Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: a qualitative study

Abstract

BackgroundObstetric fistula affects a woman’s life physically, psychosocially, and economically. Although surgery can repair the physical damage of fistula, the devastating consequences that affect a woman’s quality of life may persist when she reintegrates into her community. This qualitative study assessed long-term outcomes among women who underwent obstetric fistula repair in Malawi. We explored three domains: overall quality of life before and after repair, fertility and pregnancy outcomes after repair, and understanding of fistula.MethodsIn-depth interviews were conducted in Chichewa with 20 women from seven districts across Central Malawi. All women were interviewed 1 to 2 years after surgical repair for obstetric fistula at the Fistula Care Centre in Lilongwe, Malawi. Interviews were independently coded and analyzed using content analysis.ResultsAbout half of women were married and nine of 20 women reported some degree of urinary incontinence. With the exception of relationship challenges, women’s concerns before and after repair were different. Additionally, repair had resolved many of the concerns women had before repair. However, challenges, both directly and indirectly related to fistula, persisted. Improvements in quality of life at the individual level included feelings of freedom, confidence and personal growth, and improved income-earning ability. Interpersonal quality of life improvements included improved relationships with family and friends, reduced stigma, and increased participation with their communities. Nearly half of women desired future pregnancies, but many were uncertain about their ability to bear children and feared additional pregnancies could cause fistula recurrence. Most women were well informed about fistula development but myths about witchcraft and fear of delivery were present. Nearly all women would recommend fistula repair to other women, and many were advocates in their communities.ConclusionsNearly all women believed their quality of life had improved at the individual and interpersonal levels since fistula repair, even among women who continued to have urinary incontinence. Contrary to other studies, women reported they were welcomed back by their communities and had limited challenges when reintegrating. Despite the overall improvements in quality of life, many continued to have relationship problems and were concerned about future fertility. These issues need to be further explored in other studies.

Continence, quality of life and depression following surgical repair of obstetric vesicovaginal fistula: a cohort study

“…One study found no difference in the quality of life of women with persistent fistula before and after repair but did find a difference between those with successful and unsuccessful fistula closure, regardless of urinary incontinence symptoms . Qualitative studies further characterise the ongoing distress and social limitations in women with residual incontinence . Lower quality of life scores after fistula repair are found in unmarried women with no living children .…”

“…25 Qualitative studies further characterise the ongoing distress and social limitations in women with residual incontinence. 6 Lower quality of life scores after fistula repair are found in unmarried women with no living children. 27 Time since repair has been described as a key factor in the recovery process.…”

“…28 Women with depression and suicidal ideation often had no living children and in some cases had a hysterectomy, removing the possibility of bearing future children. The ability to have and bear children is important to many women with fistula, 6,29 although one study in Kenya found that childlessness and infertility were not associated with depression. 30 We were surprised to find the low prevalence of depressive symptoms in our study cohort after fistula repair.…”

“…4 Persistent incontinence after surgery for VVF has been termed the 'continence gap'. 5 One qualitative study found that women with residual incontinence reported poor quality of life, stigma, and mental health disorders, 6 but little quantitative data exist on this topic. Acquisition of such data has proven challenging because of limited long-term follow up of patients, 7 high rates of programme attrition, 8 and short duration (e.g.…”

Treatment-seeking for vaginal fistula in sub-Saharan Africa

“…Vaginal fistula is a debilitating condition that has pervasive consequences on women's psychological, social, physical and economic wellbeing. Without surgical intervention women with fistula face lifetime embarrassment, isolation, social stigmatization and marital separation [3][4][5]. Furthermore, they are prone to develop chronic vaginal and urinary tract infections, renal failure, pelvic inflammatory disease and amenorrhea [1,6].…”