Geospatial Analysis of Surgical Access for Obstetric Fistula Repair in Malawi: Addressing Inequities in Maternal Surgical Care

Background : Obstetric fistula remains a significant maternal health burden in Malawi, affecting 1.6 per 1,000 women of reproductive age, with an estimated 13,000–20,000 women currently living with this condition. Despite commitments to eliminating fistulas by 2030, disparities in surgical access, workforce shortages, and geographic barriers persist. The condition, resulting from prolonged obstructed labor without timely intervention, leads to chronic incontinence, stigma, and morbidity. While Malawi’s National Surgical, Obstetric, and Anaesthesia Plan (NSOAP) aims to strengthen maternal surgical care, inequities remain. This study employs geographic information systems (GISs) and national epidemiological data to assess surgical service distribution and accessibility to inform policy and intervention strategies. Methods : A mixed-methods approach was used, integrating data from the 2015–16 and 2024 Malawi Demographic and Health Surveys (MDHS), 2019–20 and Malawi Multiple Indicator Cluster Survey (MICS). GIS-based spatial analyses mapped fistula repair facilities, estimated travel times, and identified high-risk areas. Regression models were used to examine the associations between antenatal care (ANC) coverage, fistula incidence, and geographic access. Results : Obstetric fistulas remain concentrated in rural districtswith the lowest ANC coverage and greatest travel-time barriers. The Gini coefficient of 0.68highlights severe disparities, with over 80% of repairs occurring in just 20% of districts. Services remain highly centralized, with most procedures conducted in urban referral centres, leaving high-burden rural districts underserved. Malawi has fewer than 10 fistula surgeons, predominantly based in urban facilities, despite 77 who have trained for more than 10 years. The two urban facilities perform just over 400 repairs annually, covering 85% of the national casesdespite the limited number of trained surgeons. With minimal capacity elsewhere, backlog elimination remains unfeasible, prolonging median delays of 7.2 years and worsening surgical complexity and social impact. GIS analysis identified high-risk zones with travel times exceeding four hours, reinforcing geographic barriers to timely intervention. Conclusion : Persistent inequities necessitate decentralizing fistula repair services, expanding the surgical workforce, and leveraging the GIS for strategic planning. Aligning NSOAP implementation with Global Surgery 2030 through task shifting, regional access expansion, and equitable workforce distribution is essential. Without targeted investment, elimination by 2030 remains unattainable, requiring a revised long-term strategy beyond 2050.