Obstetric fistula and safe spaces: discussions of stigmatised healthcare topics at a fistula centre.

Obstetric fistula can have major psychosocial repercussions for women and their families, which are often hidden as a result of stigmatisation. We investigated how the sexual function of women with vesicovaginal fistula differs before and after fistula repair at the Fistula Care Centre in Lilongwe, Malawi. Structured interviews and physical examinations were conducted with 115 women from the central region of Malawi. The average age of participants was 32 years and the majority lived in rural communities. Patients were more responsive than expected to discussing how genital modification, gender-based violence, marital relationships and traditional medicine impact their sexual function. Of the 115 participants interviewed, 107 (93%) reported stretching their labia and 42 (37%) were coerced into sexual activities before surgery. Before repair, 56 (49%) women reported husbands being unfaithful. 12 (10%) had new cowives after surgery. 38 (33%) used traditional medicine to enhance their sexual function before surgery. We conclude that specialised centres providing care for women, such as a fistula centre, might offer a unique space in which women can more comfortably discuss stigmatised subjects. This suggests that such issues should be incorporated into services where appropriate.

Physical etiology of sexual dysfunction in obstetric fistula patients: A prospective study.

OBJECTIVE: To understand how the physical etiology of sexual dysfunction among women with obstetric fistulas can inform repair. METHODS: A prospective cohort study included women aged 18 years or over presenting at the Fistula Care Center, Bwaila Maternity Hospital, Lilongwe, Malawi, with obstetric vesicovaginal fistula before and after repair. The study took place between January 1, 2018, and December 31, 2018, and involved physical examinations and interviews. The primary outcome was sexual function. RESULTS: 115 were interviewed before and after repair. 44 (40.0%) preoperatively and 14 (12.2%) postoperatively reported sexual dysfunction. 94 women (81.7%) had little or no interest in sexual activity before repair. 55 women (47.8%) had little or no interest in sexual activity after repair. Before surgery, 69 women (60.0%) were not sexually active in the 30 days before coming to the Fistula Care Centre. After surgery, 32 women (27.8%) were not sexually active in the 30 days before returning to the Fistula Care Centre. Of those who were not sexually active in the 30 days before coming to the Fistula Care Centre (n=69), the majority cited their health as a reason before repair (n=45, 65.2%), while the most commonly cited reason after repair was an absent partner (n=23, 35%). CONCLUSION: Given the significant percentage of women with obstetric fistula reporting sexual dysfunction after repair, a more holistic perspective of health outcomes should be considered. Further investment should be made in screening tools and surgical techniques targeting sexual dysfunction.