Predictors of success in fistula surgery among vesico vaginal fistula patients in East Africa : a mixed method study

Background: A vesico vaginal fistula (VVF) is an abnormal communication between two epithelial surfaces. In VVF, an abnormal communication may develop between the urinary system and the reproductive system of a woman. Prolonged labour is a major cause of fistula in women: however, fistulas may be caused by rape, malignancies and as a traumatic outcome in abdominal surgeries. The cardinal sign of VVF is continuous urine leakage with offensive smell. Often, these patients are stigmatised and depressed. Objective: The main objectives of the study were to establish predictors of fistula healing and to gain understanding of the first-hand experience of women before and after repair of a vaginal fistula. Design: A mixed method study which employed quantitative and qualitative data collection approaches. Consecutive sampling was used to recruit participants for the quantitative component. A standard tool was developed, pilot tested and used to collect demographic and fistula characteristics. Quantitative data was managed using IBM SPSS and analysed using descriptive and inferential statistics. Purposeful sampling was used to select participants' for in-depth interviews. In-depth guide used to guide interviews. All interviews were recorded and transcribed per verbatim. Aanalysis was done in thematic themes. Results: A total of 1224 women with a confirmed diagnosis of fistula were recruited over a three year period, in East Africa. In all of the countries, literacy levels were low. Overall, most women had only been educated to primary school level 62.9%, 17.0% had no education. Only 4.8% women had been educated to college level or higher and all were from Kenya. Most women were unemployed varying from 92.1% for DR Congo and 76.1% for Southern Sudan 76.1%, to 13.5% for Rwanda and 13.2% for Uganda. The mean fistula size was 2.15 cm in diameter, with most fistulas measuring 1-2 cm from the external urethral orifice (EUO) or urethral meatus. At the time of joining the study, 22.4% of women had undergone a previous surgery to repair the fistula and lived with urine leakage for up to twelve months. Vaginal stenosis/scarring were very common (72.4%). There were few combined fistulas (VVF/RVF) (3.0%). The mean success rate of surgery was 94.1%.Sixteen women were interviewed for the qualitative component of study. Two main themes representing the women's journeys emerged: from social isolation to social reintegration. Women felt euphoric following fistula repair, believing that a ‘miracle' had occurred. However, the 'post-miracle component' demonstrated that the social and psychological impact of fistula leaves scars that are not easily healed, even when fistula repair is successful. Conclusion: Fistula surgery alone is not adequate in restoring women's health. The impact of fistula in women's lives is felt far beyond the surgical period. These findings point to the urgent need for researchers to conduct psychological assessment in the management of women with fistula and design community based programs aimed at social integration and women empowerment.