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Vesicovaginal fistula repairs in Tanzania

This is one of the stories from the September 2012 issue of International News. Dr Vindhya Pathirana describes the work taking place at the Comprehensive Community Based Rehabilitation in Tanzania Disability Hospital, Dar es Salaam.

Use the table below to access 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
Update on the FIGO/RCOG and partners competency-based fistula training manual The problem of continuing urinary incontinence after obestetric 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 transportMYpatient: overcoming the barrier of transport costs
Obstetric fistula surgery in Uganda Journal club

 

The World Health Organization estimates that approximately two million women live with fistulae worldwide and that an additional 50 000–100 000 women are affected each year. In Tanzania alone approximately 2500–3000 new cases of fistulae are estimated to occur each year. In addition to the medical problems that result, women with fistulae face numerous social, psychological and economic challenges because of the constant leaking of urine and sometimes faeces.

In Tanzania approximately 1000 vesicovaginal fistula (VVF) repairs are undertaken annually, at a number of hospitals by a small pool of surgeons brought in by the flying doctor service, organised by the African Medical and Research Foundation (AMREF). The concept of AMREF is to empower small hospitals to undertake repairs when the need arises. There are also a small number of main hospitals with dedicated staff to perform VVF repairs throughout the year, such as CCBRT (Comprehensive Community Based Rehabilitation in Tanzania) Disability Hospital in Dar es Salaam, Bugando Medical Centre in Mwanza, KCMC Hospital in Moshi, Selian Hospital in Arusha and Peramiho Hospital in Songea.

Maternal mortality in Tanzania is still high, for every woman who dies there are three women who survive the ordeal with morbidity, such as obstetric fistula, foot drop, sepsis, paralysis and so on. This leaves a challenge to treat the backlog and new cases, and to implement preventive measures to stop fistulae from occurring.

Hospitals in Tanzania are currently overcrowded and theatres are nearly always busy with emergencies, such that operating time is not available for women with fistulae. Many women wait for their operation for months or are even discharged home to come back later. Women with obstetric fistulae often never return since they lose hope, do not have the money to travel the distance back to the hospital and lack money to pay for food and so on over an extended inpatient admission. Instead they tend to isolate themselves more in their misery.

According to Dr Kees Waaldijk (Nigeria), ‘there are no simple fistulas’, which is true: the success of a fistula repair depends on the first attempt. The extent of the injury to the vagina, bladder and the urethra will determine the outcome of the repair. The repair of the ‘hole’ does not mean the woman will be completely dry – many times it leaves a very lax urethra leading to stress incontinence, hence these women need follow-up and possibly more surgery to make them completely dry and able to lead a normal life.

One challenge in Tanzania is that not many centres undertake complex surgery. The need for complex surgery or urological input means that women may be referred to another centre; the cost and time making the woman feel that she is doomed.

The CCBRT Disability Hospital in Dar es Salaam is a rehabilitation hospital, which started its fistula work in 2000; each year operating on 150–180 patients. The hospital has collaborated with AMREF to train doctors and nurses in fistula care. In 2010 CCBRT launched a community-based programme to find women with fistulae and ensure quality care with a holistic approach. This was achieved by using the potential for mobile phone transfer of funds to cover transport costs – the subject of the transportMYpatient article. This scheme has increased patient numbers and the number of fistula repairs performed each year. In 2010, 268 VVF repairs were performed; the following year this had increased to 339. CCBRT provides a fistula service throughout the year with dedicated theatres and staff. 

Sign outside Fistula Ward at CCBRT Disability Hospital, Dar es Salaam, Tanzania

Sign outside the fistula ward at CCBRT Disability Hospital, Dar es Salaam, Tanzania

There is continuing expansion of facilities at CCBRT to increase capacity for fistula repair in the whole of Tanzania. This will be achieved by partnering with other hospitals in Tanzania to provide surgery in a number of regions, as well as covering transport costs for patients, training staff in fistula care, expanding the ambassador network and a continuing community awareness programme that fistulae can be treated and hopefully cured.

Vindhya Pathirana, Head of VVF Department, Comprehensive Community Based Rehabilitation in Tanzania Disability Hospital, Dar es Salaam