This is one of the stories from the September 2012 issue of International News. Sohier Elneil, a consultant urogynaecologist at University College, London, discusses the planning for provision of fistula programmes in different countries in the developing world.
Use the table below to access the other stories in this issue.
It is generally accepted that a fistula centre should be created in a district where there is a large number of patients with fistulae awaiting treatment, ideally after a feasibility study has been done.1 The aim is to determine the size and the type of the health facility. Units can be totally separated from other health structures or be part of a hospital. Stand-alone units were the aspiration for many surgeons working in the field, because of the stigma women with this condition suffered. Many felt they not only needed a separate facility where they could seek treatment, but also a place to seek refuge. Many surgeons believed that when units were part of a teaching hospital, they could present several disadvantages regarding accessibility for poor women, availability of staff to treat cases of chronic fistulae, capacity for long-term stay of patients and providing support for family/relatives. However, being part of a hospital does offer some advantages, such as access to all aspects of health care including antenatal healthcare services, transfusion services, high-dependency care and other centralised hospital services. Most importantly, a hospital-based fistula centre ‘normalises’ the situation and makes obstetric fistulae one of many problems that women can suffer as a consequence of childbirth and not a special aberration. Indeed, it simply becomes one medical problem affecting women’s health. These issues are important and must be taken into account when establishing fistula centres.
Location and geography of fistula centres and units
Most fistula centres in sub-Saharan Africa and Asia have a well-identified geographical area of responsibility, determined by a national plan for obstetric fistula repair and prevention. The main objective of national plans is the eradication of fistulae using a multifaceted approach including capacity building in surgical services, as well as developing preventive measures in obstetric care.
Different countries have fistula centres in different environments. The vast majority of centres were all built in the last two decades and were built as part of other health complexes. There are now numerous centres in Africa and Asia, of which only a few are mentioned in this edition. In Bangladesh (under Professor Akhter),2 Gondor in Ethiopia (under Dr Muleta)3–5 and Khartoum in Sudan (under Professor Abboo) the fistula centre is a stand-alone unit next door to the main university teaching hospital, whereas in Dakar in Senegal (under Professor Gueye) and Ibadan in Nigeria (under Professor Ojengbede) the fistula centres are integrated directly within the hospital and do not have a separate environment. Other ‘incorporated’ units are found in Malawi,6–8 Niger,9–12 South Sudan and Tanzania,13,14 where the fistula centre is part of a general clinic setting. Perhaps the most famous stand-alone unit is in Addis Ababa, Ethiopia (under Dr Hamlin) where the holistic approach to fistula management was started, including surgery, physiotherapy and occupational therapy. Other stand-alone units are found in Darfur, Sudan (under Dr Adam) and Katsina, Northern Nigeria (under Dr Waaldijk).
All units, regardless of the type, are governed by the same principles. These include:
- A strong commitment from the health professionals, health management teams, governments and local authorities to women living with fistulae.
- Documentation and evaluation of the surgical/medical services delivered and promoting research activities in all aspects of fistula care.
- Engaging the affected communities, to attract women living with fistulae and to succeed in social reintegration.
- Commencing work on fistula prevention and creating strong links to nearby centres of excellence for obstetric care.
Current organisation and management of fistula centres
In the past, most fistula centres were run and managed by the lead surgeon involved in the provision of the service. But, as centres have developed and grown, it has become increasingly important to secure a unit manager to help run the centre. The increasing complexity of each centre has meant that each facet of healthcare delivery needs to be financially viable and efficient. Each technical unit for fistula treatment includes surgical services (wards, operating theatres and anaesthetic services), investigation services (laboratory, blood bank and X-ray services), physiotherapy and social-reintegration services.
Most of the fistula centres mentioned above have their own operating theatre, as sharing operating theatre space with obstetrics does not allow surgeons to treat fistulae as needed since emergencies will always have priority. In some cases, the operating theatre is shared with mainstream gynaecology and urology surgery. But, all of this depends on the workload and the average number of fistulae repaired weekly. In centres like Bangladesh, Ethiopia and Sudan, the theatre is used almost exclusively for fistula surgery because of the high numbers of fistula cases.
One of the biggest capital outlays for each centre remains the maintenance and updating of the theatre infrastructure and equipment (anaesthesia machines, operating table, operating lights and sterilisation equipment), surgical instruments (including cystoscopy sets) and the provision of consumables, such as sutures, catheters and drainage bags.
In the 1990s funding for fistula centres was in a slump. Most came through charitable donations, small government grants and local fundraising efforts. Most funding was thus not dependable and sustainable for the long term. In the early 2000s, there was a major focus by global health agencies on the problem of obstetric fistulae.15 This raised awareness dramatically revolutionised the approach to the problem. It brought a welcome injection of money into the provision of therapeutic services. With it came a change in individual government health policy, focusing not only on building capacity in surgical services but also on prevention, with the development of obstetric emergency care in tandem with antenatal care.
The fistula team
A critical resource for all fistula centres is the fistula surgeon, who must have skills in abdominal, pelvic and vaginal surgery to treat vesicovaginal and rectovaginal fistulae. Training for this type of complex surgery is highly specialised and until recently was organised differently in different institutions. Training has taken place within ‘fistula camps’,16 dedicated units,17 general hospitals, district hospitals18 and university teaching hospitals.19–21 The main issue remains capacity of the training environment. In centres where there are a large number of cases, practical experience is enhanced. The only problem for many years has been the lack of standardised training. This all changed with the publication of the International Federation of Gynecology and Obstetrics (FIGO) and Partners, including the RCOG, competency-based training manual in July 2011.
This was a consensus-derived document focusing on competency-based training in fistula surgery to a standard, advanced and expert level. The duration of training was no longer the focus, which was instead competency. It takes into account the previous skills of the trainee and the practical workload they have access to. There is also emphasis on the surgeon to be responsible for data collection, data evaluation and analysis. The accreditation and certification process is currently in the hands of FIGO and the professional fistula surgeon’s societies, namely the International Society of Obstetric Fistula Surgeons (ISOFS). In the future it is envisaged that trainees will gain officially recognised postgraduate degrees from national institutions.
Ask most fistula surgeons what affects the success of their surgery and almost everyone will tell you that their secret weapon is their nursing staff.9,22,23 Good nursing care for the patient with a fistula is essential to their surgical outcome. Nursing staff are often specially trained on site or in specialised centres, sometimes outside the country. This training includes pre-surgery and post-surgery care, psychological support,24 counselling and communication skills. It has been estimated that two qualified nurses and three to four primary level health workers (for example, nursing aides, who could be recruited from previous fistula patients), are needed for every 25 patients. Reaching this level of staffing is often not easy to achieve.
Another facet of fistula care is physiotherapy and in the last decade its importance to social reintegration has become recognised. The need for physical rehabilitation, pre- and post-surgery, is a critical determinant of long-term success following reparative surgery. Funding for specialised staff, as well as special equipment, is now an acceptable request on budget proposals.
Up until a decade ago, social reintegration services were not always included in the fistula game plan. They were often seen as being of less importance than ‘fixing the hole’. However, with increased funding, many hospitals now offer literacy, health and hygiene classes for those patients who need to stay for a long period at the centre. Social health workers are also involved in facilitating the return of cured patients to their family and community.
Accommodation on site for women awaiting fistula treatment and for those women convalescing and needing rehabilitation is also recommended. The accommodation is like a maternity waiting home, where relatives can stay also, and cooking and washing facilities are available. In developing countries, many patients come from great distances and often do not have the resource to fund themselves while waiting for surgery. Hence, onsite accommodation is a necessity.
Most hospital units operate on a minimum of 500 patients per annum (of varying complexities), and provided a hostel is available and the ward has a dayroom or outside space for ambulant patients, a 40-bedded ward block is usually sufficient for them. But in the majority of the hospitals there are more cases than can normally be accommodated. If three major operations are performed each day on five days a week for 50 weeks in the year, 750 repair operations could be performed per annum. Five hundred of these would probably be primary operations and 250 would be second phase operations or repeat procedures. An average hospital stay of 14 days for each operation would require 10 500 bed days (750 x 14). The total bed days per annum being 14 600 (365 x 40), this would allow 4100 (14 600 – 10 500) bed days for contingencies – a margin of nearly 30%, as calculated by international health agencies and health ministries.
From the same calculations, a 30-bedded unit could accommodate 375 new patients per annum, and a 20-bedded unit 250 per annum. Ward accommodation is therefore very important to capacity building.
From the Addis Ababa Fistula Hospital and the Gondor Hospital experience, the buildings are built in keeping with the social and cultural norms of the community with room for outdoor space for patients to relax and exercise in. In Sudan and Senegal, the buildings are purely built for medical purposes, with little space for accommodation for the patients awaiting surgery. While in Tanzania and Nigeria, the building plans vary from site to site, some having outdoor space for patients and some not.
Hospital funding and development
Hospital funding has changed in the last decade. Whereas fistula centres embedded in hospitals like those in Senegal and Sudan usually derive their funding from governments and academic institutions, other units get a significant proportion of their funding from non-governmental organisations (NGOs). In the last few years the funding provided by organisations such as EngenderHealth, the United Nations Population Fund, Women and Health Alliance International, the Fistula Foundation and many others has meant there has been a financial injection into many centres.15,25,26 This has resulted in expansion of many centres with a resultant increase in staff and ward sizes. It has also meant that operating theatres were refurbished and consumables were easily accessible.
One unusual feature of many fistula hospitals is that they need to provide transport fees for their patients and some living expenses. The hospitals need to be reimbursed for these expenses. This is done through agreements with the Ministry of Health, national and international NGOs and international organisations. It is estimated that each patient costs around $350 to treat and to provide social reintegration.
Fistula programme development in Africa and Asia
As a consequence of all the changes to funding, hospital and staff infrastructure and the development of supportive health and social services, the fistula programmes have also developed.
To date all training programmes have been based on the apprentice system, be it on a short- or long-term basis. The training has been variable and as a consequence the outcomes have also been variable. This is mainly because trainees went to centres or ‘fistula camps’ on an ad-hoc basis. Much of fistula surgery in Africa and Asia was also done by what the indigenous fistula community call ‘fistula tourists’.27,28 These are doctors who visit Africa on an annual or biannual basis and go in to repair a few cases and then they leave the situation behind them to continue. Very often, they did not have continuing commitments with the medical or patient community. So, the ‘good deed’ done was actually not beneficial to the patients in the long term. More worryingly, many of these surgeons had very limited fistula surgery experience and some did not even have vaginal surgery experience. As a result, simple fistula cases that could be repaired vaginally were repaired abdominally, and in some cases diversion procedures were performed. Living with the consequences of abdominal or urological diversion surgery in the rural environments of Africa and Asia is not a good option for many of the patients with fistulae. Just as there was variability in the skills of the indigenous trainees, there was also variability in the skills of the overseas visitor surgeons.
The unification of the fistula surgeons in Africa and Asia in ISOFS and the African Fistula and Continence Society has meant that ‘fistula tourism’ will be coming to a halt. It is imperative that these professional societies guide access to fistula work in the developing world. Without their input and support, the variable outcomes encountered when surgery is done by visiting surgeons will continue to afflict these patients.
It is because of these issues that the indigenous fistula surgeons, professional associations, national and international NGOs, governments and global health funding bodies came together to create a standardised training programme. There was no standardised training programme for fistula surgery prior to this, but with the advent of the FIGO and Partners manual and programme in 2011, the situation has changed.29 Most institutions in Ethiopia, Nigeria, Kenya, Senegal, Sudan, Tanzania and Bangladesh have signed up to this programme. It entails selecting trainees and developing their competency and skills through a stepwise approach. The programme has just started in many countries, and the outcome is yet to be fully determined. Detail about the programme, which is open to all comers, is available from the FIGO website.
In addition to medical training, most hospitals in Africa and Asia now provide teaching and training for nurses and midwives. At the Addis Ababa Hospital, there is a midwifery college, while in Nigeria, Sudan and Uganda there are now nursing colleges directly affiliated with the fistula units. This is important, as it brings general nursing and midwifery trainees in direct contact with women with fistulae and teaches them about the specialised type of care that they need. The same plan of integrating training is now being developed for physiotherapists, occupational therapists and social workers albeit on a smaller scale in Ethiopia, Niger, Nigeria and Sudan.
Providing a fistula surgery service in the developing world is not an easy task. It needs to provide good clinical outcomes, be cost-effective, efficient and sustainable. Furthermore, the surgical service must work in tandem with preventive strategies that are government-led. In order to achieve this, most countries are adopting the FIGO and partners, including the RCOG, competency-based fistula training programme which, along with funding from governments, academic institutions, NGOs and charities, it is hoped will provide better patient outcomes after fistula surgery.
The individual country programmes are now more complex as they do not just provide training in surgery, but many also provide nursing, physiotherapy and midwifery training. It is this holistic approach that is likely to lead to the eradication of obstetric fistulae in the developing world.
Sohier Elneil, Consultant Urogynaecologist, University College, London
1. Hamlin EC, Muleta M, Kennedy RC. Providing an obstetric fistula service. BJU International 2002;89 Suppl 1:50–3.
2. Islam AI, Begum A. A psycho-social study on genito-urinary fistula. Bangladesh Med Res Counc Bull 1992;18:82–94.
3. Muleta M, Hamlin EC, Fantahun M, Kennedy RC, Tafesse B. Health and social problems encountered by treated and untreated obstetric fistula patients in rural Ethiopia. J Obstet Gynaecol Can 2008;30:44–50.
4. Muleta M, Fantahun M, Tafesse B, Hamlin EC, Kennedy RC. Obstetric fistula in rural Ethiopia. East Afr Med J 2007;84:525–33.
5. Wakabi W. Mulu Muleta: Ethiopian surgeon working to end fistula. Lancet 2006;368:1147.
6. Yeakey MP, Chipeta E, Rijken Y, Taulo F, Tsui AO. Experiences with fistula repair surgery among women and families in Malawi. Glob Public Health 2010:6:153–67.
7. Kalilani-Phiri LV, Umar E, Lazaro D, Lunguzi J, Chilungo A. Prevalence of obstetric fistula in Malawi. Int J Gynaecol Obstet 2010;109:204–8.
8. Yeakey MP, Chipeta E, Taulo F, Tsui AO. The lived experience of Malawian women with obstetric fistula. Cult Health Sex 2009;11:499–513.
9. Narcisi L, Tieniber A, Andriani L, McKinney T. The fistula crisis in sub-Saharan Africa: an ongoing struggle in education and awareness. Urol Nurs 2010;30:341–6.
10. Olivera CK, Ascher-Walsh CJ, Gligorov N. Fistula experience in Niger: how we overcame an ethical dilemma. Mt Sinai J Med 2009;76:71–4.
11. Ndiaye P, Amoul Kini G, Adama F, Idrissa A, Tal-Dia A. [Obstetric urogenital fistula (OUGF): cost analysis at the Niamey National Hospital (Niger)]. Rev Epidemiol Sante Publique 2009;57:374–9.
12. Ndiaye P, Amoul Kini G, Abdoulaye I, Diagne Camara M, Tal-Dia A. [Epidemiology of women suffering from obstetric fistula in Niger]. Med Trop (Mars) 2009;69:61–5.
13. Bangser M, Mehta M, Singer J, Daly C, Kamugumya C, Mwangomale A. Childbirth experiences of women with obstetric fistula in Tanzania and Uganda and their implications for fistula program development. Int Urogynecol J 2011;22:91–8.
14. Tsui AO, Creanga AA, Ahmed S. The role of delayed childbearing in the prevention of obstetric fistulas. Int J Gynaecol Obstet 2007;99 Suppl 1:S98–107.
15. Donnay F, Weil L. Obstetric fistula: the international response. Lancet 2004;363:71–2.
16. Cam C, Karateke A, Ozdemir A, Gunes C, Celik C, Guney B, et al. Fistula campaigns--are they of any benefit? Taiwan J Obstet Gynecol 2010;49:291–6.
17. Kirschner CV, Yost KJ, Du H, Karshima JA, Arrowsmith SD, Wall LL. Obstetric fistula: the ECWA Evangel VVF Center surgical experience from Jos, Nigeria. Int Urogynecol J 2010;21:1525–33.
18. Ali AA, Adam I. Maternal and perinatal outcomes of uterine rupture in the Kassala Hospital, east Sudan: 2006-2009. J Obstet Gynaecol 2011;31:48–9.
19. Allen AM, Lakin T, Shobeiri SA, Nihira M. Transmural vaginal-to-bladder injury from an obstructed labor pattern. Obstet Gynecol 2011;117:468–70.
20. Ojengbede OA, Morhason-Bello IO, Shittu O. One-stage repair for combined fistulas: myth or reality? Int J Gynaecol Obstet 2007;99 Suppl 1:S90–3.
21. Ojengbede OA, Morhason-Bello IO. Local anaesthesia: an appropriate technology for simple fistula repair. Int J Gynaecol Obstet 2007;99 Suppl 1:S75–8.
22. Ng’ang’a N. Women of the courtyard. A nurse’s journey to treat obstetric fistulae in Niger. AWHONN Lifelines 2006;10:410–7.
23. Muleta M. Obstetric fistula in developing countries: a review article. J Obstet Gynaecol Can 2006;28:962–6.
24. Aina OF. An overview of the socio-cultural and psychiatric aspects of women’s reproductive health in West Africa. Niger Postgrad Med J 2007;14:231–7.
25. Velez A, Ramsey K, Tell K. The Campaign to End Fistula: what have we learned? Findings of facility and community needs assessments. Int J Gynaecol Obstet 2007;99 Suppl 1:S143–50.
26. Ramsey K, Iliyasu Z, Idoko L. Fistula Fortnight: innovative partnership brings mass treatment and public awareness towards ending obstetric fistula. Int J Gynaecol Obstet 2007;99 Suppl 1:S130–6.
27. Morgan MA. Another view of “humanitarian ventures” and “fistula tourism”. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:705–7.
28. Wall LL, Arrowsmith SD, Lassey AT, Danso K. Humanitarian ventures or ‘fistula tourism?’: the ethical perils of pelvic surgery in the developing world. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:559–62.
29. Elneil S, Browning A. Obstetric fistula–a new way forward. BJOG 2009;116 Suppl 1:30–2.