title: Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: a qualitative study.
abstract: BACKGROUND
  Obstetric fistula affects a woman's life physically, psychosocially, and economically. Although surgery can repair the physical damage of fistula, the devastating consequences that affect a woman's quality of life may persist when she reintegrates into her community. This qualitative study assessed long-term outcomes among women who underwent obstetric fistula repair in Malawi. We explored three domains: overall quality of life before and after repair, fertility and pregnancy outcomes after repair, and understanding of fistula.
  
  
  METHODS
  In-depth interviews were conducted in Chichewa with 20 women from seven districts across Central Malawi. All women were interviewed 1 to 2 years after surgical repair for obstetric fistula at the Fistula Care Centre in Lilongwe, Malawi. Interviews were independently coded and analyzed using content analysis.
  
  
  RESULTS
  About half of women were married and nine of 20 women reported some degree of urinary incontinence. With the exception of relationship challenges, women's concerns before and after repair were different. Additionally, repair had resolved many of the concerns women had before repair. However, challenges, both directly and indirectly related to fistula, persisted. Improvements in quality of life at the individual level included feelings of freedom, confidence and personal growth, and improved income-earning ability. Interpersonal quality of life improvements included improved relationships with family and friends, reduced stigma, and increased participation with their communities. Nearly half of women desired future pregnancies, but many were uncertain about their ability to bear children and feared additional pregnancies could cause fistula recurrence. Most women were well informed about fistula development but myths about witchcraft and fear of delivery were present. Nearly all women would recommend fistula repair to other women, and many were advocates in their communities.
  
  
  CONCLUSIONS
  Nearly all women believed their quality of life had improved at the individual and interpersonal levels since fistula repair, even among women who continued to have urinary incontinence. Contrary to other studies, women reported they were welcomed back by their communities and had limited challenges when reintegrating. Despite the overall improvements in quality of life, many continued to have relationship problems and were concerned about future fertility. These issues need to be further explored in other studies.
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi. laurabdrew@gmail.com.
authors.forename: Laura B
authors.initials: LB
authors.lastname: Drew
authors.affiliation: Baylor College of Medicine, Houston, TX, USA. jeffrey.wilkinson@bcm.edu.|Freedom from Fistula Care Centre, Lilongwe, Malawi. jeffrey.wilkinson@bcm.edu.|Malawi College of Medicine Department of OB-GYN, Blantyre, Malawi. jeffrey.wilkinson@bcm.edu.
authors.forename: Jeffrey P
authors.initials: JP
authors.lastname: Wilkinson
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi. willynundwe@live.co.uk.|Freedom from Fistula Care Centre, Lilongwe, Malawi. willynundwe@live.co.uk.
authors.forename: William
authors.initials: W
authors.lastname: Nundwe
authors.affiliation: Freedom from Fistula Care Centre, Lilongwe, Malawi. margaretmoyo@yahoo.com.
authors.forename: Margaret
authors.initials: M
authors.lastname: Moyo
authors.affiliation: Malawi College of Medicine Department of OB-GYN, Blantyre, Malawi. rmataya@llu.edu.|Loma Linda University School of Public Health, Loma Linda, CA, USA. rmataya@llu.edu.
authors.forename: Ronald
authors.initials: R
authors.lastname: Mataya
authors.affiliation: Lilongwe District Health Office, Lilongwe, Malawi. mwawi@hotmail.com.
authors.forename: Mwawi
authors.initials: M
authors.lastname: Mwale
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi. jennifer_tang@med.unc.edu.|Malawi College of Medicine Department of OB-GYN, Blantyre, Malawi. jennifer_tang@med.unc.edu.|UNC Department of OB-GYN, Chapel Hill, NC, USA. jennifer_tang@med.unc.edu.
authors.forename: Jennifer H
authors.initials: JH
authors.lastname: Tang
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005402:Fistula / Q000523:psychology* / Q000601:surgery; D005831:Genital Diseases, Female / Q000523:psychology* / Q000601:surgery; D006801:Humans; D008295:Malawi; D008875:Middle Aged; D013513:Obstetric Surgical Procedures / Q000009:adverse effects / Q000379:methods / Q000523:psychology*; D011247:Pregnancy; D036301:Qualitative Research; D011788:Quality of Life; D057545:Social Stigma; D014549:Urinary Incontinence / Q000209:etiology / Q000523:psychology; D014624:Vaginal Fistula / Q000523:psychology / Q000601:surgery; D055815:Young Adult