Impact of Covid-19 pandemic on obstetric fistula repair program in Zimbabwe

The advent of Covid-19 pandemic adversely affected many programs worldwide, public health, including programming for obstetric fistula were not spared. Obstetric fistula is an abnormal connection between the vagina and the bladder or the rectum resulting from obstetric causes, mainly prolonged obstructed labour. Zimbabwe has two obstetric fistula repair centers. Because the program uses specialist surgeons from outside the country, the repairs are organized in quarterly camps with a target to repair 90 women per quarter. This study aimed at assessing the impact of restrictions on movement and gathering of people brought about by the Cocid-19 pandemic and to characterize participants of the camp which was held in the midst of the Covid-19 pandemic at Mashoko Hospital. Specifically it looked at how Covid-19 pandemic affected programming for obstetric fistula repair and characterized participants of the fistula camp held in November to December 2020 at one of the repair centers. A review of the dataset and surgical log sheets for the camp and national obstetric fistula dataset was conducted. Variables of interest were extracted onto an excel spreadsheet and analyzed for frequencies and proportions. Data were presented in charts, tables and narratives. The study noted that Covid-19 pandemic negatively affected performance of fistula repairs greatly with only 25 women repaired in 2020 as compared to 313 in 2019. Ninety women were called to come for repairs but 52 did not manage to attend due to reasons related to the restriction of the Covid-19 pandemic lockdown. Two thirds of those women suffered from urinary incontinence while the other third had fecal incontinence. The successful repair rate was 92%. This study concluded that the pandemic greatly affected programming of fistula repair in the country and recommended the Ministry of Health and Child Care to institute measures to resume programming as soon as the situation allows.

Short title: Effects of Covid-19 pandemic on obstetric fistula programming in Zimbabwe   The advent of Covid-19 pandemic adversely affected many programs worldwide, public health, 22 including programming for obstetric fistula were not spared. Obstetric fistula is an abnormal 23 connection between the vagina and the bladder or the rectum resulting from obstetric causes, 24 mainly prolonged obstructed labour. Zimbabwe has two obstetric fistula repair centers. Because   In Zimbabwe, the actual burden of obstetric fistula is not known. The country started an obstetric 56 fistula repair program as a public health intervention in August 2015 at one provincial hospital.

57
Before then, obstetric fistula repair was mainly available at private hospital and it was out of 58 reach of many financially compromised women. As efforts to strengthen the fistula program, the 59 Ministry of Health and Child care piloted a community fistula surveillance system in Manicaland 60 province which is being driven by community based workers.

62
The program has since been expanded to one more hospital, Mashoko Christian Hospital in 63 Masvingo province and since then more than 700 obstetric fistula survivors have been repaired.       125 Since the volume of the data was relatively small, data were analyzed using the excel spreadsheet 126 for frequencies and proportions. Information from the key informant interviews were analyzed 127 manually for content. The data were presented in tables, figures and narratives.    This left only 30 women who actually attended the camp. This is against the initial plan of 159 repairing 90 women. Fig 3 below shows the distribution of fistula camp attendees by province.  Other demographic data are presented in Table 1 Table 1 shows that adolescents and young women below the age of 25 contributed a significant    incontinence. Of the 30 study participants, five had incontinence of stool due to 3 rd and 4 th 205 degree perineal tears so 25 were actual fistula cases.

206
Only eight participants had tried to get treatment of their fistula before.

207
Surgical outcomes among the 25 clients repaired at Mashoko hospital 208 The outcome of surgery upon discharge was classified into three categories 209 1. Dry -fistula was successfully closed and there is no leaking 210 2. Incontinence -surgery was successful in closing the fistula hole but patient is discharged 211 leaking due to stress incontinence 212 3. Fistula not closedfistula was not closed (a dye test is done to distinguish leaking due to 213 incontinence or unsuccessful surgery).

214
Those with perineal tears were repaired accordingly.     The fact that most fistula cases came from Manicaland may not necessarily mean that the 250 province has the highest fistula burden in the country but awareness raising, active surveillance 251 and publicizing of fistula repair program in the province may help explain this observation. As noted in other studies, a significant proportion of participants were adolescent and young 260 women aged 24 years and below [11]. In a study conducted in Kaptembwa-Nakuru in Kenya it 261 was noted that only 2.04% of the responds were above 25 years of age [11].

263
In their study documenting the experiences of women living with obstetric fistula in 2008, 264 Semere and Nour argued that the body of a girl below the age 20 years is not mature enough to 265 withstand the burden of child bearing, therefore they are at increased risk of developing fistula 266 [12]. Contrary to this finding, a study on fistula survivors' experiences in Ghana had only one for 267 the ten participants below 25 years [8]. These differences could be due to sampling issues. The findings of this study revealed that most participants had developed fistula 5 years or less 272 prior to data collection for this study, with the majority of the participants having developed the 273 problem less than 1 year ago. This finding is of concern as it shows that obstetric fistula   With the above findings, this study concluded that the Covid-19 pandemic negatively affected 302 the fistula repair program in the country as it was considered one of the non-essential services.

303
Women living with obstetric fistula are there in communities as shown by the Manicaland case, 304 they need to be identified, given information on available treatment services and linked to fistula 305 care programs for repair, even during the Covid-19 pandemic. 306 It also concluded that community based workers and fistula survivors can be instrumental in 307 community surveillance of fistula cases in their communities when they are trained on how to 308 use standard surveillance tools.

310
Basing on the findings of this study, it is recommended to the Ministry of Health and Child Care 311 to scale up and intensify fistula case finding in communities and link them to treatment services 312 so as to end or minimize suffering of women and girls. There is need to increase treatment 313 centers so that patients will not need to travel long distances to access services, this need has 314 been highlighted by the Covid-19 lockdown. It is also recommended to scale up the community 315 obstetric fistula surveillance system making use of community based workers and other