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Vesicovaginal fistulae in Nepal

This is one of the stories from the September 2012 issue of International News. Shirley Heywood is a gynaecologist working for the NGO International Nepalese Fellowship in the rural west of Nepal and describes the fistula treatment service that she runs in the region.

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 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

 

Nepal is a beautiful country but with difficult terrain, a largely rural population, a recent history of civil war and an unstable political situation all contributing to hinder development of health, education and communication facilities, which are less than adequate particularly in the western half of the country.

Until very recently, obstetric fistula was not officially recognised as a public health problem in Nepal. Since 2011 the United Nations Population Fund has coordinated a campaign with government health services and fistula treatment centres. There are still no firm facts about the numbers of women with fistulae but a team performing an obstetric fistula needs assessment has estimated a prevalence of 4000–5000, with an incidence of 200–400 annually. There are facilities for fistula surgery in Patan (Central Region) and Dharan (Eastern Region) but no hospitals providing surgical treatment for women with fistulae in the western half of Nepal. Patan hospital, with 13 gynaecologists, has been treating fistulae since 1987 but up until 2010 only 443 women with fistulae have undergone surgery. BP Koirala Institute of Health Sciences has 13 gynaecologists, two of whom perform fistula surgery. It held its first fistula camp in 2008 with support from Gynécologie Sans Frontières.

Since 2009 the International Nepal Fellowship Surkhet Programme has run fistula repair camps in Mid-West Nepal. The map shows Surkhet district is shown in green, Patan in blue and Sansari district (Dharan) in red.

Map of Nepal

Our first two camps were very small. The Mid West Regional Hospital in Surkhet has only 50 beds so to expand we needed to find more accommodation. In March 2011 the International Nepal Fellowship marquee, home of many INF conferences, was erected in the grounds of the Mid West Regional Hospital. For six weeks the tent was a place of peace, hope and healing. The 68 women who gathered were from 21 different districts, from the mountains and the plains, young and old, from different ethnic groups, speaking different languages, but sharing a common suffering. They all knew about grief, the loss of much-wanted children and the shame and loneliness that comes to those with fistulae.

Marquee

Marquee in the grounds of Mid West Regional Hospital, Surkhet

Marquee

Inside the marquee

In 2012 the marquee was needed again and in 11 days we operated on 31 patients. A camp does not provide the best conditions for fistula surgery and we hope for a permanent centre in the future.

INF has been running an outreach programme since 2010. In 2011 we planned a large camp with a target of 50 patients. Most patients live in isolation because of their shame and we needed to find them. We have treated over 80 women through the camps, aged from 8 to 75 years, with between 2 months and 40 years of history of incontinence.

Nepalese woman

Krishna lived alone for 40 years

Nepalese girl

Kopila (8) was injured in a fall when a toddler

Surgery for obstetric fistulae is important and can change lives but it is the second best option. Prevention is better. The outreach programme trains auxiliary nurse midwives and mother and child health workers from rural health posts. They are the immediate supervisors of the grass roots workers in the villages who are likely to know of women with fistulae.

They are also the people whose work is vital if we are to stop fistulae occurring. The majority of health workers at health post level do not know what an obstetric fistula is or how it is caused and would not recognise a patient with a fistula if she presented to them. They do not know that there is treatment.

Educating health workers about fistula in Nepal

Educating health workers about fistulae

Using drama, true-life stories and photos depicting everyday activities such as shopping in the bazaar, attending a wedding and drinking tea with friends, we tell of the suffering, isolation and shame of a woman with a fistula. We want to convince these health workers that this is a condition that needs to be eradicated. We teach about how a fistula is caused, the symptoms and prevention. Teaching on how to avoid obstructed labour starts at the beginning of life with the importance of good childhood nutrition and avoidance of early marriage and pregnancy. Family planning and good antenatal care with counselling on birth preparedness; supervised delivery by skilled birth attendants and timely referral when labour is not progressing normally; use of prophylactic catheterisation, when a macerated baby is delivered after a long labour all lie within the skills and responsibility of the health post workers.

Pauli, Nepalese womanPauri (pictured) was catheterised for six weeks after delivery because three days in labour led to a ruptured uterus and obstetric fistula. The fistula healed spontaneously.

If health workers understand the importance of what they do in preventive health, what may often seem routine and uninspiring work becomes life saving. We will never know how many women’s lives are saved or fistulae are prevented because a health worker takes the time to help their clients plan for a safe delivery.

Shirley Heywood, Gynaecologist, NGO International Nepalese Fellowship, Nepal