Quality of life of women awaiting vesicovaginal fistula repair in Uyo, Akwa Ibom State, Nigeria

Aniefiok Jackson Umoiyoho, Emmanuel Columba Inyang-Etoh

Dept of obstetrics and gynaecology, University of Uyo, Akwa Ibom State, Nigeria.

ABSTRACT
Background: Vesicovaginal fistula has devastating effects on the health of afflicted women leading to alteration in their quality of life.
Aim: This study set out to assess the quality of life of women with vesicovaginal fistula who presented for repair.
Methods: The World Health Organization quality of life- BREF questionnaire was used to evaluate the women's quality of life. Results: Only 20% of the women adjudged their general state of health and quality of life to be satisfactory. A vast majority (73.4%) of the women were assessed to have good quality of life in the physical health domain. Most (78%) of the women were evaluated to have poor quality of life in the mental health domain. The majority (63%) of the women were evaluated to have poor quality of life in the social health domain. Fifty percent of the women were assessed to have good quality of life in the area of the environment. Conclusion: Vesicovaginal fistula was associated with significant impairment of the mental and social health of afflicted women.

Keywords: assessment, quality of life, vesicovaginal fistula.

INTRODUCTION
Obstetric vesicovaginal fistula, which is one of the earliest recognized maternal morbidity is still prevalent in poor countries of Africa and parts of Asia due to inadequate maternity services.1,2 This is in contrast to what is obtained in developed countries of the world where vesicovaginal fistula arising from obstructed labour has been eradicated; surgical trauma, genital tract malignancies and ionizing irradiation are largely responsible for the few cases of genital tract fistula seen in those developed countries.[3,4]
Africa is the reservoir for obstetric vesicovaginal fistula with 33,000 new cases estimated to be added annually to the prevalent population in Sub-saharan Africa alone.[4,5] Nigeria, a sub-saharan African country is said to have an incidence of 4 vesicovaginal fistulas per 1000 deliveries.[1,2] Notwithstanding, the United Nations estimates that only 33 surgeons provide fistula repair services in Nigeria and that only about 2500 cases of vesicovaginal fistula are repaired per year.[6] This reality means that many women with vesicovaginal fistula in Nigeria and indeed Africa will continue to suffer from the devastating effects of the disease for many years to come.
Vesicovaginal fistula is characterized by continuous leakage of urine with persistent perineal wetness, urinary stench and perineal excoriation.[1,2] These rather repulsive features of the disease tend to force afflicted women to become socially withdrawn due to low self-esteem.[1,2] Some of them  may be rejected or abandoned by their spouses and relations; the community at large may ostracize them if the condition becomes protracted.[2]
The personal and inter-personal relationships of afflicted women become disrupted following the crippling effects of the disease. This probably affects all aspects of their health: the physical, mental and social health. The extent to which vesicovaginal fistula affects the health of afflicted women in our environment is however largely unknown. Published work on the quality of life of women afflicted with vesicovaginal fistula is also sparse.
The Family Health Centre located in Akwa Ibom State of Nigeria is a regional fistula centre that provides a comprehensive approach to the management of all types of genital tract fistula. Many and varied cases of genital tract fistula have been repaired successfully in the centre over the years but the quality of life of these women have never been evaluated. This study was designed to assess the quality of life of women who presented with vesicovaginal fistula to the centre. It is envisaged that the findings of this study would enable us appreciate the impact of vesicovaginal fistula on the health of these unfortunate women. The results of this study may also support the clamour for the establishment of more fistula centres to enhance early repair of vesicovaginal fistula in Nigeria.

MATERIALS AND METHODS
STUDY DESIGN AND STUDY AREA
This was a cross-sectional questionnaire based study that sought to assess the quality of life of women who presented with vesicovaginal fistula to the Family Health Centre in Akwa Ibom State of Nigeria. The assessment was carried out at presentation to the centre before repair was done.
The Family Health Centre is located at Mbribit Itam on the outskirts of Uyo, the state capital of Akwa Ibom State, which is in the south-east health zone of Nigeria. It is a referral centre for all cases of genital tract fistula in Akwa Ibom State and the neighbouring states of Abia, Cross River, Imo, Rivers and Bayelsa. All these states have similar sociocultural and traditional practices. In spite of the large number of health facilities in these states, only about 50% of pregnant women obtain antenatal care and only about 35% deliver in hospitals. (Nigeria national demographic survey, 2008). Majority of the women especially those living in rural areas for various reasons prefer to deliver in unlicensed maternity centres with inadequate intrapartum care. (Nigeria national demographic health survey, 2008).

RECRUITMENT AND DATA COLLECTION
Following approval from the ethical committee of the centre, all women who presented with vesicovaginal fistula to the Family Health Centre during the 12 months period of the study who gave their informed consent were recruited into the study.
The World Health Organization quality of life (WHOQOL) BREF questionnaire was administered to each subject by trained interviewers to assess their quality of life on presentation.
The World Health Organization quality of life (WHOQOL) BREF questionnaire is divided into two parts. The first part assesses the patient's subjective assessment of her quality of life and her feeling of satisfaction with her state of health. The second part is divided into four designated domains namely: physical health, mental health, social health and the environment. A typical question under the physical health domain is: “To what extent do you feel that physical pain prevents you from doing what you need to do? The answers are rated thus: Not at all (5), A little(4), A moderate amount(3), Very much(2) and An extreme amount(1). Under the mental health domain, a sample question is: “How well are you able to concentrate? The options are: Not at all(5), A little(4), A moderate amount(3), Very much(2) and An extreme amount(1). A typical question under the social health domain is: “How satisfied are you with your sex life? The options are: very satisfied(1), Dissatisfied(2), Neither satisfied nor dissatisfied(3), Satisfied(4) and Very satisfied(5). Under the environment domain, a sample question is: “Have you enough money to meet your needs? The options are: Not at all(1), A little(2), Moderately(3), Mostly(4) and Completely(5). A mean score in each domain was obtained by calculating the mean of transformed scores converted to 0-100 scale in each domain.7 For the purpose of this study, a mean score of <40 in each domain was regarded as poor quality of life, a mean score of 41-60 in each domain was regarded as moderate quality of life, while a mean score of >60 was regarded as good quality of life in each domain. The data obtained were analyzed using descriptive and inferential statistics.

RESULTS
Two hundred and seventy-one cases of vesicovaginal fistulas were repaired at the Family Health Centre during the 12 months period of this study. Two hundred and sixty five women gave their informed consent and so were recruited into the study. Out of the 265 women studied, only three patients sustained vesicovaginal fistula from causes other than obstructed labour. One case followed abdominal hysterectomy; another was due to penetrating pelvic injury from road traffic accident while the third case resulted from traditional excision of a tumour at the vestibule.
Using the World Health Organization quality of life (WHOQOL)- BREF questionnaire, 53 (20%) women adjudged their general health status and quality of life to be satisfactory before repair of their fistula whereas 212 (80%) were dissatisfied with their general state of health and quality of life.
Table I shows the score distribution of the women in the physical health domain. A total of 73.4% of the women were assessed to have good quality of life in the area of their physical health. Only 3.3% of the women were assessed to have poor quality of life in the area of their physical health.
The score distribution of the women in the mental health domain is shown in table II. Only 12% of the women were assessed to have good quality of life in the area of mental health. A vast majority (78%) of the women were assessed to have poor quality of life in the area of their mental health.
Table III shows the score distribution of the women in the social health domain. None of the women was assessed to have good quality of life in the area of their social health. Majority (63%) of the women were assessed to have poor quality of life in the area of their social health.
The score distribution of the women in the environment domain is shown in table IV. Fifty percent of the women were assessed to have good quality of life in the area of environment. Only 13.4% of the women were assessed to have poor quality of life in the area of their environment.

DISCUSSION
Vesicovaginal fistula with its devastating effects on afflicted women's health impacts negatively on their quality of life. Using the World Health Organization quality of life BREF questionnaire, only 20% of affected women assessed their general state of health and quality of life to be satisfactory at presentation to the centre. This contrasted sharply with the rest (80%) of the women who felt dissatisfied with their general health status and quality of life. These findings are probably a reflection of the women's self-esteem and feeling of self-worth, which can be disrupted by the obnoxious features of the disease.
A vast majority (73.4%) of the women were assessed to have good quality of life in the physical health domain. This result was not surprising when one realizes the fact that vesicovaignal fistula is not often associated with physical pain. The women being largely free of physical pain would also supposedly have minimal need for analgesic chemotherapy.
Most (78%) of the women were evaluated to have poor quality of life in the area of their mental health. This finding has confirmed the negative effects of vesicovaginal fistula on the psyche of affected women. This probably results from the disruption of the woman's self-esteem and the resulting anxiety, sense of despair and depression that may supervene.[1,2]
The majority (63%) of the women were assessed to have poor quality of life in the social health domain. This finding was not unexpected as the features of the disease are generally repulsive.[1,2]  Besides, the way afflicted women are able to cope with their condition may likely influence their relationship with other people around them. This result has nonetheless confirmed the fact that women with vesicovaginal fistula suffer social deprivation particularly, in their sexual relationship.[2]
Fifty percent of the women were evaluated to have good quality of life in their environment domain. The reason for this rather interesting finding has not been adduced by this study, although it is probably a reflection of the level of support the women were enjoying from family members and friends. Women who continue to enjoy considerable support from their spouses, family members and friends are more likely to have a favourable impact from their environment as against those who suffer abandonment, divorce or ostracism. This finding is in agreement with what Gharoro8 obtained in Benin- Nigeria where a comparable (45%) proportion of the women with vesicovaginal fistula in their study felt ostracized and 50% of the women were economically impoverished.
In conclusion, vesicovaginal fistula is associated with significant impairment of the quality of life of afflicted women particularly, in the mental and social health domains. Impairment of the quality of life of a woman with vesicovaginal fistula in the environment domain probably depends on the self-esteem of the woman and the disposition of her family and the community to her plight. Vesicovaginal fistula did not affect significantly, the quality of life of afflicted women in the physical health domain. The need for the training of more fistula surgeons and the establishment of more fistula centres in Nigeria is hereby advocated. It would also be reasonable to reassess the quality of life of these women after successful repair in order to determine whether such repair influences their quality of life.
Acknowledgement: We are grateful to Sr. (Dr) Mary Morloy, the surgeon in charge of the Family Health Centre for giving us the permission to carry out this research work at the centre.

REFERENCES

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6. United Nations (UNFPA) and Engender Health. Obstetric Fistula needs assessment: findings from nine African countries. New York: UNFPA 2003; p 57-76
7. World Health Organisation Quality of life (WHOQOL)- bref questionnaire. Introduction, administration, scoring and generic version of the assessment. Field trial version 1996
8. Gharoro EP and Agholor KN. Aspects of psychological problems of patients with vesicovaginal fistula. J obstet Gynaecol 2009; 7: 644-647