Contraceptive Preferences and Adoption Following Female Genital Fistula Surgery in Uganda: A Mixed- Methods Study

Abstract Background: Female genital fistula, largely caused by prolonged obstructed labour, is treated by surgical repair. Avoiding pregnancy for a minimum period post-repair is generally recommended to ensure adequate healing, so contraceptive preferences and use are important for optimizing post-repair outcomes. Methods: We examined contraceptive preferences and use in the year following genital fistula surgery using mixed-methods. 60 Ugandan women were enrolled starting in December 2014 with data collection completed in August 2016. Sociodemographic characteristics, fistula-related incontinence, sexual activity, contraceptive use and pregnancy status were recorded quarterly for 12 months after surgery. In-depth interviews among purposively selected participants (n=30) explored intimate relationships, sexual experiences, reproductive intentions, and contraceptive use. Results: Median participant age was 28 years (interquartile range [IQR]: 21–36 years), and almost half (48%) were married or living with partners. Counselling was provided to 97% of participants on delaying sexual intercourse and 59% received counselling on contraception. Sexual activity was reported by 7% after 3 months and 50% after 12 months. 6 (10%) women became pregnant during the study period. Eighty-three percent reported not trying for pregnancy. Among sexually active participants, contraceptive use was low at baseline (36%) but increased (to 75%) at 12 months. Interview participants who desired children immediately were young, had fewer children, experienced stillbirth at fistula development, and felt pressure from partners. Women adopted contraception to fully recover from fistula surgery and avoid adverse outcomes. Others simply preferred to delay childbearing. Reasons cited for not adopting contraception included fecundity perceptions, family planning misconceptions, and healthcare provider advice.Conclusions: Contraceptive use following genital fistula repair increased over time, but unmet need still existed, and misconceptions were prevalent despite some counselling. Provision of comprehensive patient-centred contraceptive counselling at the time of fistula surgery and beyond is important for helping women to optimize healing from fistula and minimize recurrence, as well as to meet their own reproductive preferences.