting. The credibility and trustworthiness of the tool, a phase validity, was validated by the authors of the tool. For the current researcher to ascertain credibility and trustworthiness, a reflexive journal was kept to write the researcher\u0026rsquo;s thoughts, attentive listening to the interviewed data, probing and asking relevant questions related to the topic were done, and followed by further exploration of questions until data was saturated.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData collection procedure\u003c/h2\u003e\u003cp\u003eThe data collection procedure took place at the clinic where participants were recruited for those who were admitted at the time of recruitment and those who opted to be interviewed at the clinic. The participants who were discharged at the time of recruitment were called to arrange the interview. Following that, some who could not come to the hospital or clinic were followed to their homes and interviewed. While those in the FGD similarity, were called and meetings were arranged at the hospitals where they were interviewed in two groups. However, those in the KII who opted out either did not allow the researcher to visit them in their homes or could not come to the hospital were excluded. Two sets of interviews were conducted; in the KII interview, the participants\u0026rsquo; information was read to participants who could not read English and understand, or ask a question. For those who can read in English and understand it was given to them to read and ask questions or clarification if they have any. Following their understanding and willingness to participate, a consent form was issued for them to sign or thumbprint. FDG interview, the same participant information was read to them to determine their understanding and clarification if there were any. Subsequently, they signed or thumb-printed the consent form if they agreed to partake in the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eFocus group discussion (FGD)\u003c/h3\u003e\n\u003cp\u003eTwo FGDs were carried out. A group of three women of different ages and ethnicities was recruited. An enclosed room was identified where these group discussions took place, as a sensitive issue was discussed. The participants were reassured that the collected audio data would not be shared for any reason. Rules were set as each member was given a number and only asked to talk when asked. The FGD guide focused on the forms of stigma experienced and the consequences of living with fistula. Each FDG lasted for about 1\u0026ndash;2 hours and was audio-recorded with permission from the participants and coded accordingly. The participants had some emotional flashbacks, which were very emotional; however, these feelings were resolved by positively reassuring them of their condition.\u003c/p\u003e\n\u003ch3\u003eKey informant\u003c/h3\u003e\n\u003cp\u003eThree KIIs were conducted in the hospital and three at-home settings. For those who had the interview in the hospital, a room was provided for the interview, while for those at home, the participant provided a safe and calm place to be interviewed. Participants were selected purposely, and their questions were based on the forms of stigma experiences and consequences of living with obstetric fistula. The interview lasted for about 35\u0026ndash;45 minutes, and the interview was recorded with the participant's permission and coded accordingly. Negative sentiments from emotional flashbacks were positively reassured about their condition.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis procedure\u003c/h2\u003e\u003cp\u003eThe audio-recorded data was translated from the local languages to English. The English transcripts were used for analysis. The process was guided by a thematic analysis approach that was both realistic and inductive (Burnard et al., 2008). This method was used to analyze the transcribed interview using a matrix table. The participant's responses were grouped to form meaning units within the text. A meaning unit contains information or text that relates to the research objectives (Burnard et al., 2008). After the meaning units were grouped, initial codes were assigned to each meaningful unit, which was then followed by a process during which sub-themes from the initial codes were created. Finally, these sub-themes were condensed into four themes: internalized, anticipated, and enacted stigmatization and the consequences of stigmatization.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the identification and interview methods of the participants. A total of 12 women diagnosed with obstetric fistula were interviewed.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and Fistula Characteristics (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026ndash;35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36\u0026ndash;70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMarital Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorce\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRemarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWidow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eFistula Occurrence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1st Pregnancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2nd Pregnancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3rd Pregnancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4th Pregnancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5th Pregnancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe majority were between the ages of 36 to 70 (58%) and were still married at the time of the study (n\u0026thinsp;=\u0026thinsp;8). In half of the participants (n\u0026thinsp;=\u0026thinsp;6, 50%), obstetric fistula occurred in the first pregnancy. The summary of participants\u0026rsquo; characteristics is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eForms of stigmatization experiences\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below shows the different types of stigma experienced by the study participants and their consequences. The sub-themes that emerged from the women's experiences were feelings of self-devaluation or worthlessness, insecurity, fear of being humiliated, sexual dissatisfaction, disruptive sex life, and verbal harassment (gossiping \u0026amp; backbiting). Whereas the themes experienced were internalized, anticipated, and enacted. The consequences of these stigmas were adapting to new routines, self-isolation, and anxiety.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and sub-themes on women's experiences living with fistula\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResearch Objectives\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSub-theme\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eTypes of stigma experienced identified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInternalized Stigma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFeeling of worthlessness\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInsecurity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnticipated stigma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFear of being humiliated\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnact stigma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGossip, verbal abuse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSexual dissatisfaction\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDestructive sex life\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eConsequences of stigma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCoping mechanism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdaptation of a new routine\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSelf-Isolation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePsychological concern\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFear of the unknown (anxiety)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFrom the experiences described, several themes emerged regarding the types of stigma experienced by these women. The first identified experience was the Internalized/ perceived stigma. Many participants expressed experiences of worthlessness or felt devalued due to their condition. Many of the participants reported feeling guilty that they aren't worth anything in society, as they cannot engage in any meaningful activities without people knowing their condition. One of the participants expresses this in the following quotation\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I always have the belief that people around me always talk bad about me that I don\u0026rsquo;t want. This has made me develop low self-esteem about myself. This has also made me lose my self-confidence and pride in society.\u0026rdquo; (Participant 12, Age 27)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMany of the study participants stated it was difficult for them to execute their religious rites because of their disorder. They said they believe that they cannot perform their religious activities, such as praying, touching the holy Quran or joining the religious gathering, as they would want to. They expressed that they felt unclean as a result of uncontrolled leakage of urine and or faeces, as lamented by one of a participant in the following quote:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;... \u003cem\u003esince I have no control over my urine, faeces or flatus, my ablution doesn\u0026rsquo;t remain intact for a long time, and sometimes while praying before I even finish, I will pass gas or leak urine. I\u0026rsquo;m always afraid that my prayers will be invalid ....\u0026rdquo; (Participant 9, Age 45).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother participant reported:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I do not go to the mosque or Madrassa because I am afraid to defile these places and I may be humiliated by the person next to me\u0026hellip;\u0026rdquo; (Participant 4, Age 70).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnticipated stigma refers to the degree of fear in which individuals expect that others will stigmatize them if they know about the demeaning attribute or characteristic they presented or have. In this type of stigmatization, women fear being humiliated or backbiting, verbally abused, or discriminated against. In Anticipated stigmatization, the sub-themes identified are as follows in subsequent paragraphs and quotations: Most of the participants in the study had experienced some degree of anticipated stigma as they were fearful that others would degrade, humiliate, or isolate them if people discovered their conditions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;I am always afraid that someone will know I have this problem, and if that happens, they may humiliate me in front of my husband's family members, who may use this as a tool to always say bad words to me\u0026hellip;.\u0026rdquo; (Participant 7, Age 35).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWomen shared a variety of experiences such as sexual dissatisfaction, disruptive sex life, abandonment/ divorce, verbal harassment, and avoiding social contact. These were expressed as:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eMy husband always finds it difficult to have sexual intercourse with me because I am\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eContinuously leaking either faces or urine\u0026hellip;.\u0026rdquo; (Participant 6, Age 36)\u003c/h2\u003e\u003cp\u003eSome women in this study reported that they have been gossiped at when they go out within their community, including in marketplaces. This has caused them to stay home and not interact with other community members. Many women reported experiencing verbal abuse by other women when they went to gatherings. They are often called \"wetting women\" or \"smelling women\". One participant further expresses that although this condition is against the social norms of their community, it was not their making. As highlighted in the quote below:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I am always hearing people talking badly about my condition, which has made me always dissociate myself from people, and for others not to humiliate me in front of my peers, but people should know this thing can happen to anyone (Participant 6, Age 36).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother woman stated that she always heard negative comments from her neighbors whenever she went out. As reported in the following quote:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The dirty woman is coming or has just passed, doesn\u0026rsquo;t she take bath to prevent this bad odor or use body spray\u0026rdquo; (Participant 3, Age 18)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother worrying concern was their disrupted sex life as they reported that they were seldom displeased with sexual intercourse, and they tried to dodge it because of the excretion of either urine /faces or flatus during copulation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eLacking control over my urine, faeces, and flatus, to be candid, this disease destroyed my entire life. It\u0026rsquo;s very unpleasant or uncomfortable to be suffering from such filth, as I cannot have any smooth sexual intercourse or sexual relationship with my husband, which has affected me negatively\u0026rdquo; (Participant,5 Age 45).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOn the other hand, only a few participants testified that their partners accepted them with their fistula as they (husbands) believed that they are partially responsible for the development of the disorder as expressed by a participant in the following quotes:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My husband used to tell me not to be sad about this problem because the problem has occurred because of me wanting children. If you were not pregnant for me this problem would not have happened. There were instances where other people would tell him many things like, \u0026ldquo;Why are you keeping this cursed woman? Why can\u0026rsquo;t you marry another woman? There are many clean women around and so but he used to tell them, \u0026ldquo;I found my wife in good condition before I married her, so if I accept the situation, no one can make me change my decision towards her.\u0026rdquo; (Participant 3, Age 18).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome of the women were divorced because of disruptive sexual relations with their partners. These divorced women reported that they had a very troubled relationship with their husbands. One of the women lamented that, if she had not gotten married and become pregnant, she wouldn't have had the fistula. She further stated that even after receiving surgical repair, she cannot get married because of the fear of having the fistula recur. This was expressed in the following quote:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In my previous marriage, I always had problems with my sexual relationship with my husband, and this has been the number one reason I was divorced. however, now that I have the repair, I am still afraid to get married and have babies\u0026rdquo; (Participant 6, Age 35)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother participant testified that, although she is not divorced, her husband doesn't have any sexual intercourse with her since she had the fistula. She narrated that:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;After the delivery of my son, I had both air (flatus) and water (urine)coming out of my private parts all the time. Since then, my husband and I haven't had any sexual contact\u0026hellip;.\u0026rdquo; (Participant 7, Age 35)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eConsequences of obstetric fistula\u003c/h2\u003e\u003cp\u003eThe consequences of obstetric fistula for participants in this study were an adaptation to a new routine, self-isolation, or withdrawal. Fear of the unknown or being divorced results in depression and anxiety, stemming from stigma. These coping mechanisms were expressed as follows;\u003c/p\u003e\u003cp\u003eAdaptation of new routines has been reported by most of the participants. Many reported hiding their condition by frequently washing and changing cloth pads as well as frequently showering and applying deodorant to themselves, which has become part of their daily routine activities. As a result, they said they worked tirelessly to hide their disorder from others or adjust to maintain proper hygiene, which is so demanding for them. These were lamented in the quote below;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have to get lots of clothes, as I cannot afford a sanitary pad. I use these clothes every time and change them frequently as I visit the toilet. I do it every time to avoid getting wet. Also, to avoid bad smells coming from me I have to take a bath five to six times in the day just to clean myself and apply spray, which I feel is very difficult\u0026hellip;\u0026rdquo; (Participant 9, Age 50)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn some instances, stated by a participant stated that she has to completely avoid social gatherings such as weddings/naming ceremonies, funeral ceremonies, markets, and any other social places, which in her mind could potentially lead her to involuntarily disclose her problem. This is revealed by a respondent in the quotation below:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I could not manage to stay in a group; I have to be honest. Because it can happen that I am putting on a cloth pad, which could be wet or stained. If it is not thick enough, I may leak urine, which means I have exposed myself to people; everyone will laugh at me or point fingers at me. Also, because of this, I need to frequently take baths to keep myself clean and odor free, and I find this to be a burden\u0026rdquo;. (Participant 2, Age 38)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother coping method reported was social isolation, as most of the participants reported that they were withdrawn from their community. In addition, a participant stated that they are not treated as clean women when they go to a gathering, and this has made them self-isolated because they cannot stand the harassment of being pointed at as \u0026ldquo;wetting women\u0026rdquo;. This comment was expressed as follows;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t go anywhere, even our next-door house or compound, because if I go out, they may say I'm leaking or wet. Maybe they may even say I always urinate on myself and sometimes they gossip against me which I always notice when I pass by\u0026rdquo;. This has made me always want to be alone in my house without anyone.\u0026rdquo; (Participant 1, Age 18)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe findings from this study also revealed that they are always in constant fear that something bad might happen to them because of the obstetric fistula. Their main concerns were the chance of them being divorced or abused by their partners because they could not fulfil their marital obligations, and they think they are useless in this relationship. This concern has been stated by this participant:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI always feel that someday something bad will happen to my marriage or I will be beaten by my husband if I refuse to have sexual intercourse with him because of this problem.\u0026rsquo; (Participant 11, Age 36)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother participant gave the following response: \u003cem\u003e\u0026ldquo;I try to hide my problem so that nobody notices I am suffering from fistula and because of that, I bear whatever my husband does to me as he sometimes beats or slaps me when we get into an argument.\u0026rdquo; (Participant 8, Age 45)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDepression and anxiety have been reported by many of the participants as psychological problems affecting them while living with an obstetric fistula. Almost all the participants have reported that they have gone through various stressful situations in their marital relationships. This affected them negatively, both emotionally and mentally.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;No \u003cem\u003eone can live like this, and you don\u0026rsquo;t feel bad\u003c/em\u003e. \u003cem\u003eSometimes I tell myself if I had not gotten pregnant, I would have not got this problem and the worst is when I cannot think of anything positive for myself because where will I go and not be ashamed\u0026rdquo; (Participant 2, Age 38).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, another participant also reported that she sometimes feels so sad that when she eats food, it tastes like sand to her. She sometimes has suicidal ideations. However, she further lamented that these thoughts are quickly cleared from her mind because of her religious belief in God, and she believes that one day her condition will be resolved. Her quote is found below:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eSometimes, I want to commit suicide because I am tired of this condition. But because I believe in God and I am a Muslim, killing myself will not help solve the problem, so I bear with it until the end.\u0026rdquo; (Participant 3, Age 18).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore the experience and consequences of women living with obstetric fistula. The findings of the study revealed that these women experienced three types of stigma with several consequences resulting from the Obstetric Fistula.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eTypes of stigma experienced\u003c/h2\u003e\u003cp\u003eIn this study, women with obstetric fistula experience a distinct form of stigma, which is internalized or perceived stigma, in which they hold negative beliefs and feelings towards themselves and fear humiliation if their condition is disclosed. This is in line with a study done by Changole et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and Animut et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] on women's experience of obstetric fistula in Malawi and Ethiopia, respectively. This, they said, can result in self-discrimination, shame, dejection, insecurity, and feelings of guilt and inferiority without any basis for justification [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFurthermore, the findings of this study show that women also experienced anticipated stigma. This refers to the degree of fear, in which individuals expect that others will stigmatize them if they know about the demeaning attribute or characteristic they have. In this study, women anticipated that they would be humiliated by their friends and relatives because of the obstetric fistula. This is in line with the study conducted by Ahmed and Thorsen [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] in Khartoum, Sudan, and Huraissa, Koricha, and Dadi [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] in Ethiopia, who reported that their participants were also manifesting similar thoughts. Similarly, according to Changole et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] in their study on women's experiences of obstetric fistula in Malawi, reported that all their participants experienced more anticipated stigma because of the fear they expected from others due to their genitourinary abnormalities. Huraisaa, Koricha, and Dadi [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] equally reported that women with obstetric fistula also experience anticipated stigma, which refers to the expectation of discrimination or prejudice in the future.\u003c/p\u003e\u003cp\u003eAs a result of these, the victims will always be in constant fear of being humiliated by others. The implication of such behavior on the participant will cause the victims to be stigmatized, as they will always be in constant fear. These fears can be reduced if timely interventions are available for victims.\u003c/p\u003e\u003cp\u003eAlso, enacted stigma refers to the experience of discrimination due to a stigmatizing condition. This can manifest in the form of gossiping or verbal abuse towards the affected individuals. Ahmed and Thorsen [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], Huraisaa et al [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], reported that women had experienced enacted stigma, being constantly subjected to name-calling that degraded them.\u003c/p\u003e\u003cp\u003eThe study findings also show that the women experienced sexual dissatisfaction and had a disrupted sex life. This finding is in line with a study by Bashah et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], where their result reveals that almost all the participants reported disrupted sex life and sexual dissatisfaction. Another study, a systematic review by Bashah et al [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], Animut et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] in Ethiopia, showed that women with obstetric fistula had disrupted sexual relationships, which led to divorce.\u003c/p\u003e\u003cp\u003eHowever, the finding from Dannis et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reveals that despite the disrupted sexual life, their participants were not divorced and instead were supported by their husbands/ family members. This present study also found that regardless of the participant leaking either or both urine and feces, many were in their marital relationship. Therefore, the implications for enacting stigma are numerous, as the survivors are frequently discriminated against both emotionally and psychologically.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eConsequences of obstetric fistula\u003c/h2\u003e\u003cp\u003eThe consequences of obstetric fistula for participants in this study were numerous. One significant consequence was the need to adapt to new routines. The women in the study reported frequently washing and changing pads, showering, and applying deodorant. Similar findings have been reported in other studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Strategies for addressing internalized stigma, such as identifying coping resources, building resilience, and treating health problems, are important mechanisms [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. For example, preventing and promptly treating fistula cases can reduce the impact on victims.\u003c/p\u003e\u003cp\u003eAccording to previous research, women with obstetric fistula may resort to self-isolation as a coping mechanism due to the shame associated with their disorder [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These studies have reported that these women often impose isolation on themselves or limit contact with family and friends.\u003c/p\u003e\u003cp\u003eDepression and anxiety are major consequences shown in this study. A study conducted in Ethiopia reported that women experienced a stressful situation that affected them both emotionally and psychologically [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The consequence of living with an obstetric fistula causes depression and anxiety, which limits the survivor's involvement in productive engagements.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study highlights the stigma experienced by women with obstetric fistulas, which includes internalized, anticipated, and enacted stigma. The consequences of these stigmas were adapting to a new routine, depression, and anxiety, emphasizing the need for creating awareness and advocating for prevention and prompt treatment of survivors. The recommendations include further studies to explore the outcome of treatment, nationwide studies to understand fistula-related stigma, and education and sensitization of women and their communities to prevent stigma. Creating awareness, advocating for prevention and prompt treatment of survivors, and educating and sensitizing women and their communities to prevent stigma are crucial. Further studies are required to explore the outcome of treatment, nationwide studies to understand fistula-related stigma, and strategies and policies should be put in place to help women with obstetric fistula. The study's limitations include not exploring the causes of obstetric fistula, not comparing experiences before and after repair, and limited generalizability due to the study's design setting. Despite the study's limitations, it contributes to the body of knowledge on obstetric fistulas in the Gambia and highlights the need for concerted efforts to address the issue. The strength of the study is that it is the first to explore the life experiences and consequences of women with obstetric fistula within the Greater Banjul Area of the Gambia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBAFROW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGambia Foundation for Research on Women\u0026rsquo;s Health, Productivity and the Environment\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEFSTH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEdward Francis Small Teaching Hospital\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFGD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFocus Group Discussion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFocus Group\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFace to Face\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGBoS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGambia Bureau of Statistics\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNGO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNon-Governmental Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eObstetric Fistula\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRePubiC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eResearch and Publication Committee\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRVF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRecto- Vaginal Fistula\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUNFPA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Nations Population Fund\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUNICEF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Nations Children\u0026rsquo;s Fund\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVVF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVesico-Vaginal Fistula\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003eEthical and scientific approval was received from the Gambia Government/MRC Joint Ethics Committee and the Research and Publication Committee (RePubliC) of the School of Medicine and Allied Health Sciences, respectively,\u0026nbsp;with approval number EFSTH_REC_2022_086.\u0026nbsp;Permission to conduct the study was also obtained from EFSTH and BAFROW Medical Centre. Written informed consent was sought from the participants, and the purpose of the research was well explained before obtaining consent. Participants were assured of confidentiality and privacy. Participation was voluntary, and individuals could choose to leave at any time or not participate at all. This study was performed in line with the tenets of the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e Participants provided consent for publication and participation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e Data will be made available upon request\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e No competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e There was no funding for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u0026nbsp;All authors contributed to the manuscript and read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e We would like to thank the participants, EFSTH, and BAFROW Medical Centre administrations.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAhmed SA, Thorsen VC. \u0026ldquo;I feel myself incomplete, and I am inferior to people\u0026rdquo;: experiences of Sudanese women living with obstetric fistula in Khartoum, Sudan. Reproductive Health. 2019 Dec 21; 16(1):183.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization, 10 Facts on Obstetric Fistula 2018. Available online: https://www.who.int/features/factfiles/obstetric_fistula/en/\u003c/li\u003e\n \u003cli\u003eChangole J, Thorsen V, Trovik J, Kafulafula U, Sundby J. Coping with a disruptive life caused by obstetric fistula: perspectives from Malawian women. International Journal of Environmental Research and Public Health. 2019 Sep; 16(17):3092.\u003c/li\u003e\n \u003cli\u003eBashah DT, Worku AG, Yitayal M, Azale T. The loss of dignity: social experience and coping of women with obstetric fistula, in Northwest Ethiopia. BMC Women\u0026apos;s Health. 2019 Jul 1; 19(1):84.\u003c/li\u003e\n \u003cli\u003eRyan F. The \u0026lsquo;Typical Story\u0026rsquo;of Obstetric Fistula: The Need to Enhance Awareness, Action and Funds 2012 (Doctoral dissertation, Doctoral Dissertation (working paper)\u003c/li\u003e\n \u003cli\u003eBashah DT, Worku AG, Mengistu MY. Consequences of obstetric fistula in sub-Saharan African countries, from patients\u0026rsquo; perspective: a systematic review of qualitative studies. BMC women\u0026apos;s health. 2018 Jun 20; 18(1):106.\u003c/li\u003e\n \u003cli\u003eUNFPA. Zero Fistula Gambia Campaign to empower women and bring hope to communities 2022 Online: https://gambia.unfpa.org/en/news/zero-fistula-gambia-campaign-empower-women-and-bring-hope-communities\u003c/li\u003e\n \u003cli\u003eWall LL. Tears for my sisters: the tragedy of obstetric fistula. JHU Press; 2018 Jan 15. https://books.google.gm/books?id=COdFDwAAQBAJ\u0026amp;lpg=PR7\u0026amp;ots=p-hXnlCOYg\u0026amp;dq=Tears%20for%\u003cbr\u003e20My%20Sisters%3A%20The%20Tragedy%20of%20Obstetric%20Fistula%3B%20\u0026amp;lr\u0026amp;pg=PR10#v=onepage\u0026amp;q\u0026amp;f=false\u003c/li\u003e\n \u003cli\u003eBizunesh T. Tamirat, Situational Analysis of Obstetric Fistula in The Gambia, WHO Report 2007\u003c/li\u003e\n \u003cli\u003eAnimut M, Mamo A, Abebe L, Berhe MA, Asfaw S, Birhanu Z. \u0026ldquo;The sun keeps rising but darkness surrounds us\u0026rdquo;: a qualitative exploration of the lived experiences of women with obstetric fistula in Ethiopia. BMC women\u0026apos;s health. 2019 Feb 26; 19(1):37.\u003c/li\u003e\n \u003cli\u003eHurissa BF, Koricha ZB, Dadi LS. Challenges and coping mechanisms among women living with unrepaired obstetric fistula in Ethiopia: A phenomenological study. PLoS ONE. 2022 Sep 29; 17(9): e0275318.\u003c/li\u003e\n \u003cli\u003eDennis AC, Wilson SM, Mosha MV, Masenga GG, Sikkema KJ, Terroso KE, Watt MH. Experiences of social support among women presenting for obstetric fistula repair surgery in Tanzania. International journal of women\u0026apos;s health. 2016 Sep 6:429-39.\u003c/li\u003e\n \u003cli\u003eGebrselassie YT. A qualitative study of the experience of obstetric fistula survivors in Addis Ababa, Ethiopia. International journal of women\u0026apos;s health. 2014 Dec 8:1033-43.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Experience, Stigmatization, Obstetric fistula, Women","lastPublishedDoi":"10.21203/rs.3.rs-7302806/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7302806/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMotherhood should be a time of expectation and enjoyment. However, for women, particularly in developing countries, the reality of motherhood is often unattractive. These women experience lots of morbid situations during the normal life-enhancing process of reproduction. Obstetric fistula is an abnormal opening between the vagina and the bladder or rectum, referred to as Vesico-Vaginal Fistula (VVF), Recto-Vaginal Fistula (RVF), respectively, resulting in nonstop and unremitting urinary or faecal incontinence. Obstetric fistulas are both a health and social concern. The resulting stigmatization affects the woman\u0026rsquo;s body image and psychosocial well-being. This study aimed to explore the experiences and consequences of stigma on women living with obstetric fistula within the Greater Banjul area of the Gambia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA descriptive phenomenological method was used. Participants were recruited using purposive sampling. A sample size of 12 participants was recruited. Participants were recruited in the EFSTH and Bafrow Medical Centre. Data was collected through in-depth interviews using an interview guide. Inductive analysis was employed, and results were presented in themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe findings of this study reveal that women experience various types of stigmatizations: Internalized stigma (self-devaluation, low self-esteem, and lack of self-confidence), insecurity, anticipated stigma (fear of being humiliated by others), and enacted stigma (verbal abuse from people, disrupted sex, sexual dissatisfaction). The consequences of these stigmatizations on the survivors were adapting to new routines, self-isolation, fear of being divorced or physically abused by a partner, and psychological trauma.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe study showed that women with obstetric fistula experience different forms of stigma, which exposes them to several negative psychosocial consequences. Therefore, there is a need for timely management of these conditions to avoid stigmatization and the negative consequences on the victims. Additionally, education and sensitization of survivors and their family members in the communities will help reduce the stigma attached.\u003c/p\u003e","manuscriptTitle":"Experiences and Consequences of Stigmatization on Women Living with Obstetric Fistula within the Greater Banjul Area of The Gambia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-12 09:03:18","doi":"10.21203/rs.3.rs-7302806/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-11T13:18:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-08T13:07:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-08-08T13:04:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d441fbf3-e459-484e-b8e9-098f3fdd8099","owner":[],"postedDate":"August 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-04T14:08:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-12 09:03:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7302806","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7302806","identity":"rs-7302806","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}