1. Challenges in treating Obstetric Fistula in Afghanistan Sofia Azeem Hail MD CURE International Hospital Kabul Afghanistan Dec 2010

2. Problems when setting up OF treatment centers Getting patients to the hospital Retaining well trained surgeons, nurses and anesthetist and overall system development Complexity of case Shortage of necessary equipment Poor surgery done elsewhere, redo surgery and patient misunderstandings about OF

3. 1 st challenge Getting patients to the hospital

4. OF patients seen at CURE 2006 – 2010 Average age at presentation = 34 years Average parity = 4.7 Average length of labor = 53 hours % of stillbirths = 50% Average time with OF = 6.2 years

5. Direct outreach program 2007 - 2010 Lessons learned Coordinate with MOPH and other local healthcare officials. Find the right person

6. Improved outreach efforts since October 2009 8 provinces visited and over 1440 healthcare workers trained. Emphasized the cause of OF and that its treatment including surgery, hospital accommodations, and transportation to CURE is free

7. Other ways we have gotten the word out TV and radio advertizing in Pashtu and Dari Brochures in English, Pashtu and Dari Over 200 healthcare workers from 20 provinces have received 1 month of training at CURE. All are given brochures to take back to their provinces

8. All birth injuries cases CURE International Hospital Kabul, Afghanistan

9. 2nd challenge Retaining trained staff Developing countries typically experience a “brain drain” Well trained workers have many opportunities to take higher paying jobs with USAID, US government or some other agency that can pay much more than a non-profit NGO.

10. The CURE International Hospital National Team As of August 2010, all 4 staff trained in 2007 at AAFH were still working at CIH. One nurse recently left.

11. Methods to retain staff used at CURE Ongoing professional development just like this conference. Offering an honest and fair working environment where advance is based on what you do, not on who you know. Good salaries

12. Importance of outside training 20062007200820092010 Training (Weeks)None12201623 # cases*89302141 %success **38%78%73%52%88% *Training at AAFH for all nurses and doctors working at CURE Number of weeks cumulative. ** Success is defined as completely dry.

13. Continuous professional development The aim is to develop a cadre of expert national surgeons and their team of nurses and anesthetists to be able to deal with birth injuries of all complexity.

14. Widely variable case complexity Patients think all cases are the same Local doctors able to fix simple cases are pressured to try more difficult ones Failure causes further misconceptions about OF repair for other new patients

15. 109 consecutive OF repairs as a function of surgeon experience Will compare results of cases done with and without a visiting expert surgeon. Obviously the visiting experts were operating on more difficult cases.

16. Results 109 cases junior versus senior surgeons

17. OF epitomize challenges of providing health care in developing nations Patient ignorance about healthcare Shortage of professionals Widely variable complexity of OF

18. Special thanks to our supporting team Women’s Hope International Fistula Foundation Addis Ababa Fistula Hospital Afghan MOPH CURE International