1. LIBERIA FISTULA PROJECT By Drs. John Mulbah & Philderald Pratt

2. Background Population of 3.47 million people* Basic Health Indicators:  Maternal mortality ratio 994/100,000 live births**  Infant mortality rate 72/1,000**  Proportion of home deliveries 57%*  Low contraceptive prevalence rate (CPR)11%** Severe shortage of health service providers - 3 Obstetricians in country - 412 Midwives in country * NPHS 2008 **LDHS 2007

3. Rationale for Obstetric Fistula Study Survey was conducted in 2006 with two objectives: 1. To assess the extend of the obstetric fistula situation in Liberia 2. To formulate a comprehensive fistula program which include prevention, treatment, and rehabilitation/reintegration using findings from the study

4. Map of Liberia

5. SURVEY RESULTS 351 operated by expatriates between 2004- 2005. Major causes of fistula: obstetric 87%, traumatic 13 % Only 27.4% of health institutions had ambulance services for referring patients. 37.1% of facilities had telephone or high frequency radio (HF) for communication. Stigmatization was highly noted : - Rejection by husband accounted for 56.6%

6. National Response to Survey Results A National Fistula Project was established and launched on April 6 th, 2007 by Ministry of Health and UNFPA A comprehensive approach consist of: a)Fistula prevention b)Treatment services c)Rehabilitation and reintegration

7. Summary of achievements Advocacy and Awareness creation Training of Core-team Training of health service providers Establishment of Project sites Repairing of Fistulae Establishment of Rehabilitation Center Establishment of partnership

8. Advocacy and Awareness Creation MEDIA Media campaign against fistula launched Dissemination of fistula messages in all 15 vernaculars in Liberia Conduct lives radio and television programs Print and electronic media utilized

9. Advocacy and Awareness Creation  Trained 15 journalists as special advocates  Airing of fistula jingles and messages on urban and rural radio stations  Intensified media coverage of all major fistula activities

10. Advocacy and Awareness Creation Academic high schools: Involvement of students and teachers in obstetric fistula prevention strategy in eight counties:  LofaMaryland  Grand BassaRiver-gee  NimbaGrand Gedeh  MontserradoBong

11. Advocacy and Awareness Creation Interacted with over 12,000 students from 16 schools: –Main causes of obstetric fistula –Discussed Family Planning as key to fistula prevention –Highlighted the role of students and their teachers in the prevention and treatment. –Established fistula fan clubs in each school –Finally organized a national school debate about fistula.

12. Training Fistula survivors and students: 20 fistula survivors and 10 students trained to serve as special advocates in fistula prevention and treatment Community: 800 community members from eight counties sensitized: –Traditional Birth Attendants –Traditional and religious leaders –Drivers and marketing union –Other influential groups

13. Training Health service providers 69 health county trainers trained in fistula mngt. Step-down training of 105 nurses by health county trainers Fistula management integrated in training curriculum of medical training institutions

14. Treatment -Total number of surgeries: 870 ( 2007-2011) -Average age group:11 to 20 years -Types: Obstetric: 817 94% Traumatic: 53 6%  Rape: 17  Surgery: 20  FGM: 13 Other: 3 -Overall success rate: 83%

15. A Pie Chart of types of fistula by Occurrence

16. Percent distribution of traumatic cases

17. County of origin of patients operated

18. The graph represented the cases performed in 2011 up to 24 October 2011

19. Rehabilitation/Reintegration YEARSNUMBERPERCENTAGE 2008/20094426.04% 2009/20106136.10% 2010/20116437.86% TOTAL169100%

20. Rehabilitation/Reintegration General training SkillsNumber Adult literacy169 Business ManagementSame as above Interior DecorationSame as above

21. Rehabilitation/Reintegration

22. CountryPercentage Liberian 93 Ivoirian 3 Guinean 3 Sierra Leonean 1 TOTAL 100%

23. Rehabilitation/Reintegration NationalityNumberResiding in Liberia Liberian158 Non-Liberian 11 3 169 161

24. Rehabilitation/Reintegration ESTIMATED COST FOR THE TRAINING OF ONE FISTULA SURVIVOR FOR 4 MONTHS Meals $5.00/day x 4months $620.00 Provision $10.00/month x 4 40.00 Training Materials $50.00/mn x 4 200.00 Medical care $20.00/month 4 80.00 Post training starter kit (Average) 300.00 Transportation 100.00 Total $ 1,340.00 * (*This total excludes administrative and operational cost)

25. Strength of the project 1.Strong political will and National ownership of the program 2. Commitment by County Health Teams and community members 3. Involvement of local and international NGOs 4. Unwavering Support from UNFPA, ZONTA, Johnson and Johnson, UNMIL and GoL 7. South-South Cooperation 8. Partnership with Miss Liberia, Miss ECOWAS, others 9. Accessible, available services: free of charge services

26. Way Forward 1.Establishment of a national task force on fistula 2.Establishment of a national EmONC training center in Bong county to include fistula services 3. Establishment of 3 selected excellent sites to integrate fistula services in the regular RH services

27. Way Forward 4. Training at the Rehab center in Bong County continues - Rejected treated survivors - Incurable patients 5. Diversify skill training curriculum to include agriculture 6. Establishment of maternity waiting home 7. Hosting of yearly national survivors retreat 8. Provision of fistula services in Ivoirian refugee camps in Liberia

28. Constraints 1. Bad road condition: -Access to outreach project sites difficult by the mobile team -Access to services by patients difficult at times -Limited assistance to transport patients back home 2. Limited transport facilities -The 4 wheel drive jeep has outlived it usefulness -Logistical challenges -Inadequate monitoring

29. Constraints 3. Increasing demand of fistula services -Because of effective awareness creation -Increased utilization of facilities -Effective community involvement 4. Difficulty experienced in the reintegration of rehabilitated survivors Far Distances Survivor and kit to be transported Lack of vehicle for reintegration and monitoring

30. The End