The median ages were 28 years (interquartile range [IQR]: 21–36 years) for participants in the longitudinal study and 31.5 years (IQR: 27–38 years) for participants in the nested qualitative study (Table 1). Almost half of the participants (48% and 50%, respectively) were either married or living together with their partners. Many were separated from their partners or divorced (27% and 37%, respectively). Most of the participants (68% and 63%, respectively) had some primary education, whereas few had secondary educations. Husbands were the main financial supporters of participants (40% and 43%, respectively), followed by themselves (28% and 33%, respectively), and relatives (32% and 23%, respectively). Many households had a mobile phone (65% and 57%, respectively), electricity (43% and 65%, respectively) or owned some land (47% and 37%, respectively.). Counselling on resuming sexual intercourse (97%) was reported by most women at the time of fistula surgery hospitalization, although fewer reported having received contraceptive counselling (59%; data not shown).
Resumption of Sexual Activity and Family Planning Use Following Surgery
Women gradually resumed sexual activity following surgery, with 6.8% reporting sexual activity after 3 months, 32% after 6 months, and 50% reporting sexual activity after 12 months (Table 2). A total of six women became pregnant during the study period, including two within 3 months post-fistula repair. Across the 12-month follow-up, the large majority of sexually active women (83%) reported not trying for pregnancy. Despite this, contraceptive use was low but increased over the study follow-up, with 36% reporting method use at the time of fistula surgery compared with 75% at 12 months. At 12 months post-surgery, female sterilisation was the most common method reported among family planning users (38%), followed by oral contraceptive pills (13%), implants (8%), intrauterine devices (IUDs; 4%) and injections (4%). Fewer reported using condoms.
The sociodemographic and clinical characteristics associated with sexual activity at 12-month follow up included relationship status and urinary incontinence (Table 3). Women whose urinary incontinence was resolved were also more likely to report resumption of sexual activity than those without incontinence (62% vs. 26%, p=0.012). Women married or living with partners were also more likely to report sexual activity than those without partners (80% vs. 18%, p<0.001). Parity also trended toward significance (p=0.057): women with 4 or more children (63%) were more likely to report resumption of sexual activity than women with 1–3 children (54%) or women with no children (30%). However, marital status also was patterned by parity, with 45% of women with no children currently married compared to 79% of women with 4+ children (p=0.079).
The sociodemographic and clinical characteristics associated with contraceptive use at 12-month study follow-up included relationship status, educational attainment, and number of children (Table 3). Women who were married or living with partners were less likely to use family planning than women without partners (11% vs. 50%, p=0.002). Women with higher levels of educational attainment were less likely to use family planning than less educated women (p=0.032). None of the women with secondary education or higher reported the use of family planning compared with 18% of those who completed primary education, 46% with some primary education, and 40% with no education. However, in this higher educational attainment group, only one-third were sexually active, and of those only 1 reported regular menorrhea. Contraceptive use also varied by parity; women with 4 or more children (64%) were more likely to report contraceptive use than women with 1–3 children (32%) or those with no children (55%; p<0.001).
Fertility preferences varied across the qualitative sample, with some women sharing a desire to become pregnant immediately, others wanting to postpone until later, and some not interested at all in another birth.
Qualitative participants who asserted desires to have children immediately were generally younger, had fewer children, and had experienced stillbirth at fistula development. One 23-year-old participant who lost her only child when she developed a fistula could not wait to have a child; in few words she asserted, ‘Right now I want a baby.’ (Interviewee, 23 years old, no living children; 30003) Other participants reported being anxious to become pregnant immediately due to pressure from partners who were concerned about infertility, some with the added competition from co-wives. One 24-year-old participant whose husband desperately wanted her to have a girl child shared:
I was so anxiously waiting for [pregnancy].…. Well after the six months, it was the only thing which I was waiting for…the man was also suspicious; he always said, “You see some people whose uteruses are taken out are sometimes unaware of it. So maybe you are just unaware (that yours was removed and cannot conceive).” (Interviewee, 24 years old)
Some participants in the quantitative sample (12%) began trying for pregnancy starting at six months post-surgery (Table 2). Trying for pregnancy at 6 and 9 months was inversely patterned by age and number of children, but differences were not statistically significant (not shown); young women with fewer children began trying for pregnancy around 6 months whereas older women with more children were For example, at 6 months, those trying for pregnancy were median age 22 (IQR 21-23) and had median 1 child (IQR 0-1) compared to those not trying for pregnancy who were median age 31 (IQR 24-28) and had median 3 children (IQR 1-5).
Individuals who shared that they wanted to have a child, or more children, planned for both the short and longer term, with some wanting to become pregnant in the next one to two years, and a few younger women wanting to wait at least ten years. Women had various reasons for waiting. Some wanted to ensure that they were fully healed from fistula, others wanted to take some time to work and improve their economic status before the next child, and others felt aggrieved by prior low-quality relationships and were concerned about making sure they would find new caring and supportive partners. The following quotes highlight these perspectives:
“When I look at my neighbours or friends’ children, then I feel I need a child but truthfully speaking, I am only planning to give birth when I have completely healed.” (Interviewee, 41 years old)
“There is a type of man who thinks like, “I have a child with her, but I gave her a mattress, a jerrycan to take to the well, a saucepan for cooking food, a charcoal stove and a cup, then what else does she want from me? Whenever I feel like I need to have some time with her I would pay her a visit and then leave!” However, a man who takes you into his home with his property he is respectful because he has to handle you so gently such that you take care of his property. And by the way let me tell you something; I am not interested anymore in the let’s-develop-together kind of men since I have been there before; his home is fully equipped but whenever I ask for anything he plays the same song, “Be patient!” It gives me a headache.” (Interviewee, 19 years old)
The number of children desired varied across participants who expressed interest, with most wanting several children. Some participants stated that they would be happy with just one child whereas others reported wanting up to eight children.
Participants who reported not wanting any more children all had at least one living child, with those who had undergone sterilization having a minimum of three living children. These participants were in their late thirties and forties and felt they had had their children and had moved beyond their childbearing years.
“Am old now, why would I give birth? In fact, I fear now. With where I have reached so far, my only wish is to heal and I don’t think about childbirth.?” (Interviewee, 40 years old, lived with fistula for 22 years)
I can’t imagine people seeing me pregnant at this age. My kid goes into labour and I also follow? That would mean that I am not well upstairs. That can’t be.” (Interviewee, 48 years old)
The few younger women who didn’t want additional children highlighted their focus on working to care for and educate the children that they already had. Some mentioned the intersecting fear of not being able to provide for their current children if they were to develop fistula again from a subsequent childbirth.
Desire for family planning
Participant narratives regarding family planning adoption mirrored our findings around fertility preferences but were more nuanced in their expression. These individuals thoughtfully chose to prevent pregnancy for reasons related to both their fistula experiences and broader life circumstances. Fistula-related influences included the desire to fully recovery from the fistula experience and avoid future adverse outcomes, as well as the desire to enjoy life again after suffering. Other reasons included a general desire to space children and concerns about partner commitment.
Desire to fully recover from fistula repair or prevent fistula repair breakdown
Some participants noted that they quickly adopted contraception to avoid becoming pregnant before they were fully recovered from the fistula repair. Some participants expressed their willingness to abstain from sex for longer periods of time, whereas others abstained from sex for a short period but later adopted contraception, particularly those who indicated doubts regarding whether their partners would respect their wishes to delay intercourse.
In that year, I refused to have intercourse with him because I felt that I hadn’t healed well… The reason why I had taken the injection that time was because I was afraid that he would force himself on me, something which I didn’t want; so, I chose to have that injection. (Interviewee, 23 years old)
One woman who had left her partner just prior to her fistula surgery due to an abusive relationship indicated no desire to find a new partner until she had healed:
I cannot get a man before getting better. I would love to take three more years (without having sex) and then get a man. It’s what my heart wants, and that’s after getting much better. (Interviewee, 29 years old)
Other participants were motivated to adopt family planning to avoid pregnancy and the risk of fistula recurrence because of the negative fistula experience. One interviewee observed, ‘I have to keep away from giving birth because it was through it that I got the problem (fistula).’ (Interviewee, 32 years old).
Finally, some participants had been specifically counselled by health workers about contraception because of existing complications and the risks they would be exposed to if they conceived. One participant explained, ‘The doctors did that (placing an IUD) because of the way how I had got torn and they said that would help me for three years without giving birth.’ (Interviewee, 32 years old). Although this participant did not have a partner at the time of the interview, she received an IUD because she was at high risk of fistula recurrence and indicated a desire to focus on her business and educating her existing children.
History of unplanned pregnancy or poor obstetric experiences
A history of unplanned pregnancies and certain obstetric events, such as multiple caesarean sections, compelled some participants to consider contraception to avoid the reoccurrence of such events. This perspective was voiced by one interviewee who underwent multiple caesarean surgeries and fistula repairs and wanted to avoid additional surgeries:
But since this [last] time I got pregnant without having prepared for it, then I think I need to go for family planning as well.I need [family planning] because [the doctors] have always been operating me for the births I have given. They have so far operated me on for four kids and then the bladder, it has been seven times of operation. All in all, they have operated me 11 times and it is not safe for my body for all those times. I don’t want to go back to the theatre. (Interviewee, 40 years old)
Desire to end childbearing or space children
Several participants indicated not wanting to conceive again and adopted family planning, including permanent methods, particularly women who already had multiple children. Other participants shared that they adopted family planning to space their children rather than prevent all future pregnancies: ‘I would like [family planning] if I give birth frequently … because I would like my child to grow up to a better stage …. But if not, I cannot use it.’ (Interviewee, 29 years old).
Perceived partner commitment to the relationship
Some participants experienced volatility in their intimate relationships. Although most quantitative participants (80%) reported having been married, only 60% of these were married or living with a partner at the time of the fistula surgery, and 33% reported having been divorced. At the 12-month follow-up, only 52% reported currently being married or living with a partner. The perceived stability of their intimate relationships affected the women’s views on contraception, and some participants were not willing to have children in relationships they considered to be temporary, especially in cases in which their partners were not financially supportive; thus, they indicated a willingness to use contraception to avoid becoming pregnant with such a partner:
It also depends on which kind of partner you have. Currently, if I met a person who would only give me money for food or pay rent, then I know that such a person is temporary and, therefore, it’s not a good idea to have a child for such a person. (Interviewee, 19 years old)
Desire to enjoy life after fistula
A desire to enjoy sexual life after fistula repair, following suffering with fistula, motivated some participants to adopt contraception, although they did not always involve their partners in this decision for fear of unwanted pressure to have children. One participant who finally felt free to enjoy her life after recovering from fistula stated that she preferred her partner to think her uterus was removed rather than that she was using a contraceptive: ‘These days it is all about enjoying (sex) and eating money. You just try to find all means of telling him that the uterus was removed. (Interviewee, 32 years old)
Barriers to contraception
Many women who undergo genital fistula repair are counselled regarding family planning use and the options available to them before being discharged from the hospital; however, family planning adoption varied across individuals. Although some women reported using contraception upon the resumption of sexual activity post-fistula surgery, significant unmet need was identified among our longitudinal cohort during the 12 months following fistula surgery (Table 2). To fully understand the variance in contraceptive uptake, participants in the qualitative arm who reported not adopting contraception during the year following fistula surgery despite a desire to avoid pregnancy were requested to share their decision-making process. The reasons cited included perceptions of fecundity and fears and misconceptions about contraceptives generally and in regard to certain methods. Others reported they were advised by health care workers to stop using contraception.
Perceptions of not being at risk of pregnancy
Several participants felt that they were not at risk of pregnancy due to previous failure to conceive or altered menstruation, including reduced menstrual blood flow or complete amenorrhea. Women who considered themselves infertile felt no need to use family planning:
There is no need for me using [family planning] since I don’t give birth, so why should I use them? That’s what I think since it’s been a long time…. I don’t know whether it is a God-made form of family planning, but ever since I got that pregnancy (that resulted in the fistula) and the second one which was terminated, I have never gotten another one, and yet I have never used any family planning medicine. (Interviewee, 28 years old)
Similarly, women who experienced altered menstruation or complete amenorrhea felt these symptoms were indicative of infertility. One woman described her menstrual pattern:
I can’t lie to you [that I’m using family planning, but].... I don’t bleed much blood; I get my period for a small time like for one or two days and then it stops… Since the removal of that baby. I would sometimes miss the periods for two months and then they reappear in the third month. (Interviewee, 39 years old)
Another participant shared, ‘I cannot plan when to have babies because I don’t get my periods. From the time I had an operation for the delivery of my child, I didn’t have my periods again’ (Interviewee, 22 years old).
One participant discussed how she planned to start contraception after resuming her periods and had assumed that she was infertile due to amenorrhea but was surprised by an unintended pregnancy: ‘I was waiting to first get my periods, but by the time I got them, I went to hospital for a check-up and the test came out positive; I was pregnant,’ (Interviewee, 20 years old).
Fears or misconceptions about contraception including infertility
Participants’ narratives revealed a variety of fears and misconceptions regarding contraceptives. Several expressed concerns about the effects that contraceptive methods might have on their future fertility: ‘I have never used [family planning], and it is not good because you could reach a time of desiring to give birth and you fail to get pregnant.’ (Interviewee, 28 years old).
Some participants shared concerns about particular contraceptive methods that they feared would cause short- or long-term harm. Several thought that contraceptives would give them fibroids and discussed fears of cancer due to both hormonal and non-hormonal methods, including condoms. Concerns that contraception did not actually work to prevent pregnancy also were expressed. One participant stopped taking oral contraceptive pills due to information about their effectiveness that she received from others, ‘I was told that those pills are not reliable and that I should stop using them…. So, I stopped taking them.’ (Interviewee, 19 years old). These concerns were primarily derived from information obtained from people in their communities:
Well sometimes you might try and swallow [oral contraceptive pills] but they say that tablets cause fibroids, except these things they put under the arm’s skin (implant). (Interviewee, 23 years old; 30010)
Family planning? I don’t like family planning. People say that it is bad; it causes fibroids. Every time, I hear women having issues in their menstrual periods, eh! People speak ill about family planning; they say that it is bad…people say things like, ‘I used family planning and it caused me some issues; I don’t stop bleeding when I am in my periods’ or ‘I get fibroids, which I never had before.’ And besides, the condoms that they recommend also cause illnesses. They cause cancer; they are the main causes of cancer in people, including those family planning tablets. In fact, I have never swallowed them. (Interviewee, 32-years old)
At times, however, participants cited health personnel as information sources, which may indicate miscommunication or misinformation:
The [health workers] said that for the injections, they reduce the ova that someone has and then the capsule (implant), it brings about over bleeding and having some complications. (Interviewee, 28 years old)
Other deterrents to contraception
Other deterrents included a lack of knowledge regarding available methods among some participants. One young participant who developed fistula at her first pregnancy stated, ‘I have never used family planning, [and] am actually ignorant about it.’ (Interviewee, 22 years old).
Religious beliefs were also reported as deterrents to contraceptive use among some participants, particularly those who identified as born-again who felt that their family sizes would entirely depend on the will of God. One participant noted, ‘I don’t like [family planning]. It is only God that can decide for me on that. I just fear it. [Our religion tells] us not to go for family planning.’ (Interviewee, 22 years old).
Several participants indicated they had completed childbearing and sought permanent birth control. However, regardless of their current contraceptive use, participants in the nested qualitative cohort consistently expressed a preference for the contraceptive injection. Several participants sharing this would be new contraceptive injection users, while others had previously used it in the past. Some identified family members or friends as users. Fewer participants shared the oral contraceptive pill as their preferred method.
 Sensitivity analyses of contraceptive use across follow-up excluding those women reporting amenorrhea were 40% at the time of fistula surgery to 69% at 12 months.