Understanding Women's Pregnancy Intentions, Decision-Making, and Factors Influencing Reproductive Choices After Genital Fistula Repair in Uganda: A Qualitative Study

Abstract

Female genital fistula is a debilitating injury that may affect as many as two million women globally. While studies have examined women's fertility intentions in Uganda and sub-Saharan Africa broadly, few have explored the factors influencing pregnancy decision-making among women who have undergone fistula repair. We conducted in-depth interviews with 40 women who had undergone fistula repair. Interviews were audio-recorded, transcribed into English, and coded using a group-developed collaborative coding framework. Oriented by the socio-ecological framework, we reviewed factors contributing to pregnancy desire and decision-making for women who became pregnant and those who did not following fistula repair. Factors influencing pregnancy desire included partner support, financial circumstances, number of children, and health knowledge and perspectives. Women's own beliefs about their ability to become pregnant and their fears around surgeries and fistula recurrence also influenced pregnancy desire. Participants desiring pregnancy but experiencing infertility expressed various mental health impacts including feelings of hurt, isolation, and yearning, and described infertility stigma. Finally, societal expectations of women to assume childbearing and prioritize home responsibilities influenced participants' decisions to pursue pregnancy. However, discordance between partners or infertility resulted in various consequences, such as women becoming pregnant to fulfill their partner's needs, lying to their partner about their pregnancy status, or dissolution of the relationship. A nuanced understanding of pregnancy intentions and decision-making following fistula repair can help inform patient-centered post-repair pregnancy counseling to support the unique needs of women.