Assessing Strategies of Obstetric Fistula Management by Nurses/Midwives of Yaoundé Central Hospital and University Teaching Hospital ()
1. Introduction
Female genital fistula occurs when open defects between the female genital organs and adjacent urinary and colorectal tracts create urinary or fecal incontinence [1] . These defects, literally holes, allow the urine or stool to leak into the vagina. In developing nations, where pregnant women often give birth with minimal or no obstetric care, fistula most often occurs as a result of several days of prolonged or obstructed labor. This genitourinary or rectovaginal fistula (RVF) occurring after labor and its complications are labeled obstetric fistula.
1.1. Background of Studies
Millions of girls and young women in resource poor countries are living in shame and isolation, often abandoned by their husbands and excluded by their families and communities. They usually live in abject poverty, shunned or blamed by society and, unable to earn money, many fall deeper into poverty and further despair. The reason for this suffering is that these young girls or women are living with an obstetric fistula due to complications which arose during childbirth. Their babies are also probably dead, which adds to their depression, pain and suffering [2] .
Obstetric fistula is an abnormal opening between a woman’s vagina and bladder and/or rectum, through which her urine and/or feces continually leak [3] . Naturally these women are embarrassed by their inability to control their bodily functions, that they are constantly soiled and wet, and that they smell. Their pain and shame may be further complicated by recurring infections, infertility, and damage to their vaginal tissue that makes sexual activity impossible and paralysis of the muscles in their lower legs which may require the use of crutches, if any are available [2] . The greater tragedy is that these obstetric fistulas can be largely avoided by delaying the age of first pregnancy, prevented by the cessation of harmful traditional practices and timely access to maternity and obstetric care, and repaired by simple surgery.
Obstetric fistula is an abnormal connection between the vagina, rectum and/or bladder which may develop after prolonged and obstructed labour and lead to continuous urinary or faecal incontinence [3] [4] [5] . A hole between the urinary bladder and the vagina is regarded as vesicovaginal fistula whereas a hole between the rectum and the vagina is known as rectovaginal fistula [6] . Obstetric fistula is an indicator of the health system failing to provide accessible, timely and appropriate intrapartum care [7] . Obstructed labour is one of the leading causes of maternal mortality in developing countries and with it, comes other morbidities, the most devastating being obstetric fistula. It is estimated that for every maternal death, 20 - 30 women develop serious obstetric complications including fistula. These women, apart from surviving the ordeal of obstructed labour, face the physical and psychosocial challenges of living with obstetric fistula [8] [9] [10] .
Nurses and midwives play a major role in the care of women who live with obstetric fistula and seek health care. They are responsible for many of the procedures that help prevent infection at all stages of the client’s treatment. Nurses and midwives often perform the initial assessment of women living with obstetric fistula. They also manage clients who present early. For women who decide to undergo repair surgery, nurses and midwives perform preoperative care, assist in the operating theatre, and care for the client after surgery. Catheter management is an important nursing function [11] [12] [13] .
This study was aimed at analyzing strategies of obstetric fistula management by nurses/midwives of Yaoundé central hospital and CHU.
1.2. Problem Statement
Obstetric fistula (OF), which develops after a difficult childbirth leading to continuous urinary and fecal incontinence, is the most debilitating and devastating condition among all maternal morbidities. Although it has been completely eradicated from the developed world during the early 1900s, millions of marginalized women in developing countries still suffer from obstetric fistula.
The World Health Organization (2005) estimated an annual incidence of 50,000 - 100,000 new cases of obstetric fistula worldwide, directly linked tone of the major causes of maternal mortality, obstructed labour [14] .
In Asia and sub-Saharan Africa, it is estimated that more than 2million young women live with untreated Obstetric fistula and these victims suffer constant incontinence, shame, and social segregation and health problems [15] .
In Cameroon, according to 2018 Demographic and Health Survey, it is estimated that about 20,000 women suffer from obstetric fistula and are currently living with this condition, and that Cameroon has one of the world’s highest rates of maternal mortality. Affected women remain with anatomical, functional and social defects [1] [15] .
According to the multiple indicator cluster survey conducted in Cameroon in 2020, the prevalence of obstetric fistula is 21,000 cases and about 2000 new ones occur each year. The vast majority of women affected by obstetric fistula are very young and come from poor families. In addition to the lack of resources to pay medical costs, they are victims of stigmatization, violence and other harmful cultural practices which sometimes force them into isolation and even social exclusion. For most of these affected women, obstetric fistula is nothing more or less than a life destroyed, physically, economically, socially and emotionally.
This immense number is very concerning and has generated lots of worry within the researcher especially as the actual prevalence figures may be much higher since many of the affected women live in isolation [2] .
In addition, being opportune to partake in a fistula campaign in 2019, the researcher noticed that 80% of victims had undergone surgery at least once without success. At this point, the researcher wonders if it could it be at the level of nursing management where more attention needs to be paid and for this reason, the researcher proposed to undertake a study to assess the strategies of managing obstetric fistula by nurses/midwives of Yaoundé central hospital and CHU [4] .
1.3. Research Questions
From the above problem statement, the researcher was guided by the following general and specific research questions:
1.3.1. General Research Question
What are the strategies can be used to manage obstetric fistula by nurses and midwives?
1.3.2. Specific Research Questions
What is the prevalence of obstetric fistula in Yaoundé?
v What are the different types of obstetric fistula commonly identified?
v What management strategies are offered by nurses/midwives to patients suffering from obstetric fistula in Yaoundé central hospital and CHU?
v What are the successes and challenges identified in the management obstetric fistula?
1.4. Hypothesis
The management strategy of obstetric fistula and its outcome will be determined by the qualification of health personnel, coupled to the number of years of experience.
- Null hypothesis: There is no significant relationship between qualification, longevity of service of nurse/midwife and strategies used in management of obstetric fistula in the Yaoundé central hospital and university teaching hospital.
- Alternative hypothesis: There is a significant relationship between qualification, longevity of service of nurse/midwife and strategies used in management of obstetric fistula in the Yaoundé central hospital and university teaching hospital.
2. Materials and Methodology
2.1. Study Design/Methodology
A retrospective cross-sectional descriptive study design was used to gain insight into the management of obstetric fistula by Nurses/Midwives of the Yaoundé central hospital and university teaching hospital during the research period at this site. The study which is cross-sectional in nature was conducted among Nurses/Midwives irrespective of their gender, ages, and are on active service in these respective hospitals. Quantitative questionnaires were developed from literature, theories and management policies to assess the care offered to patients suffering from obstetric fistula, by nurses and midwives, in terms of pre-operative, post-operative and discharge care. The researcher employed a quantitative data collection method using the survey approach to collect data. The survey questionnaires were created on the basis of previously validated scales and survey instruments. The primary intent of this statistical approach was to allow extrapolation of the results obtained to the population from which the sample is obtained.
2.2. Study Site
This study was carried out at Yaoundé Central Hospital and the university teaching hospital. These are two of the main teaching hospitals in the center region of Cameroon, which provide fistula care programs when need be.
2.3. Study Population
The study population consisted of nurses and midwives in active service at the Yaoundé central hospital (YCH) and CHU, who must have managed at least a case of obstetric fistula. A sample of 100 Nurses/midwives was selected and issued questionnaires.
2.4. Inclusion Criteria
Participants were enrolled in the study after meeting the following screening criteria:
- Nurses/midwives on active service in either Yaoundé central hospital or the university teaching hospital.
- Participants should have managed at least a case of obstetric fistula.
- Participants should be willing to provide information needed.
- Participants should be willing to fill a consent form.
2.5. Exclusion Criteria
Some nurses/midwives were excluded from the study if any of the following apply:
- If participants were not willing to provide necessary information.
- If they were not willing to sign the consent form.
2.6. Sample Size and Sampling Technique
According to NKOUM, 2019 a researcher should always work on a representative sample of his/her original population [15] . A sample size of 100 Nurses/ Midwives on active duty was selected from hospital records and contacted for delivery of questionnaires.
The Cochrane’s formula was used to determine the sample size for the study, whereby,
[1]
where,
no is the sample size;
e is the desired level of precision (i.e. the margin of error, for 95% confidence interval = 0.05);
p is the estimated proportion of the population which has the attribute in question;
q is 1 − p;
Z is corresponding value on Z-table for desired confidence interval (95% = 1.96).
Assumption = proportion p of nurses and midwives among other health personnel is 1:15 (1/15 = 0.066). Therefore,
which is approximately 95.
Hence, a sample size of 100 was collected.
2.7. Data Collection
Instrument for Data collection
The process of data collection involves collecting opinions and useful information from target participant about the research questions or topic [2] .
Data collection was carried out by the principal researcher through a questionnaire. The tool was designed with questions that sought to collect information on; demographic data, the pre-operative, post-operative and discharged care offered to patients towards the management of obstetric fistula. These questionnaires were drafted both in English and French which are the main languages used in these two hospitals.
2.8. Data Analysis Process
The questionnaires were analyzed using SPSS version 23 for descriptive and inferential statistics.
The data were coded before being entered into SPSS. There after it was screened for missing data or outlier. The few Missing data less than 2% were substitute with the mean value.
The descriptive central tendencies were expressed by mode or mean based on the level of measurement. They were expressed using frequencies, percentages and bar charts. MANOVA (Multivariate Analysis of Variance) was carried out to investigate any significant group differences on demographic or professional factors such as sex, experience, professional titles, and the hospital.
2.9. Ethical Consideration
Authorisation was obtained from the Faculty of Health Science; an authorisation to conduct the study was also obtained from the Directors of the Yaoundé Central Hospital and the university teaching hospital, with an informed consent gotten from each participant. Each participant was assured of privacy and confidentiality of information.
3. Results and Interpretation
3.1. Socio-Demographic Data and Health Facility
Table 1 shows that the majority of respondents (56%) were from Yaoundé central hospital
From Table 2, it can be observed that majority of the respondents were between the ages of 40 - 49 years (i.e. 59%); a greater number of them were of female gender (i.e. 82%).
Also, we realized that most of the respondents were Nurse assistants (i.e. 52%), and up to 43% of them had a longevity of service ranging between 11 - 20 years.
3.2. Prevalence of Fistula
From Table 3, we discovered that the most common type of obstetric fistula is the vesico-vagina fistula (i.e. 100%), and up to 87% of the respondents indicated that it occurred at least 6 times in every 10 cases of obstetric fistula. Up to 62% of the respondents revealed that they use 0.5% chlorine solution to effectively decontaminate instruments and other healthcare items for 10 minutes before use, 34% use it at times while 4% don’t use it at all.
Majority of the respondents i.e., 54% confirmed that they use sterile gloves when inserting a urinary catheter, and 41% of respondents said at times they use sterile gloves.
Up to 48% accepted they clean the periurethral mucosa from anterior to posterior, inner to outer, and one swipe per swab, 38% of the study population said they do that at times, while 6% said they don’t do it at all.
Majority of the respondents proved that they do not encourage clients to drink at least 5 L of water per day before surgery, 56% said Yes they do and 44% of respondents do that at times.
From Table 4, up to 73% of respondents testify that they do not encourage patients to do regular exercises before surgery, only 27% do and 0% do that at times.
Up to 66% of study population testify that they shave clients’ perineum to prepare them for surgery, 32% do that at times while 2% do not have clients at all.
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Table 1. Distribution of participants according to health Institution.
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Table 2. Distribution of participants with regards to Sociodemographic profile.
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Table 3. Distribution of participants’ responses with regards to fistula prevalence.
A majority of respondents 66% check patient’s urinary bags hourly before surgery, though 32% do check at times and 2% don’t check at all as seen in Table 4.
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Table 4. Distribution of participants’ responses regarding fistula management strategies.
Following Table 5, 61% of respondents check for bleeding 28 hours after surgery, 11% at times check for bleeding, while up to 28% don’t check.
A majority of respondents 49% revealed that they encourage client to drink at least 5 L of water per day, 24 hours after surgery, 23% do encourage patients at times and 28% do not encourage the patients.
61% of respondents confirmed that they remove vaginal pack (if used) 24 hours after surgery, unless advised otherwise by physician, 14% said “At times”, while 25% said “No” to the statement.
Majority of the respondents 83% accepted that they always ensure that client is dry, and all drainages are draining, 13% said they do that at times and 4% said they don’t do it at all.
Up to 85% of respondents affirmed that they teach and encourage the client to do a Sitz bath at least twice a day, 9% of them do it not all the time, and 6% don’t do it at all.
38% of study population accepted that they clean drainage bags daily with 0.5% chlorine solution, 27% do not clean and 25% clean drainage bags at times.
A greater proportion of the study population accepted that they administer medication following prescription order, 4% said “At times”.
According to Table 5, a majority of the respondents 82%, proved that they usually stress on the importance of sexual abstinence during the healing period (usually six months), 17% do that atimes , and 1% don’t.
According to Table 5, 54% of respondents take time to describe the signs of complications and side effects that may follow fistula repair surgery to patients, 39% do that atimes and 7% don’t take time to do that.
49% of study population revealed that they stress on the importance of delaying pregnancy for at least one year after repair surgery, 40% said “Atimes” and 11% said “No”.
61% of respondents agreed that they discuss the importance of family planning once the client resumes sexual relations, and 33% said “Atimes”
83% of respondents acknowledged the fact that they caution the client about reproductive tract infections, including sexually transmitted infections, 13% of them do that at times while the remaining 4% don’t do it at all.
A majority of the respondents 85% advise the client about healthy nutrition, 9% give advice at times and 6% don’t at all.
38% of respondents take time to remind the client that she must receive antenatal care if she becomes pregnant again, 37% do that at times and the remaining 25% don’t remind at all.
Up to 87% of the respondents confirmed that they encourage patient to respect her RDV 3 months after discharge as instructed by physician, 9% said “At times” and 4% of the respondents said “No”.
A few of respondents 9% contact their clients regularly to know how they are doing, 37% of them are irregular while 54% of them don’t contact their patients at all.
According to Table 6, there’s a highly significant difference between the health facilities (university teaching hospital and Yaoundé central hospital) in pre-operative management of obstetric fistula. The p-value equals 0.000 and is much smaller than 0.05, thus supporting the accuracy of the Chi-square test for these data.
Following the relationship between health facilities and post-op care, the test is not significant with a p-value of 0.281 which is a lot higher than 0.05, showing that there is no relationship between the health facilities (CHU and YCH) and post-op care offered to patients suffering from obstetric fistula. They produce approximately similar p-values thus supporting the accuracy of the Chi-square test for these data.
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Table 5. Distribution of participants’ responses regarding obstetric fistula management strategies.
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Table 6. Distribution of respondents according to health facilities.
The Chi square of Pearson tests between pre-op and qualification (Table 7(a) and Table 7(b)), gives the following values:
Degree of freedom (3 − 1) × (3 − 1) = 4;
Calculated Chi Square value = 23.086;
Read Chi Square value = 9.49.
➢ Read Chi Square value is less than calculated Chi Square value (9.49 < 23.086).
X2(read) < X2(calculated). Conclusion; H0 is rejected, hence H1 verified (the two crossed variables are related).
P value = 0.000 (Significant relationship).
The Chi square of Pearson tests between qualification of respondents and post-op care (Table 7(c) and Table 7(d)), gives the following values:
Degree of freedom (3 − 1) × (3 − 1) = 4;
Calculated Chi Square value = 17.471;
Read Chi Square value = 9.49.
➢ Read Chi Square value is less than calculated Chi Square value (9.49 < 17.471).
X2(read) < X2(calculated). Conclusion; H0 is rejected, hence H1 verified (the two crossed variables are related).
P value = 0.002 (Significant relationship).
The Chi square of Pearson tests between longevity of service and pre-op care (Table 8(a) and Table 8(b)), gives the following values:
Degree of freedom (3 − 1) × (3 − 1) = 4;
Calculated Chi Square value = 14.208;
Read Chi Square value = 9.49.
➢ Read Chi Square value is less than calculated Chi Square value (9.49 < 14.208).
X2(read) < X2(calculated). Conclusion; H0 is rejected, hence H1 verified (the two crossed variables are related).
P value = 0.007 (Significant relationship).
A Significant relationship exists between longevity of service and pre-op care offered to patients.
The Chi square of Pearson tests between Method of post-discharge follow up and longevity of service (Table 8(c) and Table 8(d)), gives the following values:
Degree of freedom (3 − 1) × (3 − 1) = 4;
Calculated Chi Square value = 21.885;
Read Chi Square value = 9.49.
➢ Read Chi Square value is less than calculated Chi Square value (9.49 < 21.885).
X2(read) < X2(calculated). Conclusion; H0 is rejected, hence H1 verified (the two crossed variables are related).
P value = 0.000 (Significant relationship).
3.3. Successes in Obstetric Fistula Management
From Table 9 below, we observe that only 29% of respondents confirmed that woman recovers with no complication after 6 months, up to 50% confirming no specific format of documentation and 23% not respecting available protocol.
Following Table 10 below, the test is highly statistically significant with a p-value of 0.000 which is a lot smaller than 0.05. The conclusion is that there is a relationship in the qualification of health personnel (SRN, Midwives, Assistant Nurses) and general outcome in fistula management.
The Chi square of Pearson tests between General outcome of fistula management and qualification gives the following values:
Degree of freedom (3 − 1) × (4 − 1) = 6;
Calculated Chi Square value = 41.264;
Read Chi Square value = 12.59.
➢ Read Chi Square value is less than calculated Chi Square value (12.59 < 41.264).
X2(read) < X2(calculated). Conclusion; H0 is rejected, hence H1 verified (the two crossed variables are related).
P value = 0.000 (Significant relationship).
The test below is highly statistically significant with a p-value of 0.000 which is a lot smaller than 0.05. the conclusion is that there is a relationship in the longevity of service of the health personnel (0 - 10 years, 11 - 20 years, 21 - 30 years) and general outcome in the management of fistula (Table 11(a) and Table 11(b)).
The Chi square of Pearson tests between General outcome of fistula management and longevity of service, gives the following values:
Degree of freedom (3 − 1) × (4 − 1) = 6;
Calculated Chi Square value = 44.725;
Read Chi Square value = 12.59.
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Table 9. Distribution of participants’ responses regarding their effectiveness in obstetric fistula management:
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Table 10. (a) Distribution of responses according to outcome versus qualification; (b) Chi-Square Tests result of General outcome of fistula management and qualification.
➢ Read Chi Square value is less than calculated Chi Square value (12.59 < 44.725).
X2(read) < X2(calculated). Conclusion; H0 is rejected, hence H1 verified (the two crossed variables are related).
P value = 0.000 (Significant relationship).
3.4. Challenges
From Table 12 below, we observe that only 2% of the respondents confirmed the lack of skills/knowledge in fistula management as a challenge, whereas up to 32% validated limited equipment as the main challenge.
A majority of respondents, i.e. 33% proposed that an increase in the number of staff will help improve the management of obstetric fistula.
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(b) ![]()
Table 11. (a) Distribution of responses according to outcome versus longevity of service; (b) Chi-Square Tests result of General outcome of fistula management and longevity of service.
4. Discussions, Conclusions and Recommendations
4.1. Discussions
4.1.1. Socio-Demographic Data
In this study which was meant to assess the management strategies of obstetric fistula by nurses and midwives of Yaoundé central hospital and the university hospital, it was found that amongst the 100 respondents, 6 were less than 30 years old, 25 were within 30 - 39 years old, 59 were within 40 - 49 years old and 10 were within 50 - 59 years old [5] .
A majority of the respondents i.e. 52 out of 100 were nurse assistants, 23 of them were state registered nurses while 25 of them were midwives.
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Table 12. Distribution of participants’ responses regarding their challenges in Obstetric Fistula management:
With respect to longevity of service, most of the respondents 43 out of 100 had worked within a period of 11 - 20 years, 31 of them had worked for less than 10 years and 26 of them had worked within a period of 21 - 30 years.
4.1.2. Prevalence of Fistula
In this study as shown in Table 2, the most common type of obstetric fistula is the vesico-vagina fistula at a frequency of 6 in every 10 cases and is in line with Almanda’s findings in 2014 who reported that 79.4% of obstetric fistula were vesico-vaginal the rest were both rectovaginal and combined [16] .
4.1.3. Management of Obstetric Fistula
According to Table 6, we observe that pre- and post-operative care offered to patients is similar in both Yaoundé central and university teaching hospitals. This can explain the fact that health workers in Cameroon have common training backgrounds depending on the domain, and are indiscriminately sent to different hospitals to exercise their respective functions.
Following Table 4, we observe that:
31% of SRN, 5% of midwives, and 4% of NA offer pre-operative care as standards require;
24% of SRN, 8% of midwives, and 7% of NA offer post-operative care as standards require;
42% of SRN, 8% of midwives, and 9% of NA offer post-discharge follow-up as standards require.
The better management skills observed between nurses and midwives might reflect robust in-service trainings in obstetric fistula nursing care as well as practical exposure before and after graduation from school. This can also be explained by the 3 - 5 years of intensive and detailed training depending on the degree obtained, as compared to a 1 - 2 years as with the case of a nurse assistant.
Also in Cameroon, it is given that any state registered nurse or midwife would have had a mandatory formal training on management of obstetric fistula as included in curriculum [6] [16] .
Nevertheless, the nurse assistants have contributed significantly to the provision of quality care to patients suffering from obstetric fistula and thus a reduction of maternal morbidities in Cameroon as a whole.
According to Table 8, 9% of health workers with 0 - 10 years of work experience, 21% of health workers with 11 - 20 years of work experience, and 13% of health workers with 21 - 30 years of work experience offer pre-operative care as standards require.
1% of health workers with 0 - 10 years of work experience, 14% of health workers with 11 - 20 years of work experience, and 6% of health workers with 21 -30 years of work experience offer post-operative care as standards require.
27% of health workers with 0 - 10 years of work experience, 22% of health workers with 11 - 20 years of work experience, and 10% of health workers with 21 - 30 years of work experience offer post-discharge follow-up as standards require.
Surprisingly longevity of service (i.e. years of practice) did not influence the quality of health care service towards patients suffering from obstetric fistula, that is even more experienced nurses and midwives do not properly manage due to very high nurse patient ratio in hospitals and thus overworking the personnel.
In the same line, though there is paucity of data on the current human resource for health in Cameroon today, according to Health sector strategy 2016-2027, and drawing from General Census of health Workforce (RGPS) in 2011, the total number of nurses was 18,954 thus giving a ratio of 1 nurse: 3157 inhabitants [6] [7] [8] . The few nurses/midwives are prone to high work load and so become overwhelmed with work and so errors can easily set in.
To add, poor resource management is the order of the day in most hospital settings thus leading to demotivation and a feeling of exploitation, according to Athar Institute of health and management, march 2021 [9] .
Similar to management we also observe that, outcome of patients suffering from obstetric fistula is not very different in both Yaoundé central and university teaching hospitals. This can also be explained by the fact that health workers in Cameroon have common training backgrounds depending on the domain, and are indiscriminately sent to different hospitals to exercise their respective functions.
In our study, we observed following Table 10, which up to 32% of SRN, 11% of midwives and only 4% nurse assistants confirmed that woman recovers with continence after 6 months. This shows that the more educated the nurses and midwives are, the better the management offered to patients and subsequently a better outcome. This is supported by Aiken and colleagues (2017) who proved that higher qualified staff positively affects the quality of care offered to patients [17] .
Contrary to Table 8, where we observed that longevity of service did not influence the quality of health care service towards patients suffering from obstetric fistula, our findings according to table showed that longevity had a positive impact on the outcome of obstetric fistula management. That is, a greater proportion (14%) of the more experienced group of nurses and midwives (21 - 30 years) accepted that woman recovers with continence after 6 months.
In as much as there is demotivation in health human resource, some health workers because of the love for their job, could have developed coping behaviors which have helped to sustain their motivation and the consequent quality of healthcare service they provide to patients.
4.2. Conclusions
After discussing, the following conclusions were arrived at:
A majority of the nurses and midwives in charge of patients suffering from obstetric fistula in the Yaoundé central hospital and university teaching hospital have poor management strategies. The study also shows that there is a relationship between qualification of nurse/midwife, longevity of service and the quality of care offered to patients. There is therefore need for training and retraining of health workers to help update their management skills, likewise recruiting more workers to reduce work load thus permitting a better management.
4.3. Recommendations
At the level of the health worker
- Nurses and midwives should have a stronger will, personal commitment and self-discipline in the follow up of patients suffering from obstetric fistula.
At the level of the health institution
- An experienced-based management protocol should be established to help in better follow-up of patients suffering from obstetric fistula.
- Regular in-service training sessions on the management of obstetric fistula will help update the management skills of nurses and midwives and subsequently lead to better management.
At the level of the ministry
- More seminars on fistula management should be organised with provision of more fistula centres in Cameroon, which will help relieve the disease burden carried by women living with obstetric fistula in Cameroon and in Africa as a whole.
- Provide standard equipment and instruments used in the follow-up of patients suffering from obstetric fistula.
- National recruitment of more health staff to reduce work load.
- Subsidise treatment for obstetric fistula patients.
4.4. Proposal for Further Studies
The same study should be carried out in other hospitals in Cameroon.