Journal of Obstetrics and Gynaecology

ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20

Vesicovaginal fistula in Uganda

Fiona Katherine McCurdie, Joanne Moffatt & Kevin Jones

To cite this article: Fiona Katherine McCurdie, Joanne Moffatt & Kevin Jones
(2018): Vesicovaginal fistula in Uganda, Journal of Obstetrics and Gynaecology, DOI:
10.1080/01443615.2017.1407301

To link to this article: https://doi.org/10.1080/01443615.2017.1407301

Published online: 09 Mar 2018.

Submit your article to this journal

Article views: 49

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ijog20
JOURNAL OF OBSTETRICS AND GYNAECOLOGY, 2018
https://doi.org/10.1080/01443615.2017.1407301

ORIGINAL ARTICLE

Vesicovaginal fistula in Uganda

Fiona Katherine McCurdie, Joanne Moffatt and Kevin Jones
Swindon Academy, University of Bristol, Great Western Hospitals NHS Foundation Trust, Swindon, UK

ABSTRACT KEYWORDS
Kitovu Hospital in Masaka, Uganda, is a leading obstetric fistula repair centre in the country with the Obstructed labour; obstetric
highest rates of fistula in the world. In this retrospective case review, the regional incidence and causa- fistula; vesicovaginal fistula;
tive factors were studied in patients with vesicovaginal fistula (VVF) who were admitted at Kitovu maternal morbidity;
incontinence; fistula repair
Hospital. Fistula history included severity (ICIQ score), causes and outcomes of VVF were measured.
Women suffered with symptoms of VVF for an average of 4.97 years with an average ICIQ severity score
of 7.21. Patients travelled an average distance of 153 km and the majority travelled by public transport.
Rates of prolonged labour were high. 69% of fistula-causing delivery resulted in stillbirth and 12%
resulted in early neonatal death. Following surgery, 94% of patients were dry on discharge.

IMPACT STATEMENT
 What is already known on this subject? Vesicovaginal fistula (VVF) is a severe, life-changing injury.
Although largely eradicated from the Western world thanks to modern obstetric practice, VVF is still
highly prevalent in developing countries where factors such as young childbearing age and poor
access to emergency obstetric care increase the incidence (Wall et al. 2005). At the current rate of
fistula repair, it is estimated that it would take 400 years to treat those already suffering with fistula,
providing that no new cases emerged (Browning and Patel 2004).
 What do the results of this study add? The Ugandan women in this study reiterate tales of foetal
loss, social isolation and epic journeys in search of fistula repair, as previously described in the lit-
erature. The study offers some hope for prompt help-seeking during labour and after fistulas are
developed. It demonstrates the success of fistula repairs at Kitovu Hospital but highlights the pau-
city of service provision across Uganda.
 What are the implications of these findings for clinical practice and/or further research?
Further epidemiological research is required to quantify the true burden of the disease. Only by
raising the profile of VVF in both developing and developed countries, can there be a collaborative
effort to make universal change. To embark upon the prevention and cure of the disease it is neces-
sary to continue tackling issues of poverty and gender inequality.

Introduction (Uganda Bureau of Statistics (UBOS) and Macro International

Vesicovaginal fistula (VVF) most commonly occurs as a result
of prolonged, obstructed labour (Wall 2006). The injury can
be life-shattering. Not only must the woman contend with
the myriad clinical implications – urinary incontinence,
chronic pelvic infection, renal disorders, secondary infertility,
nerve injury – the foetus from the obstructed delivery is often
stillborn or dies in the early neonatal period (Arrowsmith
et al. 1996; Ahmed and Holtz 2007). Thereafter, the woman
may be marginalised by her community where misconcep-
tions about the condition are rife. She loses her family, her
status and her dignity and is left disabled and destitute with
no means to seek the medical care that she requires
(Browning and Patel 2004; Ahmed and Holtz 2007).
Uganda has one of the highest rates of fistula in the world
(Murk 2009). Estimates suggest that 2.6% of women have
experienced fistula, which equates to about 142,000 cases
Inc. 2007; Kasamba et al. 2013). Kitovu Hospital, Central
Uganda is a vanguard institution for VVF treatment. Since
1987 more than 2000 operations have been done, and
have given training for surgeons from across the globe in
fistula repair surgery (Bishop 2012). Kitovu provides free
surgical repair for women during ‘Fistula Camps’. These
are held with the help of international surgeons four times
a year and operations are done for 60–100 women at
each camp.
This study was a retrospective review of cases with VVF
admitted to Kitovu Hospital. It aimed to describe regional
incidence, compare patient characteristics with those
described in the literature and to comment on the success of
current practice at Kitovu Hospital. It also aimed to suggest
how, in light of the information gathered, we should con-
tinue to work towards the prevention of VVF as a global
health priority.

CONTACT Fiona Katherine McCurdie fm9493@my.bristol.ac.uk Postgraduate Centre, Hammersmith House, Hammersmith Hospital, Du Cane Road, London,
W12 0HS, UK
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
2 F. K. MCCURDIE ET AL.

Materials and methods for each case. Data collection and analysis were carried out
by the author in the VVF unit, Kitovu Hospital.
This study was conducted in Kitovu Hospital in Masaka, The information from this and the medical notes were
Central Uganda. It is a private, not-for-profit, Catholic faith- retrospectively collected for all cases of VVF treated in the
based hospital with 248 beds. The study group was women preceding year. Patient records with some elements of data
with VVF participated in the Fistula Camps hosted by Kitovu missing were included as they still provided useful informa-
Hospital between July 2013 and July 2014. tion. For the purposes of this study, women with VVF who
VVF cases were identified from camp records and a retro- did not undergo surgery and those with recto-vaginal fistula
spective review of notes collected data under the following or other causes of urinary incontinence were excluded. As a
five headings: part of the analysis, Google Maps was used to calculate the
distance travelled by the patient from their home district to
1. Demography; age of patient and home town. Kitovu Hospital.
2. Fistula history; duration of symptoms of VVF before pre-
senting to Kitovu Hospital, severity of fistula and how
many repairs have been previously attempted. Results
3. Seeking treatment at Kitovu; how women were made
Data were collected from 93 patients. Unfortunately, this only
aware of Kitovu’s Fistula Camps and how far and by
represented 80% of women who were treated at Fistula
which method they travelled to attend them.
Camps over the study period, as it was not possible to access
4. Causes of VVF; how old patients were when they married,
all the relevant medical records.
how long they were in labour and how long they
delayed seeking healthcare in labour in the fistula-caus-
ing delivery. Demographic
5. Outcomes of VVF:
The average age of patients presented to Kitovu Hospital was
a. Perinatal: perinatal mortality associated with fistula- 30 years old and ranged from 14 to 80 years. Patients came
causing deliveries. from 30 different Ugandan districts, 71 patients (76%) came
b. Social: how many women were left by their hus- from a district in Central Uganda and one patient was from
bands as a result of their fistula. Tanzania (See Table 1).
c. Surgical: outcomes of the repair surgery in terms of
symptoms on discharge and number of patients fol-
lowed up.
Table 1. Demographics and how patients heard about VVF camps.
Each case presented at the Fistula Camp was clerked in by Frequency Percentage
a nurse or doctor using a standardised pro forma. As a part Age at presentation
of this assessment The International Consultation on <18 11 11.83
Incontinence Modular Questionnaire (ICIQ), a self-reported 19–28 40 43.01
29–38 28 30.11
questionnaire of the frequency and impact of urinary incon- 39–48 7 7.53
tinence, was used as a measure of fistula severity (Figure 1; 49–58 2 2.15
Avery et al. 2004). The staff at the VVF unit reported that this 59–68 3 3.23
>68 2 2.15
tool had provided useful means which helps to assess the Region of Uganda
impact of symptoms on quality of life at both presentation Central 71 76.34
and during follow-up assessments. Surgical outcomes were Eastern 11 11.83
Western 8 8.60
limited to patient reported measures at follow up, as there Tanzania 1 1.08
were limited data regarding specific surgical characteristics Not documented 2 2.15
Distance travelled (km)
<20 4 4.30
21–70 33 35.48
71–120 24 25.81
Still birth Live birth Early neonatal death Not documented
121–170 13 13.98
171–220 6 6.45
221–270 4 4.30
10% 271–320 5 5.38
>320 2 2.15
12% Not documented 2 2.15
Source of information about camps
Health clinic 13 14.61
Prison officer 1 1.12
9% Counsellor 1 1.12
Church 1 1.12
Charity: valvisions 2 2.25
69% Charity: UPDF 1 1.12
Television 2 2.25
Radio 47 52.81
VVF staff 15 2.25
Figure 1. Neonatal outcomes of fistula-causing labour. Friends 4 4.49
 JOURNAL OF OBSTETRICS AND GYNAECOLOGY 3

Fistula history advertisement (52.1%) (Table 1). Patients’ travelling distance

to Kitovu Hospital was averaged to 153 km (range 3–356 km)
The mean interval from suffering with VVF to admission at
– a journey that took an average of 4.66 hours (range
Kitovu Hospital was 4.97 years with a range from 3 weeks to
0.5–15 hours). The most commonly used mode of transport
50 years. Severity was on an average 17/21 (See Table 2). Of
was taxi and boda-boda (a Ugandan motorbike taxi), and
all the patients, 84% of women were seeking their first fistula
50% of women travelled by this mode. Apart from one, all
repair (See Table 2). Older women and those who lived fur-
patients travelled to Kitovu by public transport.
ther from Kitovu Hospital tended to have had their VVF lon-
ger before presentation (Tables 1 and 2).
Potential causative factors
Seeking treatment The average age of marriage was 18.4 years with a range of
Patients most commonly reported that their source of know- 14–27 years. The average length of time in labour was
ledge of Kitovu Hospital Fistula Camps was a radio 2.56 days (ranging from 1–14 days) with an average delay in
seeking medical care of 1.37 days (ranging from
Table 2. Fistula history and severity.
45 minutes–14 days).
Frequency Percentage
Time to presentation
<6 months 31 33.33 Outcomes
6–12 months 8 8.60
1–5 years 21 11.78 Perinatal: of the patients who presented revealed that 69% of
6–10 years 9 9.70
11–15 years 3 3.22 fistula-causing delivery resulted in still birth and 12% resulted
16–20 years 3 3.22 in early neonatal death (Figure 2).
>20 years 4 4.30
Not documented 14 15.05
Social: 30% of patients were left by their husband as a
Number of previous VVF repairs at presentation result of their fistula.
First 78 83.87 Surgical: 94% of patients were dry on discharge, conferring
Second 5 5.38
Third 6 6.45 successful repair surgery. 72% of patients did not return for
Fourth 1 1.08 follow up, and of those who did 93% were symptom free
Fifth 2 2.15 with in ICIQ of 0.
Sixth 0 0
Seventh 1 1.08
ICIQ at presentation
<10 5 5.38 Discussion
10–14 11 11.83
15–19 50 53.76 It is well-documented that women endure VVF for many
>20 22 24.00 years before seeking treatment (Hamlin and Little 2001;
Not documented 5 5.38
Bangser 2006). In this study, the average length of time

Question Score
1 How often do you leak urine? Never 0

About once a week or less often 1

Two or three times a week 2

About once a day 3

Several times a day 4

All the time 5

2 How much urine do you think None 0

leaks?
A small amount 1

A moderate amount 4

A large amount 6

3 Overall, how much does leaking urine interefere with your everyday life? 0 – 10
Choose a number between 0 (not at all) and 10 (a great deal)

ICIQ score = sum of 1 + 2 + 3

Figure 2. Summary of International Consultation on Urinary Incontinence Questionnaire.
4 F. K. MCCURDIE ET AL.
before presentation was 5 years with a median of 1 year. An
encouraging 41.9% of women sought help within 12 months
of sustaining injury (Table 2). This implies that following
birthing injuries there is an appropriate method of referral to
a Fistula Camp for repair. Of the patients who presented
quickly following injury, the majority tended to be younger;
older patients tended to live longer with their VVF before
presentation for repair (Table 1). These results may herald a
younger generation of women who have better access to
education, to media advertisements and thus to maternal
healthcare.
A factor increasing the likelihood of delay to presentation
for treatment was the distance of woman’s home district
from Kitovu Hospital. Those who travelled further had suf-
fered symptoms for longer before seeking treatment (Table
2). Women traveled the vast distances to Kitovu Hospital
using public transport, most commonly a combination of bus
and motorbike taxi. The ‘three delays’ model is often used to
characterise maternal morbidity and mortality (Thaddeus and
Maine 1994). It can be employed in this context to describe
the barriers to women seeking treatment for their fistula. The
first delay in recognising the nature of the injury – that of a
result of obstructed labour rather than a venereal disease or
the mark of bad spirits as it is sometimes perceived (Kasamba
et al. 2013) – and deciding to seek help. The second is the
delay in travelling to a medical facility which, as described,
may be a great distance and relies on transport infrastructure
and funds to travel. The final delay is in receiving the appro-
priate intervention from a trained professional once at the
medical centre. In order to facilitate fistula repair following
injury each of these three delays need to be tackled.
The extensive geographical spread of patients presenting
to Kitovu Hospital is in part encouraging as it demonstrates
that advertisement of the Fistula Camps, mostly via radio, has
infiltrated across Uganda. However, the vast distances trav-
elled to the Camps highlights the significant lack of local ser-
vice provision. FistulaCare and EngenderHealth have
identified in 17 other centres in Uganda with the capacity to
carry out fistula repairs (UNFPA 2003; Fistula Care Plus at
EngenderHealth 2010). These results imply that further devel-
opment is needed at these centres to provide a consistent
service across Uganda so that women can present sooner
and receive the same quality of care as at Kitovu Hospital
(Bacon 2003).
Prolonged labour and delay in seeking emergency medical
care have widely been documented as fundamental to the
development of obstetric fistula (Wall et al. 2005; Ahmed and
Holtz 2007; Cowgill et al. 2015). Recent statistics show that
only 57.4% of women in Uganda give birth in the presence
of a skilled healthcare worker (Newby and Say 2015). The
remainder gave birth alone or with the help of a ‘traditional
birth attendant’ who has often not received any formal train-
ing. Thus, in just under half of deliveries the decision as to
whether emergency medical care should be sought is left to
an individual without the necessary qualification or experi-
ence. In the absence of a trained professional, non-clinical
factors such as socioeconomic and cultural barriers determine
the treatment-seeking (Kyomuhendo 2003). In this sample,
prolonged labour was described with an average length of
2.56 days and a range from 1 to 14 days. However, delays in
seeking medical help were generally not described. 96% of
women reported seeking help from a ‘medical professional’
during their labour, 54% of which within the first 24 hours.
Only 6% of women in this sample delivered at home. In
many respects this is encouraging as it demonstrates know-
ledge of, and access to, emergency obstetric care. It is unfor-
tunate then that, despite this, VVFs developed in each of
these women indicating a substandard level of care provided
once at the medical facility.
Young childbearing age following early marriage is often
reported to increase the likelihood of fistula formation with
much of the literature describing patients younger than
25 years and as young as 13 years (Wall 2006). The
Millennium Development Goals Report 2015 demonstrated
that young childbearing age remains highest in sub-Saharan
Africa where little progress had been made since 1990
(United Nations 2015). In Uganda 9.9% of children are mar-
ried by 15 and 33% have delivered a baby by the age of 18
(United Nations Children’s Fund 2013). This sample demon-
strated that five women (5.3%) were married by the age of
15 and nearly a third (29%) of women were married by 18,
with an average marrying age of 18.4 years.
Deliveries that lead to fistula are associated with poor foe-
tal outcomes. The conditions the foetus is exposed to during
prolonged, obstructed labour are often incompatible with life
(Hancock and Collie 2004). This sample suffered a large pro-
portion of stillbirths (69%) and early neonatal deaths (12%).
This is in keeping with the meta-analysis by Ahmed and
Holtz (2007), which reports that 85% of women incurred foe-
tal loss as a result of their fistula-causing pregnancy.
Social isolation is another well-documented outcome of
obstetric fistula. In this study, 30% of women reported being
separated or divorced as a direct result of their fistula, echo-
ing the meta-analysis by Ahmed and Holtz (2007) which
reported a rate of 36%. Indeed this value, and the value
described in the literature, is likely an under-estimation.
When a woman is isolated by her husband she may lose her
ability to fund the transport to the hospital, she may not
have access to information about the possibility of repair (e.g.
radio) or the psychological implications of the fistula are such
that she does not have the motivation to seek help or hope
in a cure. As such, those women who are admitted to Kitovu
Hospital (or indeed any fistula repair service) are more likely
to be women with social support.
It is encouraging that among the women studied, 84%
presented for their first fistula repair. This implies two things:
firstly that there is a good catchment of new cases and sec-
ondly that VVF repairs are generally successful in the initial
attempt. At discharge 94% of women had an ICIQ of 0, con-
ferring no symptoms of urinary incontinence. However, only
a small number of patients returned for follow up and there-
fore we cannot reliably comment upon long-term success of
fistula repair. Poor follow-up rates could imply that a wom-
an’s symptoms have improved but she does not have the
time, funds or the inclination to return for follow up.
Conversely, they could imply that her incontinence may have
persisted and she might not believe that a revision surgery
will work and so does not return for follow up. On

considering whether distance from Kitovu Hospital influenced
likelihood for follow up, the difference between returners and
non-returners is unremarkable: returners lived at an average
of 90 km away whilst non-returners lived at an average of
118 km. Similarly, there was no variation between patient age
groups: returners were on an average of 30.61 years and non-
returners were on an average of 30.64 years old. It is import-
ant to encourage the follow up not just for the individual but
broadly to quantify the success of surgery and therefore the
prevalence of disease.
There remains an enormous task ahead to treat and pre-
vent fistula. Further epidemiological enquiry is needed to
assess the true burden of disease. Reporting of obstetric fis-
tula is poor in countries where the injuries are most common
and there is rarely a centralisation of information about cases
(UNFPA 2010). Learning from the strategies that are success-
ful, such as the Camps at Kitovu Hospital, is crucial. Kitovu is
a private facility funded by charitable donations and there-
fore upscaling the service would rely on private and public
collaboration and funding. Platforms such as the Obstetric
Fistula Working Group (OFWG) and the United Nations
Population Fund (2010), Campaign to End Fistula have been
set up to coordinate such efforts.
Tackling the issues that increase the incidence of fistula –
young childbearing age, education about maternal health-
care, access to services – requires a wider societal shift. Parts
of the world where marginalisation of women by social and
economic discrimination is seen are those where fistula are
endemic. Although there has been some global development
in women’s access to primary education, paid employment
and their political representation, huge gender-based dispar-
ities remain (United Nations 2015). As set out by the World
Health Organisation, there needs to be a universal under-
standing of maternal mortality and morbidity as a fundamen-
tal human rights issue (WHO 2015).
Conclusions
In many respects, the women described here echo those
throughout the literature. They have suffered enormously,
some for decades, and tell a tragic tale of pain, shame and
loss. In this study the rates of perinatal mortality and social
isolation were unacceptably high. Women tended to marry
young, conferring an increased risk of fistula. Despite seeking
medical attention during labour, appropriate management
was not employed to avoid fistula development. They trav-
elled vast distances and by precarious transport methods in
search of fistula repair.
Despite these concerns, this study is highly encouraging.
Many women presented for fistula repair soon after the fis-
tula had developed. These women tended to be younger and
as such we might be hopeful that this marks a change in
young generation. Fistula repair surgery was highly successful
in the immediate period and very few women presented had
had a previous fistula repair.
As discussed, the treatment and prevention of fistula
worldwide is a daunting task. Despite this, we should identify
and learn from those institutions that have begun paving the
way to a brighter, fistula-free future. Kitovu Hospital is a
JOURNAL OF OBSTETRICS AND GYNAECOLOGY 5
centre of excellence in VVF and holds the torch for the rest
of Uganda, indeed the whole developing world, for the repair
of obstetric fistula.
Acknowledgements
The staff at Kitovu Hospital for their enthusiasm and hospitality.
Disclosure statement
The authors report no conflict of interests.
References
Ahmed S, Holtz SA. 2007. Social and economic consequences of obstetric
fistula: Life changed forever? International Journal of Gynaecology and
Obstetrics 99:S10–SS1.
Arrowsmith SD, Hamlin E, Wall L. 1996. Obstructed labor injury complex:
obstetric fistula formation and the multifaceted mobility of maternal
birth trauma in the developing world. Obstetrical & Gynecological
Survey 51:568–574.
Avery K, Donovan J, Peters T, Shaw C, Gotoh M, Abrams P. 2004. ICIQ:
a brief and robust measure for evaluating the symptoms and
impact of urinary incontinence. Neurourology and Urodynamics
23:322–330.
Bacon C, editor. 2003. Obstetric fistula needs assessment report: findings
of nine African Countries. New York: UNFPA and EngenderHealth.
p. 77–81.
Bangser M. 2006. Obstetric fistula and stigma. Lancet (London, England)
367:535–536.
Bishop M. 2012. Obstetric fistula surgery in Uganda. Royal College of
Obstetricians & Gynaecologists; [cited 2017 Apr 17]. Available from:
https://www.rcog.org.uk/en/global-network/global-health-news/inter-
national-news/international-news-september-2012/obstetric-fistula-sur-
gery-in-uganda/
Browning A, Patel TL. 2004. FIGO initiative for the prevention and treat-
ment of vaginal fistula. International Journal of Gynaecology and
Obstetrics: The Official Organ of the International Federation of
Gynaecology and Obstetrics 86:317–322.
Cowgill KD, Bishop J, Norgaard AK, Rubens CE, Gravett MG. 2015.
Obstetric fistula in low-resource countries: an under-valued and under-
studied problem-systematic review of its incidence, prevalence, and
association with stillbirth. BMC Pregnancy and Childbirth 15:193.
Fistula Care Plus at EngenderHealth. 2010. Putting Fistula Care Services
on the Map in Uganda. Fistula Care; [cited 2017 Apr 17].
Hamlin C, Little J. 2001. The hospital by the river: a story of hope.
Sydney: Pan Macmillan Australia. p. 9–10.
Hancock B, Collie M. 2004. Vesicovaginal fistula surgery in Uganda. East
and Central African Journal of Surgery 2:95–99.
Kasamba N, Kaye DK, Mbalinda S. 2013. Community awareness about risk
factors, presentation and prevention and obstetric fistula in Nabitovu
village, Iganga district, Uganda. BMC Pregnancy and Childbirth 13:229.
Kyomuhendo G. 2003. Low use of rural maternity services in Uganda:
impact of women’s status, traditional beliefs and limited resources.
Reproductive Health Matters 11:16–26.
Murk W. 2009. Experiences with obstetric fistula in rural Uganda. The
Yale Journal of Biology and Medicine 82:79–82.
Newby H, Say L. 2015. Births attended by skilled health personnel,
percentage. Mdgs.un.org; [cited 2017 Apr 17].
Thaddeus S, Maine D. 1994. Too far to walk: maternal mortality in
context. Social Science & Medicine (1982) 38:1091.
Uganda Bureau of Statistics (UBOS) and Macro International Inc. 2007.
Uganda Demographic and Health Survey 2006. Maryland: UBOS and
Macro International. p. 135–136.
United Nations. 2015. The Millennium Development Goals Report 2015.
New York: United Nations. p. 39–42.
6 F. K. MCCURDIE ET AL.
United Nations Children’s Fund. 2013. Statistics: Uganda. New York:
UNICEF; [cited 2017 Apr 17].
United Nations Population Fund. 2010. Thematic Evaluation of
National Programmes and UNFPA Experience in the Campaign
to End Fistula Assessment of global/regional activities Volume
I: Global/Regional Report. New York: UNFPA; [cited 2017
Apr 17].
Wall LL. 2006. Obstetric vesicovaginal fistula as an international public-
health problem. Lancet 368:201–209.
Wall LL, Arrowsmith SD, Briggs ND, Browning A, Lassey AT. 2005. The
obstetric vesicovaginal fistula in the developing world. Obstetrics and
Gynaecology Survey 60:S1–S51.
World Health Organisation. 2015. MDG 5: Improve Maternal Health. WHO
Int; [cited 2017 Apr 17].