User:T.sandzimier/sandbox

Uganda Village Project
The Uganda Village Project, an NGO in Iganga, Uganda, promotes public health and sustainable development in the rural communities of this marginalized district. I will intern with UVP for eight weeks and my roles will include (1) conducting detailed needs assessments utilizing qualitative and quantitative methods (e.g. house to house visits, community meetings, interviews, focus groups, Health Center record inspection) (2) collaborating with community-based organizations and the local government to utilize local knowledge and maximize community ownership of public health and development solutions and (3) training the Village Health Team (VHT), a group of voluntary community health workers in the village, in general public health knowledge (e.g., safe water, hygiene, sanitation, HIV/AIDS, malaria, family planning, reproductive health, obstetric fistula). I look forward to a hands-on experience that offers me the opportunity to meet people from different cultures, social backgrounds, and political perspectives, enhances my understanding of global health as a multidisciplinary field, allows me to experience firsthand challenges of grassroots public health work, and pushes me to think critically about my role as a leader in the movement for global health equity.

W.article for area:

 * Maternal health in Uganda

I chose the Maternal health in Uganda Wikipedia article for my area article selection. Several of the programs and activities interns with Uganda Village Project work on are centered around reproductive health. A large portion of outreach done by intern cohorts with UVP helps identify various factors contributing to poor child and maternal health and explores ways in which positive change can be made. I hope to add information about how different perceptions of pregnancy influence patterns of seeking care in Uganda. I have found literature on different perspectives women have on childbearing and believe that the Maternal health in Uganda wikipedia page currently lacks this information. I also play to add additional information to the “Limited access to healthcare services” portion of the page. This section currently discusses cultural barriers, mistreatment by medical personnel, limited health literacy, reliance on traditional medicine, malaria and pregnancy; however, I think a section on a woman's decision to bypass local healthcare facilities to receive a higher quality of care would serve beneficial as I have found much literature on this. I also hope to edit and add more information to the challenges already existing on the page–editing typos and structural nuances along the way.

W.article for sector:

 * Obstetric fistula

For my sector, I selected the Obstetric fistula Wikipedia article. One of the main focuses of UVP is helping women who have obstetric fistula, an abnormal connection between the rectum and vagina. Uganda is characterized by a large number of obstetric fistula cases; however, many women are unaware they have it. There are many causes of obstetric fistula; however, in Uganda the injury is usually caused from prolonged labor without timely medical attention. Obstetric fistula is harmful to both children and mothers and often leads to death. I plan to add valuable information to the “Challenges” portion of this Wikipedia page, focusing on the challenges surrounding obstetric fistula treatment on a global scale, such as mental health services (not looking at Uganda specifically). I am also interested in further exploring the “Society and Culture” section and potentially adding useful information about social isolation women face around the world due to this condition; however, some of this has been discussed in the challenges section. I will not be focusing on the medical aspects of this condition because I will not be performing any surgeries or other medical procedures while working with UVP nor am I qualified to do so. I also plan to add some information about the needs talk surrounding obstetric fistula–how did fistula campaigns gain awareness and are they of any benefit. I am very excited about my area and sector article selections because I enjoy researching and reading about maternal and child health on both a local and global scale.

Article Evaluation
Article Selected: Maternal health in Uganda

Elements of Quality Articles

 * 1) Detailed Lead Section: This article has a clear and easy to understand overview.
 * 2) Clear Structure: There are several headings and subheadings arranged by themes. There are a couple of pictures; however, the article's content does not really require images or diagrams.
 * 3) Balanced Content: The article covers many different aspects of maternal health in Uganda; however, there are a few sections that could go more in depth or sections that could be added.
 * 4) Neutral Tone: The article is written without bias.
 * 5) Good Sourcing: All of the sources are reliable and peer-reviewed.
 * 6) Value Statements: The article does not use the statements "the best," "some people say," or "many believe;" however, it does use the phrase "the most important." However, when it uses this phrase it is referring to a quote an economist said.
 * 7) Imbalanced Sections: There are some sections that are shorter than others and could use more information.

Evaluation of the Talk Page
The talk page seems very promising. It begins with a list of "rules" for addressing one another: "Be polite, and welcoming to new users, assume good faith, avoid personal attacks, and for disputes, seek dispute resolution." It also has "article policies:" "no original research, neutral point of view, and verifiability." All of these policies make for a reliable, non-biased, and helpful wikipedia article. The talk page also states that this article has been mentioned by a media organization which is really cool.

Following the initial rules, policies, articles of interest, and where the article has been mentioned/acknowledged, is a lengthy comment and peer review section where you can see people who have posted what they are interested in contributing to the page and peers have left feedback and comments. Everyone in the talk page is supportive of one another, provides very insightful and helpful feedback, and also links their peers to other scholarly articles they can use which is extremely helpful.

One thing I am interested in knowing is the rating of the talk page. In the tutorial it said you can see what volunteers have ranked the article, but I am unsure where to find that.

Potential Area Article 1
Assessing access barriers to maternal health care: measuring bypassing to identify health centre needs in rural Uganda

Analysis
This article is published by Oxford University in association with The London School of Hygiene and Tropical Medicine in 2009. It explores the barriers individuals face in low income countries that impact their use of health services for child delivery, including distance, transportation, informal costs, and low perceived quality. The results of the study proved the need for improvements in access to delivery of care and the study serves as an example of what other health managers and organizations can research in their local communities to better understand the successes and failures of their own delivery of care. What I found most interesting about this article was the discussion on how a large number of women choose to bypass local facilities to go to health facilities farther away in order to receive more professional care. This article will be valuable for adding information to my current area article selection because it assesses maternal health in rural Uganda in a broad sense, provides insightful information about how individuals in Uganda perceive their care based on societal and cultural pressures, and the sacrifices and choices women make in order to access more advanced care. The difference in the quality of care provided across communities in Uganda presents a challenge in accessibility to care for women because many women feel the need to travel farther, which oftentimes leads to a lack of immediacy causing more adverse health effects. This article demonstrates why women in Uganda choose to bypass certain health facilities or decide to not go to clinics at all, which enhances my understanding of the decisions individuals in Uganda make. This research provides me with context and will help me better approach conversations relating to health care facilities while interning in Iganga. The reference section of the article cites several other valuable resources and I believe it will help make my wikipedia assignment stronger and more developed.

Potential Area Article 2
Maternal Health Care in Rural Uganda: Leveraging Traditional and Modern Knowledge Systems

Analysis
This article was written by Dr. Maria G.N. Musoke (PhD) at Makerere University in Kampala, Uganda. It was published in January of 2002, examining fairly recent data. This article addresses the high maternal mortality problem in Uganda and discusses a project carried out in the Iganga district to help reduce maternal mortality. The RESCUER project was designed to link traditional rural community health providers with the formal health delivery system, so that when an obstetric fistula emergency occurred in the village, professionals could use a walkie talkie system to get assistance from the closest health unit. Although the project served beneficial to the community in some ways, it also further highlighted challenges these communities suffer from in regard to technology, complementarity amongst health workers, and institutional capacity; all barriers I plan to discuss in my final Wikipedia article assignment. This article is especially valuable because it analyzes a project similar to what my practice experience organization is doing and analyzes the pros and cons of the project’s design allowing me to think critically about the effectiveness of UVP’s approach to combating high maternal mortality rates.

Potential Area Article 3
Maternal Health Review Uganda

Analysis
This article was published by the Makerere University Institute of Public Health. The article explores maternal health indicators, the structure of the health system in Uganda, population level service characteristics, maternal services delivery at facility level, and client views of services, providing a foundation for my research and offering insight into many different aspects of maternal health in Uganda. The research done on the structure of the health system in Uganda, maternal health policies, access to delivery services, and the financing of maternal health services provides me with valuable information I can use in my final Wikipedia article assignment because it explores various systematic failures that influence maternal health in Uganda. This article will serve extremely beneficial for my exploration of the work UVP does because it provides a wonderful foundation for my understanding of the entire structure of the healthcare system in Uganda and the complications that arise when trying to improve access to various health services. The reference section of the paper has over 75 articles cited which will be extremely beneficial when wanting to dive deeper into certain aspects of maternal health. This article is fairly lengthy, however, I am excited to continue to analyze it and explore all of the references it has to offer.

Potential Area Article 4
Maternal mental health priorities, help-seeking behaviors, and resources in post-conflict settings: a qualitative study in eastern Uganda

Analysis
This article was published in 2018 by BioMed Central, making the data, analysis, results and conclusion of this study relevant. Because limited knowledge exists regarding the selection and introduction of relevant, tangible, and effective mental health interventions, researchers examined stakeholders' perspectives on mental health priorities, behaviors, and existing resources in order to help better develop and integrate non-specialized are in eastern Uganda (exactly where I will be going!). In the article it explores what various groups of people believe to be the most important mental health problem. "Sickness of thoughts" was prioritized as the most important problem among perinatal women, alluding to mental health consequences of being a mother. The article goes on further to explore how the absence of a supportive partner amplifies sickness of thought because of the economic and social consequences it causes. I think this article will serve beneficial in analyzing financial burden as a limit to healthcare access in my area article.

Potential Area Article 5
Gender dynamics affecting maternal health and health care access and use in Uganda

Analysis
The purpose of this source is to examine the root causes of why women underutilize maternal health care services. Morgan et al. explain how gender power relations affect maternal health care access and utilization in relation to access to resources, lack of spousal support, perceptions and attitudes toward pregnancy, men’s attitudes towards fatherhood, prevalence domestic violence, mistreatment by medical personnel, and autonomy over one’s self. It concludes with an emphasis on the need to integrate gender into maternal healthcare interventions in order to improve both access and use of maternal health services in the future. I used this source as a complement to the information I utilized from Macpherson et al.’s critical overview. Both sources discuss how gender power relations impact the autonomy of women in decision-making. This article helped support the argument I made in my area research that sociocultural beliefs surrounding gender often negatively impacts a woman’s ability to utilize the resources she desires. The information provided in this source has enhanced my understanding of gender dynamics in Uganda that I will be able to draw upon when working for Uganda Village Project this summer.

Potential Area Article 6
Influence of pregnancy perceptions on patterns of seeking antenatal care among women in reproductive age of Masaka District, Uganda

Analysis
Sub-Saharan Africa is characterized by a high maternal mortality rate and antenatal care is a recommended measure to improve maternal and child health; however, the influence of pregnancy perceptions on patterns of seeking care is not known. The objective of Atekyereza and Mubiru’s study is to better understand how perceptions on pregnancies and sociocultural beliefs influence the way in which women seek care in Uganda. 45 women, mothers, and pregnant women were selected from a small district in Uganda to participate in this study. After several interviews and focus group discussions, the key findings indicated that women’s social definition and perceptions of pregnancy do in fact influence the extent in which they seek antenatal care. This article emphasizes the importance of understanding perceptions surrounding childbearing in Uganda, as it allows outsiders to better approach individualized and culturally sensitive care. A key aspect of my practice experience is partaking in obstetric fistula outreach to strengthen maternal healthcare in Uganda. Therefore, this article is both relevant to the work I will be doing with Uganda Village Project and the area research I have done all semester in hopes to better understand how women perceive childbearing and maternal healthcare services.

Potential Area Article 8
Low use of rural maternity services in Uganda: impact of women’s status, traditional beliefs and limited resources

Analysis
Maternal healthcare in Uganda is characterized by a lack of resources, unskilled staff, low quality healthcare services, and a high maternal and infant mortality rate. This paper explores a study conducted in 2001 in Hoima District in western Uganda, aimed to enhance individuals’ understandings of why women choose high risk options when experiencing complications with childbearing. The findings demonstrate that adherence to traditional practices and beliefs that pregnancy is a test of endurance and strength are common ideologies in this marginalized district in Uganda, leading to a lack of utilization of healthcare services and a higher prevalence of maternal mortality. I will be working in Iganga, a marginalized district in eastern Uganda, this summer to promote public health and sustainable development in rural communities. Having extensive knowledge on the use, or lack thereof, of maternity and other healthcare services will provide me with insight on how to better approach the programs and interventions I will be working on. In addition, this article provided me with knowledge on how women perceive child birthing that served beneficial for my area research.

Potential Area Article 9
Culture and Birth Outcomes in Sub-Saharan Africa: A Review of Literature

Analysis
In this article, Lang-Balde and Amerson explore how cultural beliefs impact pregnancy outcomes for women in sub-Saharan Africa. This review focuses on 25 articles that explore the association between cultural values and beliefs and perspectives women have on childbearing. The findings demonstrate that cultural values and beliefs play a substantial role in how women perceive and seek care and emphasize the need to better understand these sociocultural beliefs and practices to more effectively encourage the use of maternal healthcare services in addition to traditional practices. This article relates to my practice experience because it provides insight on how various cultural barriers prevalent in sub-Saharan Africa impact birth outcomes, providing me with knowledge to better understand the cultural backgrounds of community members I will be working with this summer. I used this article for my area research for the WikiR assignment, specifically to help myself conceptualize different pregnancy perceptions that result from sociocultural beliefs.

Potential Area Article 10
Gender equity and sexual and reproductive health in Eastern and Southern Africa: a critical overview of the literature

Analysis
This critical overview explores gender inequities in sexual and reproductive health in eastern and southern Africa identifying means for action. MacPherson and Richards discuss the impact gender inequalities have on various health issues related to sexual and reproductive health. They explore how social and biological determinants combine to increase vulnerability to maternal mortality and various sexual and reproductive complications. MacPherson and Richards go on to demonstrate how women are particularly disadvantaged in health systems in terms of access and quality of care. This source is valuable to me because it demonstrates how gender inequities impact maternal health and mortality in Africa, providing insight into gender norms and power relations in communities of Africa. I used this source in my discussion on how gendered power relations diminish women’s autonomy, limiting their ability to receive proper maternal care.

Potential Area Article 11
Childbirth experiences and their derived meaning: a qualitative study among postnatal mothers in Mbale regional referral hospital, Uganda

Analysis
In this article, Namujju et al. explore the meaning behind childbirth experiences for postnatal mothers. Namujju et al. argue that understanding the childbirth experiences of women in Uganda allows individuals to better design interventions focused on individualized care that meet individual needs and expectations of mothers during childbirth. I utilized this source to summarize the importance of understanding perceptions on childbearing in Uganda for organizations, healthcare workers, and government entities when designing interventions and services for expectant mothers. By giving women an environment in which they feel valued, accepted, and trusting of those around them, the utilization of maternal health services may increase, directly impacting maternal and infant mortality rates in various regions of Uganda. This article demonstrated to me the extent in which women in Uganda portray their childbirth experiences as a sign of power and weakness–an idea I had not thought much of before. I believe this article has helped shaped my understanding of how childbearing experiences can vary from person to person and country to country and instilled in me the ability to empathize with the women I will be working with this summer.

Potential Area Article 12
Women's autonomy in health care decision-making in developing countries: a synthesis of the literature

Analysis
This article explores women’s autonomy, or lack thereof, in healthcare decision-making and the role sociodemographic factors play in this process. Osamor and Grady argue that most studies examine women’s autonomy in the context of reproductive health; however, neglect other healthcare utilized by women. The findings of this paper suggest that sociodemographic factors including age, education, and income impact a women’s autonomy. I used this source in my area research to demonstrate how the intersection of gender and various other sociodemographic factors amplifies the burden women face on their autonomy, leading to not only the underutilization of sexual and reproductive healthcare services, but also various other services and day-to-day decision making. I found this article to be extraordinarily interesting as it discussed several social determinants of health prevalent in the area of my practice experience, converging my practice experience, theory from the global poverty and practice minor, and my public health major coursework.

Potential Sector Article 1
Social and economic consequences of obstetric fistula: Life changed forever?

Analysis
In their article, Ahmed and Holtz explore the social, economic, emotional, and psychological consequences women with obstetric fistula face. They specifically look at two major consequences of obstetric fistula: divorce/separation and perinatal loss. They provide insight into health improvements, including the ability to help women maintain high self-esteem throughout their condition and reintegrate into society after repair. This source was useful for my original sector research on the psychological consequences of fistula and the need for mental health services. This article was particularly useful for my Wikipedia additions on the treatment section of the Obstetric fistula page. This article relates to my practice experience because it provides insight into various consequences of obstetric fistula and has allowed me to better understand the impacts this condition has on community members.

Potential Sector Article 2
Obstetric fistula in low‐income countries

Analysis
This article was published in November of 2008 bu the Obstetrics & Gynecology Foundation. The purpose of this article is to review other peer-reviewed articles and the current knowledge regarding obstetric fistula as a public health problem in low-income countries. I found this article valuable because it further analyzes existing research, which allows me to think more critically about other articles I analyze.

Potential Sector Article 3
Burden of obstetric fistula: from measurement to action

Analysis
This article outlines the challenges researchers face when attempting to estimate the prevalence and incidence of obstetric fistula worldwide. The two most common sources of data for obstetric fistula are medical records and self-reported surveys and both underestimate the prevalence and incidence of the condition, leading to a lack of care accessible to women because no one understands the urgent need for it. The authors discuss how obstetric fistula cases could be prevented if we were just able to provide emergency care in a timely matter. I believe this article will serve beneficial for my writing for my Wikipedia page because it presents a new challenge various societies face in regard to measuring prevalence of obstetric fistula. In addition, this article will allow me to better prepare for the work I will be conducting with UVP because it enhances my understanding of the difficulties behind quantifying the burden of disease, making it hard to spark action at the policy level, a task UVP aims to complete.

Potential Sector Article 4
Obstetric fistula: the challenge to human rights

Analysis
This article is from the International Journal of Gynecology and Obstetrics. The article explores the various causes of obstetric fistula, as well as discusses the drastic prevalence of this condition in resource-poor countries. It then delves deeper into statistics about the amount of new global cases there are each year and the number of women affected by this condition. It examines the social isolation women suffer from this condition including being expelled from their husbands and isolated from their families and communities. The article suggests that the failure of states to provide preventive prenatal care and timely fistula repair violates human rights and should not be taken lightly. This particular discussion on the failure of states to provide for its citizens strikes me as something that will be useful for editing the challenges section for the Wikipedia article I have selected. More broadly, this article is relevant to my practice experience because it allows me to better understand what states could be doing better for its people and broadens the scope of the outreach I will be conducting in Uganda to a more global scale.

Potential Sector Article 5
Adolescent sexual and reproductive health: The global challenges

Analysis
This article is from the International Journal of Gynecology and Obstetrics. The authors discuss how adolescent sexual and reproductive health (ASRH) has historically been neglected on a global scale and examines the challenges and barriers it has created including pregnancy, contraception, abortion, HIV/AIDS, STIs, poor health systems for sexual health, family planning, and maternal health, and corruption and lack of availability of supplies and equipment for adolescents. The “Global Challenges” and “Barriers and Challenges” sections of this article will serve beneficial for both supplementing my understanding of the work my practice experience organization is doing and editing the Wikipedia article I have selected. This article provides me with valuable information on how the lack of information provided to adolescents in regard sexual and reproductive health amplifies the barriers and challenges they face in society and drastically impacts their health and well-being.

Potential Sector Article 6
Fistula Campaigns—Are They of Any Benefit?

Analysis
In their article, Cam et. al evaluate the problems obstetric fistula patients faced during a fistula campaign in a regional hospital in Niger, Africa. The purpose of the evaluation was to better understand the strengths and weaknesses of fistula campaigns and their ability to meet the needs of women suffering from this condition. 62 women were examined, 51 of whom suffered from obstetric fistula, and it was concluded that short term programs and volunteers are not a sustainable way to address the issue of global fistula worldwide and directing efforts to creating specialist centers and creating reliable scenic evidence is necessary. The discussion and conclusions Cam et al. made were useful for my sector research on the needs talk surrounding obstetric fistula and the benefits of fistula campaigns. I was able to incorporate Cam et al.'s concerns on the effectiveness of fistula campaigns within the strengths and weakness of UVP's intervention strategy portion of this essay–discussing concerns over the safety of hospitals used for fistula campaigns, the utilization of short-term programs and volunteers, and the ability for program and campaigns to follow-up with their patients.

Potential Sector Article 7
Eliminating obstetric fistula: Progress in partnerships

Analysis
In their article, Donnay and Ramsey discuss the needs talk surrounding obstetric fistula and the efforts being made by various organizations and partnerships to address this neglected condition. Donnay and Ramsey demonstrate the need for global awareness of this condition and how global and national organizations have collaborate to strength the prevention and treatment of this condition. This article was particularly helpful for my sector research because it provided insight into how fistula campaigns came to be. I was able to incorporate what I learned from this article into the Why Obstetric Fistula portion of this essay–further analyzing the needs talk surrounding the condition. This article relates to the work I will be doing this summer as it demonstrates the reason behind UVP's decision to create a program focused on obstetric fistula prevention and treatment, providing insight into the importance of the outreach I will be doing.

Potential Sector Article 8
Obstetric fistulas in Africa and the developing world: New efforts to solve an age-old problem

Analysis
In this article, Lewis Wall compares and contrasts the issue of obstetric fistula in the developing and developed world. Lewis Wall conveys that although the developed world has successfully addressed the issue of obstetric fistula there is still much work to be done in the developing world. In addition, Lewis Wall provides insight into the devastation this condition has in the developing world, describing how difficult it is for organizations and other agencies to fully address all the needs of those suffering from fistula holistically and effectively. This article was particularly helpful for my understanding of the extent in which the developed world does not fully understand the effects and prevalence of fistula in the developed world. I was able to incorporate what I learned from this article in my understanding of the needs talk surrounding obstetric fistula in the developed world and in my analysis of the strengths and weaknesses of UVP. Because obstetric fistula is coupled by a lack of resources, an inadequate healthcare system, sociocultural beliefs, and gender power relations, the adverse health effects and stigma women in the developing world face are amplified. This article is also useful in my understanding of the work my practice experience aims to do because it demonstrates how difficult it is for organization to provide the proper care and the need to think critically about the work being done surrounding this condition.

Potential Sector Article 9
Where urology and obstetrics meet: the Campaign to End Fistula

Analysis
In their article, Ramsey and Pinel explore the vast disparities in maternal health care, including inequities in access to skilled care and the lack of available and affordable treatment. Ramey and Pinel delve deep into the roles nurses and midwives play in preventing and treating obstetric fistula, as well as their impact on global fistula campaigns. This article was particularly useful for my sector research because it allowed me to explore the role of medical professionals in global fistula campaigns and the fight to end this injustice.

Potential Sector Article 10
[https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1016/j.ijgo.2007.06.036 The Campaign to End Fistula: What have we learned? Findings of facility and community needs assessments]

Analysis
Velez, Ramsey, and Tell present a summary of fistula needs assessments done in various countries in Africa and Asia. In doing so, Velez, Ramsey, and Tell provide insight into the developing world’s capacity to manage the problem of fistula and where gaps and inequities lie. In addition, Velez and Ramsey convey how The Campaign to End Fistula has helped address the problem of obstetric fistula in various countries. The analysis of needs assessments specifically looks at each country’s ability to socially reintegrate women after they receive care. This summary of the findings of fistula needs assessments enhanced my sector research, providing data on the strengths and weaknesses of fistula campaigns. In addition, this article is helpful for my understanding of the work my practice experience does because it has helped me identify clinical and programmatic gaps and inequities.

Additional Articles about Obstetric Fistula in Uganda

 * Childbirth experiences of women with obstetric fistula in Tanzania and Uganda and their implications for fistula program development


 * Experiences with Obstetric Fistula in Rural Uganda


 * Referral practices and perceived barriers to timely obstetric care among Ugandan traditional birth attendants (TBA)


 * Predictors and outcome of surgical repair of obstetric fistula at a regional referral hospital, Mbarara, western Uganda


 * Community awareness about risk factors, presentation and prevention and obstetric fistula in Nabitovu village, Iganga district, Uganda
 * Group Psychological Therapy in Obstetric Fistula Care: A Complementary Recipe for the Accompanying Mental Ill Health Morbidities?

Additional Articles about Maternal Health

 * "Guilty until proven innocent": the contested use of maternal mortality indicators in global health
 * "SOMEONE DIES IN YOUR LAP": STRUCTURAL ECOLOGICAL AND POLITICAL EFFECTS ON CHILD AND MATERNAL HEALTH CARE DECISIONS, MOROTO DISTRICT, UGANDA, 2004

Obstetric fistula
This is the article I plan to use for my sector. I added a citation to this wikipedia page. If you go to the wikipedia page, look at the contents drop down menu. Click on where it says "Community organizations" in the "Society and culture" section of the wikipedia page (7th thing down on the contents box). Once you get relocated to this section of the wikipedia page, read the first sentence and notice the [74] after it. This is my citation. You can click on the 74 and see the details of my citations. Then if you go to the references section of the wikipedia page you can look at number 74, click on the internal hyperlink and access the article I used for this citation.

Area
For my area article, I now better understand the structure of the health care system in Uganda, various policies that have been implemented in the past that make it difficult for individuals to access health services, the financing of services, and various challenges women in Uganda face every day in regard to getting the care they need. Musoke brought to attention the need for improvement in technology, collaboration amongst health workers, and increased institutional capacity in regard to advancing access to health care, challenges I had not thought about before. Ssengooba and Parkhurst enhanced my understanding of how health facilities in Uganda differ in terms of professionalism and technological advancements, which impacts a woman’s decision to pursue treatment at that facility. Atekyereza, Mubiru, Kyomuhendo, Lang-Balde, Amerson, Macpherson et al., Morgan et al., Namujju et al., Osamor and Grady demonstrated to me how women's perceptions of childbirth in Uganda influence patterns of seeking care, as well as the strengths and weaknesses of fistula campaigns. For my area article, I plan to add a section to the "Limited Access to Healthcare Services" section called "Distance, quality, and bypassing" that explores why women choose to travel further instead of using their local healthcare facilities. In addition, I will add a new section called "Perceptions on pregnancy influence patterns of seeking care" that explores various perspectives women have on childbearing in Uganda and how these views are shaped by sociocultural beliefs and values and gender power relations.

Sector
Through my sector sources, I have a broader understanding of challenges surrounding obstetric fistula treatment on a global scale and the needs talk surrounding the condition. Ahmed and Tuncalp identified and explained how difficult it is to even measure the prevalence and incidence of the condition which then makes expressing the need for treatment difficult. Cook provides valuable information and statistics on where obstetric fistula is most prevalent and why, as well as expresses how states are failing to provide for their citizens. Morris and Rushwan take an even further step back to examine the neglect of adolescent sexual and reproductive health worldwide and the implications that have occurred as a result. These authors look at challenges adolescents in particular face and how that perpetuates the drastic impacts of obstetric fistula in relation to older women. Ahmed and Holtz explore the social and economic consequences of having the condition, resulting in poor mental health. Cam et al., demonstrate how fistula campaigns came to be and how obstetric fistula gained international attention. In addition, they demonstrate various ways in which fistula campaigns are of benefit and how they can perpetuate the problem. Donnay and Ramsey demonstrated the partnerships that surround fistula campaigns and their creation. Lewis Wall compares and contrast the issue of obstetric fistula in the developing and developed world. Ramsey and Pinel delve deep into the role nurses and midwives play in global fistula campaigns. Velez, Ramey, and tell provide insight into the results of various needs assessment on fistula campaigns worldwide. For my sector article I plan to add a section called "Mental health services" to the treatment section where I will explore how obstetric fistula impacts a woman's mental health and self esteem and the importance of social reintegration and rehabilitation. In addition, I plan to edit the "Society and Culture" section about the needs talk surrounding obstetric fistula; however, this section is pretty well developed already.

Drafting
Bold = new material. Non-bold = copy-pasted from current Wikipedia article.

Perceptions on pregnancy influence patterns of seeking care
'''Uganda's socioeconomic and political instability, characterized by the destruction of health infrastructure, chronic shortages of staff and healthcare supplies, low wages for health workers, low accessibility to health services and mistreatment by medical personnel, have long been to blame for its high infant and maternal mortality rate. Although these barriers play a substantial role in the limited access to healthcare services in Uganda, it has also become apparent that the way in which women perceive pregnancy can heavily influence patterns of seeking care .'''

Some perceive pregnancy as natural, an honor, an achievement, or an exaltation of femininity, that brings joy to families and awards women respect, power, and status in their community '''. Oftentimes these women feel socially accepted and excited for their futures, motivating them to seek antenatal care . Others perceive pregnancy as a life-threatening experience, characterized by fear, unpredictable timing, and a level of uncertainty'''. '''They often define their pregnancies as a painful or regrettable experience, especially if they conceived accidentally or against their will. This mentality towards pregnancy is associated with a decrease in the amount of antenatal care sought, exacerbating issues surrounding maternal health'''.

Many women also define their pregnancy based on sociocultural values systems, including through gender and power relations  '''. In societies where women are seen as inferior to men in the public sphere, the idea that birthing yields immense power has been attributed to the nature of childbearing. It is not uncommon for women to conceptualize their birth as a battle–a test of endurance and tolerance of physical pain. This conceptualization often leads to pregnant women suppressing their concerns about potential complications or the need for immediate medical attention'''.

It is crucial that one understands various childbirth experiences and perceptions, as it allows individuals to better understand patterns of seeking care and how to approach individualized and culturally sensitive maternal health care.

Limited Access to Healthcare Services

Cultural barriers in seeking access

There is not only the issue of lack of resources in healthcare services, there are also cultural barriers in women seeking professional care. Ugandan women adhere to very traditional birthing practices and believe that pregnancy is a test of endurance and maternal death is merely a sad, but normal event. This cultural view  also  hinders the chances of women seeking professional maternal care. In the Kiboga community it is evident that pregnancy and childbirth  were one  are some of the major areas where women still command power and status, which they  would  strive to keep to embody in order to enhance their status within the household and community.

Another factor preventing women from seeking emergency obstetric care among Ugandan women is the cultural desire for Ugandan women to 'protect their own integrity.' A common birthing practice is for women to give birth completely alone and the individual is the one who decides if outside help is needed. It has also been found that women feel that they have the most power and control during the birthing process, which is something they often lack in other aspects of their lives. Women are considered to be strong and independent if they can handle the birthing process by themselves. These beliefs often lead to very dangerous circumstances as the women often delay assistance, which sometimes costs their life or the life of the baby. Oftentimes one of these main issues is obstructed labor. When women realize labor is not progressing normally they first seek female friends or traditional birth attendants. This can result in a further delay in seeking medical attention from someone who is trained to handle such complications.

A study conducted in 2001 found that one common remedy used for obstructed labor in home births was herbs. As high as 80% of childbirths used herbs. Ugandan culture also sees the birthing process as a woman's affair and therefore oftentimes there is little male involvement. Transportation is also another issue in Uganda. Most families do not own personal cars and cannot afford taxi fares. More remote and rural areas cannot be reached by car but must be reached using a motorcycle. These conditions are not ideal in transporting a woman in labor, so women tend to choose to stay home during labor. Women also avoid healthcare facilities as this also inhibits their own integrity. They feel that they are powerless in a hospital, have little say in decisions, and know little about procedures being done to them. There is also a lack of medical supplies in Ugandan hospitals and healthcare is run on a fee for service basis. Many women do not have the funds necessary to both travel to a hospital and pay for hospital services and supplies. Or if they do have the funds, hospitals could also be out of supplies. This further discourages them from giving birth in a healthcare setting.

There is an urgent need to educate both men and women on the risks of having home or solitary childbirths that aren't assisted by a skilled attendant. A study conducted in 2011, suggests that birthing outcomes would improve if men were intimately involved in the process and could assist in making decisions regarding obstructed labor or other complications. The integrity of women could be maintained if health workers were more compassionate and more able to support women and provide understandable information during labor. There is also a great need to improve both access and quality of healthcare offered to the masses in Uganda.

Emergency response

One major issue in regard to maternal health is access to quality emergency obstetric care and the many barriers Ugandan women face to gain access to such care. A needs assessment of emergency obstetric care was carried out in 197 health facilities in 19 out of 5 health districts in Uganda, covering 38% of the total population. The study found in 2005, that there was a large number of missing signal functions at health facilities and an urgent need to improve the availability of emergency obstetric care. It was found that the improvement of care begins by improving district health workers' skills in emergency obstetric care so that they can effectively manage and treat obstetric complications. Part of this training includes hospital staff on how to properly manage data systems to better monitor and evaluate program implementation. An effective advocacy tool, known as REDUCE, has already been developed for Uganda to stimulate policy dialog and strategic planning. The REDUCE tool uses computer models to estimate the human and economic consequences of maternal mortality, and generates data that can be used to create arguments for giving higher priority to maternal mortality reduction in creating policies, strategy development, and resource allocation. [I moved this section out of the cultural barriers section and into its own section because I was not sure why it was there]

Distance, quality, bypassing

'''A number of barriers to the use of professional maternal health services have been identified, including distance to facilities and perceived quality of services. A study conducted in 2003 examined the proportion of deliveries from individuals in local area and the number of deliveries each year for several different facilities to assess barriers influencing an individual's access to maternal health care. The results of the study found that many people travel outside their local area, bypassing several other healthcare facilities, to reach more popular services–facilities with a high number of deliveries per year. Women associated popularity with a higher quality of care and costs, making the extra travel time worth it. As a result of this perceived quality of care, some facilities are underutilized and others over-stretched, decreasing the availability of staff and supplies .'''

Mistreatment by medical personnel

In 2003, a study was conducted in Hoima, Uganda, whose aim was to examine the reasons why, when faced with complications of pregnancy or delivery,  women continued to choose high-risk options when faced with complications of pregnancy and delivery, ultimately leading to severe morbidity and mortality. The study found that women considered the use of primary health units and the referral hospital when complication occurred as a last resort. Women reported that a lack of skilled staff, complaints of abuse, neglect, and poor treatment in the hospital, and poorly understood reasons for procedures, plus health workers’ views that women are ignorant, also explain why many women consider going to a hospital for delivery as a last resort.

Limited Reproductive Health Literacy

Many women do not utilize healthcare services because they do not understand reasons for procedures. Health literacy is also a large issue among women in Uganda. It not only affects birthing outcomes but also information on reproductive care. Another study conducted in 2012, found that many Ugandan women rely on myths, rumors, and misconceptions that discourage them from using reproductive health services, particularly family planning.

Another study conducted in 2011 found that even those pregnant women who attended antenatal classes had very little knowledge of danger signs during pregnancy. An association was found between birthing preparedness and knowledge of danger signs. The most common birth preparedness practice was saving money to facilitate referral in case of complications. While only 68% of women in the study had attended at least four antenatal care visits during their last pregnancy. Only 19% of women in the study could indicate at least three danger signs. This shows that a considerable share of those who seek professional care are not receiving or retaining vital information. It was found that women appear to be unaware of the risk they take by subjecting themselves to prolonged labor. The study found that among women who went to antenatal visits 40% had not been advised where to deliver and the staff were allegedly unfriendly. There also seems to be an association between having a delivery by skilled birth attendants and being under the age of twenty. It is hoped that it is becoming more culturally acceptable to give birth with the assistance of a skilled attendant than it is among the older generations. The study concluded that every woman should be made aware of the likelihood of complications during pregnancy, childbirth, labour, and the postpartum periods. There has also been success using mobile phones to provide health information in HIV programs in Uganda. Since mobile phones are becoming more and more common, it appears this could also be a good route for antenatal education.

Reliance on traditional medicine

In rural areas, conceiving pregnant women seek the help of traditional birth attendants (TBAs) due to difficulty in accessing formal health services and also high transportation or treatment costs. TBAs are trusted as they embody the cultural and social life of the community. However, the TBAs’ lack of knowledge and training and the use of traditional practices have led to risky medical procedures resulting in high maternal mortalities.

In 2006 it was found that some rural areas of Uganda up to 90% of the population uses traditional medicine for day to day healthcare needs. The World Health Organization estimates that 80% of the developing world uses traditional medicinal practices. It was found that over 80% of child births that are conducted at home use herbal remedies in the Bushenyi district of Uganda. Over seventy five plants have been recorded for use to induce labor and some of these plants could be oxytocic. The danger lies in levels of dosage as to whether or not the plants could potentially bring harm to the mother and baby. These medicinal herbs are often used because Ugandans cannot afford western pharmaceuticals. These herbal remedies are also socially and culturally accepted. In Uganda reproductive health issues such as maternal mortality and morbidity, account for the number one disease burden. Perinatal and maternal-related conditions account for 20.4%, malaria 15.4%, acute lower respiratory infections 10.5%, AIDS 9.1%, and diarrhea 8.4%. These conditions account for over 60% of the total burden.

In Uganda, it is viewed that a woman who had died in childbirth is equated to a soldier who had died during a war. Maternal death is considered a natural phenomenon and encourages the use of herbs, while undermining safe birthing practices with a skilled birth attendant. Women in Uganda are generally more disadvantaged than men. There tends to be a patriarchal order of communities. Therefore, women have a very limited control of resources and in most cases have poorer health. The study found that dosing and toxicity levels need to be monitored in the use of medicinal herbs during labor. There is a need for further field and laboratory research to establish appropriate dosage levels. In 2006, the maternal mortality rate in Uganda is 506 deaths per 100,00 live births. There is a need for health provision programs, safe motherhood programs, health policies in reproductive health care, and collaborative approaches involving traditional medicinal practitioners such as traditional birth attendants. It is possible that a lack of knowledge on plant species used to induce labor and speed up childbirth could be one of the main factors that contribute to high maternal mortality in Uganda.

Malaria and pregnancy

Malaria is a leading cause of morbidity and mortality in Uganda. It is especially lethal among pregnant women and children under five. The mortality rate for all ages is estimated at 32.1% in 2004. A study in Mukono, Uganda, determined that the most effective delivery system of intermittent preventive treatment (IPTp) for pregnant women was that education was a factor in health seeking behaviors. Those who were a part of the study accessed IPTp early and most of them adhered to the two doses of SP. Women experienced a reduction in malaria episodes, anemia, parasitaemia and low birth weight. While these results cannot be attributed to the intervention alone, after controlling for age, education, parity, and occupation, there were still significant differences for parasitaemia, reported malaria episodes and birth weight, indicating the importance of access and adherence to IPTp.

Sector
Treatment

Surgery

The nature of the injury varies depending on the size and location of the fistula, so a surgeon with experience is needed to improvise on the spot.[add space]Before the person undergoes surgery, treatment and evaluation are needed for conditions including anemia, malnutrition, and malaria. Quality treatment in low-resource settings are possible (as in the cases of Nigeria and Ethiopia).

Treatment is available through reconstructive surgery. Primary fistula repair has a 91% success rate. The corrective surgery costs about US$100 – 400, and the cost for the entire procedure, which includes the actual surgery, postoperative care, and rehabilitation support, is estimated to cost $300–450. Initial surgeries done by inadequately trained doctors and midwives increase the number of follow-up surgeries that must be performed to restore full continence. Successful surgery enables women to live normal lives and have more children, but it is recommended to have a cesarean section to prevent the fistula from recurring. Postoperative care is vital to prevent infection. Some women are not candidates for this surgery due to other health problems. In those cases, fecal diversion can help the patient, but not necessarily cure them.

Mental health services

Besides physical treatment, mental health services are also needed to rehabilitate fistula patients, who experience psychological trauma from being ostracized by the community and from fear of developing fistula again.

'''Among all morbid conditions, obstetric fistula is said to be the most debilitating and devastating, changing the lives of those affected. Major consequences of obstetric fistula impacting a woman's mental health are the loss of a husband/spouse and stigmatization from society.'''

'''An analysis of literature published between 1985 and 2005 on fistula in developing countries analyzed two major social and economic consequences of the condition: divorce/separation and fetal/perinatal child loss. The loss of a child from obstructed labor and the formation of fistula negatively impact the social status of women and may lead to divorce or separation. Without adequate support from family members and friends, divorced/separated women suffer immense economic hardship, impacting their mental health and overall well-bring. In addition to the lack of emotional and financial support from a husband, women with fistula are often sent to their parents' home until they are cured and are not allowed to cook, participate in social events, or perform religious rituals. The combination of mourning the death of a child and fighting survival, social position, and value in society leaves women mentally devastated .'''

Several treatment facilities have recognized the importance and need for rehabilitation and social reintegration for women suffering from obstetric fistula . In Nigeria, crafting programs have served beneficial to rehabilitation and social reintegration, as well as the hiring of social worker to help women fight the stigma of having obstetric fistula . A study on the first formal counseling program for fistula survivors in Eritrea shows positive results, whereby counseling significantly improved the women's self-esteem, knowledge about fistula and fistula prevention, and behavioral intentions for "health maintenance and social reintegration" following surgery.

Despite the tragedy of having obstetric fistula, women with successful repair and social reintegration express interest in returning to school and starting businesses in their villages .

Catheterization '''[moved this section from below the challenges subheading to before it; instead of surgery, challenges, catheterization... I felt that surgery, catheterization, and then challenges made more sense because it presents all of the treatments and then the challenges that result]'''

Fistula cases can also be treated through urethral catheterization if identified early enough. The Foley catheter is recommended because it has a balloon to hold it in place. The indwelling Foley catheter drains urine from the bladder. This decompresses the bladder wall so that the wounded edges come together and stay together, giving it a greater chance of closing naturally, at least in the smaller fistula.

About 37% of obstetric fistula that are treated within 75 days after birth with a Foley catheter resolve. Even without preselecting the least complicated obstetric fistula cases, a Foley catheter by midwives after the onset of urinary incontinence could treat over 25% of all new fistula.

Challenges

Challenges with regards to treatment include the very high number of women needing reconstructive surgery, access to facilities and trained surgeons, and the cost of treatment. For many women, US $300 [added space] is a price they cannot afford. Access and availability of treatment also vary widely across different sub-Saharan countries. Certain regions  also  do not have enough maternal care clinics that are properly equipped, willing to treat fistula patients, and adequately staffed. At the Evangelical Hospital of Bemberéke in Benin, only one expatriate volunteer obstetrics and gynecology doctor is available a few months per year, with one certified nurse and seven informal hospital workers. In all of Niger, two medical centers treat fistula patients. In Nigeria, more dedicated health professionals operate on up to 1,600 women with a fistula per year. The world is currently severely under capacity for treating the problem; it would take up to 400 years to treat the backlog of patients. To prevent any new cases of obstetric fistula, about 75,000 new emergency obstetric care facilities would have to be built in Africa alone, plus an increase in financial support and an even higher number of certified doctors, midwives, and nurses needed.

Another challenge standing between women and fistula treatment is information. Most women have no idea that treatment is available. Because this is a condition of shame and embarrassment, most women hide themselves and their condition and suffer in silence. In addition, after receiving initial treatment, health education is important to prevent fistula in subsequent pregnancies.

Another challenge is the lack of trained professionals to provide surgery for fistula patients. As a result, nonphysicians are sometimes trained to provide obstetric services. For example, the Addis Ababa Fistula Hospital has medical staff without formal degrees, and one of its top surgeons was illiterate, but she had been trained over years and now regularly successfully performs fistula surgery.

Society and culture

During most of the 20th century, obstetric fistula were largely missing from the international global health agenda. This is reflected by the fact that the condition was not included as a topic at the landmark United Nations 1994 International Conference on Population and Development (ICPD).[68] The 194-page report from the ICPD does not include any reference to obstetric fistula. In 2000, eight Millennium Development Goals were adopted after the United Nations Millennium Summit to be achieved by 2015. The fifth goal of improving maternal health is directly related to obstetric fistula. Since 2003, obstetric fistula has been gaining awareness amongst the general public and has received critical attention from UNFPA, who has organized a global "Campaign to End Fistula," aimed to make obstetric fistula cases as rare in developing countries as in the industrialized world [69]. The campaign is devoted to gaining support and resources for the elimination of obstetric fistula, as well as raising awareness of inequities in maternal health services and how gender power relations limit women's autonomy. New York Times columnist Nicholas Kristof, a Pulitzer Prize–winning writer, wrote several columns in 2003, 2005, and 2006[70] focusing on fistula and particularly treatment provided by Catherine Hamlin at the Fistula Hospital in Ethiopia. In 2007, Fistula Foundation, Engel Entertainment, and a number of other organizations including PBS NOVA released the documentary film, A Walk to Beautiful, which traced the journey of five women from Ethiopia who sought treatment for their obstetric fistula at the Addis Ababa Fistula Hospital in Ethiopia. The film still airs frequently on PBS in the U.S. and is credited with increasing awareness of obstetric fistula greatly. Increased public awareness and corresponding political pressure have helped fund the UNFPA's Campaign to End Fistula, and helped motivate the United States Agency for International Development to dramatically increase funding for the prevention and treatment of obstetric fistula.

Countries that signed the United Nations Millennium Declaration have begun adopting policies and creating task forces to address issues of maternal morbidity and infant mortality, including Tanzania, Democratic Republic of Congo, Sudan, Pakistan, Bangladesh, Burkina Faso, Chad, Mali, Uganda, Eritrea, Niger, and Kenya. Laws to increase the minimum age for marriage have also been enacted in Bangladesh, Nigeria, and Kenya. To monitor these countries and hold them accountable, the UN has developed six "process indicators", a benchmark tool with minimum acceptable levels that measures whether or not women receive the services they need.[16]

The UNFPA set out several strategies to address fistula, including "postponing marriage and pregnancy for young girls, increasing access to education and family planning services for women and men, provide access to adequate medical care for all pregnant women and emergency obstetric care for all who develop complications, and repairing physical damage through medical intervention and emotional damage through counselling."[71] One of the UNFPA's initiatives to reduce the cost of transportation in accessing medical care provided ambulances and motorcycles for women in Benin, Chad, Guinea, Guinea-Bissau, Kenya, Rwanda, Senegal, Tanzania, Uganda, and Zambia.[16]

Campaign to end fistula

The Addis Ababa Fistula Hospital in Ethiopia successfully treats women with obstetric fistula, even in less than desirable environments. As a result, the UNFPA gathered partners in London in 2001, and officially launched an international initiative to address obstetric fistula later in 2003. Partners in this initiative include Columbia University's Averting Maternal Death and Disability Program, the International Federation of Gynecology and Obstetrics, and the World Health Organization. The official international partnership formed by the Campaign to End Fistula is named the Obstetric Fistula Working Group (OFWG) and its purpose is to coordinate and collaborate global efforts to eliminate obstetric fistula.[17]

The first thing that the initiative did was to quantitatively assess the issue in countries where the prevalence is suspected to be high, including nine countries in sub-Saharan Africa. The studies found that fistula patients are mostly illiterate, young, and poor women. Moreover, local legislators and government officials' lack of awareness exacerbate the problem.[60][72] The OFWG improves awareness for prenatal and neonatal care and develops strategies for clinically managing obstetric fistula cases.[17]

To date, the Campaign to End Fistula has involved more than 30 countries in sub-Saharan Africa, South Asia, and the Middle East, and completed rapid needs assessments in many of those countries to continually assess the needs in each country. The national strategies that the campaign helps each nation to develop are three-fold: prevention of new cases, treatment for patients, and support for reintegration into society after the operation. Prevention efforts include access to maternal health services and mobilizing communities and legislators to increase awareness of maternal health problems. Training health providers and ensuring affordable treatment services, as well as providing social services such as health education and mental health services, help treat and reintegrate women into their communities. Other tasks undertaken by the campaign include fundraising and introducing new donors and gathering new partners of all perspectives, such as faith-based organizations, NGOs, and private-sector companies.[17]

Community Organizations

People recovering from a fistula in the postoperative period need support to fully reintegrate into society. In particular, physical labor is limited in the first year of recovery, so women need alternative ways to earn an income. Since poverty is an indirect cause of obstetric fistula, some community organizations aim to provide postoperative services to enhance the women's socioeconomic situation. Delta Survie, located in Mopti, Mali, is a community center that provides skills training and helps women to produce hand-made jewelry to generate income and meet other women while they recover. Another organization, IAMANEH Suisse, identifies Malian fistula patients, facilitates operations for those without the financial means, and helps them access follow-up services to prevent recurrence of fistula in their subsequent pregnancies.

Other organizations also help to arrange mission trips for medical personnel to visit countries with women affected by fistula, perform surgeries, and train local doctors to give medical assistance for fistula patients. The International Organization for Women and Development (IOWD) is one such nonprofit organization. The IOWD hosts four to five mission trips per year to provide relief to obstetric fistula patients in West Africa. IOWD mission trip members have evaluated thousands of patients at no cost and performed surgeries for over a thousand women.