"Poverty is the big thing": exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda

Abstract

Background: Women living with obstetric fistula often live in poverty and in remote areas far from hospitals offering surgical repair. These women and their families face a range of costs while accessing fistula repair, some of which include: management of their condition, lost productivity and time, and transport to facilities. This study explores, through women's, communities', and providers' perspectives, the financial, transport, and opportunity cost barriers and enabling factors for seeking repair services.

Methods: A qualitative approach was applied in Kano and Ebonyi in Nigeria and Hoima and Masaka in Uganda. Between June and December 2015, the study team conducted in-depth interviews (IDIs) with women affected by fistula (n = 52) - including those awaiting repair, living with fistula, and after repair, and their spouses and other family members (n = 17), along with health service providers involved in fistula repair and counseling (n = 38). Focus group discussions (FGDs) with male and female community stakeholders (n = 8) and post-repair clients (n = 6) were also conducted.

Results: Women's experiences indicate the obstetric fistula results in a combined set of costs associated with delivery, repair, transportation, lost income, and companion expenses that are often limiting. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly among all fistula care centers or camps due to funding shortages. In Uganda, experienced transport costs indicate that women spend Ugandan Shilling (UGX) 10,000 to 90,000 (US$3.00-US$25.00) for two people for a single trip to a camp (client and her caregiver), while Nigerian women (Kano) spent Naira 250 to 2000 (US$0.80-US$6.41) for transportation. Factors that influence women's and families' ability to cover costs of fistula care access include education and vocational skills, community savings mechanisms, available resources in repair centers, client counseling, and subsidized care and transportation.

Conclusions: The concentration of women in poverty and the perceived and actual out of pocket costs associated with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Findings recommend innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers.

Keywords: Barriers; Employment; Enablers; Financial cost; Fistula; Opportunity cost; Transportation cost.

Conflict of interest statement

Ethical approval for this study (protocol 733) was granted by the Population Council in New York. Local ethical approvals were received from the Nigeria’s National Health Research Ethics Committee of the Federal Ministry of Health, Kano State Health Research Ethics Committee, and Ebonyi State Research Ethics Committee State Ministry of Health, in addition to Uganda’s Makerere University College of Health Sciences School of Medicine Research Ethics Committee.

All the respondents were interviewed understood their contributions would be aggregated for publication—each provided informed consent after reading or having explained to them the study, interview process, risks and benefits, confidentiality and dissemination.

The authors declare that they have no competing interests.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1

Combined and catastrophic costs of obstetric fistula care seeking