Networking to Improve Fistula Treatment in Nigeria Evelyn Landry, Fistula Care Erin Mielke, USAID

Session Outline Fistula Care Project Overview Fistula Repair Pooled Effort Events Quarterly Professional Retreats Q & A

Fistula: a preventable and treatable tragedy Predominantly in sub-Saharan Africa and south Asia Caused by prolonged obstructed labor, iatrogenic injury, and sexual violence Estimated global prevalence is unknown Most obstetric cases are preventable through timely C- section In most cases treatable through a simple, low-cost surgical procedure

Fistula Care Strengthening fistula management and prevention services worldwide Global project for treatment and prevention of fistula, now in 25 sites in 11 countries Implemented by EngenderHealth with public, private, nongovernmental, and faith-based partners in Africa and Asia Five-years, USAID-funded

… Fistula Care … Trains doctors in fistula repair surgery and strengthens hospital capacity to provide fistula care Improves the quality of existing fistula services Raises awareness about prevention and the availability of care for women with fistula Removes barriers to emergency obstetric care that lead to fistula in the first place Supports women as they reenter family and community life

Nigeria Program Since 2007 Fistula Care supports six hospitals: 1.Faridat Yakubu General Hospital, Zamfara State 2.Maryam Abacha Women and Children’s Hospital, Sokoto State 3.Birnin Kebbi Specialist Fistula Center, Kebbi State 4.Laure Fistula Center at Murtala Mohammed Specialist Hospital, Kano State 5.Babbar Ruga Hospital, Katsina State 6.The South East VVF Center, Ebonyi State

Initial Site Assessments Identified: Variations in pre-, intra-, and post-operative procedures for management of obstetric fistula at project start up Different levels of administrative support for provision of services among the different sites also observed Backlog of women waiting for fistula repair services in all sites.

Clinical Support Network Developed Includes all Fistula surgeons and nurses in the 6 FC- supported sites Created to standardize and improve the quality of services across facilities. This provider network is supported by two complementary strategies: –Periodic pooled repair efforts –Quarterly professional retreats to discuss clinical issues

Fistula Repair Pooled Effort Events Organized 3-5 surgeons from the network travel to one host site for 1 week Events serve important purposes: –Reduce backlog of women awaiting care –Newly trained surgeons gain more experience and receive coaching from senior trainers –Several surgeons competent to handle a range of repairs are available to treat women with complex or difficult fistula –Raise awareness of fistula and the availability of repair in communities surrounding the repair center

Pooled Effort Event – Fistula Care Project Role Send letters informing the state MOH and MoWCA about event dates and location. Send invitation letters to visiting surgeons via their hospital management boards (who must approve their participation). Ideally, surgical teams include one expert or senior surgeon to perform complex repairs and two other surgeons for the less- complicated repairs. Fund the host site to purchase consumable surgical supplies and diesel fuel for generators, to ensure a steady supply of power during the pooled effort. Arrange surgeons’ travel (by road or air) and accommodations. Provide a per diem allowance for visiting surgeons.

Pooled Effort Event - Host Repair Center Role Coordinate with State ministries to support logistics, e.g., food for patients, and radio and TV announcements about the event. Estimate the current backlog of patients. Ensure nursing staff are available (24 hours) for pre-, intra-, and post-operative care. Ensure nurse or counselor is available to counsel patients preoperatively and postoperatively (and at discharge). Ensure surgical equipment is in good working order. Ensure food is provided for the patients. Ensure other facility services are functioning (laundry, laboratory) Ensure patient record files are sufficient for all of the surgeries, and manage the recording and reporting of surgical data.

Pooled Efforts - Results Increasingly uniform pre-, intra-, and post-operative procedures, including: –Informed consent –Counseling –Patient follow-up schedules Improved interaction between surgeons and nurses Between October 2007 and June 2009 a total of 539 clients were repaired through pooled efforts, representing approximately 20% of all repairs during this time period.

Pooled Effort Results: Oct 2007-June 2009

Pooled Efforts - Lessons Learned (1) Ensuring true partnership among stakeholders is crucial. Clear roles and responsibilities for each partner lead to continued success. Providing visiting surgeons with funds for meals and incidental expenses while traveling for a pooled effort event is important. The opportunity for surgeons to participate with colleagues in pooled events, share experiences, learn from each other and advance their own skills, teach younger surgeons and help each other reduce backlogs, as well as the formation of a network of surgical teams all serve to motivate continued participation Surgeons have the opportunity to learn from each other regardless of their seniority.

Pooled Efforts – Lessons Learned (2) The number of cases that can be treated at a single site is increased periodically. By rotating where the pooled effort events happen, each site has the opportunity to increase access to services for women in its state. Pooled effort events allow visiting surgeons to focus on fistula repairs for five days, without their other usual clinical and administrative duties at their home institution. Inviting nursing staff to participate in a pooled event away from their home facility provides learning opportunities. Scheduling of pooled effort events requires advance planning (2–3 months)

Quarterly Professional Retreats Two-day meetings unite fistula surgeons and nurses from supported centers to discuss clinical practices in pre-, intra-, and post-operative fistula care FC staff review with partners the progress to date on overall achievements across all states. Forum to build agreement on standards of quality services and opportunity for surgeons to review and comment on project tools under development Facilitate smooth conduct of the pooled effort events through agreement upon standards of care

Quarterly Professional Retreats Surgeons and nurses participate together in meetings, fostering a team approach to fistula care management Surgeons and nurses discuss challenges they face in their work, and strategize together to address the challenges Build collaboration and create a professional network of surgeons and nurses working on fistula care programs

Quarterly Retreats – Results (1) Providers reported many advantages of these quarterly retreats: –Interactive –Provided new information and learning opportunities –Enabled providers and sites to manage complicated cases in a cost-effective way Experiences were shared on a range of topics: –how to effectively engage state-level stakeholders –how to advise the government about the need for fistula care –how to involve the First Ladies of the states (following the example of Zamfara and Ebonyi State First Ladies, who are actively engaged in supporting fistula care)

Quarterly Retreats – Results (2) Provided a forum to discuss how to implement a standard set of record-keeping tools Provided opportunity to review and comment on new written standards and protocols for managing fistula surgery: –Fistula Care Complications Reporting –Clinical Monitoring Indicators Reinforced the importance of evidence-based medicine and built consensus about issues requiring further study Prompted agreement among sites about how to make supervision more facilitative