Contraceptive preferences and adoption following female genital fistula surgery in Uganda: a mixed-methods study

We recruited 60 women at the time of genital fistula surgery for 12-month longitudinal cohort participation. Our study was launched in December 2014 and recruitment lasted through June 2015. Study follow-up was completed in August 2016. Women were eligible if they spoke Luganda or English, resided in a community with cellular telephone coverage, and were able to provide informed consent for study participation. Individuals under age 18 years who experience genital fistula are considered emancipated minors; thus, no age-related eligibility restrictions were defined. All eligible participants were enrolled in the study following the provision of informed consent. Quantitative data were captured at baseline, 3-, 6-, 9- and 12-months post-surgery. Questions included sociodemographic characteristics; incontinence severity (International Consultation on Incontinence Questionnaire, Short Form) [19], sexual activity, contraceptive use, and pregnancy intention and status.

A purposively selected sample of 30 women from the quantitative longitudinal cohort were invited by the study team for an in-depth interview following the conclusion of the 12-month quantitative portion of the study to supplement our quantitative findings. Interviews took place from January-August 2016. Women were selected for a range of physical and psychosocial recovery experiences based on our quantitative data. In-depth interviews were conducted in-person in a private room at Mulago Hospital and lasted approximately 1–1.5 h each. The in-depth interview guide included open-ended questions on women’s post-repair recovery and reintegration experiences, including their relationships with their partners, sexual experiences, reproductive intentions, and contraceptive attitudes and use. Interviews were translated and transcribed into English for analysis.

Quantitative data analyses were performed utilising Stata v17 software (StataCorp, College Station, TX, USA). Univariate analyses were performed to describe participant characteristics. Descriptive statistics, including the mean and standard deviation for continuous variables and the number and proportion for categorical variables, were utilised to describe relationship status, fertility status, and contraceptive use among the longitudinal cohort over the 12-month follow-up period. We compared sexual activity and contraceptive use at 12 months by age group, parity, relationship status, educational attainment, number of living children, household asset score, time lived with fistula, urinary incontinence, and whether or not they were trying for pregnancy using Fisher’s exact test. Analyses of contraceptive use at 12 months included only those individuals reporting current sexual activity and included the 2 individuals who had reported sterilization on baseline questionnaire. These analyses used compressed categories for certain variables based on sample size. Qualitative data analyses were performed utilising Atlas.ti software. Transcripts from in-depth interviews were coded using inductive and deductive codes within Atlas.ti software, which were analysed to understand women’s sexual behaviours, experiences, and contraceptive use following recovery from obstetric fistula surgery. Two members of the research team were involved in coding the qualitative data (HN and AE), one Ugandan and one American. Coding disagreements were resolved by discussion. Coded data were analysed thematically to describe the different dimensions and commonalities of each theme and the patterns and linkages between themes.

The study protocol was approved by the Makerere University School of Medicine Research and Ethics Committee (Ref# 2014-052) and the University of California, San Francisco Human Research Protection Program, Committee on Human Research (IRB# 12-09573 and IRB# 15-17467) and the Uganda National Council for Science and Technology (REF#:1541212101). All individuals eligible for participation underwent an informed consent process; those individuals unable to provide signatures for informed consent provided thumbprint confirmation. All study methods were performed in accordance with the relevant guidelines and regulations.

The median age was 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 education. 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). Most women had vesicovaginal fistula (98%); one woman had rectovaginal fistula and was included in our quantitative but not our qualitative sample (not shown).

Counselling on resuming sexual intercourse (97%) was routinely reported at the time of fistula surgery hospitalization, although fewer participants reported having received contraceptive counselling (59%). 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.¹ At 12 months post-surgery, female sterilisation was the most common method reported among contraceptive users (38%), followed by oral contraceptive pills (13%), implants (8%), intrauterine devices (IUDs; 4%) and injections (4%). Condom use was rare. No participants reported use of traditional methods.

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 = 0.024). Women married or living with partners were also more likely to report sexual activity than those without partners (80% vs. 18%, p < 0.001). Women with 1 or more living children were more likely to report resumption of sexual activity than women with no children, slightly short of significance (61% vs. 30%, p = 0.052). However, marital status also was patterned by parity, with 45% of women with no children currently married compared to 55% of women with children (p = 0.582).

Among a reduced sample of sexually active individuals at 12 months (n = 29), number of living children and completion of primary education were both significantly associated with contraceptive use (Table 3). Contraceptive use varied by the number of living children a woman had; 90% of women with 4 or more children were more likely to report contraceptive use compared to 62% of women with 1–3 children and 17% of those with no children (p < 0.012). Contraceptive use was lower among women who had completed primary education (25%) compared to those with less than primary education (88%, p < 0.001); however, education and parity were related, with 50% of women who had completed primary education reporting 1 or more living children compared to 76% of women who had not (p = 0.055, not shown).

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 desiring 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) 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 you cannot conceive]. (Interviewee, 24 years old)

Few participants overall in the quantitative sample reported trying for pregnancy during the study period (n = 7) but a couple of young women (median age 22) began trying for pregnancy starting at 6 months post-surgery (Table 2).

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 1–2  years, and a few younger women wanting to wait further out. 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.

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)

I think about remarrying to someone who already has a home but not renting. In fact, I don’t want a man to marry me from a rental house (jeers in disgust). After these young men have impregnated you, they desert you in the (single roomed) rental house and then you suffer with both the child and paying rent; I am not interested in such…. [If I get] the right person, someone sent from God, someone who even has some money, I could hope of giving birth to maybe four children; those would be enough for me. (Interviewee, 32 years)

The number of children desired varied across participants who expressed interest, with most wanting several children. Those 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 moved beyond their childbearing years.

I 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.

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 contraceptives 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.

A history of unplanned pregnancies and certain obstetric events, such as multiple caesarean sections, compelled some participants to consider contraception to avoid reoccurrence. 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 [contraception] because [the doctors] have always been operating me for my births. 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)

Several participants indicated not wanting to conceive again and adopted contraceptives, including permanent methods, particularly those with multiple children. Other participants shared that they adopted contraceptives 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).

Fistula can impact relationships with partners, and 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)

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 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.²You just try to find all means of telling him that the uterus was removed. (Interviewee, 32 years old).

Several participants indicated they had completed childbearing and sought permanent birth control. Even though only 4% of participants in full sample relied on injections, the 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 used it in the past. Some identified family members or friends as users. Fewer participants shared the oral contraceptive pill as their preferred method.

Several participants felt that they were not at risk of pregnancy due to previous failure to conceive or altered menstruation, including amenorrhea. Women who considered themselves infertile felt no need to use contraceptives:

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 amenorrhea felt these symptoms were indicative of infertility and were not using contraception. One woman described her menstrual pattern:

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).

Participants revealed a variety of fears of infertility 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 methods that they feared would cause harm. Several thought that contraceptives would give them fibroids. They also 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 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)

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, or at least the need for more comprehensive counselling on preferred methods:

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 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).