Background: Obstetric fistula, a debilitating birthing injury, results in urinary incontinence and psychosocial and economic consequences. This dissertation examined the socio-cultural aspects shaping the stigma process for women with fistula in Ghana, explored women’s strategies for coping with and resisting stigma, and assessed stakeholder perspectives on determinants of implementation of therapeutic tools for fistula management in LMICs.

Methods: This convergent mixed methods study collected semi-structured interviews among women with fistula in Ghana (n=38) and in-depth interviews with global stakeholders (n=21). Qualitative findings on women’s experiences and on stakeholders’ perspectives emerged from thematic analyses. Quantitative results among women, including socio-demographics, clinical characteristics, coping effectiveness, and stigma severity, were reported as descriptive statistics. Data were merged to generate meta-inferences.

Results: Paper 1 elucidates how fistula-related stigma threatens women’s ability to fulfill social expectations and roles as woman, partner, and mother. Women able to keep themselves very well, or maintain a neat appearance and home, experienced less stigma. This was related to expectations of labor that allowed for giving to others and getting/keeping a partner, making childbearing more likely. In the agrarian, patriarchal North, stigma was more severe as fistula additionally challenged the ability to farm and respect male family. Women with a living child and supportive partner were less stigmatized.

Paper 2 finds that women in Ghana are using homemade incontinence management tools, although with limited effectiveness. Most manage stigma through concealing, withdrawing, or religious coping; those keeping themselves very well perceive coping effectiveness. Some resist stigma, through confronting, educating, or rejecting negative self-perceptions, despite reduced gender power.

Paper 3 suggests implementation facilitated by the relative advantage and cost, beliefs about effectiveness, supportive implementation climate, clear tension for change, and compatibility with existing fistula programming. Barriers include provider acceptability, low prioritization of therapeutic options, and lack of knowledge of comparative effectiveness of tools for different patient needs.

Conclusion: This examination of intrapersonal and socio-cultural factors shaping fistula-related stigma and its management in this context will guide development of culturally informed measures and interventions to support coping. Innovations for self-management of incontinence that support effective coping should be integrated into fistula programming.