In this study of 125 patients with a history of urogenital fistula following CS in the DRC, over one-third had a fistula attributable to their CS and all of these fistulas required abdominal surgery to repair. Women with a fistula attributable to obstructed labor were more likely to have attempted delivery prior to arriving at the hospital and were more likely to undergo vaginal surgery for repair.
Previous studies conducted in Sub-Saharan Africa have found that obstetric fistulas are more common in uneducated women [12, 13]. In 2013, Hawkins et al. reported that 45% of women in Kenya who developed an obstetric fistula had no prior education, similar to our findings in this study that 46% of women with an obstetric fistula had no prior education . With more than half of the participants waiting six years or more to seek treatment for their obstetric fistula, future analyses should explore women’s knowledge of obstetric fistulas and their treatment options in the DRC.
Of significance, 42% of women in our study reported experiencing a separation or divorce as a consequence of their urogenital fistula, obstructed labor, or CS. Khisa et al. previously analyzed the experiences of women with obstetric fistula in Kenya and found similar adverse societal impacts, specifically noting the high prevalence of divorce, stigma, and psychological trauma . Unfortunately, even after fistula repair, women continue to experience social isolation from their families and communities and are referred to as “spoiled and not accepted,” indicating that even if their fistula is repaired, residual effects may persist [14, 15].
While the association between younger age at marriage and first birth and development of obstetric fistula has been documented in other sub-Saharan African countries [16,17,18], the median age at symptom development in our cohort was relatively old (24 years). It is possible that our unique sample of patients who participated in a surgical outreach campaign accounts for this difference.
A previous literature review concluded that obstetric fistulas can be reduced if women seek timely care in labor . Of note, the women in this study were from remote, underserved areas, which may explain why women attempted delivery prior to arriving at the hospital. Importantly, even when women arrived at the hospital, they were likely to undergo CS for a stillborn neonate.
Of the 125 patients in this study that experienced prolonged obstructed labor, 119 (95%) resulted in fetal demise. The fistula etiology, among women who had a stillbirth, was later attributed to CS in 42 (35%) and obstructed labor in 77 (65%); a fistula attributed to CS on ischemic tissues after prolonged obstructed labor shows a peculiar pattern of development compared to fistula attributed to vaginal extraction. Similar findings have been reported by Ngongo et al. in a retrospective review of nine sub-Saharan African countries (not including the DRC) . Ngongo et al. found that in women delivering a stillborn baby, CS increased while assisted vaginal delivery decreased . This common finding is likely due to the lack of resources in hospitals to perform alternative procedures and inadequate training for obstetric providers and staff on alternative fetal extraction options [20, 21]. Instead of potentially inducing a triple burden of tragedy on women, including fetal demise, CS, and urogenital fistula, future initiatives need to (1) focus on training obstetric providers and staff on alternative fetal extraction options; (2) train providers how to assess maternal status upon arrival at the hospital; and (3) build healthcare infrastructure allowing for supplies to be adequately acquired by healthcare facilities.
With limited research examining the etiology and factors associated with urogenital fistula in women from the DRC, this study provides meaningful insight about factors associated with the development of urogenital fistula in low-resource settings. Importantly, complex fistulas develop following CS after obstructed labor. Although the cross-sectional methodology used for this analysis limits the conclusions we are able to make, this study highlights the increased morbidity associated with CS among women with obstructed labor. Namely, among women who developed fistulas following obstructed labor, more than one-third have complex fistulas related to cesarean delivery. Future studies should explore barriers experienced by birthing people from the DRC and other sub-Saharan African countries. Additionally, research should explore how to prevent unnecessary CS in women with obstructed labor and fetal demise to prevent the development of more complicated obstetric fistula.