Background

Female genital fistulas include vesico-vaginal fistulas, recto-vaginal fistulas, and ureteric injuries: abnormal communications between the genital tract and the bladder, urethra, ureters, colon, or rectum that lead to urinary and/or fecal incontinence. Most genital fistulas are obstetric, arising from pressure necrosis during prolonged, obstructed labor. Obstruction occurs when the presenting part of the fetus cannot progress into the birth canal despite strong uterine contractions, due to cephalo-pelvic disproportion, malpresentation, or malposition. Obstructed labor occurs in an estimated 4.6% of childbirths, causing 8% of maternal deaths [1]. Over 90% of women with obstetric fistula give birth to stillborn babies [2].

Obstetric fistula prevention requires appropriate labor monitoring and access to quality basic and comprehensive emergency obstetric care. High-income countries eliminated obstetric fistula by the mid-twentieth century [3]. These countries now report rare cases of genital fistula due to other causes, such as gynecological hysterectomy, radiotherapy, and cervical carcinoma [4, 5]. Iatrogenic fistula can occur as a complication of obstetric and gynecological surgery, especially cesarean section [6,7,8]. Genital fistula remains a challenge in low-resource settings where women do not have sufficient access to quality emergency obstetric care.

The relative rarity of genital fistula makes prevalence estimation difficult. Pooled prevalence from population-based studies indicates that one million women may have fistulas in sub-Saharan Africa and South Asia, with over 6,000 new cases per year [9]. Demographic and Health Survey estimates from 2005–2011 include urinary fistula symptoms point prevalence of 10.0 per 1,000 women of reproductive age in Uganda, 5.6 in Ethiopia, 5.0 in Kenya, 2.1 in Tanzania, and 1.5 in Malawi, which translates to urinary fistula symptoms in approximately 1 per 1000 women of reproductive age in sub-Saharan Africa [10]. The prevalence of fistula following gynecological surgery, trauma, and other causes is not known.

The objective of this paper is to compare the characteristics of women with fistula to understand how countries differ from one another in the circumstances of genital fistula development. Documenting geographic differences can help policymakers to tailor appropriate strategies to reduce fistula incidence.

Methods

This retrospective records review evaluated the circumstances of fistula development for women who sought fistula treatment in nine African countries. Women were interviewed in 89 facilities in Tanzania, Uganda, Kenya, Malawi, Zambia, Rwanda, Ethiopia, Somalia, and South Sudan. Women consented to fistula repair, following each hospital’s counseling and informed consent process. The number of women in each country reflects the number of repairs conducted by the second and third author and colleagues in those countries. Data were collected between June 1994 and December 2017. We excluded women whose fistulas were of unclear origin or developed before 1980.

One of the surgeons interviewed each woman and recorded information on a standard form, documenting demographics, obstetric history, and duration of leaking [11]. Women who developed fistula during childbirth reported birth location and outcomes, including whether the baby lived more than two days (“alive”), died within two days (“early neonatal death”), or was stillborn. In case of multiples, births were counted “alive” if at least one baby was alive at birth. Most cesarean births in this series were emergency procedures; only five women had elective cesarean birth without labor. During fistula repair one of the surgeons noted the numbers of fistula and type(s), using the Waaldijk classification system [12]. The unit of analysis in Table 3 was fistulas; elsewhere the unit of analysis was women.

Data were entered into an Excel database, with names changed to unique identification numbers to protect women’s privacy. Data were analyzed using Stata 16 software (StataCorp).

Results

This review includes 6,787 women who sought treatment for genital fistula. Table 1 provides characteristics of the women with fistula by country. Most variables are reported for all women seeking genital fistula repair, including fistula number and type, age at fistula development, education, duration of leaking, maternal height, and relationship status. Previous abdominal surgery, place of birth, and stillbirth were applicable only to women who developed fistula during childbirth, whether vaginal or by cesarean birth.

Table 1 Demographics of women with genital fistula
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Most women had a single fistula (5,738, 84.5%), while 1,049 (15.5%) presented with multiple fistulas, meaning a combination of fistulas in different locations. Ethiopia had the highest proportion of women incontinent of both urine and feces due to the combination of vesico- and recto-vaginal fistulas (30/110, 27.3%), followed by South Sudan (40/242, 16.5%) (Table 1).

More than 40% of women developed fistula during adolescence in Somalia (137/316, 43.4%), South Sudan (100/242, 41.3%), and Kenya (461/1,131, 40.8%), while the proportion of women developing fistula after age 30 was highest in Malawi (206/662, 31.1%) and Rwanda (128/418, 30.6%). More than one quarter of women with fistula had been incontinent for ten years or longer in Rwanda (126/417, 30.2%) and Zambia (46/168, 27.4%).

Most women with fistula had not completed primary school, and 39.2% (2,615/6,678) had not attended formal school at all. Low educational access was particularly pronounced in Somalia (270/314, 86.0%), South Sudan (190/241, 78.8%), and Ethiopia (80/105, 76.2%).

Women who developed fistula during labor and childbirth most commonly reported giving birth in health facilities (5,693/6,607, 86.2%), with proportions near or above 90% in Zambia (153/163, 93.9%), Tanzania (1,941/2,150, 90.3%), Rwanda (374/416, 89.9%), and Uganda (1,329/1,488, 89.3%). In contrast, between 60 and 70% of women with fistula had given birth in health facilities in South Sudan (147/240, 61.3%), Ethiopia (67/104, 64.4%), and Somalia (210/306, 68.6%). The proportion of women with fistula who gave birth to a live baby varied by country. While 5,216/6,490 (80.4%) women reported a stillbirth overall, the percentage varied from 94/102 (92.2%) in Ethiopia to 120/161 (74.5%) in Zambia (Table 1).

Table 2 groups women according to the circumstances of their fistula development, whether vaginal birth, cesarean birth, gynecological surgery, or other causes. “Cesarean birth” includes cesarean section, cesarean hysterectomy, and uterine rupture repair. “Other causes” include trauma (from accidents, traditional healers, or sexual violence), congenital fistula, and fistula related to abortion, HIV infection, or radiation, as further explored elsewhere [13].

Table 2 Circumstantial origin of women's genital fistulas, by country
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Most genital fistulas followed childbirth, whether vaginal (3,234/6,786, 47.7%) or by cesarean section (3,262/6,787, 48.1%) (Table 2). Fistula following cesarean birth was most common in women in Uganda (844/1,527, 55.3%), Zambia (88/168, 52.4%), and Malawi (341/662, 51.5%). In contrast, high proportions of fistula followed vaginal births in Ethiopia (87/110, 79.1%), Somalia (232/316, 73.4%), and South Sudan (160/242, 66.1%) (Table 2).

Just over 3% of women developed fistula from gynecological surgery (215/6,787, 3.2%), while 1.1% of women developed fistula through other circumstances (76/6,787). The proportion of fistulas following gynecological surgery was highest in Kenya (41/1,131, 3.6%), Tanzania (78/2,213, 3.5%), Uganda (52/1,527, 3.4%) and Malawi (22/662, 3.3%), while fistulas following gynecological surgery constituted less than 2% of fistulas repaired in Somalia, South Sudan, and Ethiopia (Table 2).

Fistula types differ by circumstances of development. Iatrogenic ureteric injuries and vault fistulas occur after cesarean birth or gynecological surgery (Table 3) [11, 14]. The exceptions were “postrepair” ureteric injuries that arose during fistula surgery in women who had initially developed other fistulas during childbirth. Over one quarter of fistulas following cesarean birth were vesico-[utero]/-cervico-vaginal (26.1%, 914/3,508), compared to just 6.8% (244/3,614) of fistulas following vaginal birth.

Table 3 Genital fistula type by circumstantial origin
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Previous abdominal surgery complicates cesarean section. Nearly all reported previous abdominal operations were cesarean sections (98.5%, 601/610). Others included two bilateral tubal ligations, two myomectomies, one myomectomy and salpingectomy, and four other laparotomies (for intestinal obstruction, abortion, ectopic pregnancy, or menorrhagia). In this series over 10% of women with fistula after childbirth reported previous abdominal surgery in Rwanda (54/417, 12.9%), Kenya (134/1,116, 12.0%), and Uganda (156/1,518, 10.3%) (Table 1). While just 4.1% (132/3,229) of women developing fistula after vaginal birth reported previous abdominal surgery, the frequency was much higher for those developing fistula after cesarean section (13.4%, 341/2,554), cesarean section/hysterectomy (13.9%, 83/598), uterine rupture repair (18.7%, 20/107), and gynecological surgery (16.3%, 34/209) (Table 4).

Table 4 Previous abdominal operation by circumstantial origin of genital fistula
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Country differences are evident in World Health Organization data on maternal deaths per 100,000 live births between 2000 and 2015 (Fig. 1). All countries have made progress in reducing maternal mortality ratios (MMRs) over the period, but with differing starting points and speed. MMRs in Somalia and South Sudan in 2015 were higher than in most other countries in 2000. Change was most rapid in Rwanda and Ethiopia, where MMRs fell from more than 1000 per 100,000 live births in 2000 to fewer than 500 by 2015.

Fig. 1
figure 1

Country differences in maternal mortality ratios (World Health Organization)

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Stillbirth rates from the World Health Organization similarly give insight into country differences in care during childbirth (Fig. 2). All countries made progress in reducing stillbirth rates between 2000 and 2015, with Rwanda and Ethiopia experiencing the most dramatic change. Progress was most muted in Somalia. Stillbirth rates were highest in Ethiopia, South Sudan, and Somalia. Stillbirth rates were lowest in Zambia and Malawi.

Fig. 2
figure 2

Country differences in stillbirth rate (World Health Organization)

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Discussion

Policymakers and advocates have long emphasized access to care: women experiencing obstetric complications should be able to reach health facilities offering basic and comprehensive emergency obstetric care. This comparison reveals important country-level differences in the characteristics of women who develop genital fistula. The emerging story is not simple lack of access to health care, but of both lack of access and quality of care.

Some women experiencing prolonged, obstructed labor give birth at home without accessing a health facility, indicating comparative challenges in access to care. This was most common in South Sudan, Somalia, and Ethiopia, where a substantial share of genital fistulas followed childbirth at home. Women who developed fistula after birth at home are survivors; others in their circumstances might have died. The complexity of such cases is reflected in the high proportion of women with multiple fistulas who experience both urinary and fecal incontinence. The proportions of home birth and multiple fistulas reported by women with fistula in South Sudan, Somalia, and Ethiopia correspond to high MMRs and high stillbirth rates illustrated by World Health Organization data in Figs. 1 and 2.

Most women with genital fistula gave birth in health facilities. Although some women arrive late in health facilities, one report found that nearly three-quarters of women with fistula presented to hospitals or health centers during early labor [15]. Appropriate labor monitoring, decision-making, and referrals are crucial. The proportion of facility births and specifically cesarean births among women with fistula indicates greater comparative access to obstetric care in Kenya, Malawi, Rwanda, Tanzania, Uganda, and Zambia as compared to Ethiopia, South Sudan, and Somalia.

Cesarean section can be a lifesaving procedure for women experiencing prolonged, obstructed labor. Cesarean birth is increasingly common, both generally at population level and specifically among women who later present for fistula repair [16, 17]. Some of this increase is saving lives and preventing fistula, a positive outcome that is not captured in this population of women who developed fistula.

Despite its important place in enabling fistula elimination, however, rising numbers of cesarean births increase the risk of all associated complications, including iatrogenic fistula. Location and circumstances can indicate that a fistula is iatrogenic rather than attributable to pressure necrosis [7, 11]. Evidence has been mounting about the proportion of iatrogenic fistula amongst repaired fistulas [18,19,20,21]. In a separate analysis we reported that 26.8% (787/2,942) of women with fistula after cesarean section have injuries caused by surgery rather than pressure necrosis from prolonged, obstructed labor [7]. This aligns with reports from others [6]. Iatrogenic vesico-[utero]/-cervico-vaginal, vault, and ureteric fistulas generally occur after cesarean birth and gynecological surgery, not after vaginal birth. In this series 80% of women with fistula following childbirth had stillbirths, in contrast to 90% reported by other investigators [2]. Together, these observations support a conclusion that some of these fistulas following childbirth are the result of surgical complications rather than unattended prolonged, obstructed labor.

One interpretation of these data is that countries are at different points on their developmental journeys toward fistula elimination. In South Sudan, Somalia, and Ethiopia, access to emergency obstetric care remains difficult. Widespread insecurity and danger in South Sudan and Somalia have created particular challenges for women experiencing obstetric complications. Ethiopia’s population is largely rural and spread across difficult terrain.

In contrast, Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia are likely further along on the journey toward reducing the incidence of obstetric fistula, witnessing higher proportions of fistula following cesarean birth and gynecological surgery (Table 2). Given the risk of iatrogenic fistula following cesarean birth, a less positive interpretation could be that these countries are providing increasing numbers of cesarean births without ensuring that surgeries are safely performed following the right indications. As women have greater access to health care, emphasis must be placed on its quality.

Strengths and limitations

The strength of this study is the size and geographic breadth of its sample, which offers a unique opportunity to assess the circumstances of fistula development in nine African countries. We documented women’s demographic information and circumstances of fistula development in detail. The study is not without limitations, however. Included countries have different sample sizes, reflecting variation in where the second and third author and colleagues repaired fistulas. While women sought repair in multiple hospitals with wide catchment areas in most countries, the countries with large sample sizes may be more representative of all women seeking fistula repair than those with smaller samples. This series includes women who sought surgical treatment for their fistula. It cannot include women who developed fistula but did not reach treatment centers. Overall fistula circumstances may be different among all women with fistula if particular women are more likely than others to reach treatment centers. Demographic information and data on birth experiences relied on women’s accounts of past events. Women know their obstetric history well, but in some cases many years passed between the original event and fistula treatment. We acknowledge that women’s recollection of childbirth may differ from how providers diagnose obstetric complications. We did not have medical records information on the duration of labor or indications for cesarean birth (where applicable). Additional research is needed on surgical complications from cesarean birth.

Conclusions

Continued progress toward fistula elimination requires countries to ensure adequate infrastructure and security for women to access basic and comprehensive emergency obstetric care. Providers should have the knowledge, experience, and environment to be able to provide quality care to all women, particularly those who experience labor complications. Facilities and providers should consider the quality of emergency obstetric care, including timing and decision-making for cesarean birth. Safe surgical care requires robust provider training, supervision, and mentoring, appropriate work environments, and clear safety standards. Fistula elimination will require a holistic systems approach that improves emergency obstetric care and surgical safety.