Reducing Iatrogenic Female Genitourinary Fistula: Impact of Short-Term Obstetric Training for Lower Cadre Surgeons in Uganda

Abstract

Background: In Uganda, almost 50% of genitourinary fistulae are iatrogenic, primarily resulting from inadvertent urinary tract injuries during obstetric and gynecologic surgeries. Cesarean sections (CS), often performed by less experienced providers at lower-level facilities, account for 70% of these cases. In 2022, the Essential Training in Operative Obstetrics (ETOO) program was introduced to improve surgical skills among lower cadre surgeons. This study evaluated the program’s impact on iatrogenic fistula incidence at a tertiary teaching hospital in southwestern Uganda. Methods: A retrospective review was conducted on women who underwent fistula repair at a tertiary teaching hospital in southwestern Uganda between January 2020 and December 2024. Data from the pre-training period (2020– 2021) were compared with post-training data (2022– 2024). Fistulae were classified as iatrogenic if caused by surgical error rather than obstructed labor. Anatomical subtypes included ureteric injuries, vault fistulas, and vesico-[utero]/-cervico-vaginal fistulas. The primary outcome was the annual number and proportion of iatrogenic fistula cases. Results: Among 102 fistula cases post-training, 57 (55.9%) were iatrogenic. Most followed CS (66.7%) and involved ureteric injuries (54.3%). A significant portion (34.8%) originated from private facilities. Following ETOO implementation, annual iatrogenic cases declined from 39 in 2020 to 19 in 2024. A marked drop occurred in late 2022, aligning with program rollout. The trend slope of − 5.4 suggests a steady annual decline. Conclusion: The ETOO program is associated with a notable reduction in iatrogenic fistula incidence. Expansion to private and lower-level facilities is recommended to enhance nationwide surgical safety. Plain Language Summary: In Uganda, some women develop urine leakage after an operation during childbirth, especially after cesarean section. This can happen when the urinary tract is accidentally injured during surgery. These injuries can cause serious physical, emotional, and social problems for women. Because of this, improving the safety of childbirth surgery is very important. This study looked at whether a short practical training program for doctors, called Essential Training in Operative Obstetrics (ETOO), was linked to fewer of these injuries. The training was designed to improve skills in safe cesarean section and other emergency childbirth operations. We reviewed records of women who had fistula repair surgery at a teaching hospital in southwestern Uganda between 2020 and 2024. We then looked at the pattern of cases before and after the ETOO program started. The study found encouraging results. After the training program was introduced, the number of women treated for these surgery-related fistulas went down over time. Most of the injuries were linked to cesarean section, showing why safe surgical training is so important. The findings suggest that practical, hands-on training can help improve surgical safety and may help prevent avoidable harm to women. A key strength of this study is that it used real hospital data collected over several years, and all cases were diagnosed by experienced specialists. Overall, the results support continued investment in surgical training, supervision, and safer maternity care to protect women during childbirth. Keywords: iatrogenic genitourinary fistula, cesarean section, essential training in operative obstetrics