Outcomes and Determinants of Obstetric Fistula Surgical Repair in Ethiopia: A Mixed-Method – Longitudinal Cohort Study

An obstetric fistula is an abnormal opening between a woman’s vagina and her bladder and/or rectum through which her urine and/or faeces continually leak. The problem is limited to human beings, attributed to their bipedalism and the encephalisation process. Obstetric fistula is a health issue that has been nearly eradicated in developed nations, but it remains among the significant public health problems in low- and middle-income countries, including in sub-Saharan Africa. The World Health Organization estimates that nearly 2 million women are living with obstetric fistula in the world, with 50,000 to 100,000 new cases added each year. In Ethiopia, the burden is especially high, with an estimated 142,000 women living with the condition and around 9,000 new cases arising each year. The primary cause of obstetric fistula is lack of access to skilled birth attendants, compounded by a range of underlying risk factors. Untreated obstetric fistula imposes various consequences, impairing the physical, psychological, social and economic welfare of the affected women and their families. Therefore, treatment services play a fundamental role in restoring the well-being of the affected women and their families. The management of obstetric fistula can be achieved through either conservative or surgical interventions. The conservative approach is advised for fresh fistulas (within 3 months), with catheterisation to allow spontaneous healing of the fistula. This approach is effective in simple fistulas. Surgical correction of the fistula is the ultimate management option, using transvaginal, transabdominal, laparoscopic and robotic approaches depending on the fistula location, accessibility and available resources. The treatment outcomes vary, from successful repair to failure, incontinence and impaired quality of life. Those with failure outcomes after their first operation might undergo subsequent operations. Diversion surgeries are also considered for those who fail to achieve a successful repair outcome in the subsequent operations. Successful repair outcomes are determined by multiple factors, which can be grouped under remote, intermediate, immediate and miscellaneous factors. Our study aimed to assess surgical repair outcomes and determinants of obstetric fistula in Ethiopia. Previous studies conducted in Ethiopia have shown variability in the rate of successful surgical repair outcomes of obstetric fistula, ranging from 64.7% to 89.7%. In addition to the variability of the findings, studies conducted in Ethiopia have lacked involvement of multiple fistula treatment centres, and most studies used retrospective card review. Our study addressed these gaps through the involvement of multiple treatment centres and primary longitudinal data to truly assess surgical repair outcomes and determinants of obstetric fistula in Ethiopia. The study was conducted in six fistula treatment centres in Ethiopia using a mixed-method longitudinal cohort study. The study involved patients, healthcare providers and fistula treatment centre heads. The quantitative arm was conducted among patients using surveys taken before and after the surgical repair. Medical card reviews were conducted to supplement patients’ surveys, to identify fistula-related characteristics that were not obtained by patient interviews. The data collection tools were developed after reviewing relevant literature, and comprised multiple components – sociodemographic, medical and obstetric, facility and infrastructure, fistula-related characteristics and quality of life assessment. The quality-of-life assessment was conducted using the World Health Organization quality of life assessment tool, which yielded an acceptable Cronbach’s alpha reliability test in previous studies in Ethiopia and sub-Saharan Africa. The qualitative arm was conducted using in-depth interviews among patients and facility heads and focus group discussions among health care providers. The quantitative data were analysed using R software, and the qualitative data were analysed using NVivo software. The quantitative data are presented using descriptive statistics (proportions, mean, standard deviations, median and interquartile deviations) and inferential statistics (logistic regression, t-test and linear regression). Our study findings indicated that 77.5% of patients underwent surgical repair achieved a successful repair outcome. Underweight body mass index, fistula length >2 cm and urethral damage reduce the odds of a successful surgical repair outcome, and having an alive child increases the odds of a successful repair outcome. Qualitatively, the participants underscored that obstetric fistula remains a public health problem, and a significant proportion of patients undergoing surgical repair fail to attain a successful repair outcome. Furthermore, the qualitative findings show that there are many challenges to successful surgical repair outcomes. These challenges relate to clinical factors, knowledge and behaviour, undernourishment, stigma and isolation, affordability, access, tradition and religion, suboptimal healthcare services and inadequate health infrastructure, public education, and ineffective policy implementation. Regarding changes in quality of life after surgical repair, our findings show that patients experience a significant quality-of-life improvement, with an overall improvement in quality-of-life score from 35.7 ± 14.4 before repair to 59.3 ± 13.5 after repair (t=23.9, p-value <0.001). Additionally, the quality-of-life improvement is associated with secondary-and-above education, nearest health facility type, urethral damage, specialist surgery and successful repair outcomes. In conclusion, surgical repair of obstetric fistula significantly improves the health and quality of life of affected women in Ethiopia. Nonetheless, clinical, social and systemic barriers continue to hinder optimal outcomes, highlighting the need for integrated strategies addressing both medical and contextual determinants.