Surgery-related obstetric fistulas across health facilities in sub-Saharan African countries: systematic review and meta-analysis

Background Surgery-related (iatrogenic) obstetric fistulas are a major public health threat in sub-Saharan Africa (SSA), but the actual burden is largely unknown due to a paucity of data. This review aimed to collate empirical evidence on the magnitude and determinants of iatrogenic obstetric fistulas in SSA. Methods PubMed, LILACS, CINAHL, SCOPUS and Google Scholar were searched from 1st January 2000 to 31st March 2025, without language restrictions, via comprehensive search terms. The Cochrane Library, African Journals Online, Data Base of African Thesis and Dissertations, including Research (DATAD-R D Space), Preprint Repositories and reference lists of relevant studies, were also searched. The retrieved studies were deduplicated in Endnote, screened and selected in Rayyan. Two authors independently selected studies, extracted data and assessed the quality of the included studies via pretested tools. Disagreements between reviewers were resolved through discussion. Weighted proportions were estimated via STATA SE 18. Heterogeneity between studies was assessed graphically and statistically, and where significant, random effects model meta-analysis was performed. Estimates are reported with 95% confidence intervals (CIs). Subgroup analysis was conducted to address heterogeneity, and sensitivity analyses were performed to test the robustness of the pooled estimates. Results The proportion of surgery-related obstetric fistulas among urogenital/rectovaginal fistulas in SSA is 40% (95% CI 34–47, 60 studies, n=25825), whereas among obstetric fistulas, it is 44% (95% CI 37–51, 55 studies, n=17504). The procedures that frequently preceded obstetric fistulas were as follows: caesarean section (34%, 95% CI 28–40; 54 studies, n=17491) and instrumental vaginal deliveries (11%, 95% CI 9–13; 34 studies, n=12727). Most procedures that resulted in obstetric fistulas were performed by nonspecialists (92%, 3 studies, n=749). Conclusions The proportions of iatrogenic obstetric fistulas among urogenital/rectovaginal fistulas (40%) and obstetric fistulas (44%) are high and raise serious concerns about the quality of obstetric surgical care delivery in SSA. The fact that more than 92% of obstetric surgeries are performed by nonspecialists and that the incidence of iatrogenic fistulas is high calls for increased efforts towards capacity building and quality improvement across countries in SSA.