Obstetric Fistula in Sub-Saharan Africa: A Comprehensive Review of Community-Based Strategies for Elimination
Main Article Content
Abstract
Obstetric fistula is a devastating childbearing injury that results from poorly managed prolonged obstructed labour without timely surgical intervention. The effects of this injury are long-lasting, and profound as the women become incontinent and marginalized from their communities. While clinical interventions such as conservative care and surgical repair, remain central to its treatment and prevention, community-based initiatives play a critical yet underutilised role in addressing the broader social and structural determinants of obstetric fistula. This review explores the community-based support initiatives focusing on strategies in promoting early identification, recovery, reintegration, and long-term prevention of obstetric fistula. These community-driven approaches not only impact the health of fistula survivors but also contribute to community empowerment and transformation of sociocultural norms in eliminating obstetric fistula. Key community-based interventions include educational programs, stigma reduction efforts, empowering fistula survivors as advocates, and engaging community and religious leaders to enhance awareness and care-seeking behaviour. To effectively eliminate obstetric fistula and restore dignity to affected women, a multi-sectoral, context-specific strategy that integrates medical care with community-driven psychosocial and advocacy interventions is essential to improve quality of life to fistula survivors.
Keywords:
obstetric fistula, community-based initiatives, prevention, elimination
Article Details
How to Cite
BELLO, Oluwasomidoyin O.; LAWAL, Olatunji O..
Obstetric Fistula in Sub-Saharan Africa: A Comprehensive Review of Community-Based Strategies for Elimination.
Medical Research Archives, [S.l.], v. 13, n. 6, june 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6668>. Date accessed: 15 july 2025.
doi: https://doi.org/10.18103/mra.v13i6.6668.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Elneil S, Romanzi L, Goh J, et al. An International Continence Society (ICS) report on the terminology for female pelvic floor fistulas. Neurourology and Urodynamics. 2020;39(8):2040-2071. doi:10.1002/nau.24508
2. Wall, L.L. Overcoming phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries. BMC Pregnancy Childbirth. 2012;12:68. doi: 10.1186/1471-2393-12-68
3. FIGO: Destigmatising obstetric fistula through education and community engagement – Dr Wanjala’s initiative to train community health volunteers | Figo. Published April 6, 2023. https://www.figo.org/news/destigmatising-obstetric-fistula-through-education-and-community-engagement-dr-wanjalas.
4. Tayler-Smith K, Zachariah R, Manzi M, et al. Obstetric Fistula in Burundi: a comprehensive approach to managing women with this neglected disease. BMC Pregnancy and Childbirth. 2013;13(1):164. doi:10.1186/1471-2393-13-164
5. Baker Z, Bellows B, Bach R, Warren C. Barriers to obstetric fistula treatment in low-income countries: a systematic review. Trop Med Int Health. 2017;22(8):938-959. doi:10.1111/tmi.12893
6. Ruder B, Emasu A. The Promise and Neglect of Follow-up care in Obstetric Fistula treatment in Uganda. In: Global Maternal and Child Health. 2022:37-55. doi:10.1007/978-3-030-84514-8_3
7. Anindhita M, Haniifah M, Putri AMN, et al. Community-based psychosocial support interventions to reduce stigma and improve mental health of people with infectious diseases: a scoping review. Infectious Diseases of Poverty. 2024;13(1). doi:10.1186/s40249-024-01257-6
8. Bellows B, Bach R, Baker Z, Warren C. Barriers to Obstetric Fistula Treatment in Low-income Countries: A Systematic Review. Nairobi: Population Council. 2015. https://knowledgecommons.popcouncil.org/cgi/viewcontent.cgi?article=1940&context=departments_sbsr-rh
9. Fiander A, Ndahani C, Mmuya K, Vanneste T. Results from 2011 for the transportMYpatient program for overcoming transport costs among women seeking treatment for obstetric fistula in Tanzania. International Journal of Gynecology & Obstetrics. 2012;120(3), 292–295. doi:10.1016/j.ijgo.2012.09.026
10. Delamou A, Douno M, Bouédouno P, et al. Social Immersion for Women After Repair for Obstetric Fistula: An Experience in Guinea. Front Glob Womens Health. 2021;2:713350. doi:10.3389/fgwh.2021.713350
11. Atuhaire S, Ojengbede OA, Mugisha JF, Odukogbe AA et al., 2018. Social Reintegration and Rehabilitation of Obstetric Fistula Patients Before and After Repair in Sub-Saharan Africa: A systematic review. NJOG. 2018;24(1): 5-14.
12. World Health Organization. Maternal Mortality. 2023. https://www.who.int/en/news-room/fact
13. Bowen C, Draper L, Moore H. 4.5 Community-Based Healthcare Initiatives - Fundamentals of Nursing | OpenStax. Published September 4, 2024.https://openstax.org/books/fundamentals-nursing/pages/4-5-community-based-healthcare-initiatives.
14. Masebo ST MP. Obstetric Fistula Strategic Plan 2022 – 2026.; 2022. https://www.afro.who.int/sites/default/files/2023-05/Obstetric%20Fistula%20Strategic%20Plan%202022%20%202026%20Final%281%29.pdf
15. Lavender T, Wakasiaka S, Khisa W. A Multidisciplinary approach to Obstetric fistula in Africa: public health, sociological, and medical perspectives. In: Global Maternal and Child Health. 2022:77-89. doi:10.1007/978-3-031-06314-5_6
16. United Nations. International Day to End Obstetric Fistula | United Nations. United Nations. https://www.un.org/en/observances/end-fistula-day.
17. Slinger G, Trautvetter L. Addressing the fistula treatment gap and rising to the 2030 challenge. International Journal of Gynecology & Obstetrics, 2020;148(S1), 9–15. doi:10.1002/ijgo.13033
18. Johnson EE, O'Connor N, Hilton P, Pearson F, Goh J, Vale L. Interventions for treating obstetric fistula: An evidence gap map. PLOS Global Public Health. 2023;3(1):e0001481. doi:10.1371/journal.pgph.0001481
19. Nduka IR, Ali N, Kabasinguzi I, Abdy D. The psycho-social impact of obstetric fistula and available support for women residing in Nigeria: a systematic review. BMC Women S Health. 2023;23(1):87. doi:10.1186/s12905-023-02220-7
20. Debele TZ, Macdonald D, Aldersey HM, Mengistu Z, Mekonnen DG, Batorowicz B. "I became a person again": Social inclusion and participation experiences of Ethiopian women post-obstetric fistula surgical repair. PLoS ONE. 2024;19(7):e0307021. doi:10.1371/journal.pone.0307021
21. Sanni OF, Dada MO, Ariyo AO, Salami AO, Afelumo OL, Ayosanmi OS, Abiodun OP, Sanni EA. The prevalence and management of obstetric fistula among women of reproductive age in a low-resource setting. Health Low-Resour Settings.2023;11(1). doi: 10.4081/hls.2023.11566
22. Hareru HE, Wtsadik DS, Ashenafi E, et al. Variability and awareness of obstetric fistula among women of reproductive age in sub-Saharan African countries: A systematic review and meta-analysis. Heliyon. 2023;9(8):e18126. doi:10.1016/j.heliyon.2023.e18126
23. World Health Organization: WHO. Obstetric fistula. Published February 19, 2018. https://www.who.int/news-room/facts-in-pictures/detail/10-facts-on-obstetric-fistula
24. Whitcomb K. Obstetric Fistulas in Sub-Saharan Africa. Ballard Brief. Published January 2, 2024. https://ballardbrief.byu.edu/issue-briefs/obstetric-fistulas-in-sub-saharan-africa
25. Obstetric Fistula Strategic Plan. Obstetric Fistula Strategic Plan 2019-2023.; 2019. https://nigeria.unfpa.org/sites/default/files/pub-pdf/FMOH-NSF-2019-2023%20Fistula.pdf.
26. Pollaczek L, El Ayadi AM, Mohamed HC. Building a country-wide Fistula Treatment Network in Kenya: results from the first six years (2014-2020). BMC Health Serv Res. 2022;22(1):280. doi:10.1186/s12913-021-07351-x
27. Fistula Manual Steering Committee, Mola G, Vangeenderhuysen C, et al. Guiding principles for clinical management and programme development: Obstetric Fistula. (Lewis G, De Bernis L, eds.).; 2005. https://www.afro.who.int/sites/default/files/2017-06/mps%20Fistula2.pdf
28. Adi A. ABUJA: ECOWAS supports 8 countries in Fistula care. Published December 2023. https://www.gbcghanaonline.com/general/abuja-ecowas-supports-8-countries-in-fistula-care/2023/
29. Amref Health Africa, UK. Expanding support for fistula survivors. Published November 2022.
https://amrefuk.org/news/2022/11/expanding-support-for-fistula-survivors-1
30. Ministry of Gender, Children and Social Protection. MoGCSP Supports Launch of GOFPMSP. https://www.mogcsp.gov.gh/mogcsp-supports-launch-of-gofpmsp/
31. Ghana web. Ghana launches 2024 Obstetric Fistula Programme. Published September 8, 2024. https://www.ghanaweb.com/GhanaHomePage/NewsArchive/Ghana-launches-2024-Obstetric-Fistula-Programme-1949642
32. Government, UNFPA launch 2023-2030 National Fistula Strategy. Published June 25, 2023. https://www.nyasatimes.com/government-unfpa-launch-2023-2030-national-fistula-strategy/.
33. Mohammad RH. A community program for women’s health and development: Implications for the long-term care of women with fistulas. International Journal of Gynecology & Obstetrics. 2007; 99(Suppl 1):S137–S142. doi:10.1016/j.ijgo.2007.06.035
34. Mohamed HC, Pollaczek L. It takes a village: The vital role of community organizations in enhancing fistula patient identification, referral, and reintegration in Kenya. Nepal J Obstet Gynaecol. 2018;13(2). https://www.nepjol.info/index.php/NJOG/article/view/21924
35. Vowles Z, Bash-Taqi R, Kamara A, et al. The effect of becoming a fistula advocate on the recovery of women with obstetric fistula in Sierra Leone: A qualitative study. PLOS Glob Public Health. 2023;3(4): e0000765. doi.org/10.1371/journal. pgph.00007 65
36. Tunçalp Ö, Isah A, Landry E, Stanton CK. Community-based screening for obstetric fistula in Nigeria: a novel approach. BMC Pregnancy Childbirth. 2014;14(1):44. doi:10.1186/1471-2393-14-44
37. Drew LB, Wilkinson JP, Nundwe W, et al. Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: a qualitative study. BMC Pregnancy and Childbirth. 2016;16(1):2. doi:10.1186/s12884-015-0755-1
38. United States Agency for International Development, EngenderHealth. Fistula Care Plus: Key Achievements and the Way Forward to End Fistula. 2021. https://www.engenderhealth.org/wp-content/uploads/imported-files/Fistula-Care-Plus-Key-Achievements-and-the-Way-Forward-to-End-Fistula.pdf.
39. Miller S, Lester F, Webster M, Cowan B. Obstetric fistula: a preventable tragedy. J Midwifery Womens Health. 2005;50(4):286-294. doi:10.1016/j.jmwh.2005.03.009
40. Oluwasola TAO, Bello OO. Clinical and Psychosocial Outcomes of Obstetrics Fistulae in Sub-Saharan Africa: A Review of Literature. J Basic Clin Reprod Sci. 2020;9(1):8-16. doi: 10.4103/2278- 960X.1945139
41. Chanie WF, Berhe A, Tilahun AD, et al. Community perceptions and determinants of obstetric fistula across gender lines. Scientific Reports. 2025;15(1). doi:10.1038/s41598-025-87192-4
42. Lufumpa, E, Doos L, Lindenmeyer, A. Barriers and facilitators to preventive interventions for the development of obstetric fistulas among women in sub-Saharan Africa: a systematic review. BMC Pregnancy Childbirth. 2018;18(1):155. doi:10.1186/s12884-018-1787-0
43. Wegner MN, Ruminjo J, Sinclair E, Pesso L, Mehta M. Improving community knowledge of obstetric fistula prevention and treatment. International Journal of Gynecology & Obstetrics. 2007;99(1): S108-S111. doi:10.1016/j.ijgo.2007.06.030
44. Freedom From Fistula USA. Economic empowerment - Freedom from fistula USA. Published August 18, 2024. https://www.freedomfromfistula.org/economic-empowerment/
45. Muleta M, Hamlin EC, Fantahun M, Kennedy RC, Tafesse B. Health and social problems encountered by treated and untreated obstetric fistula patients in rural Ethiopia. J Obstet Gynaecol Can. 2008;30(1):44-50. doi:10.1016/S1701-2163(16)32712-8
46. Swain D, Parida SP, Jena SK, Das M, Das H. Prevalence and risk factors of obstetric fistula: implementation of a need-based preventive action plan in a South-eastern rural community of India. BMC Womens Health. 2020;20(1):40. doi:10.1186/s12905-020-00906-w
47. Mahmoodi H, Bolbanabad AM, Shaghaghi A, Zokaie M, Gheshlagh RG, Afkhamzadeh A. Barriers to implementing health programs based on community participation: the Q method derived perspectives of healthcare professional. BMC Public Health. 2023;23(1). doi:10.1186/s12889-023-16961-5
48. Sullivan G, O’Brien B, Mwini-Nyaledzigbor P. Sources of support for women experiencing obstetric fistula in northern Ghana: A focused ethnography. Midwifery. 2016;40:162-168. doi:10.1016/j.midw.2016.07.005
2. Wall, L.L. Overcoming phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries. BMC Pregnancy Childbirth. 2012;12:68. doi: 10.1186/1471-2393-12-68
3. FIGO: Destigmatising obstetric fistula through education and community engagement – Dr Wanjala’s initiative to train community health volunteers | Figo. Published April 6, 2023. https://www.figo.org/news/destigmatising-obstetric-fistula-through-education-and-community-engagement-dr-wanjalas.
4. Tayler-Smith K, Zachariah R, Manzi M, et al. Obstetric Fistula in Burundi: a comprehensive approach to managing women with this neglected disease. BMC Pregnancy and Childbirth. 2013;13(1):164. doi:10.1186/1471-2393-13-164
5. Baker Z, Bellows B, Bach R, Warren C. Barriers to obstetric fistula treatment in low-income countries: a systematic review. Trop Med Int Health. 2017;22(8):938-959. doi:10.1111/tmi.12893
6. Ruder B, Emasu A. The Promise and Neglect of Follow-up care in Obstetric Fistula treatment in Uganda. In: Global Maternal and Child Health. 2022:37-55. doi:10.1007/978-3-030-84514-8_3
7. Anindhita M, Haniifah M, Putri AMN, et al. Community-based psychosocial support interventions to reduce stigma and improve mental health of people with infectious diseases: a scoping review. Infectious Diseases of Poverty. 2024;13(1). doi:10.1186/s40249-024-01257-6
8. Bellows B, Bach R, Baker Z, Warren C. Barriers to Obstetric Fistula Treatment in Low-income Countries: A Systematic Review. Nairobi: Population Council. 2015. https://knowledgecommons.popcouncil.org/cgi/viewcontent.cgi?article=1940&context=departments_sbsr-rh
9. Fiander A, Ndahani C, Mmuya K, Vanneste T. Results from 2011 for the transportMYpatient program for overcoming transport costs among women seeking treatment for obstetric fistula in Tanzania. International Journal of Gynecology & Obstetrics. 2012;120(3), 292–295. doi:10.1016/j.ijgo.2012.09.026
10. Delamou A, Douno M, Bouédouno P, et al. Social Immersion for Women After Repair for Obstetric Fistula: An Experience in Guinea. Front Glob Womens Health. 2021;2:713350. doi:10.3389/fgwh.2021.713350
11. Atuhaire S, Ojengbede OA, Mugisha JF, Odukogbe AA et al., 2018. Social Reintegration and Rehabilitation of Obstetric Fistula Patients Before and After Repair in Sub-Saharan Africa: A systematic review. NJOG. 2018;24(1): 5-14.
12. World Health Organization. Maternal Mortality. 2023. https://www.who.int/en/news-room/fact
13. Bowen C, Draper L, Moore H. 4.5 Community-Based Healthcare Initiatives - Fundamentals of Nursing | OpenStax. Published September 4, 2024.https://openstax.org/books/fundamentals-nursing/pages/4-5-community-based-healthcare-initiatives.
14. Masebo ST MP. Obstetric Fistula Strategic Plan 2022 – 2026.; 2022. https://www.afro.who.int/sites/default/files/2023-05/Obstetric%20Fistula%20Strategic%20Plan%202022%20%202026%20Final%281%29.pdf
15. Lavender T, Wakasiaka S, Khisa W. A Multidisciplinary approach to Obstetric fistula in Africa: public health, sociological, and medical perspectives. In: Global Maternal and Child Health. 2022:77-89. doi:10.1007/978-3-031-06314-5_6
16. United Nations. International Day to End Obstetric Fistula | United Nations. United Nations. https://www.un.org/en/observances/end-fistula-day.
17. Slinger G, Trautvetter L. Addressing the fistula treatment gap and rising to the 2030 challenge. International Journal of Gynecology & Obstetrics, 2020;148(S1), 9–15. doi:10.1002/ijgo.13033
18. Johnson EE, O'Connor N, Hilton P, Pearson F, Goh J, Vale L. Interventions for treating obstetric fistula: An evidence gap map. PLOS Global Public Health. 2023;3(1):e0001481. doi:10.1371/journal.pgph.0001481
19. Nduka IR, Ali N, Kabasinguzi I, Abdy D. The psycho-social impact of obstetric fistula and available support for women residing in Nigeria: a systematic review. BMC Women S Health. 2023;23(1):87. doi:10.1186/s12905-023-02220-7
20. Debele TZ, Macdonald D, Aldersey HM, Mengistu Z, Mekonnen DG, Batorowicz B. "I became a person again": Social inclusion and participation experiences of Ethiopian women post-obstetric fistula surgical repair. PLoS ONE. 2024;19(7):e0307021. doi:10.1371/journal.pone.0307021
21. Sanni OF, Dada MO, Ariyo AO, Salami AO, Afelumo OL, Ayosanmi OS, Abiodun OP, Sanni EA. The prevalence and management of obstetric fistula among women of reproductive age in a low-resource setting. Health Low-Resour Settings.2023;11(1). doi: 10.4081/hls.2023.11566
22. Hareru HE, Wtsadik DS, Ashenafi E, et al. Variability and awareness of obstetric fistula among women of reproductive age in sub-Saharan African countries: A systematic review and meta-analysis. Heliyon. 2023;9(8):e18126. doi:10.1016/j.heliyon.2023.e18126
23. World Health Organization: WHO. Obstetric fistula. Published February 19, 2018. https://www.who.int/news-room/facts-in-pictures/detail/10-facts-on-obstetric-fistula
24. Whitcomb K. Obstetric Fistulas in Sub-Saharan Africa. Ballard Brief. Published January 2, 2024. https://ballardbrief.byu.edu/issue-briefs/obstetric-fistulas-in-sub-saharan-africa
25. Obstetric Fistula Strategic Plan. Obstetric Fistula Strategic Plan 2019-2023.; 2019. https://nigeria.unfpa.org/sites/default/files/pub-pdf/FMOH-NSF-2019-2023%20Fistula.pdf.
26. Pollaczek L, El Ayadi AM, Mohamed HC. Building a country-wide Fistula Treatment Network in Kenya: results from the first six years (2014-2020). BMC Health Serv Res. 2022;22(1):280. doi:10.1186/s12913-021-07351-x
27. Fistula Manual Steering Committee, Mola G, Vangeenderhuysen C, et al. Guiding principles for clinical management and programme development: Obstetric Fistula. (Lewis G, De Bernis L, eds.).; 2005. https://www.afro.who.int/sites/default/files/2017-06/mps%20Fistula2.pdf
28. Adi A. ABUJA: ECOWAS supports 8 countries in Fistula care. Published December 2023. https://www.gbcghanaonline.com/general/abuja-ecowas-supports-8-countries-in-fistula-care/2023/
29. Amref Health Africa, UK. Expanding support for fistula survivors. Published November 2022.
https://amrefuk.org/news/2022/11/expanding-support-for-fistula-survivors-1
30. Ministry of Gender, Children and Social Protection. MoGCSP Supports Launch of GOFPMSP. https://www.mogcsp.gov.gh/mogcsp-supports-launch-of-gofpmsp/
31. Ghana web. Ghana launches 2024 Obstetric Fistula Programme. Published September 8, 2024. https://www.ghanaweb.com/GhanaHomePage/NewsArchive/Ghana-launches-2024-Obstetric-Fistula-Programme-1949642
32. Government, UNFPA launch 2023-2030 National Fistula Strategy. Published June 25, 2023. https://www.nyasatimes.com/government-unfpa-launch-2023-2030-national-fistula-strategy/.
33. Mohammad RH. A community program for women’s health and development: Implications for the long-term care of women with fistulas. International Journal of Gynecology & Obstetrics. 2007; 99(Suppl 1):S137–S142. doi:10.1016/j.ijgo.2007.06.035
34. Mohamed HC, Pollaczek L. It takes a village: The vital role of community organizations in enhancing fistula patient identification, referral, and reintegration in Kenya. Nepal J Obstet Gynaecol. 2018;13(2). https://www.nepjol.info/index.php/NJOG/article/view/21924
35. Vowles Z, Bash-Taqi R, Kamara A, et al. The effect of becoming a fistula advocate on the recovery of women with obstetric fistula in Sierra Leone: A qualitative study. PLOS Glob Public Health. 2023;3(4): e0000765. doi.org/10.1371/journal. pgph.00007 65
36. Tunçalp Ö, Isah A, Landry E, Stanton CK. Community-based screening for obstetric fistula in Nigeria: a novel approach. BMC Pregnancy Childbirth. 2014;14(1):44. doi:10.1186/1471-2393-14-44
37. Drew LB, Wilkinson JP, Nundwe W, et al. Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: a qualitative study. BMC Pregnancy and Childbirth. 2016;16(1):2. doi:10.1186/s12884-015-0755-1
38. United States Agency for International Development, EngenderHealth. Fistula Care Plus: Key Achievements and the Way Forward to End Fistula. 2021. https://www.engenderhealth.org/wp-content/uploads/imported-files/Fistula-Care-Plus-Key-Achievements-and-the-Way-Forward-to-End-Fistula.pdf.
39. Miller S, Lester F, Webster M, Cowan B. Obstetric fistula: a preventable tragedy. J Midwifery Womens Health. 2005;50(4):286-294. doi:10.1016/j.jmwh.2005.03.009
40. Oluwasola TAO, Bello OO. Clinical and Psychosocial Outcomes of Obstetrics Fistulae in Sub-Saharan Africa: A Review of Literature. J Basic Clin Reprod Sci. 2020;9(1):8-16. doi: 10.4103/2278- 960X.1945139
41. Chanie WF, Berhe A, Tilahun AD, et al. Community perceptions and determinants of obstetric fistula across gender lines. Scientific Reports. 2025;15(1). doi:10.1038/s41598-025-87192-4
42. Lufumpa, E, Doos L, Lindenmeyer, A. Barriers and facilitators to preventive interventions for the development of obstetric fistulas among women in sub-Saharan Africa: a systematic review. BMC Pregnancy Childbirth. 2018;18(1):155. doi:10.1186/s12884-018-1787-0
43. Wegner MN, Ruminjo J, Sinclair E, Pesso L, Mehta M. Improving community knowledge of obstetric fistula prevention and treatment. International Journal of Gynecology & Obstetrics. 2007;99(1): S108-S111. doi:10.1016/j.ijgo.2007.06.030
44. Freedom From Fistula USA. Economic empowerment - Freedom from fistula USA. Published August 18, 2024. https://www.freedomfromfistula.org/economic-empowerment/
45. Muleta M, Hamlin EC, Fantahun M, Kennedy RC, Tafesse B. Health and social problems encountered by treated and untreated obstetric fistula patients in rural Ethiopia. J Obstet Gynaecol Can. 2008;30(1):44-50. doi:10.1016/S1701-2163(16)32712-8
46. Swain D, Parida SP, Jena SK, Das M, Das H. Prevalence and risk factors of obstetric fistula: implementation of a need-based preventive action plan in a South-eastern rural community of India. BMC Womens Health. 2020;20(1):40. doi:10.1186/s12905-020-00906-w
47. Mahmoodi H, Bolbanabad AM, Shaghaghi A, Zokaie M, Gheshlagh RG, Afkhamzadeh A. Barriers to implementing health programs based on community participation: the Q method derived perspectives of healthcare professional. BMC Public Health. 2023;23(1). doi:10.1186/s12889-023-16961-5
48. Sullivan G, O’Brien B, Mwini-Nyaledzigbor P. Sources of support for women experiencing obstetric fistula in northern Ghana: A focused ethnography. Midwifery. 2016;40:162-168. doi:10.1016/j.midw.2016.07.005