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Update on the FIGO/RCOG and partners competency-based fistula manual

This is one of the stories from the September 2012 issue of International News. Sohier Elneil describes how the publication and implementation of the FIGO and partners competency-based training programme is helping to provide a standardised approach to medical and surgical management of obstetric fistulae.

Use the table below to access the other stories in this issue.

Editorial In their own words: 12 stories of vesicovaginal fistulae
The problem of obstetric fistula: a personal view Provision of fistula services and programmes
The problem of continuing urinary incontinence after obstetric vesicovaginal surgery Creating a balanced narrative about women living with fistulae
Moving beyond incontinence Vesicovaginal fistulae in Nepal
Vesicovaginal fistula repairs at Aberdeen Women’s Centre in Sierra Leone Vesicovaginal fistulae in Bangladesh
Vesicovaginal fistula repairs in Tanzania transportMYpatient: overcoming the barrier of transport costs
Obstetric fistula surgery in Uganda Journal club


Obstetric fistulae still pose a major problem in Africa and Asia.1,2 Access to modern obstetric care, including caesarean sections, can be limited in these countries. Furthermore, long distances combined with the high cost of care and poor nutrition make women more vulnerable to obstetric fistulae, particularly in West Africa,3 the horn of Africa4 and the Indian subcontinent.5–7 The tremendous disparity between risks associated with pregnancy and labour faced by women in the developing world compared with women from wealthier nations is always evident.

In the last four years two significant unifying worldwide initiatives have contributed significantly to this field.

The first initiative was by the International Federation of Gynecology and Obstetrics (FIGO), an international multidisciplinary body of obstetricians and gynaecologists, who along with their partners the Royal College of Obstetricians and Gynaecologists (RCOG), the United Nations Population Fund, EngenderHealth and the Pan African Urological Surgeons Association, have published a competency-based training manual on urogenital fistulae, sustained as a consequence of obstetric trauma.8 The aim of the manual was to provide standardised training and provide a competency-based approach to training in fistula surgery. The training structure is modular, with each module or subject area being further subcategorised into specific objectives. Each module can be achieved within a stipulated period of time, as determined by the trainer and the trainee. Using the agreed information provided by the fistula surgeons, the manual was created in a similar vein to the RCOG training programme for general obstetrics and gynaecology with learning tools, logbooks and objective structured assessments of technical skill for each module. This was the first time that such an initiative had been developed for a specific internationally recognised health problem. The manual’s design was not just to provide a guide to surgical training, but also to initiate audit of surgical outcomes, thus facilitating research in the field and promoting publication in the medical and nursing literature.

The second initiative took place in 2008 with the formation of two societies: the International Society of Obstetric Fistula Surgeons (ISOFS) in Ethiopia, and the African Fistula and Continence Society (AFCS) in Egypt. The roles of both societies are yet to be fully elucidated, but their importance lies in the world listening to the voice of the fistula surgeons. Those surgeons who are already working within a dedicated institution are protected to some degree, but those who work in isolation will need local, national and international support. By agreeing to form a body of experts in the field, the societies have already overcome a huge barrier – acceptance of each other’s expertise and position. Under the guidance of the first elected president of ISOFS, Dr Kees Waaldijk, an eminent urological surgeon who has worked on patients with obstetric fistulae in Katsina in Northern Nigeria for over 28 years, and the president of AFCS Professor Sherif Mourad, Professor of Urology at Ain Shams University in Egypt, who runs masterclasses on fistula surgery throughout Africa, there will be no option but for them to succeed as a negotiating body for all fistula surgeons working so hard in this field.

The main objective of both societies is to unify surgeons from all over the world in adopting the same strategy in classification, training and education. Both societies have successfully become the ‘voice’ of fistula surgeons throughout the world. Like all societies in their infancy there are still many aspects to be developed, but with the dedication of its members they will no doubt flourish in years to come.

Current status

The FIGO/RCOG and Partners manual underwent pilot studies in 2010 in Anglophone and Francophone parts of Africa and Asia. The initial results showed that we needed to modify some aspects of the manual, such as making the language easier to understand and translating it into French. This was duly done and the manual was finally published in June 2011.

The first ‘training the trainers’ course took place in Dar es Salaam, Tanzania in August 2011. This was to introduce the manual and to train the current senior fistula surgeons in Africa and Asia on how to use the manual. The training took place over two days and discussions were held on how to implement the competency-based training system within different teaching environments, how to appraise and achieve accreditation in fistula surgery and how to manage the difficult trainee. All participants, being well-established fistula surgeons within their own right, found the training sessions very helpful in understanding how the manual should be used. Competency-based learning in Africa and Asia is a new concept in medical education and is only now starting to take off in mainstream postgraduate medical training.

Training the Trainers participants, obstetric fistula, Dar es Salam, TanzaniaParticipants in the first Training of the Trainers Course on the FIGO/RCOG and Partners Competency-based fistula Training Manual in Dar es Salaam, Tanzania

Back row, L–R: Esam Gaffar (Sudan), Peter Melchert (USA), Joseph Rumingo (EngenderHealth), Andrew Browning (Tanzania), Hamid Rushwan (CEO, FIGO), Abdelrahman Al-Fakih (Sudan), Lord Patel (Chair, FIGO Fistula Committee), Gordon Williams (Ethiopia), Kevin Hayes (RCOG) and Tom Rassen (Kenya)

Front row, L–R: Mulu Muleta (Ethiopia), Marietta Mahendeka (Tanzania), Serigne Gueye (Senegal), Sohier Elneil (Author/Editor), Ambaye Woldemichael (Ethiopia) and Louise Knight (WAHA International)

The manual has been distributed to many trainers, who through the ‘grandfather clause’ by ISOFS and AFCS are universally accepted as trainers by the fistula surgeons’ community. Many of the initial trainers selected included those who contributed to the manual, throughout Africa and Asia.

Following the publication of the manual, several challenging issues arose. These included how the trainees will be selected, how long it will take to train each trainee, who will provide accreditation and how the programme will be funded.

The challenges

Selecting the trainee

Guidelines for the selection of trainees for the fistula training programme were determined by members of the FIGO and Partners committee. They believed that all applicants should have completed at least three years of surgical or obstetrics and gynaecology training following graduation from medical school. In essence, trainees would be self-selecting. But retaining the trainees was also an important consideration. One of the major problems, in the past, has been that many trained fistula surgeons often did not stay in their homeland but left to pursue careers elsewhere. This presented a form of ‘brain drain’ of fistula surgeons throughout the developing world. The committee felt that all prospective trainees should be encouraged to offer a minimum term of service determined by their country in providing a fistula surgery service, be it within a dedicated fistula hospital or a general hospital setting. This was felt to be very important, so that each country’s Ministry of Health could maintain autonomy of its own manpower development strategy.

The training period

All trainees need to be accepted by a trainer who must ensure that the appropriate facilities for training are available, for example, adequate patient numbers, good surgical facilities and equipment, computer access and accommodation. Feedback and evaluation are critical to ensure that the programme is fit for purpose.

The training period should be individually tailored following discussion between trainee and trainer. The manual is divided into standard, advanced and expert levels of competency. As the trainees complete each phase of training, they achieve the next level of competency and can be signed off by their trainer. The training programme currently has seven trainees in place, all of them training for the standard level of competency. It is anticipated that most trainees will need a minimum of two months of training in an accredited centre to achieve a standard level of competency. To achieve a higher level of competency will be determined on an individual basis.

Accreditation and certification

The accreditation and certification process for completion of each level of competency is to be shared between FIGO and the professional societies. To date, FIGO is working in tandem with the professional societies to accredit centres and trainers. The accreditation and certification of the trainees is currently in the hands of FIGO. As the numbers of trainees increase, it is planned that each country’s designated professional body along with its academic institutions will provide the competency-based fistula surgery training programme as a specialised form of postgraduate education. They will then become the certification body. This will require negotiation between academic institutions, professional bodies, Ministries of Health and FIGO with their partners.

Funding of the training programme

The funding of trainees on the training programme was surprisingly the easiest of the challenges that arose after completion and publication of the manual. FIGO was integral to this. It negotiated with several non-governmental organisations that were active in the field. These included WAHA International, EngenderHealth, the Fistula Foundation, the United Nations Population Fund and many others. These organisations were able to provide funding for accommodation, expenses and travel, as well as help the hospitals and trainers with improved infrastructure.

In the future, it is anticipated that governments and institutions will take over funding of the training programme, when they become part of the established postgraduate education system.


In the last few years so many positive changes have taken place in the fistula world that it has been overwhelming at times. Raising awareness of obstetric fistulae was the starting point of interest in this field, and has been the reason why we are able to move forward as a community. The tremendous efforts of the surgeons past have brought obstetric fistulae to the forefront of the world’s medical media. This exacting work has meant that more women were being treated, more dedicated units were being developed, more doctors were being trained and most importantly, more lives were being rebuilt. The doctors were not the only ‘heroes’ in this story. Without the continuing support of dedicated nurses, physiotherapists, occupational health therapists, social workers, cured and non-cured patients working as health auxiliaries, non-government organisations and philanthropists, none of their effort would have been fully realised. But it must not be forgotten that this condition is completely preventable. Therefore, the issues which are the basis for it, social and economic development of ‘at risk’ girls/women, must be on the agenda for them to be tackled.

Until there is universal access to emergency obstetric services, antenatal healthcare services, improved transport and socio-economic status, improving medical care for these women will be a challenge. A holistic approach to medical and surgical treatment, rehabilitation and follow-up in the community is a step in the right direction. The publication and implementation of the FIGO and partners competency-based training programme is helping provide a standardised approach to medical and surgical management of this condition. We anticipate that in time it will improve outcomes. However, the training programme has to be part of a wider picture, incorporating integrated social, economic and cultural development programmes. Together they can help prevent the problem. There is no doubt that in the long term, social and economic development will be more cost-effective than medical treatment and highly sustainable. But until then, we must rely on the dedication and delivery of good care by all the professionals working in this field. The FIGO and partners competency-based training programme goes some way in contributing to this laudable objective.

Sohier Elneil, Consultant Urogynaecologist, University College, London


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