Social reintegration of women after obstetric fistula surgery: Evidence from a longitudinal multilevel mixed-effects study in Zambia

Abstract

Introduction

Obstetric fistula remains a persistent maternal health challenge in sub-Saharan Africa, severely impairing women's physical, social, and psychological well-being. Although surgical repair restores continence, less is known about the factors influencing women's social reintegration after treatment. This study examined the association of continence status and follow-up time on social reintegration among women who underwent obstetric fistula repair in Zambia.

Material and Methods

This prospective cohort study included 2172 women who underwent fistula repair between 2017 and 2023 at eight hospitals across Zambia. Multilevel mixed-effects models were used to assess the effects of continence and follow-up time on a composite social reintegration score (0–100), derived from the five domains using principal component factor analysis (eigenvalue = 4.02) and demonstrating internal consistency (Cronbach's α = 0.94), while adjusting for baseline covariates.

Results

Among all participants, 86.3% achieved continence, whereas 13.7% remained incontinent at discharge. The null model yielded negligible between-patient variance (intraclass correlation coefficient, ICC <0.001). In the fully adjusted model, continent women had higher reintegration scores than their incontinent counterparts (β = 38.62; 95% CI: 36.10–41.14). Social reintegration improved substantially within the first 3 months after surgery (β = 10.83; 95% CI: 8.23–13.43), and remained stable at 6 months (β = 9.34; 95% CI: 6.70–11.98), and 12 months (β = 9.66; 95% CI: 6.97–12.34). Interaction analyses indicated that although continent women consistently reported higher social reintegration scores, the difference between continent and incontinent women narrowed over time, reflecting gradual improvements in social reintegration among incontinent women (β = −4.85; 95% CI: −6.30 to −3.40).

Conclusions

Restoration of continence was the strongest predictor of improved social reintegration following fistula repair. However, the largest social reintegration improvement was observed among incontinent women within the first 3 months after surgery. These findings highlight the importance of combining high-quality surgical care with structured early postoperative follow-up and reintegration support to sustain recovery among women affected by obstetric fistula, regardless of the surgical repair outcome.