OBSTETRIC FISTULA IN AFRICA: Challenges to quality delivery of repair services G. SANDA 1, Erika SINCLAIR 2 1 Clinic of Urology, Lamordé National Hospital Niamey, Niger, West Africa 2 Associate, Maternity and Postabortion Care EngenderHealth, New York, USA

Objective 1. To discuss some challenges faced in establishing and sustaining clinical care in resource-poor settings 2. To inform on how the staff of Lamordé Hospital has managed to provide clinical care in the face of these barriers.

INTRODUCTION “The Fistula situation remains critical and is only growing more serious”

Reported Caseloads in Sub-Saharan Africa Large caseload: 200 –1000 cases per year WHO estimates over two million women living with obstetric fistula About 50 – 100 thousand new cases per year Current estimate of unrepaired fistulae in Nigeria alone is 800 thousand

Backlog in Niger Holds 55 women, who have been waiting years for repair They live here as an option to living on the streets Niamey National Hospital Fistula Pavilion

Major challenges with regard to providing fistula repair services in Africa

Social barriers to providing care Limited access to/coverage of EmOC services High number of home deliveries, attended by TBAs, relatives or neighbors

Clinical barriers to providing care Lack of trained surgeons and appropriate facilities Staff reluctance to stay in remote areas Heavy reliance on the assistance of foreign physicians Sizable backlog of complicated fistulae No knowledge of infection prevention practices

Shortage of supplies & equipment sutures and catheters, antibiotics, blood Fistula as a low priority when supplies are available

Lack of political support. informal mention is made of fistula in the context of general maternal health care policy no adequate budget allotted to fistula management

Addressing the challenges Clinic of Urology: 72 beds 20 beds for fistula patients 4 operations per week 2 urologists

Training issues

Training objectives To improve the access to obstetric fistula surgery To enhance the capacity of local health workers in the understanding & management of fistula To provide skilled doctors at referral centres in different areas

Training objectives (cont’d) To provide skilled nurses in pre and post operative fistula care To support and rehabilitate women with fistula

Who should be trained? Surgery: medical students, residents general practitioners, surgeons obstetrician-gynaecologists, urologists Recognition of labour complications midwives, nurses, health assistants TBAs to help them understand signs of complications in labour

How? Incorporate fistula repair training into the medical school curriculum. Implement a comprehensive EmOC program

Training program for providers Specialist MDs: One-month training program each year and regular surgical training workshops to perfect their skills Residents in Ob/Gyn, urology, surgery 6 -month training Ward, theatre nurses, midwives Six-week training in pre-and post operative care

Diagnosis of fistulae Simple fistulae Urethro-vaginal Vesico-vaginal Recto-vaginal Complicated fistulae High fistulae Vesico-uterine Uretero-vaginal Extensive sloughing of bladder mucosa & trigone Extensive scarring of vagina

Diagnosis of fistulae (cont’d) Assessment of fistula site Size and number of fistula Degree of scarring Relationship of ureteric orifices

First diagnostic step Inspection

Using a metal sound

Methylene blue dye test

Gynecologic examination Protrusion of bladder mucosa

Complicated fistula Full thickness cutaneous graft After several unsuccessful attempts at repair

Cystoscopy High VVF, vesico-uterine Fistula to localize fistula site, size, & relation to ureteric orifices

Complex fistulae VVF RVF Vaginal fibrosis

Patient positioning

Surgical guidelines Adequate exposure of the operative field Minimize bleeding and haematoma formation Avoid ureteral obstruction

Surgical guidelines (cont’d) Use ureteral catheters if a VVF involves ureteric orifices Timing of repair weeks after fistula occurrence

Surgical approaches Transvaginal approach: Exposure (suturing of the labial folds to the ipsilateral thigh) Abdominal approach

Typical practices for repair Fistula closure Reconstruction of the urethra Operation for stress incontinence Urinary diversion procedures

Initial Dissection injecting 1% lidocain with epinephrine beneath the vaginal tissue  accentuate tissue planes

Complex fistulae, large obstetric VVF ( >4 cm ) fistula closure + Modified Martius' procedure: fibroadipose tissue in the labium majus

Bladder Closure Low-tension closure Absorbable suture (2-0 or 3-0 vicryl, dexon,) 2 interrupted suture layers Pass water mixed with methylene blue dye to check for leaks in the closure

Transvaginal approach

Transperitoneal approach (Ureteral dissection & reimplantation)

Postoperative care Continuous bladder drainage with a large- caliber catheter Antibiotic therapy Stool softeners and a high-fiber diet

Competency-based Assessment of Learning Levels of performance Skill acquisition Skill competency Skill proficiency

Rehabilitation/ reintegration Social workers ensure vocational training in tailoring and basket weaving, dyeing to earn an income. Counseling (the need for a lot of encouragement, support and someone simply to talk to about their lives)

Cured Fistula Patient What a smile for a new life !!

Cured Fistula Patient Life with restored dignity

Discussion It is possible to successfully address these barriers, when there is motivation, political will and commitment.

1.That would help establish an efficient national referral system

2. Create low-risk birth centers (four to six beds) attached to a district hospital &staffed by nurses, and midwives

3. Provide Community healthcare workers with adequate salaries, housing and equipment !!!

4. Educate TBA on methods used to detect risk factors related to pregnancy, labor, delivery at rural Healthcare unit level

Recommendations To standardize protocols and guidelines for fistula surgery, as well as pre-operative and post-operative care. To provide financial incentives to attract skilled medical personnel to areas with the greatest needs.

Recommendations (cont’d) To increase collaboration between institutions providing repairs Launch public awareness campaign on issues surrounding safe deliveries.

Conclusion Training healthcare providers should help : -provide skilled personnel in rural areas - solve the problem of sizable backlog of patients - raise community awareness on the matter

- Promote & improve EmOC services in remote rural areas !!

- Help rural population understand and better implement this proverb: “The sun should not rise or set twice on a labouring woman” —African proverb