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Fertility desires and the feasibility of contraception counseling among genital fistula patients in eastern Democratic Republic of the Congo
International Journal of Gynecology and Obstetrics 114 (2011) 265–267
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Fertility desires and the feasibility of contraception counseling among genital fistula patients in eastern Democratic Republic of the Congo Nerys Benfield a,⁎, Rogatien M. Kinsindja b, Christophe Kimona c, Maurice Masoda d, Joseph Ndume b, Jody Steinauer a a
Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, USA Department of Obstetrics and Gynecology, HEAL Africa Hospital, Goma, Democratic Republic of the Congo Department of Surgery, HEAL Africa Hospital, Goma, Democratic Republic of the Congo d Department of Family Medicine, HEAL Africa Hospital, Goma, Democratic Republic of the Congo b c
a r t i c l e
i n f o
Article history: Received 5 January 2011 Received in revised form 22 February 2011 Accepted 3 June 2011 Keywords: Contraception Democratic Republic of the Congo Genital fistula Obstetric fistula
a b s t r a c t Objective: To determine the fertility and contraceptive desires of genital fistula patients in eastern Democratic Republic of the Congo (DRC) and to evaluate the impact of contraceptive counseling and its effect on contraceptive knowledge and use. Methods: Group contraceptive counseling was offered to fistula patients at HEAL Africa Hospital between February and May 2010. Fertility desires and contraceptive knowledge were assessed via verbally administered questionnaires before and after counseling, and use of modern contraceptive methods was tracked. Results: Of the 61 participants, 22/34 (64.7%) of those who desired children wanted to wait at least 1 year after repair before attempting pregnancy. Overall, 31/58 (53.4%) women had heard of birth control, although only 15 (24.6%) knew any specific methods, and none had ever used contraception. After counseling, all participants could recall 1 or more methods. Of the 25 participants discharged over the subsequent 3 months, 5 (20.0%) and 3 additional fistula patients selected a modern method of contraception. Conclusion: Desire for contraception and birth spacing among women with fistula is significant. Basic group contraception counseling and access are feasible and lead to increased contraceptive knowledge and use. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Genital fistula is a connection between any combination of the bladder, vagina, cervix, and rectum resulting from the destruction of pelvic tissue, most commonly occurring after obstructed labor and fetal demise, and less commonly after trauma or surgery [1]. The physical symptoms of fistula are continuous urinary and/or fecal incontinence, vaginal stenosis, pain, frequent infections, and malnutrition. The psychosocial effects include divorce and isolation, in addition to the emotional effects of depression and post-traumatic stress [2–4]. Fortunately, the chance of successful surgical repair of obstetric fistula is typically greater than 90% and there are increasing numbers of local, international, and multinational groups providing systems for surgical fistula repair [5,6]. Little is known about how these experiences influence women's fertility and contraceptive desires, and whether there is interest in reproductive control in this highly vulnerable and at-risk population.
⁎ Corresponding author at: UCSF Box 0842, Ward 6D-14, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA. Tel.: + 1 415 216 9384; fax: + 1 415 206 3112. E-mail addresses: benfi[email protected], [email protected] (N. Benfield).
It is believed that over 3 million women worldwide currently have genital fistula—with the vast majority of the burden in low-income countries, particularly in Africa [7]. Low-resource countries are greatly affected because these injuries can typically be avoided with early and appropriate access to emergency obstetric care, which is often not available in these countries. This is especially true in the war-affected region of eastern Democratic Republic of the Congo (DRC)—a region that has experienced prolonged civil war, poverty, and massive population displacement, which have decimated the healthcare infrastructure, caused an epidemic of sexual violence, and led to a large fistula burden [8,9]. With a high estimated fertility rate of 6.7 per woman and a maternal mortality rate of 990 per 100 000 live births, women in the DRC are particularly vulnerable to the current limitations of the healthcare system [10]. Although the health community has mobilized to treat genital fistula through surgical repair systems, post-surgical care is still limited, especially with regard to fertility after repair. Owing to the difficulties of follow-up in this population, information on pregnancy outcomes after fistula repair is limited. The existing data indicate that women who become pregnant after surgical repair are at risk of fistula recurrence and poor obstetric outcome [11]. A study in Nigeria of 155 pregnant women with a history of genital fistula between 1986 and 1990 reported a rate of fistula recurrence of 11% [12]. Delivery via
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.02.024
266
N. Benfield et al. / International Journal of Gynecology and Obstetrics 114 (2011) 265–267
cesarean seems to decrease the risk of fistula recurrence significantly, but very little is known about the obstetric outcomes of women who continue to have limited access to obstetric care [13]. There is also limited information about the fertility intentions of fistula patients. Because genital fistula typically occurs in a first pregnancy and ends in stillbirth, affected women have traditionally been thought to strongly desire pregnancy soon after surgical repair, especially in cultures in which childbearing is the most important measure of a woman's status. Opposing this idea is the concept of fistula sufferers as women who have undergone a traumatic obstetric experience that may, in fact, increase their motivation to avoid or delay pregnancy. Studies of traumatic birth experience have demonstrated decreased subsequent fertility [14]. An analysis of Demographic and Health Surveys data from 22 countries in Sub-Saharan Africa, using cesarean delivery as a proxy measure for a complicated obstetric experience, found decreased subsequent fertility and desire for children, and increased contraceptive use in the population with previous cesarean [15]. A small study in Eritrea assessing 1-on-1 comprehensive fistula counseling, which included mention of family planning, found that women with fistula were more interested in family planning when presented with information about contraception, although no access to contraception was offered and contraceptive knowledge and use were not assessed [16]. Contraceptive prevalence among partnered women in the DRC was estimated at 20.6% in 2007, although women who develop fistula in conflictaffected eastern DRC are likely to have less contraceptive access than the national average [10]. In 2008, the current investigators undertook a baseline needs assessment of the fertility interests of the fistula population at HEAL Africa Hospital, Goma, DRC. The vast majority (84%) of the 78 women interviewed wanted to delay pregnancy after surgery, and 68% reported that they had less desire for children after developing fistula (unpublished data). Despite a very low level of contraceptive knowledge, women reported that they would consider using contraception if it were offered to them. After a desire for birth spacing and contraceptive access had been demonstrated among women with genital fistula, a group contraceptive counseling and access program was initiated for fistula patients at HEAL Africa Hospital. The aim of the present study was to conduct a systematic evaluation of this program using pre- and post-counseling interviews and tracking of contraceptive uptake, together with further observational research, to understand the fertility and contraceptive intentions of this high-risk group and to evaluate the impact of contraceptive counseling and its effect on contraceptive knowledge and use. 2. Materials and methods The primary outcomes of the present study were changes in contraceptive knowledge and contraceptive use. The ultimate goal of the project was to assess the unmet need for contraception in the study population and evaluate the success of a program of contraceptive counseling for meeting that need. HEAL Africa Hospital is a Congolese non-governmental organization and tertiary-care hospital that has performed more than 1300 fistula repair surgeries since 2004. An outreach program locates patients with fistula symptoms in remote villages and brings them to the hospital for surgical repair; other patients arrive independently. The program is funded by EngenderHealth and Tides Foundation. The present study was approved by the Institutional Review Boards at the University of California, San Francisco, USA, and HEAL Africa, and by the Ministry of Health for North Kivu, DRC. The first phase of the study was an assessment of genital fistula patients’ birth experiences, fertility and contraceptive desires, and contraceptive knowledge. This was carried out through individual verbally administered surveys, which included questions on obstetric
history, fistula history, sexual violence history, fertility desires, and contraceptive knowledge and exposure. Demographic information such as distance to nearest hospital from residence (reported in kilometers or time walking [at an estimated speed of 4.5 km/hour and an average of 12 hours of walking per day walked]) was also obtained. Contraceptive knowledge was measured by asking women to define contraception, recall specific birth control methods, and answer questions about details of method use (e.g. timeframe and adverse effects). Verbal consent was obtained and all questionnaires were administered by the investigators via translation from French to Swahili. Subsequently, all interested women with fistula underwent group contraceptive education and counseling. These sessions were slightly modified from the standard contraceptive education offered at the hospital for postpartum women to include a small amount of information on the etiology of fistula, and physician and physical therapist recommendations regarding recovery from surgery and treatment (which typically includes abstinence for 3 months). Groups contained 10–30 women and lasted approximately 1 hour, including contraceptive education and discussion time. Group education was selected in an effort to make the intervention sustainable, given that this was the typical system for contraceptive education at HEAL Africa and because staff limitations made large-scale individual counseling unfeasible. After the group sessions, women who desired contraception subsequently underwent individual counseling to select a specific method. Available and discussed methods included rhythm beads/fertility awareness, condoms, combined hormonal and progestin-only contraceptive pills, progestin injection, contraceptive implant, non-hormonal intrauterine device, and sterilization. All methods were provided by UNFPA. After counseling, the individual verbally administered questionnaires were again performed to assess the change in contraceptive knowledge and intention. Those patients who desired contraception then self-presented to the family-planning office on hospital grounds to select and procure a method. The follow-up period comprised the subsequent 3 months, and contraceptive use at hospital discharge was measured for all participants who were discharged during this period— using hospital records confirmed by family-planning nurse report. 3. Results In total, 61 women with genital fistula were included in the present study. The average age of the participants was 31 years (range, 16–46 years). Overall, 49/57 (85.9%) women were married at the time of their first pregnancy, although 2 (3.5%) women reported forced marriage and 3 (5.3%) pregnancies were the result of rape. Of the women who had been married, 20/49 (40.8%) divorced after developing fistula and 9/49 (18.4%) were widowed primarily as a result of the war. Four (6.6%) women developed fistula secondary to surgical complications, primarily cesarean delivery, and the remaining 57 (93.4%) fistulas were directly caused by obstructed labor. Average age at time of fistula development was 19 years (range, 12– 40 years), and 36/59 (61.0%) women were primigravidae. Among the pregnancies that caused fistula, 52/57 (87.7%) infants were stillborn or died within 24 hours of birth, and 17/59 (71.2%) women had no living children. Most participants lived far from a hospital, with a median distance of 67.75 km, and 35/59 (59.3%) women walked at least 5 hours (range, 10 minutes to 3 days). Most women (34/58 [58.6%]) began their labor with family, a traditional birth attendant, or health worker, whereas 16 (27.6%) underwent labor with a nurse or midwife in attendance. The average length of labor was 4.1 days. Only 11 women were eventually transferred and completed their delivery in a hospital. As with many other women in this war-affected region, 23/59 (38.9%) had also experienced sexual violence. Most women felt that their birth experience was traumatic; 55 of 57 (96.5%) women with obstetric fistula reported that they had been afraid they would be seriously hurt or would die during the labor that caused the fistula. Overall, 56 of 57 (98.2%) rated their birth
N. Benfield et al. / International Journal of Gynecology and Obstetrics 114 (2011) 265–267
experience as very distressing or terrifying. As 1 women stated, “I survived only by the grace of God.” Most (34/45 [75.5%]) of the women surveyed planned to have children in the future, but a similar majority (44/51 [86.3%]) reported that their desire for children had decreased after developing genital fistula. Of the women who planned to have children, most (22/34 [64.7%]) wanted to wait at least 1 year after repair before attempting pregnancy (range, 3 months to 4 years). Before contraceptive counseling, 24/35 (68.6%) participants stated that they would use or consider using contraception. Before counseling, 31/58 (53.4%) women had heard of birth control—described as medicines to prevent or delay pregnancy. Only 15/61 (24.6%) knew of any specific methods. The most commonly known methods were progestin injection, which was known by 14 women, and condoms, which were known by 10 women. None of the participants had ever used contraception. After counseling, knowledge of contraception increased to 96.7% (n = 30/31), with only 1 respondent unable to explain what was meant by contraception. The average number of methods recalled was 5.2 (range, 3–7), and 25/31 (80.6%) women recalled 5 or 6 methods. The proportion of participants who knew 5 or more methods increased from 1.7% (n = 1/58) to 93.5% (n = 29/31) after counseling. Accuracy of knowledge also improved, with the proportion of respondents who answered at least 1 knowledge question correctly for the majority of their known methods increasing from 40.0% (n = 6/15) to 83.8% (n = 26/31). Ever use of a modern method of birth control increased from 0.0% and, of the 25 women who were discharged from the institution over the subsequent 3 months, 5 (20.0%) and 3 additional fistula patients selected a modern contraceptive method. One woman chose progestin injection, whereas all others chose oral contraceptives. Over this time period, there was an interruption in the supply of implant contraceptives, so it is unknown how this lack of access impacted method choice. 4. Discussion To the best of our knowledge, there does not currently exist any literature on the contraceptive and fertility desires of the genital fistula population, or any systematic programs to offer and assess contraceptive uptake. The present study showed that desire for birth spacing and contraception exists in this population, despite a low level of pre-existing contraceptive knowledge and exposure. Furthermore, it showed that group contraceptive counseling is feasible, even in a severely resource-limited setting, for women with very low health literacy. Counseling successfully increased accurate contraceptive knowledge, especially knowledge of the specific contraceptive method options, and led to first-time use of modern methods of birth control. The present study was obviously limited by the small sample size, making it difficult to apply these findings to the general fistula population. Given the dearth of literature and the extreme vulnerability of this population, it is crucial to corroborate the current findings and determine the contraceptive interest of women with fistula. A current expansion of the project to involve an additional site and more subjects should help to confirm this contraceptive interest and the impact of contraception counseling in the region of eastern DRC. Furthermore, the present study was limited in assessing long-term outcomes because there were was not a system for assessing contraceptive continuation and post-repair pregnancy and birth outcomes. There is no way to guarantee continued contraceptive access for women once they leave the hospital and return to their
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home communities. Given the current and continued political instability and violence in the region, the fractured healthcare system, and the economic situation of women with fistula, we assume that many of the contraceptive users will not have access to further doses of contraception. Because of the success of the present pilot program, research is currently being expanded to a larger regional fistula repair program in the neighboring province, while counseling continues and use is tracked at HEAL Africa Hospital. This is a model that could easily be replicated in other fistula-focused programs worldwide, increasing genital fistula patients’ contraceptive knowledge and access. Ultimately, the crucial step in comprehensive family-planning care for women with fistula is long-term contraceptive access, which can be developed through an improvement in regional and national contraceptive counseling and distribution programs. Only with continued contraceptive access and exposure can this vulnerable population have true reproductive control. Acknowledgments The fistula repair program at HEAL Africa Hospital is funded by EngenderHealth and the Tides Foundation. UNFPA provided no-cost contraceptive methods. The research was funded by the Fellowship in Family Planning and the Department of Obstetrics and Gynecology at San Francisco General Hospital. Conflict of interest The authors have no conflicts of interest. References [1] Onsrud M, Sjøveian S, Luhiriri R, Mukwege D. Sexual violence-related fistulas in the Democratic Republic of Congo. Int J Gynecol Obstet 2008;103(3):265–9. [2] Muleta M, Hamlin EC, Fantahun M, Kennedy RC, Tafesse B. Health and social problems encountered by treated and untreated obstetric fistula patients in rural Ethiopia. J Obstet Gynaecol Can 2008;30(1):44–50. [3] Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;190(4):1011–9. [4] Muleta M. Socio-demographic profile and obstetric experience of fistula patients managed at the Addis Ababa Fistula Hospital. Ethiop Med J 2004;42(1):9–16. [5] de Bernis L. Obstetric fistula: guiding principles for clinical management and programme development, a new WHO guideline. Int J Gynecol Obstet 2007;99 (Suppl. 1):S117–21. [6] Muleta M, Rasmussen S, Kiserud T. Obstetric fistula in 14,928 Ethiopian women. Acta Obstet Gynecol Scand 2010;89(7):945–51. [7] Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 2006;368(9542):1201–9. [8] Trenholm JE, Olsson P, Ahlberg BM. Battles on women's bodies: war, rape and traumatisation in eastern Democratic Republic of Congo. Glob Public Health 2011;6(2):139–52. [9] Coghlan B, Brennan RJ, Ngoy P, Dofara D, Otto B, Clements M, et al. Mortality in the Democratic Republic of Congo: a nationwide survey. Lancet 2006;367(9504): 44–51. [10] Global Health Observatory, World Health Organization. Democratic Republic of Congo. www.who.int. http://www.who.int/countries/cod/en/. Published 2007. [11] Otubu JA, Kumi GO, Ezem BU. Pregnancy and delivery after successful repair of vesicovaginal fistula. Int J Gynecol Obstet 1982;20(2):163–6. [12] Emembolu J. The obstetric fistula: factors associated with improved pregnancy outcome after a successful repair. Int J Gynecol Obstet 1992;39(3):205–12. [13] Browning A. Pregnancy following obstetric fistula repair, the management of delivery. BJOG 2009;116(9):1265–7. [14] Gottvall K, Waldenström U. Does a traumatic birth experience have an impact on future reproduction? BJOG 2002;109(3):254–60. [15] Collin SM, Marshall T, Filippi V. Caesarean section and subsequent fertility in subSaharan Africa. BJOG 2006;113(3):276–83. [16] Johnson KA, Turan JM, Hailemariam L, Mengsteab E, Jena D, Polan ML. The role of counseling for obstetric fistula patients: lessons learned from Eritrea. Patient Educ Couns 2010;80(2):262–5.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Fertility desires and the feasibility of contraception counseling among genital fistula patients in eastern Democratic Republic of the Congo Nerys Benfield a,⁎, Rogatien M. Kinsindja b, Christophe Kimona c, Maurice Masoda d, Joseph Ndume b, Jody Steinauer a a
Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, USA Department of Obstetrics and Gynecology, HEAL Africa Hospital, Goma, Democratic Republic of the Congo Department of Surgery, HEAL Africa Hospital, Goma, Democratic Republic of the Congo d Department of Family Medicine, HEAL Africa Hospital, Goma, Democratic Republic of the Congo b c
a r t i c l e
i n f o
Article history: Received 5 January 2011 Received in revised form 22 February 2011 Accepted 3 June 2011 Keywords: Contraception Democratic Republic of the Congo Genital fistula Obstetric fistula
a b s t r a c t Objective: To determine the fertility and contraceptive desires of genital fistula patients in eastern Democratic Republic of the Congo (DRC) and to evaluate the impact of contraceptive counseling and its effect on contraceptive knowledge and use. Methods: Group contraceptive counseling was offered to fistula patients at HEAL Africa Hospital between February and May 2010. Fertility desires and contraceptive knowledge were assessed via verbally administered questionnaires before and after counseling, and use of modern contraceptive methods was tracked. Results: Of the 61 participants, 22/34 (64.7%) of those who desired children wanted to wait at least 1 year after repair before attempting pregnancy. Overall, 31/58 (53.4%) women had heard of birth control, although only 15 (24.6%) knew any specific methods, and none had ever used contraception. After counseling, all participants could recall 1 or more methods. Of the 25 participants discharged over the subsequent 3 months, 5 (20.0%) and 3 additional fistula patients selected a modern method of contraception. Conclusion: Desire for contraception and birth spacing among women with fistula is significant. Basic group contraception counseling and access are feasible and lead to increased contraceptive knowledge and use. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Genital fistula is a connection between any combination of the bladder, vagina, cervix, and rectum resulting from the destruction of pelvic tissue, most commonly occurring after obstructed labor and fetal demise, and less commonly after trauma or surgery [1]. The physical symptoms of fistula are continuous urinary and/or fecal incontinence, vaginal stenosis, pain, frequent infections, and malnutrition. The psychosocial effects include divorce and isolation, in addition to the emotional effects of depression and post-traumatic stress [2–4]. Fortunately, the chance of successful surgical repair of obstetric fistula is typically greater than 90% and there are increasing numbers of local, international, and multinational groups providing systems for surgical fistula repair [5,6]. Little is known about how these experiences influence women's fertility and contraceptive desires, and whether there is interest in reproductive control in this highly vulnerable and at-risk population.
⁎ Corresponding author at: UCSF Box 0842, Ward 6D-14, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA. Tel.: + 1 415 216 9384; fax: + 1 415 206 3112. E-mail addresses: benfi[email protected], [email protected] (N. Benfield).
It is believed that over 3 million women worldwide currently have genital fistula—with the vast majority of the burden in low-income countries, particularly in Africa [7]. Low-resource countries are greatly affected because these injuries can typically be avoided with early and appropriate access to emergency obstetric care, which is often not available in these countries. This is especially true in the war-affected region of eastern Democratic Republic of the Congo (DRC)—a region that has experienced prolonged civil war, poverty, and massive population displacement, which have decimated the healthcare infrastructure, caused an epidemic of sexual violence, and led to a large fistula burden [8,9]. With a high estimated fertility rate of 6.7 per woman and a maternal mortality rate of 990 per 100 000 live births, women in the DRC are particularly vulnerable to the current limitations of the healthcare system [10]. Although the health community has mobilized to treat genital fistula through surgical repair systems, post-surgical care is still limited, especially with regard to fertility after repair. Owing to the difficulties of follow-up in this population, information on pregnancy outcomes after fistula repair is limited. The existing data indicate that women who become pregnant after surgical repair are at risk of fistula recurrence and poor obstetric outcome [11]. A study in Nigeria of 155 pregnant women with a history of genital fistula between 1986 and 1990 reported a rate of fistula recurrence of 11% [12]. Delivery via
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.02.024
266
N. Benfield et al. / International Journal of Gynecology and Obstetrics 114 (2011) 265–267
cesarean seems to decrease the risk of fistula recurrence significantly, but very little is known about the obstetric outcomes of women who continue to have limited access to obstetric care [13]. There is also limited information about the fertility intentions of fistula patients. Because genital fistula typically occurs in a first pregnancy and ends in stillbirth, affected women have traditionally been thought to strongly desire pregnancy soon after surgical repair, especially in cultures in which childbearing is the most important measure of a woman's status. Opposing this idea is the concept of fistula sufferers as women who have undergone a traumatic obstetric experience that may, in fact, increase their motivation to avoid or delay pregnancy. Studies of traumatic birth experience have demonstrated decreased subsequent fertility [14]. An analysis of Demographic and Health Surveys data from 22 countries in Sub-Saharan Africa, using cesarean delivery as a proxy measure for a complicated obstetric experience, found decreased subsequent fertility and desire for children, and increased contraceptive use in the population with previous cesarean [15]. A small study in Eritrea assessing 1-on-1 comprehensive fistula counseling, which included mention of family planning, found that women with fistula were more interested in family planning when presented with information about contraception, although no access to contraception was offered and contraceptive knowledge and use were not assessed [16]. Contraceptive prevalence among partnered women in the DRC was estimated at 20.6% in 2007, although women who develop fistula in conflictaffected eastern DRC are likely to have less contraceptive access than the national average [10]. In 2008, the current investigators undertook a baseline needs assessment of the fertility interests of the fistula population at HEAL Africa Hospital, Goma, DRC. The vast majority (84%) of the 78 women interviewed wanted to delay pregnancy after surgery, and 68% reported that they had less desire for children after developing fistula (unpublished data). Despite a very low level of contraceptive knowledge, women reported that they would consider using contraception if it were offered to them. After a desire for birth spacing and contraceptive access had been demonstrated among women with genital fistula, a group contraceptive counseling and access program was initiated for fistula patients at HEAL Africa Hospital. The aim of the present study was to conduct a systematic evaluation of this program using pre- and post-counseling interviews and tracking of contraceptive uptake, together with further observational research, to understand the fertility and contraceptive intentions of this high-risk group and to evaluate the impact of contraceptive counseling and its effect on contraceptive knowledge and use. 2. Materials and methods The primary outcomes of the present study were changes in contraceptive knowledge and contraceptive use. The ultimate goal of the project was to assess the unmet need for contraception in the study population and evaluate the success of a program of contraceptive counseling for meeting that need. HEAL Africa Hospital is a Congolese non-governmental organization and tertiary-care hospital that has performed more than 1300 fistula repair surgeries since 2004. An outreach program locates patients with fistula symptoms in remote villages and brings them to the hospital for surgical repair; other patients arrive independently. The program is funded by EngenderHealth and Tides Foundation. The present study was approved by the Institutional Review Boards at the University of California, San Francisco, USA, and HEAL Africa, and by the Ministry of Health for North Kivu, DRC. The first phase of the study was an assessment of genital fistula patients’ birth experiences, fertility and contraceptive desires, and contraceptive knowledge. This was carried out through individual verbally administered surveys, which included questions on obstetric
history, fistula history, sexual violence history, fertility desires, and contraceptive knowledge and exposure. Demographic information such as distance to nearest hospital from residence (reported in kilometers or time walking [at an estimated speed of 4.5 km/hour and an average of 12 hours of walking per day walked]) was also obtained. Contraceptive knowledge was measured by asking women to define contraception, recall specific birth control methods, and answer questions about details of method use (e.g. timeframe and adverse effects). Verbal consent was obtained and all questionnaires were administered by the investigators via translation from French to Swahili. Subsequently, all interested women with fistula underwent group contraceptive education and counseling. These sessions were slightly modified from the standard contraceptive education offered at the hospital for postpartum women to include a small amount of information on the etiology of fistula, and physician and physical therapist recommendations regarding recovery from surgery and treatment (which typically includes abstinence for 3 months). Groups contained 10–30 women and lasted approximately 1 hour, including contraceptive education and discussion time. Group education was selected in an effort to make the intervention sustainable, given that this was the typical system for contraceptive education at HEAL Africa and because staff limitations made large-scale individual counseling unfeasible. After the group sessions, women who desired contraception subsequently underwent individual counseling to select a specific method. Available and discussed methods included rhythm beads/fertility awareness, condoms, combined hormonal and progestin-only contraceptive pills, progestin injection, contraceptive implant, non-hormonal intrauterine device, and sterilization. All methods were provided by UNFPA. After counseling, the individual verbally administered questionnaires were again performed to assess the change in contraceptive knowledge and intention. Those patients who desired contraception then self-presented to the family-planning office on hospital grounds to select and procure a method. The follow-up period comprised the subsequent 3 months, and contraceptive use at hospital discharge was measured for all participants who were discharged during this period— using hospital records confirmed by family-planning nurse report. 3. Results In total, 61 women with genital fistula were included in the present study. The average age of the participants was 31 years (range, 16–46 years). Overall, 49/57 (85.9%) women were married at the time of their first pregnancy, although 2 (3.5%) women reported forced marriage and 3 (5.3%) pregnancies were the result of rape. Of the women who had been married, 20/49 (40.8%) divorced after developing fistula and 9/49 (18.4%) were widowed primarily as a result of the war. Four (6.6%) women developed fistula secondary to surgical complications, primarily cesarean delivery, and the remaining 57 (93.4%) fistulas were directly caused by obstructed labor. Average age at time of fistula development was 19 years (range, 12– 40 years), and 36/59 (61.0%) women were primigravidae. Among the pregnancies that caused fistula, 52/57 (87.7%) infants were stillborn or died within 24 hours of birth, and 17/59 (71.2%) women had no living children. Most participants lived far from a hospital, with a median distance of 67.75 km, and 35/59 (59.3%) women walked at least 5 hours (range, 10 minutes to 3 days). Most women (34/58 [58.6%]) began their labor with family, a traditional birth attendant, or health worker, whereas 16 (27.6%) underwent labor with a nurse or midwife in attendance. The average length of labor was 4.1 days. Only 11 women were eventually transferred and completed their delivery in a hospital. As with many other women in this war-affected region, 23/59 (38.9%) had also experienced sexual violence. Most women felt that their birth experience was traumatic; 55 of 57 (96.5%) women with obstetric fistula reported that they had been afraid they would be seriously hurt or would die during the labor that caused the fistula. Overall, 56 of 57 (98.2%) rated their birth
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experience as very distressing or terrifying. As 1 women stated, “I survived only by the grace of God.” Most (34/45 [75.5%]) of the women surveyed planned to have children in the future, but a similar majority (44/51 [86.3%]) reported that their desire for children had decreased after developing genital fistula. Of the women who planned to have children, most (22/34 [64.7%]) wanted to wait at least 1 year after repair before attempting pregnancy (range, 3 months to 4 years). Before contraceptive counseling, 24/35 (68.6%) participants stated that they would use or consider using contraception. Before counseling, 31/58 (53.4%) women had heard of birth control—described as medicines to prevent or delay pregnancy. Only 15/61 (24.6%) knew of any specific methods. The most commonly known methods were progestin injection, which was known by 14 women, and condoms, which were known by 10 women. None of the participants had ever used contraception. After counseling, knowledge of contraception increased to 96.7% (n = 30/31), with only 1 respondent unable to explain what was meant by contraception. The average number of methods recalled was 5.2 (range, 3–7), and 25/31 (80.6%) women recalled 5 or 6 methods. The proportion of participants who knew 5 or more methods increased from 1.7% (n = 1/58) to 93.5% (n = 29/31) after counseling. Accuracy of knowledge also improved, with the proportion of respondents who answered at least 1 knowledge question correctly for the majority of their known methods increasing from 40.0% (n = 6/15) to 83.8% (n = 26/31). Ever use of a modern method of birth control increased from 0.0% and, of the 25 women who were discharged from the institution over the subsequent 3 months, 5 (20.0%) and 3 additional fistula patients selected a modern contraceptive method. One woman chose progestin injection, whereas all others chose oral contraceptives. Over this time period, there was an interruption in the supply of implant contraceptives, so it is unknown how this lack of access impacted method choice. 4. Discussion To the best of our knowledge, there does not currently exist any literature on the contraceptive and fertility desires of the genital fistula population, or any systematic programs to offer and assess contraceptive uptake. The present study showed that desire for birth spacing and contraception exists in this population, despite a low level of pre-existing contraceptive knowledge and exposure. Furthermore, it showed that group contraceptive counseling is feasible, even in a severely resource-limited setting, for women with very low health literacy. Counseling successfully increased accurate contraceptive knowledge, especially knowledge of the specific contraceptive method options, and led to first-time use of modern methods of birth control. The present study was obviously limited by the small sample size, making it difficult to apply these findings to the general fistula population. Given the dearth of literature and the extreme vulnerability of this population, it is crucial to corroborate the current findings and determine the contraceptive interest of women with fistula. A current expansion of the project to involve an additional site and more subjects should help to confirm this contraceptive interest and the impact of contraception counseling in the region of eastern DRC. Furthermore, the present study was limited in assessing long-term outcomes because there were was not a system for assessing contraceptive continuation and post-repair pregnancy and birth outcomes. There is no way to guarantee continued contraceptive access for women once they leave the hospital and return to their
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home communities. Given the current and continued political instability and violence in the region, the fractured healthcare system, and the economic situation of women with fistula, we assume that many of the contraceptive users will not have access to further doses of contraception. Because of the success of the present pilot program, research is currently being expanded to a larger regional fistula repair program in the neighboring province, while counseling continues and use is tracked at HEAL Africa Hospital. This is a model that could easily be replicated in other fistula-focused programs worldwide, increasing genital fistula patients’ contraceptive knowledge and access. Ultimately, the crucial step in comprehensive family-planning care for women with fistula is long-term contraceptive access, which can be developed through an improvement in regional and national contraceptive counseling and distribution programs. Only with continued contraceptive access and exposure can this vulnerable population have true reproductive control. Acknowledgments The fistula repair program at HEAL Africa Hospital is funded by EngenderHealth and the Tides Foundation. UNFPA provided no-cost contraceptive methods. The research was funded by the Fellowship in Family Planning and the Department of Obstetrics and Gynecology at San Francisco General Hospital. Conflict of interest The authors have no conflicts of interest. References [1] Onsrud M, Sjøveian S, Luhiriri R, Mukwege D. Sexual violence-related fistulas in the Democratic Republic of Congo. Int J Gynecol Obstet 2008;103(3):265–9. [2] Muleta M, Hamlin EC, Fantahun M, Kennedy RC, Tafesse B. Health and social problems encountered by treated and untreated obstetric fistula patients in rural Ethiopia. J Obstet Gynaecol Can 2008;30(1):44–50. [3] Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;190(4):1011–9. [4] Muleta M. Socio-demographic profile and obstetric experience of fistula patients managed at the Addis Ababa Fistula Hospital. Ethiop Med J 2004;42(1):9–16. [5] de Bernis L. Obstetric fistula: guiding principles for clinical management and programme development, a new WHO guideline. Int J Gynecol Obstet 2007;99 (Suppl. 1):S117–21. [6] Muleta M, Rasmussen S, Kiserud T. Obstetric fistula in 14,928 Ethiopian women. Acta Obstet Gynecol Scand 2010;89(7):945–51. [7] Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 2006;368(9542):1201–9. [8] Trenholm JE, Olsson P, Ahlberg BM. Battles on women's bodies: war, rape and traumatisation in eastern Democratic Republic of Congo. Glob Public Health 2011;6(2):139–52. [9] Coghlan B, Brennan RJ, Ngoy P, Dofara D, Otto B, Clements M, et al. Mortality in the Democratic Republic of Congo: a nationwide survey. Lancet 2006;367(9504): 44–51. [10] Global Health Observatory, World Health Organization. Democratic Republic of Congo. www.who.int. http://www.who.int/countries/cod/en/. Published 2007. [11] Otubu JA, Kumi GO, Ezem BU. Pregnancy and delivery after successful repair of vesicovaginal fistula. Int J Gynecol Obstet 1982;20(2):163–6. [12] Emembolu J. The obstetric fistula: factors associated with improved pregnancy outcome after a successful repair. Int J Gynecol Obstet 1992;39(3):205–12. [13] Browning A. Pregnancy following obstetric fistula repair, the management of delivery. BJOG 2009;116(9):1265–7. [14] Gottvall K, Waldenström U. Does a traumatic birth experience have an impact on future reproduction? BJOG 2002;109(3):254–60. [15] Collin SM, Marshall T, Filippi V. Caesarean section and subsequent fertility in subSaharan Africa. BJOG 2006;113(3):276–83. [16] Johnson KA, Turan JM, Hailemariam L, Mengsteab E, Jena D, Polan ML. The role of counseling for obstetric fistula patients: lessons learned from Eritrea. Patient Educ Couns 2010;80(2):262–5.