Submission ID 131656
| Issue/Objective | Female genital fistula (FGF) is an abnormal opening between the vagina and bladder or rectum causing chronic incontinence and affects an estimated 500,000 women globally (overwhelmingly in sub-Saharan Africa). Obstetric fistula, the most common aetiology, results from prolonged obstructed labour and is widely framed as preventable through improved access to emergency obstetric care. Yet this framing centres a single point of intervention (the delivery facility) while obscuring how place-based configurations of inequality generate risk long before labour begins. In Togo, where the maternal mortality ratio remains approximately 399 per 100,000 live births and specialist services are concentrated almost exclusively in the capital Lomé, the upstream structural determinants that produce obstetric fistula remain underexamined. This qualitative study mapped the risk trajectories of 27 women with obstetric fistula presenting for surgical repair in Lomé, Togo. Drawing on trajectory mapping and codebook thematic analysis informed by critical junctures and structural violence theories, we identified two distinct pathway typologies. In the Sequential Juncture Pathway (n=14), obstetric fistula developed following compounding structural failures: non-access to prenatal care, lack of decisional power, transport barriers, and inadequate facility response. In the Complex Case Pathway (n=13), clinical risk factors (twin pregnancies, macrosomia, malpresentation) went undetected or unmanaged despite women's contact with the healthcare system. Across both pathways, intersecting structural determinants (gender inequality in decision-making, healthcare system failures, and economic constraints) shaped the critical junctures at which women's trajectories progressed toward injury. Findings demonstrate that obstetric fistula results not from the inevitability of poverty but from preventable failures at identifiable moments where place-based structural arrangements caused injury. Different places produced qualitatively distinct pathways to harm through their specific configurations of health infrastructure, social norms, and institutional capacity. This analysis speaks directly to the conference theme of reclaiming global health equity by identifying upstream, place-specific determinants of a preventable injury and demonstrating that prevention must be calibrated to each setting's distinct risk profile rather than applied uniformly. |
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| Methodology/Approach | Setting: CHU Sylvanus Olympio, the national tertiary teaching hospital in Lomé, Togo, during two NGO-organised surgical repair missions. Index pregnancies and deliveries occurred across all six of Togo's geographic regions, spanning rural health centres, regional hospitals, private urban clinics, and home settings. Design: Qualitative descriptive design employing semi-structured interviews using the McGill Illness Narrative Interview (MINI), adapted for obstetric fistula trajectories. Analysis combined trajectory mapping with codebook thematic analysis (Braun & Clarke, 2022), informed by critical junctures theory and structural violence theory. Timeframe: Data collection April and November 2024; 40 women with FGF interviewed, with the present analysis focusing on 27 obstetric cases. |
| Results | Trajectory mapping revealed that place organised risk at every juncture. In the Sequential Juncture Pathway, rural remoteness produced compounding access failures: half of women (7/14) received no prenatal care; in 13/14 cases, women required permission from husbands or in-laws to seek facility care; 22/27 women across both pathways faced significant transport barriers, with journey times ranging from 40 minutes to over 27 hours; and 20/27 were transferred between multiple facilities without receiving definitive care. In the Complex Case Pathway, women reached facilities but encountered a healthcare system unable to manage the clinical complexity it faced (conditions detectable through routine prenatal screening went unidentified or unacted upon). Across both pathways, 18/27 cases documented care consistent with under-resourced and inadequately supported facilities. The healthcare system thus functioned not only as a responder to obstetric emergencies but, in many cases, as a contributor to the injury itself. These findings expose limitations of prevention frameworks centred on emergency intrapartum care and identify prenatal care accessibility and quality as the earliest and most consequential missed opportunity for prevention. Place-specific prevention strategies are indicated: mobile midwifery and birth preparedness programming for settings producing Pathway A, and investment in provider training, clinical protocols, and functional referral systems for settings producing Pathway B. |
| Discussion/Conclusion | This study provides mechanistic evidence that obstetric fistula results from specific, preventable failures at identifiable moments. By tracing how gender inequality, healthcare system underinvestment, and geographic isolation become inscribed on women's bodies as injury, our analysis makes structural violence empirically visible and actionable. Three implications emerge. First, prevention must move upstream: prenatal screening represents the earliest point at which most trajectories could be interrupted, yet current frameworks centre emergency intrapartum care. Second, expanding facility-based delivery without commensurate quality investment may compound rather than reduce risk, as our Complex Case Pathway demonstrates. Third, prevention must be place-specific: different configurations of structural determinants produce qualitatively different pathways to injury, requiring differently calibrated interventions. These findings speak directly to reclaiming global health equity in a fragmented world. Obstetric fistula persists because of fragmentation, or between tiers of a healthcare system that do not communicate, between policy frameworks that acknowledge structural determinants but do not theorise place, and between the communities where injury is produced and the capital where repair is available. The trajectory approach demonstrated here is transferable beyond fistula and beyond Togo, offering a methodology for identifying where, when, and how structural forces materialise as preventable harm across maternal health contexts. |
| Presenters and Affiliations | Maya Low McGill University Erensu Baysak McGill University Danielle Groleau McGill University Jacques Corcos McGill University |
