Building a country-wide Fistula Treatment Network in Kenya: results from the first six years (2014-2020)

Understanding Women's Pregnancy Intentions, Decision-Making, and Factors Influencing Reproductive Choices After Genital Fistula Repair in Uganda: A Qualitative Study

Female genital fistula is a debilitating injury that may affect as many as two million women globally. While studies have examined women's fertility intentions in Uganda and sub-Saharan Africa broadly, few have explored the factors influencing pregnancy decision-making among women who have undergone fistula repair. We conducted in-depth interviews with 40 women who had undergone fistula repair. Interviews were audio-recorded, transcribed into English, and coded using a group-developed collaborative coding framework. Oriented by the socio-ecological framework, we reviewed factors contributing to pregnancy desire and decision-making for women who became pregnant and those who did not following fistula repair. Factors influencing pregnancy desire included partner support, financial circumstances, number of children, and health knowledge and perspectives. Women's own beliefs about their ability to become pregnant and their fears around surgeries and fistula recurrence also influenced pregnancy desire. Participants desiring pregnancy but experiencing infertility expressed various mental health impacts including feelings of hurt, isolation, and yearning, and described infertility stigma. Finally, societal expectations of women to assume childbearing and prioritize home responsibilities influenced participants' decisions to pursue pregnancy. However, discordance between partners or infertility resulted in various consequences, such as women becoming pregnant to fulfill their partner's needs, lying to their partner about their pregnancy status, or dissolution of the relationship. A nuanced understanding of pregnancy intentions and decision-making following fistula repair can help inform patient-centered post-repair pregnancy counseling to support the unique needs of women.

Community perceptions and determinants of obstetric fistula across gender lines

Obstetric fistula is a major maternal health challenge in low-income countries like Ethiopia. Misperceptions about obstetric fistula delay seeking and accessing healthcare. Understanding community attitudes is crucial for prevention, early detection, and support for affected women. A community-based study was conducted from February 1 to April 26, 2024, among 640 women and men to assess attitudes and influencing factors. Participants were selected using a multistage sampling. Multivariable logistic regression analysis was performed, with a p-value < 0.05 considered statistically significant. The study included nearly equal proportions of males (49.1%) and females (50.9%), with a median age of 32 years (IQR: 19-64). Among participants, 47.8% (95%CI: 43.7-51.6) had a favourable attitude towards obstetric fistula. Those under 20 years (AOR: 7.7; 95%CI: 2.3-28.6), aged 20-35 (AOR: 3.9; 95%CI: 1.8-8.5), and aged 36-50 (AOR: 6.36; 95%CI: 3.0-14.1) were more likely to have a favourable attitude compared to those over 50 years. Female gender (AOR: 1.5; 95%CI: 1.1-2.2), primary education (AOR: 1.86; 95%CI: 1.3-2.9), and awareness of obstetric fistula (AOR: 3.04; 95%CI: 2.0-4.6) were significant determinants. The study revealed unfavourable community attitudes towards obstetric fistula, with notable gender and age differences. Enhancing attitudes requires a comprehensive, tailored program involving all relevant stakeholders.

Development and Pilot Test of a Multi-Component Intervention to Support Women's Recovery from Female Genital Fistula

INTRODUCTION AND HYPOTHESIS

We evaluated a pilot multi-component reintegration intervention to improve women's physical and psychosocial quality of life after genital fistula surgery.

METHODS

Twelve women undergoing fistula repair at Mulago Specialized Women and Neonatal Hospital (Kampala, Uganda) anticipated in a 2-week multi-component intervention including health education, psychosocial therapy, physiotherapy, and economic investment. We assessed feasibility through recruitment, retention, and adherence, acceptability through intervention satisfaction, and preliminary effectiveness through reintegration, mental health, physical health, and economic status. We collected quantitative data at enrollment, 6 weeks, 3 months, and 6 months. We conducted in-depth interviews with six participants. Quantitative data are presented descriptively, and qualitative data analyzed thematically.

RESULTS

Participants had a median age of 34.5 years (25.5-38.0), 50% were married/partnered, 42% were separated, 50$ had completed less than primary education, and 67% were unemployed. Mean number of sessions received was 12 for health education (range 5-15), 8 for counseling (range 8-9), and 6 for physiotherapy (range 4-8). Feasibility was demonstrated by study acceptance among all those eligible (100%); comfort with study measures, data collection frequency and approach; and procedural fidelity. Acceptability was high; all participants reported being very satisfied with the intervention and each of the components. Participant narratives echoed quantitative findings and contributed nuanced perspectives to understanding approach and content.

CONCLUSIONS

Our results suggest that the intervention and associated research were both feasible and acceptable, and suggested certain modifications to the intervention protocol to reduce participant burden. Further research to determine the effectiveness of the intervention above and beyond surgery alone with regard to the health and well-being of women with fistulas is warranted.

Measuring the cost-effectiveness of treating rectovaginal and vesicovaginal fistulas: A multicenter global study by the Fistula Foundation

OBJECTIVE

Surgery for obstetric fistula is a highly effective treatment to restore continence and improve quality of life. However, a lack of data on the cost-effectiveness of this procedure limits prioritization of this essential treatment. This study measures the effectiveness of fistula surgeries using disability-adjusted life years (DALYs) averted.

METHODS

In 2021 and 2022, the Fistula Foundation funded 20 179 fistula surgeries and related procedures at 143 hospitals among 27 countries. We calculated DALYs averted specifically for vesicovaginal fistula and rectovaginal fistula procedure types (n = 13 235 surgeries) by using disability weights from the 2019 Global Burden of Disease study. We based cost calculations on direct treatment expenses, including medical supplies, health provider fees, and preoperative and postoperative care. We measured effectiveness using data on the risk of permanent disability, country-specific average life spans, and treatment outcomes.

RESULTS

The total treatment cost was $7.6 million, and a total of 131 433 DALYs were averted. Thus, the cost per DALY averted-the cost to restore 1 year of healthy life-was $58. For this analysis, we took a cautious approach and weighted only surgeries that resulted in a closed fistula with restored continence. We calculated DALYs averted by country. Limitations of the study include data entry errors inherent in patient logs and lack of long-term outcomes.

CONCLUSION

The current study demonstrates that obstetric fistula surgery, along with having a significant positive impact on maternal health outcomes, is highly cost-effective in comparison with other interventions. The study therefore highlights the benefits of prioritizing fistula treatment as part of the global agenda for maternal health care.

Patient characteristics, surgery outcomes, presumed aetiology and other characteristics of fistula surgeries and related procedures supported by Fistula Foundation from 2019 to 2021: a multicentre, retrospective observational study

OBJECTIVES

Obstetric fistula is a devastating childbirth injury primarily caused by prolonged, obstructed labour. It leaves women incontinent, severely stigmatised and isolated. Fistula repair surgery can restore a woman's health and well-being. Fistula Foundation, a non-profit organisation, works in partnership with local hospitals and community organisations in Africa and Asia to address key barriers to treatment and to increase the number of women receiving surgical care. This paper presents data on fistula and fistula repair surgery across a large global network of hospitals supported by Fistula Foundation. The data were collected between 2019 and 2021.

DESIGN

Multicentre, retrospective, observational, descriptive study.

SETTING AND PARTICIPANTS

The study analysed deidentified data from 24 568 surgical repairs supported by Fistula Foundation to treat women with obstetric fistula at 110 hospitals in 27 countries.

RESULTS

The data highlight patient characteristics and key trends and outcomes from obstetric fistula repair surgeries and related procedures. Of those surgeries, 87% resulted in a successful outcome (fistula dry and closed) at the time of discharge, highlighting the effectiveness of fistula repair in restoring continence and improving quality of life. Over the period studied, the number of supported surgeries increased by 14%, but there remains an urgent need to strengthen local surgical capacity and improve access to treatment. Women suffered an average of 5.7 years before they received surgery and only 4% of women sought care independently. This underscores the importance of enhancing community awareness and strengthening referral networks.

CONCLUSIONS

This research provides essential insight from a vast, global network of hospitals providing highly effective fistula repair surgery. Further investment is needed to strengthen surgical capacity, increase awareness of fistula and remove financial barriers to treatment if stakeholders are to make significant progress towards the United Nations' ambitious vision of ending fistula by 2030.

Impact of Beyond Fistula programming on economic, psychosocial and empowerment outcomes following female genital fistula repair: A retrospective study

OBJECTIVE

To retrospectively assess changes in economic status, psychosocial status and empowerment among women who participated in Beyond Fistula reintegration programming following fistula repair.

METHODS

We conducted a retrospective study among 100 Beyond Fistula program participants capturing sociodemographic characteristics, obstetric and fistula history, program participation, and our primary outcomes: economic status, psychosocial status, and empowerment via quantitative survey at two time points: before program participation and currently. Data were collected from November 2020 to July 2021 from 2013 to 2019 program participants. We compared outcomes across these two time points using paired t tests or McNemar's tests.

RESULTS

The proportion of individuals owning property (28.0% vs. 38.0%, P = 0.006), having a current source of income (19.0% vs. 56.0%, P < 0.001), and saving or investing income (11.0% vs. 37.0%, P < 0.001) increased significantly from pre- to post-programming. We also identified statistically significant increases from pre- to post-programming in self-esteem (5.0 [IQR 4.0-5.0] vs. 5.0 [IQR 5.0-5.0], P < 0.001), reintegration (53.0 [IQR 43.0-69.0] vs. 65.0 [IQR 51.0-72.0], P < 0.001) and level of input into household economic decision making (2.0 [SD 1.0] vs. 2.3 [SD 1.0], P = 0.004).

CONCLUSION

Beyond Fistula programming likely improved economic status, psychosocial status, and empowerment of participants. Post-surgical interventions incorporating a holistic approach can advance recovery through supporting psychosocial and economic wellbeing and should be offered to women undergoing genital fistula repair.

Training and capacity building in obstetric fistula repair: A scoping review

BACKGROUND

An ongoing barrier to sustainable obstetric fistula (OF) care is the lack of trained fistula surgeons. Despite a standardized training curriculum, data regarding OF repair training remain limited.

OBJECTIVES

To assess the availability of literature on the case numbers or training duration required for OF repair competency and whether these data are stratified by trainee background or repair complexity.

SEARCH STRATEGY

A systematic search of MEDLINE, Embase, and OVID Global Health electronic databases and gray literature.

SELECTION CRITERIA

All English sources from all years from low- and middle-income and high-income countries were eligible. Identified titles and abstracts were screened and full-text articles were reviewed.

DATA COLLECTION AND ANALYSIS

Data collection and analysis included a descriptive summary organized by training case numbers, training duration, trainee background, and repair complexity.

RESULTS

Of the 405 sources retrieved, 24 were included in the study. The only concrete recommendations were in the International Federation of Gynecology and Obstetrics 2022 Fistula Surgery Training Manual, which proposes 50 to 100 repairs (Level 1), 200 to 300 repairs (Level 2), and trainer discretion for Level 3 competency.

CONCLUSIONS

More case- or time-based data, particularly if stratified by trainee background and repair complexity, would be useful at the individual, institutional, and policy level for fistula care implementation or expansion.

Successful surgical closure and continence rate of obstetric fistula in Africa: systematic review and meta-analysis

Background

A female genital fistula is an abnormal connection between a woman's reproductive tract and her urinary tract or rectum. While numerous studies have aimed to determine the success rate of obstetric fistula closure in different health settings, there remains a significant scarcity of data on closure success rates and incontinence rates for various types of fistulas at the regional and sub-regional levels. The success rate reflects the continent's healthcare setup in regard to the World Health Organization standards. Thus, this study aims to determine the success of surgical closure and the continence rate of obstetric fistula in Africa.

Methods

This systematic review and meta-analysis review includes studies conducted up to February 2023. Search engines like EMBBASE, Medline, Google, PubMed, Google Scholar, African Journals Online, and ScienceDirect databases were utilized to find articles. The Joanna Briggs Institute critical evaluation checklist was used to evaluate the quality of our review, which was conducted in accordance with PRISMA criteria. Heterogeneity was indicated by a p-value for I2 statistics of less than 0.05. Publication bias was assessed using the Egger regression asymmetry test. Data were entered into Microsoft Excel and analyzed using STATA 16.

Result

This review includes 85 studies. A total of 24 countries from East, West, Central, North, and Southern African sub-regions were included. The overall pooled estimated rate of successful obstetric fistula closure is 86.15 (95% CI: 83.88-88.42). Moreover, the pooled estimated rate of successfully closed vesico-vaginal fistulas but with ongoing or residual incontinence (wet) was revealed as 13.41% (95% CI: 11.15-15.68). The pooled estimated rate of successfully closed rectovaginal fistulas and combined VVF and RVF are 91.06% (95% CI: 86.08-96.03) and 62.21% (95% CI: 48.94-75.49), respectively.

Conclusions

The rate of successful obstetric fistula closure in Africa is 86.15, which is higher than the WHO target. However, the surgical closure rate of a combined VVF and RVF is 62.2%, which is significantly lower than the WHO target.

Economic empowerment of the pilot reintegration program for female genital fistula survivors in Kenya during the COVID-19 pandemic

Objective

To determine whether a pilot reintegration program for female genital fistula survivors that included a combination of financial support, psychosocial support, and mentoring would result in their long-term economic empowerment during the COVID-19 pandemic.

Results

Nine fistula survivors participated in a 29-month pilot reintegration program offered by Kenya Quilts for Empowerment (KQFE), a registered Community Based Organization in Kenya. Originally, the program was intended to last for 18 months, but as a result of the pandemic, this was extended to achieve the long-term economic empowerment of women. The program was based on best practices for poverty alleviation that included multiple sources of income, psychosocial support, and mentoring, sustained over the entire 29-month period. All the women were severely impoverished at the baseline assessment, with one having some savings, and a few having productive assets, which were primarily chickens. Financial training and an initial non-refundable cash transfer provided start-up funds for small businesses; these initially flourished before floundering during the pandemic and eventually recovering. Funds were also used to buy livestock. A key component of the program was the provision of national health insurance for each woman and her family, which helped them stay healthy without having to sell any income-generating livestock. Other key components were the psychosocial support and mentoring provided within their support group. After 29 months, every woman had achieved long-term economic empowerment and “graduated” to become a KQFE ambassador, tasked with identifying fistula survivors within their communities, and referring them for surgery and participation in a reintegration support group.