Determinants of health seeking behaviour of women with obstetric fistula in south- south and south east, Nigeria: A review of the impact of availability and quality of health care services through a cross-sectional study

Background: Obstetric fi stula is a condition that results from obstructed labour, which occurs when the baby cannot pass through the mother’s birth canal because it either does not come head fi rst or is too large for her pelvis. Prompt medical intervention, often including Caesarean section, permits a safe delivery for both mother and child. Despite this possibility, yearly, thousands of women across the country receive no such aid and their labour is a futile agony lasting between three and fi ve days, with uterine contractions constantly forcing the baby, usually head fi rst, against the organs of the pelvic and unyielding pelvic bone resulting in Vesico Vaginal Fistula (VVF). The main thrust of this study was to examine how health system factors aff ect health seeking behaviour of women with obstetric fi stula in Akwa Ibom and Ebonyi States, Nigeria. Methods: Qualitative and descriptive research approaches were adopted for the study and a total sample of two hundred and sixteen (216) respondents comprising of one hundred and fi fty (150) post fi stula repair operative patients and sixty six (66) health workers were purposively selected using simple random techniques. The data were analyzed using thematic analysis and tables of frequency. Results: The respondents views showed that availability of treatment centre and quality of health care services infl uenced health seeking behaviour of women with obstetric fi stula in Nigeria. Conclusion: The study indicated that health seeking behaviour of women with obstetric fi stula is a major challenge in Nigeria. Establishment and proper equipment of obstetric fi stula treatment centres as well as subsidization of the cost of treatment to allow women with this health problem to access health care services are strongly recommended. Therefore, government at all level and non-governmental organizations need to educate the women and create awareness on the causes and dangers of VVF.


Introduction
Obstetric istula has become a serious health challenge in Nigeria in particular and the world at large. This occurs as a result of obstructed labour, when the baby cannot pass through the mother's birth canal because it either does not come head irst or is too large for her pelvis. Prompt medical intervention, often including Caesarean section, permits a safe delivery for both mother and child [1]. Despite this possibility, yearly, thousands of women across the country receive no such aid and their labour is a futile agony lasting between three and ive days, with uterine contractions constantly forcing the baby, usually head irst, against the organs of the pelvic and unyielding pelvic bone resulting in Vesico Vaginal Fistula (VVF).
This devastating and humiliating condition results mainly from obstruction of labour. In most of istula cases, delivery usually had occurred at home, was attended to by family members, unskilled birth attendants, or traditional midwives. On some occasions there were some attendants delay making a referral to an emergency obstetric facility. Obstetric istula presents as latulence, urinary or fecal incontinence (which may be continual or only happen at night), foul-smelling vaginal discharge, repeated vaginal or urinary tract infections, irritation or pain in the vagina or surrounding areas as well as pain during sexual activity [2].
Apart from continuous leakage of urine, vesico vaginal istula also often leaves its victims with foetal demise, cervical and pelvic damages, and neurological conditions such as foot-drop, urogenital infections, ammonia dermatitis, genital lacerations, kidney infections and amenorrhea. Obstetric istula has a negative toll on victims' family too [3]. For instance, family inances decline when a woman with the condition becomes incapacitated and rendered unemployable. Also, substantial costs are incurred in seeking treatment and in purchasing essential supplies such as soap, sanitary pad and perfumes to mask odour and maintain personal hygiene on a daily basis.
According to Adebayo [4], it is estimated that two million women suffer from obstetric istula globally, while the United Nations Children's Fund (UNICEF) also revealed that over 0.4 to 0.8 million women suffer from obstetric istula in Nigeria, ranking the country as having the highest prevalence of obstetric istula in the world [5]. In Ebonyi State of Nigeria, the United States Agency for International Development (USAID) reported that over 12,000 women are af licted with vesico vaginal istula with the State having the highest of over 3,000 cases [6]. While in Akwa Ibom State [7], revealed that the prevalence of vesico vaginal istula is high and pose a serious health problem not only in Uyo Local Government Area but also in Nigeria as a whole. The factors that commonly determine the health seeking behaviour of women with obstetric istula are multi-varied and hence, produce different results. Some of these factors include: religion, culture of the people, level of education/awareness of the women, availability of treatment centres and quality of health care services among others.
More distressing is the fact that from available reports, Nigeria has inadequate and un equal distribution of vesico vaginal istula specialists among areas or state where women are suffering from the disease [8]. There is also the problem of lack of treatment centres across the nation with northern part of the country having most of the centres while in the southern part of Nigeria only a handful of the centres exist which include National Fistula Centre, Abakaliki; University College Hospital, Ibadan and Family Life Centre, Mbreibit Itam which has no specialist Doctor in the hospital. That is why women with istula cannot walk into the hospital at any time for treatment except during the camp period where they are given appointment to meet the specialist Doctors who come from different hospitals and from different States voluntarily to offer humanitarian services. This may affect the health seeking behaviour of these women.
Despite the severity of the consequences of this major reproductive health challenge, little is known about the health seeking behaviour pattern of women with obstetric istula. Furthermore, there is a paucity of research on the community and health system factors and how they affect health seeking behaviour of women with this disease condition. It is against this backdrop, that this study seeks to examine how community factors such as availability of treatment centre, the distance from the environment to the treatment centre, the conditions of the road in addition to health system factors including quality of health care services, availability of quali ied health personnel (Specialist Doctors, Nurses) and modern equipment affect the health seeking behaviour of istula patients in Akwa Ibom and Ebonyi States of Nigeria.

Study design
The research design for the study was the cross-sectional study design.

Study location
The study was carried out in two locations: Family Life Centre, Mbiribit Itam, Uyo, Akwa Ibom State and the National Fistula Centre, Abakaliki which is located at Abakaliki/Enugu Way, Abakaliki, the State Capital because both are referral centres where cases of VVF are referred to for treatment. They are also research centres where proper records are kept for research.

Study population
The population of the study consisted of all the women with obstetric istula attending Family Life Centre, Mbreibit Itam, Uyo and National Fistula Centre, Abakaliki and all the health workers from both centres during the period of research January 2018 -January 2019.

Sample size
In a situation where the actual population size is in inite or cannot be accurately estimated, Bill's [9] opined that the in inite population sampling formula can be used to determine the sample size. The total number of VVF patients who attended Family Life Centre, Mbreibit Itam, Uyo was 300 women, out of which 250 women were operated upon (repair of istula) because they were it for the operation. The researcher through simple random technique selected 120 https://www.heighpubs.org/cjog 062 https://doi.org/10.29328/journal.cjog.1001088 women who gave their consent to participate in the study. At National Fistula Centre, Abakaliki, the number of VVF patients who visited the hospital during the period of research were 52 women, 30 were operated upon. The researcher conveniently selected all the 30 women because they all gave their consent to participate in the study. The health workers in both centres comprised of all the staff who work directly with these patients in the hospital which includes: Doctors, Nurses, Pharmacists, and Health Attendants among others and were 66 in number.

Sampling techniques
The sample size for the study was 216 and was purposively selected using simple random techniques.

Method of data analysis
The study adopted qualitative method. The data were analyzed using qualitative analysis and tables of frequency.

Ethical approval and consent to participate
Ethical approval for this study was obtained from the Health Research Ethical Committees of the Family Life Centre, Mbreibit Itam, Uyo and National Fistula Centre, Abakaliki. Participants were required to sign an informed consent form, personal identi iers were not used and information obtained was treated con identially.

Results
Majority (64; 53.4% and 64; 53.4%) of the respondents for Uyo and Abakaliki respectively were adults. Similarly, majority (65; 54.2% and18; 60%) from both centres were married. The level of education percentage distribution revealed that the population was mostly illiterate. All the respondents in both centres were Christians. Most of the respondents (> 90%) were indigenes of both centres while just a few came from from other States. This implied that both Uyo Centre and Abakaliki had non indigenes that were referred to the Centres for treatment. Majority of the respondents from both centres were farmers. In Mbreibit Itam centre only 20 health care workers which consist of 3 Consultant, 10 Nurses, 2 Pharmacists and 5 Senior Registrar were interviewed because they were few. However, at National Hospital, Abakaliki, a total of 46 health care workers made up of 11 Consultants, 24 Nurses, 7 Pharmacists and 24 Senior Registrars were interviewed (Table 1).
Respondents View on the Impact of Availability of Treatment Centre and Health Seeking Behavior.
The availability of treatment centre is a major challenge in the utilization of health care facilities. Most of the recorded interviews had it that majority of the respondents complained of travelling a long distance for about 2-8 hours before reaching the treatment centre. While some responded that in the remote communities where they live, the only health facilities available were private clinics, some said they were only primary health centres. The major constraint by respondents was that, at times no health worker would be seen around the facility and even though they were available since they were not specialists they could not handle these cases. However, before these women would be referred to the treatment centre, they will incur additional expenses and at times they were not referred on time.
Most of the respondents linked the delay in utilizing the VVF treatment centres to poor and deplorable conditions of the road from their area to the hospital; hence they always look for alternative treatment which was not the best.
The roads in their community were not motorable, leaving them with the use of motor cycle while some have to pass through river in a boat. The duration of traveling ranges from 2 -8 hours thus discouraging many patients.
Respondents view on the impact of quality of Health care Services and Health Seeking Behaviour. was very friendly and cordial. Similarly, in terms of cost it was subsidized by the mission in Uyo centre and totally free in Abakaliki centre. These affected the health seeking behaviour of women with obstetrics istula positively as most of the patients said they would help to refer other women with VVF to these centres.

Discussion
Unavailability of obstetric istula treatment centres was a major challenge in the utilization of health facilities by women with obstetric istula. The result of the study revealed that majority of the respondents travelled from far distance of 2-8hours before reaching the treatment centre with poor and deplorable state of the roads while some responded that in the remote area, where they live, the only health facilities available were private clinics and primary health centres. This indings collaborated with the study of Ajaegbu, [10] who opined that insuf icient number of facilities partially account for the low rate of institutional deliveries which affect their health seeking behavior. He further added that roads are often inaccessible and transportation systems are problematic. The Federal Ministry of Health, [11] also con irmed that although obstetric istulae can be repaired successfully, patients' unawareness of availability of treatment facilities, and the cost of the repair have made access to the much needed care unobtainable for many. Gbola, [12] opined that a vast majority of pregnant women in developing nations lack access to basic obstetric care. The study of Ibekwe, [13] also revealed that women are at further risk of morbidity and mortality due to poor health seeking practices and limited access to health facilities. He further explained that there is a gross de iciency in the distribution of health facilities as many communities in rural Nigeria do not have access to health facilities because such facilities are non-existent. This insuf icient number of facilities may partially account for the low rate of institutional deliveries which affect their health seeking behaviour. Edeh, [14] also agreed that no fewer than 12,000 women develop vesico vaginal istula every year in Nigeria and that most of these women affected by the condition come from the remote villages which lack motorable roads, health care facilities and numerous barriers to seeking health care. This lack of VVF health facilities within the reach of the women affects their health seeking behaviour as it concerns the treatment of VVF.
Quality of health care services was a key theme in the data collected. Most of the respondents responded with all amount of happiness that the attitude of the health workers was very satisfactory, friendly and they related with them very well; that the hospital had quali ied Doctors, Nurses, Specialists, Pharmacists and other health workers. The hospital environment was conducive for them in terms of neatness, regular power and water supply and the health workers also af irmed that the hospital had what it takes to handle these cases in terms of sophisticated instrument, equipment, quali ied personnel and they have been handling Quality of health care services was a major determinant of health seeking behavior. Quality of health care services was a key theme in the data collected and was simply described by the respondents as "good", "Very good" and excellent. Most of the respondents with all amount of happiness described the attitude of the health workers as being friendly, of good character and also relating with them very well.
From the recorded interviews, most of the respondents reported that the hospitals had quali ied Doctors, nurses and other health workers that was why their VVF repair was successful. Most of the women interviewed from Uyo centre reported that even though they heard that most of the Doctors came from different states to do the operations during camp, they were all specialists resulting in their problems being solved. Majority of the respondents asserted that the health workers were very active, they knew their job, what to do at a particular time and they did it very well.
While majority of the respondents expressed their gratitude to God for receiving total healing and coming back to life, many other women with partial repair also attested to the fact that even though their own VVF were not totally repaired, they still knew that the hospitals have quali ied personnel.
Also, responses by the VVF women showed how effective the quality of health care services rendered to them through quali ied health personnel were and their attitude towards them compared to the quality of health care services obtained in other health institutions was satisfactory.
The quality of health care services received by these women was not without challenges especially in Family Life Centre, Uyo where most of the respondents complained that most of the drugs prescribed for them were out of stock in the centre, the patients had to go outside to procure them. They were also asked to pay for all the investigations requested in addition to taking care of their feeding as against free medical treatment they were told at the beginning. These also pose a lot of inancial challenges to them.
Similarly, lack of proper communication regarding the inancial aspect of the treatment posed some challenges to some of these patients in Uyo Centre, but the situation was different in Abakaliki centre where in addition to the quali ied and dedicated staff, the treatment was totally free from the irst day till discharge including feeding.
On the whole, the recorded responses from the interview revealed that the hospital environment was very conducive for their stay in terms of neatness and regular power and water supply. The quality of health care services provided for women with obstetric istula in both centres were different from what was obtainable in other secondary and tertiary health institutions as reported by some of the respondents in terms of quali ied and dedicated staff. The relationship between the health workers in these hospitals and the patients https://www.heighpubs.org/cjog 064 https://doi.org/10.29328/journal.cjog.1001088 these cases for long time. The success rate was about 78% -84%. The relationship with patients was very cordial and that they were satis ied with their job performance. This inding was contrary to the view of Adesegun, [15] who argued that Nigeria's health facilities are also in poor shape in terms of medical supplies and related logistics. Another area of shortcoming was human resources as most facilities lack the required human resources (at least 4 midwives) to operate effectively on 24-hour basis. Only 6.1 percent of primary health care facilities nationally had up to 4 midwives. The technical competence of many of the available health personnel is poor in the area of various service delivery activities. Similarly, Sina, Jegede and Ibikunle, [16] in their study observed that several factors have been identi ied for poor utilization of modern health facilities and especially the primary health centre (PHC). These include proximity to health facilities, clients'/patients' affordability, staff attitude, availability of equipment and quali ied personnel. Ordinarily, a person would not use a product that does not meet his need unless he has no choice. Meeting these needs go beyond the goods and services alone but also include environmental conditions that are conducive. They noted that there was higher use of private health facilities attributed mostly to issues of easy access, shorter waiting time, longer or lexible opening hours, better availability of staff and drugs, better attitude and more con identiality in socially stigmatized diseases. The Nigeria Federal Ministry of Health, [17] also argued that the issues of availability of services within equitable geographic reach, cost expended to utilize the services, opportunities lost in actual uptake, attitudes of service providers and quality of services provided, are issues that affect service uptake. Gbola, [12] and Warren, Agbonkhese and Ishaku, [18] equally noted that facility shortages comprised both of lack of human resources as well as lack of material resources. These barriers are signi icant both in terms of the quality of medical care women receive as well as the quality of post-surgery support and counseling women and their families receive. It also impacts the extent of community outreach a facility is able to engage in. Fistula repair care not only requires adequate numbers of specialized surgeons to be able to examine and treat various levels of tears, but also a supportive nurse-counseling staff to counsel patients pre-and post-repair. Recovery takes a longer time, requiring longer hospitalization and follow up services, and facility shortages negatively in luence the quality of all these elements. Other factors responsible for increasing vesico vaginal istula include lack of skilled obstetric care providers. They noted that, women who are supervised by skilled professionals such as midwives are very unlikely to develop obstetric istula, especially where there is access to emergency obstetric care. This is because, women who are supervised by health professionals during labour would be properly monitored with the use of a partograph, therefore any deviation from normal would be detected early and prompt action taken to avert some of these preventable complications like obstetric istula. It is for this reason that obstetric istula is almost non-existent in the western world where every woman has access to emergency obstetric care.
From the information gathered through those interviewed, the researcher noted that the quality of health care services provided for women with obstetric istula in both centres were quite different from what is obtainable in other health institutions like tertiary and secondary hospitals and that was why these women who had successful VVF repairs promised to encourage other women with same problem to come for treatment.
However, the nature of the disease was a limitation of this study. This was because VVF is a condition that needs privacy and which attracts stigmatization as these women felt so ashamed to open up freely and answer questions concerning their conditions. The researcher was able to overcome these challenges by creating a good rapport with the patients, creating conducive environment and interviewing patients one after the other before and after the operation. These allowed the women to gain con ident in the researcher and answer questions freely.

Conclusion
The study indicated that health seeking behaviour of women with obstetric istula is a major challenge in Nigeria. Findings of the study revealed that availability of treatment centre is a serious challenge to health seeking behaviour. However, quality of health care services soothes the health seeking behaviour of the women with VVF. It was therefore recommended that there is need to educate the women and create awareness on the causes and dangers of VVF through the use of local languages in community, youth and women associations in the churches for the people to understand. More VVF Centres should be established especially in the rural and remote communities and adequately equipped to enable women with this health problem to access the best care at any time. Also, community-based istula committee should be established which will incorporate those VVF women who had under gone repairs and are now free to help in sensitizing the public.