Obstructed labor is the leading cause of obstetric fistulas globally, and is more common in settings with limited access to emergency obstetric care. When women present to a tertiary care facility following prolonged obstructed labor, Cesarean delivery may increase morbidity. We sought to describe characteristics of DRC women who developed urogenital fistulae following Cesarean section to determine characteristics associated with 2 different fistula etiologies: (1) obstructed labor; and (2) Cesarean section.

We abstracted data from all patients with urogenital fistula following Cesarean section who received care during an outreach surgical campaign in the north of DRC (Haut-Uele province) in 2016. Based on findings at the time of surgical fistula repair, urogenital fistula etiology was designated as either (1) related to prolonged obstructed labor; or (2) surgical complication of Cesarean section. Data were abstracted regarding patient age, parity, labor, duration of symptoms, and characteristics of fistula. 

Descriptive analyses characterized patients with urogenital fistulae related to obstructed labor versus Cesarean section. Univariate and multivariate logistic regression identified factors associated with fistula etiology. Variables were included in the logistic regression models based upon biological plausibility: age, parity, days in labor, whether labor started at the hospital, and whether delivery was attempted before hospital arrival. A p-value of .05 or less was considered statistically significant.

Among 125 patients, the etiology of the urogenital fistula was attributed to obstructed labor in 77 (62%) and to complications of the Cesarean section in 48 (38%). 

Table 1 describes the sample stratified by fistula etiology. The median age at presentation was 30 years (range 16-80) and the median age at fistula development was 24 years (range 11-51). More than half of participants had a fistula for 6 years or more prior to undergoing surgical correction. 

Women with a fistula attributed to obstructed labor developed the fistula at a significantly younger age than women with a fistula related to Cesarean section (23 versus 26 years, p=.04) and had a lower parity (median 2 versus 4, p=.02). While both groups were in labor for a similar duration, women whose fistula was attributable to obstructed labor were more likely to have started labor at home and attempted delivery prior to arrival at the hospital. Women whose fistula was related to the Cesarean section were more likely to develop urine leakage delayed from delivery. The vast majority of fistulas related to obstructed labor were repaired vaginally, while fistulas related to Cesarean section were repaired abdominally. 

Factors associated with obstetric fistulas are displayed in Table 2. On univariate analysis, age and parity were associated with decreased risk of obstetric fistula; attempted delivery prior to hospital arrival was associated with increased risk. Only attempted delivery prior to hospital arrival was significant in the multivariate model.

Over one-third of DRC women with urogenital fistula following Cesarean delivery had a fistula attributable to their Cesarean delivery, and all of these fistulas required abdominal surgery to repair. Women with a fistula attributable to obstructed labor were more likely to have attempted delivery prior to hospital arrival and were more likely to undergo vaginal surgery for repair.

In the DRC, Cesarean sections are commonly performed on women who arrive at the hospital following prolonged obstructed labor and fetal demise. These women are already at high risk for urogenital fistula, and Cesarean section increases the risk of complex fistula requiring abdominal approach to repair. We propose that fetal extraction rather than Cesarean section should be performed to decrease additional morbidity in this population. Training obstetric providers and staff to assess maternal status on arrival may prevent unnecessary Cesarean sections and decrease women’s risk of complex urogenital fistula development.