NAMING THE WOUND, REWRITING THE RECORD: UTERINE FIBROIDS AND THE COST OF SILENCE IN SIERRA LEONE

Abstract

Uterine fibroids affect up to eighty percent of women of African descent and account for 34 percent of gynecologic admissions at Sierra Leone’s national referral hospital. They appear in no national policy document, receive no dedicated financing, and generate no national data. This thesis asks how that happens and at what cost, not as a failure of any single actor, but as the outcome of how reproductive health systems across the region have been built, what they were designed to measure, and whose suffering they were structured to see. Women living with fibroids navigate delayed diagnosis, social stigma, and catastrophic out-of-pocket costs with no public support. This thesis traces how that exclusion is produced and what it means for women, households, and the health system. The study uses a convergent mixed-methods design. A retrospective chart review of 262 gynecologic admissions at Princess Christian Maternity Hospital documents clinical burden, diagnostic pathways, and treatment costs. Fifteen in-depth interviews, five focus group discussions, and seven key informant interviews explore how women interpret symptoms, seek care, and sustain their families while managing chronic illness. Fibroids accounted for 34 percent of gynecologic admissions. Most diagnoses relied on clinical examination alone because imaging was unavailable or unaffordable. Surgical care required out-of-pocket payments equivalent to several months of household income, with no cases receiving subsidy or insurance coverage. The thesis develops the Cycle of Suffering and Resilience (COSAR), an original analytic framework that traces six mechanisms, diagnostic invisibility, clinical disregard, epistemic negotiation, financial exclusion, moral surveillance, and survival labor, through which women absorb the costs of a system not designed to see them. Reproductive health frameworks across the region are built around maternity and are not structured to respond to chronic gynecologic suffering. This thesis provides the evidence and the conceptual foundation for integrating uterine health into national data systems, financing, and service delivery. Naming the wound is the precondition for rewriting the record.