UNFPA and EngenderHealth Obstetric Fistula Needs Assessment Report

Publication date: 2003

NEEDS ASSESSMENT REPORT: FINDINGS FROM NINE AFRICAN COUNTRIES OBSTETRIC FISTULA United Nations Population Fund 220 East 42nd Street New York, NY 10017 U.S.A. Tel: (212) 297-5000 Fax: (212) 557-6416 www.unfpa.org EngenderHealth 440 Ninth Avenue New York, NY 10001 U.S.A. Tel: (212) 561-8000 Fax: (212) 561-8067 www.engenderhealth.org UNFPA, the United Nations Population Fund, is the world’s largest multilateral source of population assistance. Since it became operational in 1969, the Fund has provided close to $6 billion to developing countries to meet reproductive health needs and support sustainable development issues. UNFPA helps women, men and young people plan their families and avoid accidental pregnancies; undergo pregnancy and childbirth safely; avoid sexually transmitted diseases, including HIV/AIDS; and combat discrimination and violence against women. EngenderHealth works worldwide to improve the lives of individuals by making reproductive health services safe, available and sustainable. We provide technical assistance, training, and information, with a focus on practical solutions that improve services where resources are scarce. We believe that individuals have the right to make informed decisions about their reproductive health and to receive care that meets their needs. We work in partnership with governments, institutions and health care professionals to make this right a reality. The views expressed in this publication are those of the authors, and do not necessarily represent the views of UNFPA, the United Nations or any of its affiliated organizations. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries © 2003 UNFPA and EngenderHealth ISBN: 0-89714-661-1 220 East 42nd Street New York, NY 10017 U.S.A. Tel: (212) 297-5000 Fax: (212) 557-6416 www.unfpa.org 440 Ninth Avenue New York, NY 10001 U.S.A. Tel: (212) 561-8000 Fax: (212) 561-8067 e-mail: info@engenderhealth.org www.engenderhealth.org Editor: Charlotte Bacon Cover and book design: Mary Zehngut Printer: Kay Printing Printed in the United States of America on recycled paper. Acknowledgments The needs assessments were carried out with financial contributions from UNFPA and EngenderHealth. UNFPA and EngenderHealth are indebted to the many individuals who contributed to the creation of this report. This is a facilities-based needs assessment, and the administrators and health providers at each of the facilities visited provided invaluable insights that shaped our understanding of the situation of fistula in the places where they work and the countries where they live: Benin, Chad, Malawi, Mali, Mozambique, Niger, Nigeria, Uganda and Zambia. These individuals (who are noted at the end of each country section in the report) gave freely of their time, shared their insights, often served as translators, and hosted us in the midst of many other responsibilities. In addition, we are deeply grateful to the staff at UNFPA’s and EngenderHealth’s regional and country offices (also noted at the end of each country section in the report), all of whom devoted much time and effort to the project. Their help in arranging logistics and in facilitating communication enabled the work to be completed. Without the support and guidance of critical individuals working in obstetric fistula—Maggie Bangser, Brian Hancock, Festus Ilako, John Kelly, Julius Kiiru, Maura Lynch and Tom Raassen—this assessment could not have gone forward. They provided important encouragement and critical details every step of the way. We acknowledge the invaluable contribution of the UNFPA staff who helped to prepare this report, notably France Donnay, Micol Zarb and Anuradha Naidu. In addition, EngenderHealth staff Joseph Ruminjo, Erika Sinclair, Josephine Ventunelli and Mary Nell Wegner, as well as consultant Charlotte Bacon, were key contributors. Finally and most importantly, we offer our deepest gratitude to the many women who have experienced obstetric fistula and were willing to share their stories with us. From them we have learned far more than could be included in this report. 2 List of Acronyms 3 Executive Summary 4 Findings by country Benin Summary of findings 10 Fact sheets on facilities visited 13 Key Contacts 16 Chad Summary of findings 17 Fact sheets on facilities visited 21 Key Contacts 23 Malawi Summary of findings 24 Fact sheets on facilities visited 29 Key Contacts 33 Mali Summary of findings 34 Fact sheets on facilities visited 37 Key Contacts 39 Mozambique Summary of findings 40 Fact sheets on facilities visited 43 Key Contacts 45 Niger Summary of findings 46 Fact sheets on facilities visited 50 Key Contacts 56 Nigeria Summary of findings 57 Fact sheets on facilities visited 61 Key Contacts 76 Uganda Summary of findings 77 Fact sheets on facilities visited 82 Key Contacts 86 Zambia Summary of findings 87 Fact sheets on facilities visited 91 Key Contacts 93 Appendix Questionnaire for Mapping Exercise 94 Notes 95 Table of Contents 3 List of Acronyms AIDS Acquired Immune Deficiency Syndrome AMREF African Medical and Research Foundation AZT Azidothymidine C-section Caesarean Section CBH Central Board of Health CFA Franc des Colonies Françaises d'Afrique (Franc of the denomination of the Central African States) CHC Community Health Committees CIDA Canadian International Development Agency CNHU National Hospital and University Centre CONGAFEN Coordination of NGOs and Feminine Associations of Niger CONIPRAT Nigerien Committee on Traditional Practices CPR Contraceptive Prevalence Rate DfID Department for International Development DHS Demographic and Health Survey DIMOL Reproductive Health for Low Risk Maternity ECWA Evangelical Church of West Africa FIGO International Federation of Gynaecology and Obstetrics FGM Female Genital Mutilation FORWARD Foundation for Women’s Health Research and Development GHON Grass Roots Health Organization of Nigeria HIV Human Immunodeficiency Virus Project HOPE Project Health Opportunity for Everyone IVP Intravenous Pyelogram JHPIEGO Johns Hopkins Program for International Education on Gynecology and Obstetrics KNARDA Kano Agricultural and Rural Development Agency MCH Maternal and Child Health MMR Maternal Mortality Ratio MOH Ministry of Health MTCT Mother To Child Transmission NAPEP National Programme on Eradication of Poverty NGO Non-Governmental Organization OB/GYN Obstetrician/Gynaecologist RVF Recto-Vaginal Fistula STI Sexually Transmitted Infection TBA Traditional Birth Attendant UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development USD United States Dollar UTH University Teaching Hospital VCT Voluntary Counselling and Testing VVF Vesico-Vaginal Fistula WHO World Health Organization 4 “The sun should not rise or set twice on a labouring woman” —African proverb When people first learn about obstetric fistula, their reaction is often to reject hearing more. The subject is just too unpleasant. Yet, rejection is often what happens to women living with fistula. Obstetric fistula is a devastating pregnancy- related disability and affects an estimated 50,000–100,000 women each year.1 While fistula is a global problem, it appears to be particularly common in Africa. Fistula is a condition that often develops during obstructed labour, when a woman cannot get a Caesarean section (C-Section). Obstruction can occur due to malnutrition and pregnancy at a young age (which both lead to small pelvis width, and thus pronounced cephalo-pelvic disproportion). The woman can be in labour for five days or more without medical help, although obstructed labour for even a single day can yield damaging outcomes. If the obstruction is not inter- rupted in a timely manner, the prolonged pressure of the baby’s head against the mother’s pelvis cuts off the blood supply to the soft tissues surrounding her bladder, rectum and vagina, leading to tissue necrosis. The baby usually dies, and fistula is the result. If the fistula is between the woman’s vagina and bladder (vesico-vaginal), she has continuous leakage of urine; and if it is between her vagina and rectum (recto-vaginal), she loses control of her bowel movement. In most cases, permanent incontinence ensues until the fistula can be surgically repaired. In addition, most women are either unaware that treatment is available, or cannot access or afford it. Unable to stay dry, many women live with the constant and humiliating smell of urine and/or feces. Nerve damage to the legs can also make it difficult to walk. Affected women are often reject- ed by their husband or partner, shunned by their community and blamed for their condition. Women who remain untreated may not only face a life of shame and isolation, but may also face a slow, pre- mature death from infection and kidney failure. Because of their poverty and their lack of political status, not to mention the stigma that their condi- tion causes, these women have remained largely invisible to policy makers both in and out of their countries. Preventing the Tragedy Obstetric fistula is a preventable and treatable condition, one that no woman should have to endure. Direct causes of fistula include child- bearing at too early an age, malnutrition and limited access to emergency obstetric care. Some of the indirect causes, such as poverty and lack of education, prevent women from accessing services that could preclude the onset of such conditions. Prevalence is highest in impoverished communities in Africa and Asia. The World Health Organization estimates that over two million women are currently living with obstetric fistulas. Estimates are based on the number of people who seek treatment in hospitals and clinics and are, therefore, likely to be much too low as many women never seek care.2 Fortunately, most fistulas can be repaired surgically, even if they are several years old. The cost ranges from $100–$400 USD, but this amount is far beyond what most patients can afford. If done properly, the success rate for surgical repair is as high as 90 per cent and women can usually continue to bear children. Attentive post-operative care, for a minimum of 10-14 days, is critical to pre- vent infection, catheter blockage and breakdown of the repair site while the surgery heals. Education and counselling are also needed to help restore the woman’s self-esteem and allow her to reintegrate into her community once she is healed. Executive Summary 5 Fistula was once common throughout the world, but has been eradicated in areas such as Europe and North America through improved obstetric care. Obstetric fistulas are virtually unknown in places where early marriage is discouraged, women are educated about their bodies have access to family planning and skilled medical care is provided at childbirth. Strategies to address fistula include preventa- tive methods (postponing marriage and pregnancy for young girls and increasing access to education and family planning services for women and men, and providing access to quality medical care for all pregnant women to avoid complications); curative methods (repairing physical damage through surgi- cal intervention); and rehabilitative methods (repairing emotional damage through counselling, social rehabilitation and vocational training). Recognizing the Problem: A New Study Reliable data on obstetric fistula are scarce. The full extent of the problem has never been mapped. To address this need for information, UNFPA, the United Nations Population Fund, partnered with EngenderHealth to conduct a ground-breaking study on the incidence of fistula in sub-Saharan Africa and the capacity of hospitals to treat patients. A team of researchers travelled to nine countries over a period of six months to visit public and private sector hospitals that provide fistula surgery and to interview doctors, nurses, midwives and patients. Over 35 facilities in Benin, Chad, Malawi, Mali, Mozambique, Niger, Nigeria, Uganda and Zambia were visited during this rapid assessment process. The team also met with government officials and U.N. representatives. Results from this nine-coun- try study will lay the groundwork for future action to prevent and treat fistula in the region. In the countries in which facility-based assess- ments were conducted, it was learned that many of those who suffer from fistula are under 20 (some as young as 13); they are also often illiterate and poor. Many have been abandoned by their husbands or partners, forced out of their homes, ostracized by family and friends and even disdained by health workers. Rarely do they have the skills to earn a living and some may turn to commercial sex work to procure an income for themselves, further heightening their social and physical vulnerability. Despite these hardships, the women interviewed showed another common trait: tremendous courage and resilience. Understanding the Context Source: UNFPA State of World Population 2002 indicators Total Maternal Infant % of Contraceptive HIV Prevalence Fertility Mortality Mortality Births Prevalence Rate for Rate Ratio (Deaths (Per 1000 with Skilled (%) Women (%) (2000-2005) per 100,000 Live Births) Attendants (Any Method) (age 15-24) Live Births) country Benin 5.68 880 81 60 16 3.72 Chad 6.65 1,500 116 16 8 4.28 Malawi 6.34 580 130 56 31 14.89 Mali 7.0 630 120 24 8 2.08 Mozambique 5.86 980 128 44 6 14.67 Niger 8.0 920 126 16 14 NA Nigeria 5.42 1,100 79 42 15 5.83 Uganda 7.10 1,100 94 38 23 4.63 Zambia 5.66 870 80 47 25 20.98 Sub-Saharan Africa is a region devastated by AIDS, malaria, famine, endemic poverty and years of political instability. This backdrop presents numerous challenges to the quality of health care. Because health care infrastructures are fragile and becoming more so in most of the countries visited, it is increasingly difficult for providers to maintain their level of skill and successfully repair fistulas once they have occurred. Many public hospitals face chronic shortages of funding, staff, equipment and surgical supplies. This lack of essential and emergency obstetric options means that services at facilities capable of performing emergency C-sections are still out of reach for women who want and are able to access treatment. Critical Needs Because of poverty and the stigma associated with their condition, most women living with fistulas remain invisible to policy makers both in their own countries and abroad. The assessment outlines the following critical areas that need to be addressed in order to lower the incidence of fistula in the region: • INFORMATION AND AWARENESS In many rural areas, girls are married just after they experience their first menstrual flow— between 10 and 15 years of age. In some cases, early marriage for girls occurs before the onset of their menstrual cycle, as a way to ensure virginity. Postponing the age of marriage and delaying childbirth can significantly reduce their risk of obstructed labour. Better education for women and their families about the dangers of pregnancy and childbirth and the value of emergency obstetric care is crucial. Information about family planning, sexually transmitted infections and HIV/AIDS should also be provided. Culturally sensitive advo- cacy campaigns on maternal health and obstetric fistula could educate communities about the warn- ing signs of pregnancy complications and the need to get prompt medical attention. Women who have been successfully treated for fistula could also be trained to help with community outreach. Support from local and national policy makers is needed for all educational efforts. • EMPOWERMENT OF WOMEN Women have the right to education and health care. Yet girls are frequently denied schooling, which tends to delay marriage and give them skills to earn an income. Social and cultural barriers also limit a woman’s ability to seek medical care when needed. In many countries, pregnant women require per- mission from their husbands or male relatives to see a doctor. Cultural beliefs around the causes of obstructed labour—such as infidelity or being cursed—further limit a woman’s ability to seek treatment. Legal and social change is needed to improve the status of women and provide girls with access to proper nutrition, health care and education. Men’s involvement is crucial to achieve this change and to give young women other options in life besides childbearing. • TRAINING Reconstructive surgery is a delicate procedure that requires a specially trained surgeon and skilled nurses. Carefully monitored post-operative care is also crucial to a patient’s recovery. In each of the nine countries visited, there is an urgent need for more doctors and support staff to handle the demand for treatment. Many hospitals rely heavily on the assistance of expatriate doctors. Local sur- geons and nurses should be trained in fistula repair and their skills should be updated regularly. Midwives should immediately refer patients to emergency obstetric care when they detect obstructed labour. Referral systems and transpor- tation to hospitals should be established and supported. Since emergency obstetric care is especially scarce in rural areas, incentives should be offered to attract skilled medical personnel to areas with the greatest needs. • EQUIPMENT Basic medical equipment and supplies must be in place in order to perform successful fistula surgery. In most of the hospitals visited, lack of supplies— 6 from suture material to a safe supply of blood—is a major problem. Financial support is urgently required to properly equip hospitals and help women in need. • TRANSPORTATION Many women with fistulas live in rural areas, far from medical help. Safe and reliable transportation to a hospital is often scarce or too expensive for poor women and their families. Many women interviewed had travelled for months on foot, by donkey or any other means available in search of a hospital that could treat them. Better transporta- tion and communication systems between remote villages and hospitals should be a priority. Midwives can play a key role in the referral process, but measures to get women to hospitals quickly must first be established. Three classic delays (a delay in the decision to seek medical attention, a delay in reaching a health care facility and a delay in receiving emergency obstetric care at the facility) must be addressed in order to change the odds so that women get the high quality care they need. • SUBSIDIZED CARE Fistula surgery needs to be accessible and afford- able to poor women. Some patients arrive at hospitals accompanied by family members after travelling long distances and having exhausted the last of their resources. Then they may need to find money for surgery, food at the hospital and lodging for their relatives. Poverty makes even moderate sums difficult to afford. In each country, one or two fistula centres that can provide free or subsi- dized services are needed. They should be located in areas that will serve the largest number of clients and should be easy to access. • SUPPORT SERVICES Fistula survivors who have been shunned and iso- lated typically experience intense feelings of shame, self-loathing and depression. They may blame themselves for their situation. Education and counselling can help restore their self-esteem after surgery. Information on family planning, the need for a C-section for future pregnancies and HIV prevention is also essential. Social rehabilitation programmes can help women reintegrate into their communities and reconnect with their families. Life skills training can give women the means to earn an income once they are healed and prevent them from resorting to commercial sex work to survive. Social support services, offered in conjunc- tion with hospital care, will significantly enhance a woman’s physical and mental well-being. The critical needs outlined above must also encompass the fundamental preventative, curative and rehabilitative interventions that contribute to reducing the incidence of obstetric fistula. Essential training of providers includes the broad range of emergency obstetric care to which fistula repair training can be added, in order to provide the highest quality of care possible. This includes setting up linkages to the community to help women access services on time, diagnosis of actual or potential complications before they occur, and monitoring the progress of labour to initiate early referrals when problems arise. Facilities must also have the necessary range of supplies and equipment to carry out emergency surgical procedures (such as C-sections) for women, so that morbidities such as fistula are limited. Transportation issues can be addressed with work- ing ambulance systems and radio networks that enable facilities to communicate effectively with each other during maternal emergencies. And finally, subsidized care should be available for women who cannot afford set fees, so that treat- ment for maternal care and complications is widely accessible. 7 8 Introduction Obstetric fistula, which includes both vesico- vaginal (VVF) and recto-vaginal fistula (RVF)*, represents a critically important and largely neglected issue in the field of reproductive health. The World Health Organization (WHO) estimates that at least two million girls and women currently live with fistula and that an additional 50,000 to 100,000 are affected each year.1 For the vast majority of these girls and women, services to repair their condition remain unattainable for a number of reasons: their lack of knowledge that such a condition can be repaired; the distance they must travel to reach a facility that provides treatment; the low likeli- hood that, even if they can get to a facility, it will offer fistula repair in its portfolio of services; their inability to pay for the services if they are available; and the backlog with which facilities that do provide repairs are faced. The clinical component of fistula care pres- ents a number of difficulties, yet the context in which facilities are based and the degree to which communities are equipped to reintegrate women once repaired may also prove to be obsta- cles to treatment. The social rehabilitation of women after a successful fistula repair is chal- lenging, as these clients are often extremely poor, abandoned by their husbands or partners and without skills to earn a living on their own. These conditions may render them especially vulnerable once they return to a community. Background on Obstetric Fistula In general, in low resource settings, fistulas are caused by obstructed labour. During this time, the baby’s head remains pressed against vaginal and bladder wall tissue for a prolonged period of time, causing necrosis and, ultimately, a fistula to develop.2 While some women also develop fistulas following a hysterectomy or C-section, the majority of women in the countries where the needs assessment took place appear to have them at a young age, most often in conjunction with their first vaginal delivery.3 In the nine countries visited, the underlying causes are likely to include malnutrition (and possibly repeated infections) leading to small stature which, when combined with pregnancy at a young age, results in pronounced cephalo-pelvic disproportion. In addition, insufficient access to emergency obstetric care, coupled with the desire to deliver babies at home (which often occurs without skilled attendance) results in a situation where women, especially young women, are at high risk. In addition to these well known causes, physicians in the region also report fistu- las resulting from poorly managed C-sections and deliveries within health facilities.4 Exact prevalence rates in the region (and, indeed, the world) are not known, but Dr. Tom Raassen and Dr. Festus Ilako extrapolate a figure of 6,000 to 15,000 new fistulas occurring each year in East Africa. This figure is based on the knowledge that every year, three million women survive deliveries in the region; for each thou- sand of these surviving mothers, there are an estimated two to five cases of fistula.5 If approxi- mately 1,000 repairs are performed each year in the region, at least 80 per cent of women with fistula are not getting services. Applying the same calculation to all the coun- tries visited would mask significant differences between them and might paint an overly general picture of a condition affected by everything from health care infrastructure to cultural atti- * It should be noted that VVF in this report is used to refer to all varieties of fistula that result in urinary incontinence. Up to 85 per cent of the fistulas in this category will be vesico-vaginal, but others may be urethro-vaginal or due to stress incontinence. RVF refers to fistulas that result in stool incontinence, although a few will stem from third-degree tears to the perineum. Fistula Needs Assessment Report 9 tudes to labour. However, given that the circum- stances that lead to fistula are widespread in each nation, it is safe to assume that many women in these countries are living with fistula and that the vast majority of them are not able to seek repair services. Needs Assessment To begin to grasp how best to address the range of possible strategic interventions, it is important to understand what facilities exist, how they operate and whether they are well situated to improve and/or expand their services. This needs assess- ment is intended to provide a snapshot of how some clinical services for fistula clients have been organized. It does not include survey data nor does it necessarily cover every facility in each country offering services. Rather, it is a glimpse of the issue, as seen through the eyes of the clients who seek services, the health service infrastructure that supports services and the professional staff who provide surgical repairs and care for the women as they recover from surgery. Importantly, the data gathered by the individu- als who conducted the research are primarily qualitative and represent one moment in time. These data were gathered via a series of rapid needs assessments during a six month period. While additional data have been shared from some locations since the research took place, this supplemental information is not included in this report, as the information within it is considered timebound. The intention was to create a picture of the situation in various locations in order to flag issues for further investigation. Methodology The needs assessment was conducted by one clinical and one programme staff member from EngenderHealth during a series of site visits between May and October 2002. In each country, two to 12 public sector (usually district level) and private sector (usually mission) hospitals were visited. Administrators and professional staff (physicians, nurses and midwives) were inter- viewed, as well as fistula clients whenever possible. The fistula clients interviewed included those who a) were awaiting repair surgery; b) were immedi- ately post-surgery and were recovering in the post-operative ward; c) were significantly (> 6 months) post-surgery and d) had carried a pregnancy post-surgery and delivered by C-section. In addition, each country visit included meet- ings with representatives from the Ministry of Health (MOH) and local policy makers, as well as UNFPA (United Nations Population Fund) country offices, which all have an interest in supporting fistula work. A simple, nine-question survey instrument (see appendix for sample) was used for each interview. Clinical facilities were toured and the wards, wait- ing areas and operating theatres were observed whenever possible. When it was feasible to review theatre logbooks, team members took advantage of the opportunity. Country-Specific Findings The following is an analysis and summary of find- ings at a country level, followed by fact sheets on each site visit. Background Some of the indicators of reproductive health in Benin are quite positive. More than 70 per cent of women seek antenatal care, 62 per cent of whom have had four or more visits per pregnancy. In the capital city of Cotonou, 98 per cent of births are assisted. Even so, 23 per cent of women overall still deliver at home with unskilled traditional birth attendants (TBAs). The total fertility rate is 5.68 and UNFPA data suggest a 3 per cent prevalence rate of modern method contraceptive use, as compared to 16 per cent for all methods.6 With a C-section rate of 3 per cent, Benin’s maternal mortality ratio is, not surprisingly, very high at 880 deaths for every 100,000 live births.7 Since Benin’s democratic elections in 1996, interest in reproductive health policy has emerged. For instance, some legislators are trying to pass a law that prohibits female genital mutilation (FGM) and promotes training those who perform excisions in other skills. Additional features of their proposal involve the improved management of rape cases and therapeutic inter- ruptions of pregnancy. While none of these issues has a direct bearing on fistula in terms of policy, the burgeoning interest in and commitment to reproductive health is evidence of a positive envi- ronment in which fistula care takes place. UNFPA plans to work with providers of fistula surgery in two ways: 1) prevention aimed at improving conditions around prolonged and com- plex deliveries with rapid diagnosis, better access to hospital care and C-sections and 2) identification of existing cases, actions to reintegrate women into communities and the inclusion of fistula surgery in OB/GYN and urology residencies. The MOH notes that it is ready to support any action that will lead to the reduction of maternal mortality and morbidity. Programming for the management of obstetric fistula is included in the national plan for 2002 to 2005. Benin has made the reduction of HIV/AIDS a priority, although prevalence has risen from less than 1 per cent to 4.1 per cent during the past 10 years. HIV/AIDS and malaria have been the health issues given the most attention in Benin, as they are the source of the most illness and death and require frequent interventions. Fistula has not been acknowledged as an urgent concern. Issues and Challenges The needs assessment team visited four hospitals. National Hospital and University Centre (CNHU); Evangelical Hospital of Bemberéké (where there was one woman who had been repaired and was receiving post-operative care); Brothers of St. Jean of God Hospital; and Zone Hospital of Natitingou (where no fistula surgery is currently performed, although cases have presented at the facility and been referred elsewhere). Two of these are private hospitals and two are public. In addition, the team met with the Atacora and Borgou Departmental Directors of Public Health and with the MOH Direction of Family Health Division. Members of the UNFPA country office also provided background information. Discussions with UNFPA staff, district adminis- trators and health care workers suggest that fistula is not yet acknowledged as a critical issue in Benin. Of the four sites visited, only three offer fistula repair surgery. Fistula is seldom recorded in provider logs and information on prevalence or incidence has never been gathered. Many women prefer to go to Niger, Nigeria or Togo for treatment to maintain their anonymity. Most cases are found in the North, where few hospitals exist. It should be noted that some women develop a fistula at a young age; oth- ers occur in women who are multiparous. Women may also have had a fistula with a first pregnancy and have been living with the condition for years. Still, providers only report 80 cases a year, a number they acknowledge is likely to be an 10 B E N I N undercount. It should be noted that this is not an exhaustive finding and is only used to give a very general idea of the national caseload, but it may also be true that due to initiatives to improve women’s health, the incidence of fistula is lower. On the other hand, in the North, where fistula is most common, FGM is also prevalent, a factor which can predispose women not only to fistula but to maternal mortality. It is, then, possible that women with obstructed labour die before they can reach emergency care. For the most part, however, fistula repair has been deemed by some providers in Benin as “luxury” surgery, since women rarely die from the condition, though they often live as outcasts in their communities. In this way, fistula is perceived as more of a social than a medical crisis. Indeed, many men and women are not aware that fistula is a curable medical problem. Other traditions practiced in Benin may influence women’s decisions to seek treatment. Women afraid to discuss their symptoms in a hospital may consult local healers for help. Some healers, unaware that fistula is a treatable condition, may try to help women overcome their “curse”. Consequently, women develop the belief that there is no hope for a cure and, in the process, may exhaust their limited financial resources. Should women choose to seek repair, only a few local qualified personnel are available to operate and most facilities visited rely on the services of expatriate doctors. Sometimes these foreign nationals serve on a continuous basis, but others may only visit intermittently. Although this system has been sufficient to handle the current demand, it is neither a sustainable nor an optimal arrange- ment. Problems also exist in keeping an adequate provision of supplies. Providers mentioned that it was often difficult to obtain surgical necessities, such as suture material. In the CNHU of Cotonou, the problem affected both fistula repairs as well as general surgery. However, other features of Benin’s situation could create an excellent atmosphere for the care and prevention of fistula. For instance, strong resources for training in surgery and public health exist around the country. The medical school has introduced reproductive health training modules for professors to use during their lectures to medical students in the Certificat d’Etudes Spéciales phase. In addition, two facili- ties with the potential to train providers and administrators in aspects of reproductive health have recently opened. The first is the Regional Institute of Public Health in Ouidah, which offers masters degrees in areas such as epidemiology as well as training in social communication and advocacy, health information systems, vaccinology and infection prevention. Programmes in quality of care and reproductive health were also introduced recently. This centre specializes in research, an invaluable asset for investigating and helping to prevent fistula. The other facility is a university with a medical school, located in the northern city of Parakou, of particular interest in relation to fistula as that region reports the largest number of cases. This school could be an excellent setting for doctors and students to learn about fistula care and surgery. Recommendations and Critical Needs • Gather qualitative data to better understand the circumstances of clients’ lives. The Regional Institute of Public Health in Ouidah has the capacity to conduct research to establish a better understanding of how women in Benin live with fistula. With fields of study here including epidemiology and public health, Benin is in a good position to collect information that could illumi- nate many issues surrounding the condition. • Spread awareness of how fistulas occur and what can be done about them. National health staff and providers understand the need for this kind of education, but community leaders and policy makers at all levels of govern- ment, as well as the kings and queens, must be made more conscious of the problem and how to prevent it. 11 12 • Create programmes that allow women to support themselves financially. Fistulas occur in a climate where FGM and low age at marriage predispose women to the problem. The chance for women to earn their own living and learn skills that allow them to do so may improve their social, educational and economic status in Benin. • Train local specialists in fistula surgery so services can be offered on a continuous basis. Since the majority of fistula service providers are expatriate doctors who either visit intermittently or help a facility with a variety of tasks, it is imperative to train local physicians and medical students. Fistula services need to be sustainable and less reliant on expatriate doctors who may eventually leave. • Develop a referral system for fistula services. In Benin, information spreads quickly by word of mouth throughout villages and larger towns. Simply by talking about her experience, a woman who has received treatment for fistula can moti- vate others with the same condition to seek care. But village clinics need more advanced technology, such as a network of radios, to refer cases that involve prolonged labour or other complications. • Consider building a model for fistula care at Tanguièta. The hospital at Tanguièta, Brothers of St. Jean of God, has had great success. The efforts of its providers suggest it might well serve as a base for regional training. Every year, a provider organizes missions with several collaborators to repair obstet- ric fistula, and the hospital has now expanded its services to include measures that help prevent fis- tula as well as cure it. Part of their strategy has involved trying to improve accessibility to remote regions, including the timely evacuation of clients. They have made a 24-hour ambulance available for responses from any of the 14 village clinics connect- ed to the hospital’s radio network. However, this initiative is completely funded by donations from private organizations that key staff members have solicited on their own time. They have submitted a proposal to launch the project in an attempt to make the entire endeavour more sustainable. Other options might be to designate Tanguièta as an internship site where medical students could get hands-on training in fistula surgery. A video- recording system in the operating theatre would allow them to become better acquainted with surgical techniques. A. CNHU - Centre National Hospitalier et Universitaire (National Hospital and University Centre), Cotonou, visited 1 October 2002 Size: Eight beds in maternity ward, one operating theatre. Medical staff: Three urologists, of whom one is a professor who no longer performs surgery. Gynaecologists here refer fistula cases to urologists. There are three or four nurses on the surgical team to assist during operations. Caseload: In 2001, three cases were seen and oper- ated on. Normal yearly average is six. RVF cases are sent to the gastrointestinal surgery team, but these cases have become less prevalent. Provenance of clients: Most come from Cotonou or other parts of the southern region of the country. Typical client profile: The typical client is between 18 and 30 years old. Most clients developed a fistula during the course of C-section deliveries and were immediately referred to CNHU for surgery— usually 10 to 14 days after developing The fistula. One woman in recovery at CNHU had been living with a fistula for six years. She had seen several doctors who were not able to diagnose the problem, which could indicate a low rate of prevalence. Assessment and screening process: • Consultation. • Strong odor of urine or faeces is often used as the determining factor. • Physical examination to determine the size of the fistula. • Analyses of blood (to check for anaemia), heart, blood pressure, etc. • If fistula is not immediately recognized upon physical examination, complete x-rays are taken (e.g. for vesicle-uterine fistulas). Post-operative care: • Clients are kept in recovery for two weeks. • Clients are advised to consult a gynaecologist if they would like to have more children. • Clients are counselled not to get pregnant for at least two years and to have a C-section if pregnancy occurs. • Women are scheduled to return in one month to ensure symptoms have not recurred. Rehabilitation/reintegration: No information. Community outreach: None known. Perceived support at the policy level: None known. Estimated fully-loaded cost per procedure: 10,000 CFA francs (approximately $14 USD) per day for hos- pitalization; 126,000 CFA ($190 USD) for the surgery; and 50,000 CFA ($75 USD) for pre-operative tests. If a woman is hospitalized for 17 days, which is the average time for fistula clients, the total cost can rise to $365 USD, not including medication. If the first surgery is unsuccessful and the client comes back for a second attempt, all costs are the same except for the surgery, the price of which goes down to 62,000 CFA ($90 USD). If a woman cannot pay, either the surgical team will contribute to the costs or she is referred to Tanguièta in the North or to Togo, where a German missionary physician sometimes comes to do surgery. Resources: None. Barriers: • Lack of necessary equipment (stitching thread is often depleted). • More doctors need to be trained: the surgical team needs strengthening as only two doctors operate. B. Hôpital de Zone de Natitingou (Zone Hospital of Natitingou), visited 2 October 2002 (hospital visited informally) Size: Not known. Medical staff: One midwife performs the majority of deliveries; information on other staff was not available. Caseload: Five cases in the past three years, none of which were surgically treated. Volunteer doctors who work there have, at times, told the clients that 13 Fact Sheets on Benin Site Visits they are suffering a gynaecological problem that may heal on its own. They are told to go home, but to return if their state does not improve. Only one has returned. All cases have been the result of com- plications during C-sections and hysterectomies. Provenance of clients: Rural areas just outside of Natitingou. Typical client profile: Most women are in their 30s. Assessment and screening process: • If a woman says that she no longer has the urge to urinate and that her clothes are always wet, fistula is assumed. • Speculum is inserted so that clearer image of fistula can be observed. Post-operative care: Not available. Rehabilitation/reintegration: Not available. Community outreach: Not available. Perceived support at the policy level: Not available. Estimated fully-loaded cost per procedure: Not available. Resources: Not available. Barriers: Not available. C. Brothers of St. Jean of God Hospital, Hôpital de Zone de Tanguièta (Zone Hospital of Tanguièta), visited 3 October 2002 Size: 250 beds, 40 of which are in the maternity ward. Two operating theatres and special follow-up rooms for post-operative care. Medical staff: One full-time expatriate physician who performs surgery; two general practitioners, both of whom perform C-sections; one gynaecolo- gist, who comes once a year in April for two weeks to operate on fistula clients; four maternity ward nurses; and three midwives. Caseload: The majority of fistula surgeries are performed during three specific blocks of time dur- ing the year, when the foreign delegation arrives. These missions arrive during the dry seasons because during the rainy season, women, even those with fistula, work in the fields. During each mission, up to 15 women are operated on. Cases that emerge outside of one of the three periods are operated on by an expatriate doctor, Brother Florent, whose caseload runs to about seven clients a year. Each operation takes on average from four to six hours, depending on the complexity of the fistula. Provenance of clients: The majority of clients come from Burkina Faso. Others arrive from other parts of Benin, Niger and Togo. Typical client profile: Usually the women are very poor and developed the fistula with a first pregnancy. They range in age from 13 to 20 years old and are rarely older. However, one doctor remembers a woman in her 50s who had been liv- ing with fistula for 25 years before coming for treatment. Most women have been abandoned by their husbands, and many cases are due to compli- cations from C-section or hysterectomy. Assessment and screening process: • Client is examined during an initial screening. • The size and location of her fistula is determined. If the location of the fistula is not immediately obvious, a blue dye is inserted into the bladder to make the path of fluid conspicuous. • Blood is drawn to prepare for the operation. • Client is given parasite medication. • Vitamins and minerals are administered if client is physically exhausted, anaemic or weak. This course of action can last up to two weeks. Once the initial screening process is completed, she is given a specific date upon which to return for surgery. Post-operative care: • Client remains in hospital for several weeks to recover. • She is advised to wait two years before her next pregnancy, but often the timing of subsequent pregnancies is not the client’s decision. • She is also advised that it is necessary to have a C-section in the event of future pregnancies. Rehabilitation/reintegration: No information. Community outreach: Brother Florent goes on the radio as often as possible to announce the arrival of the surgery team. Also, the Swiss doctor who 14 organizes the surgical team missions to Tanguièta has enhanced the exchange of equipment and inter-clinic communication. A 24-hour ambulance is available, and a radio network between the hos- pital and the 14 peripheral clinics is in place. This facilitates rapid evacuation for emergency obstetric care, a critical tool in preventing fistula. Perceived support at the policy level: The Beninese government has selected the region sur- rounding Tanguièta as its first health zone. Estimated fully-loaded cost per procedure: The cost of the procedure is about 400,000 CFA, just shy of $600 USD. However, actual costs incurred by women are far less, due to Brother Florent’s fundraising initiatives, which have resulted in private organizations giving several donations to the hospital. Because of the subsidies, women pay what they can, in a model that is simi- lar to the idea of a sliding scale. Women usually pay from 20,000 to 80,000 CFA (between $30 and $120 USD). Resources: Three new surgeons have recently been added to the fistula surgery team that comes three times a year. The most recent mission included the filming of an operation, to be included in a docu- mentary that will be used for fundraising purposes. Barriers: • Funds. Missionary fundraising efforts are not sustainable. • Support from Beninese government is openly encouraging but not yet tangible. D. Hôpital Evangélique de Bemberéké (Evangelical Hospital of Bemberéké), Bemberéké, visited 4 October 2002 Size: 60 beds, three operating theatres. Medical staff: The operating team includes one expatriate OB/GYN, who volunteers three to four months out of the year; one person with a nursing certificate; and seven hospital workers who have been trained informally by the doctor. Caseload: Surgeries are carried out three to four months of the year, when the fistula surgeon is present. Many doctors who have been trained at the centre in Addis Ababa also come at various times during the year. When there is a fistula spe- cialist present, information is spread very quickly by word of mouth, and women appear in higher numbers. The yearly caseload is about 10 to 15 cases. Most operations are successful. Provenance of clients: Surrounding villages, as well as Niger and Nigeria. Typical client profile: Clients are under 30 years old, live in the countryside and have typically suf- fered a very long labour. Assessment and screening process: • Client is examined. • Catheter is inserted to determine location of fistula. Post-operative care: • Recovery period is normally considered 10 days. • Antibiotics are given. • Women who developed fistula during C-sections are supervised in the hospital for three weeks to see if the wound will heal on its own. Years ago, the physician would insist that the client undergo tubal ligation, because the level of health educa- tion (and women’s decision-making power) was such that women would not be able to return for follow-up care, and full recovery would not take place. Rehabilitation/reintegration: Since many clients later return to the hospital for C-sections, it is inferred that they have either returned to their husbands or that they have found new ones. Community outreach: Word of mouth. Perceived support at the policy level: None necessary. Estimated fully-loaded cost per procedure: 30,000 CFA ($45 USD); most women pay. Resources: Not available. Barriers: Not available. 15 16 Key Contacts The needs assessment team is deeply grateful to the following individuals in Benin for their assistance with this project: UNFPA Country Office Mr. Philippe Delanne, Country Representative Dr. Edwige Adékambi, National Programme Officer Dr. Théodore Soudé, Reproductive Health Advisor and National Project Professional Ministry of Health Dr. Valère Goyito, Director of Public Health, Direction of Family Health Division Department of Atacora Dr. Emile Konassandé, Departmental Director of Public Health Department of Borgou Dr. Abdoulaye Souley, Departmental Director of Public Health Brothers of St. Jean of God Hospital (Zone Hospital of Tanguièta) Dr. Priuli G.B. Brother Florent, fistula surgeon CNHU Dr. César Akpo, Chief of Urology Services Dr. Eusèbe Alihonou, Chief of Gynaecology and Obstetric Services Dr. Prince-Pascal Hounnasso, urological surgeon Evangelical Hospital of Bemberéké Dr. Peter Staer, expatriate gynaecologist Dr. Martin Luther Hosseu, General Physician Ms. Martha Koetsier, expatriate midwife Zone Hospital of Natitingou Dr. Séko Bassongu, General Physician Dr. Clément Glélé, Coordinator Ms. Lucie Tidjani, certified midwife Regional Institute of Public Health Dr. Khaled Bessaoud, Director Dr. Servais Capo-Chichi Background Ensuring reproductive health in Chad presents some daunting challenges to its citizens, politicians and health care providers. By the age of 15, 9 per cent of women have had sexual relations and by 17, 40 per cent have had at least one child or are preg- nant. Only 16 per cent of total births occur with skilled attendance.8 In addition, according to the most recent DHS, less than 1 per cent of deliveries in Chad are C-sections. Research on contraceptive prevalence is a relatively new phe- nomenon in the country: until 1996, the rate of contraceptive use was not known at the national level. Use of modern methods is now 2 per cent, as compared to an overall rate (including all meth- ods) of 8 per cent.9 UNFPA’s 2002 State of World Population report indicates a fertility rate of 6.65 and a maternal mortality ratio of 1,500 for every 100,000 live births. However, Chad only reports 241 cases of fistula a year. Given other reproductive health data, as well as the prevalence of risk factors such as FGM, this estimate is probably low. And as word that treatment is available has spread, women have emerged in great numbers to receive care. For instance, Swiss missionaries performing fistula surgeries in a public hospital in the north- ern town of Adré invited a team of surgeons from the training centre in Addis Ababa to come in March. These missionaries, along with the Chief Hospital Director, organized a campaign to report on the severity of fistula in the region. They went from village to village to talk to women with the condition. What they found were women aban- doned, hiding, ashamed and unaware that there was hope for recovery. Within one week of the missionaries beginning their rounds, 70 women emerged to receive treatment. This event stands in stark contrast to the typical scenario, which involves women living with fistula not seeking treatment in part because they do not realize that fistula can be repaired. Both non-governmental organizations (NGOs) and governmental initiatives are underway to improve reproductive health care in general and fistula treatment in particular. UNFPA has select- ed Chad as a pilot country for the expansion of resources for fistula, donating start-up funds, while sponsoring two projects related to the condi- tion. The first is based in N’djamena’s public hospital with a goal of treating and operating on clients in a region where the fistula situation appears dire. The second involves supporting a fistula knowledge sharing group, which plans to establish a network of people across Africa to dis- cuss the improvement of fistula treatment and the reintegration of women into their communities. One goal of the group is to establish a website which would enable other countries to learn more about possible planning for fistula repair projects and programmes. On another front, the government has recently tried to enhance the protection of its citizens’ reproductive health rights with a new law that makes forced marriage and FGM, among other practices, illegal and punishable by substantial fines of 500,000 CFA, approximate- ly $725 USD. Once established and recognized as a national decree, such a law could have a dramatic influence on the prevalence of fistula in the country. The MOH has also recognized the need at both the policy and community level to make Chadians more aware of and sensitive to issues around fistula. In May 2001, Chadian officials attended the 2010 Vision Forum for Central and West Africa, a conference whose topic was maternal mortality and morbidity. While there, they saw a film called “Guérir oú Mourir” (“To Heal or Die”), produced by the United Nations Children’s Fund (UNICEF), about the prevalence of fistula in Mali. Before then, many had never heard of the condi- tion. In addition, the MOH is concerned with devising incentives for women service providers to 17 C H A D remain in remote locations to increase the avail- ability of services to women ashamed to seek care from male health professionals. Finally, two doc- tors spent this August in Addis Ababa receiving formal training in fistula repair. Issues and Challenges The needs assessment team visited the UNFPA country office and met with staff there, working closely with the country representative and the programme director. The team also visited two serv- ice delivery sites where fistula repairs are offered. Hôpital de la Liberté in N’djamena is a public hos- pital that provides services for women from all over the country. There the team met with the Medical Director and the Chief Gynaecologist, who was trained in fistula repair at the centre in Addis Ababa. At Liberté, the team had the opportunity to speak with several women who were awaiting sur- gery, as well as six who had already had their operations and were in recovery. In Abéché, the team met with a general practitioner, also trained in Addis Ababa, who performed fistula repair at the Public Hospital of Abéché, and with an expatriate gynaecologist who volunteers in the maternity ward and offers assistance during fistula surgeries. Interviews were conducted with the Minister of Health, the District Commissioner of Ouaddaï and the Health Delegate for the region of Ouaddaï. In Abéché, there were no fistula clients present; however, the team was informed that many are expected during the month of December, when the providers from Addis Ababa are scheduled to return. The information gathered from these discus- sions and observations gave rise to a complex view of fistula in Chad, one that is influenced by both cultural and economic factors. Women between the ages of 15 and 20 comprise the majority of fistula cases, and many of these clients reported being married at 13, with some women stating that they had been married as early as nine. The belief is that forcing a woman into marriage at a young age will reduce the likelihood that she will become sexually active before marriage and so dis- honour her family. Furthermore, women who are not yet married have no access to contraception, which means that single women who get pregnant and develop fistula see the condition as some kind of punishment for their “mistake”, a sentiment with which providers may agree. Even married women with fistula are sometimes accused of infi- delity. Long labour may mean that they are asked to confess the names of other sexual partners. Traditional beliefs may contribute to a culture of shame that exists around fistula in Chad, linked to a prevailing notion that fistula cannot be medically treated. Some other traditional practices may put women at significant risk for fistula as well. As noted above, most women choose home births, helped by TBAs, their parents or no one at all. While this is the least costly option for women, many TBAs have not received any clinical training. For example, it is not uncommon for a TBA to use practices such as spreading crushed okra over her hands and arms to improve lubrication before reaching inside a woman’s vagina to try to pull the baby out. If the baby has presented in a breech position, and the TBA has not been able to feel the baby’s head, she might, with the assistance of another unskilled helper, take a woman by her ankles and shake her up and down to shift the baby’s orientation in the womb. If TBAs had the opportunity for some additional training, it might be that practices such as these—which potentially prolong an already complicated labour, heighten the risk of fistula and jeopardize the woman’s health—would be less prevalent. Given these scenarios, it would seem that hospi- tal care would be more appealing to some women; however, this rarely appears to be the case. If a woman is seeking fistula repair, she may well have heard about botched surgeries that wors- ened a woman’s condition. All of the physicians interviewed spoke of the frequency with which unskilled physicians operate on women, inter- ventions that sometimes create an additional fistula or make the existing one bigger and more complex to repair. The team spoke with one woman 18 who had been operated on at several hospitals before her arrival at Liberté. As a result of random cutting and failed surgeries, she would have to wait for the December arrival of the Addis Ababa team in Abéché to be treated. Another facet of treatment that was mentioned several times is that women prefer to talk about intimate health issues with other women; yet, Chad currently suffers from a shortage of female health providers. This preference is so strong that the District Commissioner of Ouaddaï felt that the lack of women providers posed a significant obstacle to the reduction of maternal morbidity. Women health care workers are particu- larly absent in rural areas and often refuse to work in these regions even when the government posts them there. No incentive for women to work in these locales is in place at a national level. Furthermore, the staffing problem is not only limited to women providers. The dearth of physi- cians has meant that at times maintenance staff are trained to carry out certain medical and surgical procedures. The cost of both treatment and transportation hinders women seeking help as well. Hospitals are associated with needing to pay substantial sums of money for fees and medications, and women rarely have the resources. Furthermore, trans- portation is difficult, time-consuming and expensive. Most women do not have access to a car and often arrive at hospitals by donkey or camel. In addition, women may well need to obtain permission from their husbands and parents to seek health care. Recommendations and Critical Needs • Sponsor more fistula repair training for current staff and recruit more providers. To date, only two doctors have received advanced technical training. Yet other providers report being interested in learning more about fistula repair and improving their current skills. If proper train- ing were available, including access to protocols to follow, it would not only reduce the incidence of repeated surgery for some women, but increase the availability of repairs for more women. • Provide more and better information about fistula to potential clients. Those interviewed suggested that communicating with women about the condition and possible repair services on radio and television in French, Arabic and local languages would be a good means to raise awareness about the condition. These mes- sages might also address related concerns, such as some of the complications of early marriage, pro- longed labour in the absence of a trained health professional and the location of facilities. The inclusion of the personal stories of one or two women in these messages was also suggested as a way to reach and influence a large audience. • Gather data from communities to paint a more accurate picture of the impact of fistula. Comprehensive forms created by Hôpital de la Liberté in N’djamena to report on their cases could be used to gather information about fistula near other health care facilities. A clearer picture of fistula and how it affects the health and well-being of women and families would be more likely to persuade the MOH and the national government, as well as other possible partners, either to imple- ment policies or to sponsor specific programmes. • Develop ways for local leaders, parents and district level officials to become involved in increasing awareness about fistula. Providers feel that establishing local commissions, especially those that draw on the skills of regional administrators, would help to bring the issue of fistula to the forefront. Having a variety of local spokespeople would raise awareness and perhaps even improve the responsibility of caring for women and girls with fistula. • Incorporate fistula repair training into the medical school curriculum. While this idea is an important goal, local authori- ties suggest that it is an aim that is not feasible in 19 the short term. Once the skill level and number of providers equipped to repair fistula has increased, this may, however, be an important avenue toward improving local capacity. One important step along the way is undoubtedly the creation of a protocol for doctors in training to follow. • Consider establishing a national fistula centre at Hôpital de la Liberté. This hospital is a potential candidate for such a centre, given the space in the facility, the interest on the part of providers, as well as the equipment, resources and assistance they now receive from other partners. 20 A. Hôpital Préféctoral d’Abéché (District Hospital of Abéché ), Abéché (region of Ouaddaï), visited 26 September 2002 Size: 214 beds, two operating theatres, one delivery room with three stations and two delivery beds per station. Medical staff: Five medical doctors, including Dr. Barrah Mallah, a general practitioner who was trained in Addis Ababa to perform fistula surgery; six nurses; and one midwife, who is the only trained midwife for the entire region of Ouaddaï. Because of hospital staffing shortages, mainte- nance workers are sometimes trained for certain surgical procedures, such as administering injec- tions, delivering babies and performing minor surgeries, among other tasks. In the event of com- plications, a doctor is called in for assistance. Caseload: About 80 deliveries per month. Fistula surgery is done every Wednesday. From the period of January to March, before the fistula team from Addis Ababa arrived, 42 surgeries were performed, 32 of which were successful. Between March and August 2002, 20 surgeries were performed. Provenance of clients: Clients come from the entire region of Ouaddaï, Biltine and Salamata, in the south. They generally reach the facility on don- keys or camels and very rarely by taxi. Typical client profile: Most clients are nomads from the Peuhl ethnic group and generally come from very rural and distant villages. They are usu- ally under 20 years of age (between 12 and 18) and most developed the fistula in their first, or in some cases their second, pregnancy. Assessment and screening process: • There is no pre-operative laboratory screening process (although there is a laboratory). • There is no equipment available to perform intake tests such as for haemoglobin or sexually transmitted infections (STIs). Only a physical exam is conducted to measure vitals: blood pressure, pulse, temperature. • In examining the site of the fistula, the doctor looks at the bladder, vagina and the tracts associated with each. If the bladder is completely destroyed, he usually will not operate, because complete reconstruction of such delicate tissue is very difficult. Recently, when faced with such cases, he advised women to return in December 2002, when the team from Addis Ababa would be on-site. • RVF is extremely rare and such cases have not emerged at Abéché. Post-operative care: • Clients are kept in post-op, in the maternity ward, for about two weeks. • A catheter is inserted after the operation and kept in for the entire period of recovery. On the 13th day after the operation, the catheter is clamped and is then removed the following day. This allows the physician to check for inconti- nence. If the urinary muscles are intact and there is no sign of incontinence, the client is released in another week. • Before the client is released, she is given a booklet that indicates that she has had fistula surgery. This booklet is presented to providers if she is once again admitted for delivery, so that they know to deliver her by C-section. Rehabilitation/reintegration: No physical rehabil- itation is done at the hospital level. Parents are advised (if present) about exercises possible for muscular therapy. No process of social reintegra- tion is known. Community outreach: None known. Perceived support at the policy level: There is a state credit given every year to health workers; however, none was distributed in 2002. Estimated fully-loaded cost per procedure: 10,000 CFA, approximately $14 USD. This is a minimal cost, which only covers the procedure itself. Clients pay for food during recovery and for medications as well. Abéché is hoping that the UNFPA project will soon be extended to include their hospital, so that 21 Fact Sheets on Chad Site Visits international funding will be available for support. Resources: See support at policy level. Barriers: • Lack of necessary equipment. Equipment is often subsidized through the doctors’ salaries. • Lack of qualified personnel. It is very difficult to entice people to work in that area as it is very remote and conditions are rough. • Lack of adequate infrastructure to support hospital activities. • No mattresses for beds in fistula wards. Only hard cardboard-like mats are available. • A space exists for a laboratory, but there is no support for its upkeep so it is not used. • Lack and poor quality of transportation from villages to hospital, including bad roads. B. Hôpital de la Liberté (Liberty Hospital), N’djamena, visited 23 September 2002 Size: 300 beds; 30 beds in maternity ward, where about 45 deliveries per month are conducted, 3 per cent of which are C-sections; two rooms reserved for fistula clients, one for pre-op and one for post- op; one rehabilitation room, for kinesthesiology; one operating theatre. Medical staff: Two gynaecologists, one of whom, Dr. Mahamat Koyolta, performs the majority of the fistula surgeries; two general practitioners; four anaesthetists; one acupuncturist, who helps with physical rehabilitation; two medical students, one of whom is writing his medical thesis on obstetric fistula; 10 midwives; eight nurses; and 11 ward assistants. Caseload: During the past three months, Liberté has seen 32 cases, including clients with mostly VVFs. RVFs are much less common and are usually not seen here. Some operations are performed on women who have had operations in other hospitals by doctors who were not properly trained. These cases are often very difficult and if they are too complex, surgery cannot be performed here. Provenance of clients: Clients come from all regions of the country, but are primarily from cen- tral and northern Chad where, for cultural reasons, women tend to marry much younger than in other regions of the country. Many women are brought to the hospital by their parents or accompanied by a friend. Of all the women who have come to Liberté, only one has been accompanied by her husband. He cared for her while she was a client and later took her home and continued to look after her through- out her recovery period. Typical client profile: They tend to be between 15 and 20 years old, and many of them were married at 13. Most live in rural settings, are housewives and are very poor. They have almost always been in labour for over 48 hours. The majority had undergone FGM. Assessment and screening process: • The size and condition of the fistula is assessed. • The client is given a physical exam to establish the state of her bladder, urethra and cervix, and determine, for example, if the tissue is inflamed or damaged. Most cases are eligible for operation; however, fistulas that are too large or those that have already been operated on once or even several times by unskilled surgeons are sometimes too difficult to be attempted again. Post-operative care: • Clients remain in post-op for one month of recovery. • Some who have nowhere to go are asked to remain on after healing is complete to work in the maternity or fistula wards as ward assistants. • If a woman who has already had one or several operations comes to Liberté, she will wait for three months before Dr. Koyalta makes an attempt at surgery. • Women are advised to abstain from sexual inter- course for three months after the operation. • Women are counselled to make sure to either have a C-section or to deliver in a hospital setting if they have subsequent pregnancies. Rehabilitation/reintegration: Women are given a $60 USD subsidy, which is separate from the project money used to pay for each operation, to help them get back on their feet. But this amount is largely insufficient, as it is used to buy food during their 22 recovery in the hospital (Liberté only pays for one meal per day) and for transportation back home. There are no funds to cover social reintegration to their communities. Community outreach: None known. Perceived support at the policy level: Virtually none. Many high-level government officials are not aware that the problem exists. Estimated fully-loaded cost per procedure: $222 USD, paid by the UNFPA project. This amount covers surgical equipment, the cost of medications and three months of room and board, with one meal per day during recovery. Resources: UNFPA project funds and technical assistance from the training centre in Addis Ababa. Barriers: • Having only one surgeon is very difficult. Considering the caseload, there should be at least two. • Current equipment on hand is not sufficient. However, UNFPA has provided some funds to purchase materials that were outlined in a list generated by the training centre in Addis Ababa. Key Contacts The needs assessment team is deeply grateful to the following individuals in Chad for their assistance with this project: UNFPA Country Office Dr. Daniel Sala-Diankanda, Country Representative Dr. Sephora Kono, Programme Assistant Ministry of Health Mr. Maïna Touka, Minister of Health Abéché Commissioner’s Office Mr. Haroun Saleh, Commissioner Health Delegation for the Region of Ouaddaï Dr. Brahim Issa, Health Delegate, Abéché Mr. Mahamat Taher, Epidemiologist and Health Statistician, Abéché Hôpital de la Liberté, N’Djamena Dr. Abdoulaye Adam, Medical Director Dr. Mahamat Koyolta, Chief Maternity Gynaecologist, fistula surgeon Hôpital Préfectoral d’Abéché, Abéché Dr. Barrah S. Mallah, Chief Medical Doctor, fistula surgeon Dr. Lidia Martinez Gomakick, UN Gynaecologist, expatriate volunteer Dr. Grace Kodindo 23 Background Reproductive health in Malawi is framed by “uniform poverty”, according to a physician in the southern district, and the many challenges to health this poverty poses. In addition, a famine which started several months ago in pockets of the country is becoming more widespread. The latest published prevalence figures for HIV suggest infection rates among adults of about 25 per cent in urban areas and 13 per cent in rural areas.10 Among women 15 to 24 years old, the estimated prevalence rate is 13 per cent. Ten per cent of women attending antenatal care in rural areas are HIV positive, as are 20 per cent of urban women who seek antenatal care. While the rates vary in the North and South, it is estimated that 70 per cent of the country’s hospital beds are occupied by those who are HIV positive. The maternal mortality ratio has probably increased dramatically in the last decade.11 Of note is the fact that the C-section rate (as reported in the southern region) is very low, 2.7 per cent.12 The rate of obstructed labour ranges from 10 per cent13 to 22 per cent14. Since fistulas form as a result of obstructed labour when emergency C-sections are not available, the logical conclusion is that fistula is a common occurrence. In addition, the review of a theatre logbook at one site revealed a consider- able number of destructive vaginal operations for obstructed labour. It was apparent that fistula is widespread in the districts that were visited, although it should be noted that the study was done in only four districts and that the findings are not intended as generalizations about the fistu- la situation in the country. For these and other reasons, despite an unknown prevalence rate in the country, providers concur that fistula is a major problem in Malawi. There is some good news on the reproductive health front, however. The contraceptive preva- lence rate for modern methods has more than tripled since 1992. Currently, 30.5 per cent of married women are using a method—and 26 per cent are using a modern method; in 1992, the latter figure was only 7 per cent.15 In addition, 91 per cent of mothers who had children in the previous five years had at least one antenatal care visit. For 56 per cent of the births, the mothers had four or more antenatal care visits. Unfortunately, fully half of all pregnant women had not had even one antenatal care visit by the start of their sixth month of pregnancy, so the timing of visits remains a challenge. Despite this fact, the percent- age of attended births delivered within a facility is 56 per cent, significantly higher than in neigh- bouring countries.16 The Government of Malawi, recognizing that maternal health needed to be made a priority, instituted a Safe Motherhood Initiatives programme in 1995, with the ultimate goal of “reduc[ing] maternal and infant mortality by improving access to quality essential obstetric and neonatal care”.17 To improve access, one key objective has been to obtain more vehicle and bicycle ambulances and to put these in the hands of headmen, whom experience has suggested are recognized by the community as those best suited to manage dispatch. There remains conflicting evidence, however, on the cultural acceptability of bicycle ambulances.18 In addition to increasing access, the programme has also aimed to improve the attitudes of health care providers as well as to sharpen their tech- nical skills. To understand the current situation, research will be conducted on attitudes and moti- vations, as well as what can be done to improve the supervisory system. A key component of the current initiative is to work closely at the commu- nity level to establish village committees on safe motherhood, organize transportation plans and enhance the knowledge of TBAs so that they can recognize signs of obstructed labour and act effi- ciently to get a woman to a facility. The (relatively high) percentage of women who deliver in a facili- 24 M A L AW I ty, as mentioned above, may be due to the interven- tions of the safe motherhood programme to date. Issues and Challenges The needs assessment team met with UNFPA country office staff, the MOH Reproductive Health Unit and staff of the United States Agency for International Development (USAID) in Lilongwe. In Blantyre, the team met with a representative of the Safe Motherhood Programme in the southern district, funded by the UK Department for International Development (DfID), as well as with staff of Queen Elizabeth Central Hospital and Mwaiwathu Hospital, a private hospital that provides services only for clients who can pay. Finally, the team met with staff at Mulanje Mission Hospital in Mulanje, Zomba Central Hospital in Zomba, Machinga District Hospital in Machinga and Nkhoma Mission Hospital in Nkhoma. At a debriefing meeting, the team also had the opportu- nity to engage in discussion with representatives from WHO and the Canadian International Development Agency (CIDA). Of note is the fact that a gap exists between some policy makers and the service delivery community in terms of perspectives on fistula and knowledge about the condition. Among those who had not had the opportunity to spend a lot of time in treatment settings, there was little knowledge about fistula as a key reproductive mor- bidity within the country. At service delivery sites, the consensus among all levels of providers was that fistula is a big and growing problem. In fact, when asked whether any official communication (or advertising) about the availability of fistula repair services had been done in the community, one provider said, “Oh no, we would be too scared to do so…we would be overwhelmed.” The situation of women and their ability to seek maternal health care services is strongly influ- enced by local cultural beliefs, pregnancy at a young age, profound gender inequities and limited transportation options. In addition, at the facility level, there have been such dramatic staffing shortages that many health centres have had to close. Within the existing facilities, there are a number of challenges to quality of care, most notably poor staff treatment of clients and short- ages of materials and supplies. Finally, as other reproductive morbidities, such as cervical cancer, are becoming more widely recognized, there is competition within facilities for operating theatre space as, understandably, clients with potentially life-threatening conditions take priority over fistula clients. At the community level, depending on the region or area of the country, a number of local beliefs about pregnancy and delivery serve as obstacles to women seeking care, even when in obstructed labour. For example, in deference to local traditions, a woman will try not to tell anyone her due date. During antenatal care visits at health facilities, when asked the first date of her last menstrual period, she will reply that she must consult with her husband, as he will know. Indeed, he does know, as it is his responsibility to report a missed period to the elders, since menstru- ating woman are considered “impure” and, for this reason, are not allowed to perform certain tasks within the community. As is often cited in neighbouring countries, women in the areas visited, are expected to give birth at home, especially for the first time. If a woman has a prolonged labour, she is assumed to have had other sexual partners, and must shout them out in order for the baby to be “released” through the birth canal. In some communities, the husband or partner is also expected to name other partners. One reason cited for a woman not deliver- ing at facilities, therefore, is that it would appear that she is anticipating a difficult delivery because she has had other partners—thus labelling herself guilty of such actions even before enduring a pro- longed labour. Decisions about when and where to seek care are usually made by the uncle (or occasionally, by the husband); without their input, a woman would be unlikely to seek care on her own. Because it is considered embarrassing to be in labour, if a woman needs to be transported to a health facility, she will wait until it grows 25 dark so that others will not see her. Given that women most often experience first pregnancies as adolescents, the risk of obstruct- ed labour is even greater because of insufficient pelvic size. Moreover, since they may have par- ticipated in rites of initiation, they are prime candidates for early and repeated STIs. While some initiation rites are educational and designed to teach girls about hygiene, cooking, housekeeping and sewing, others put them at significant risk. Notably, in some parts of the southern district, practicing “afisi” (which means hyena) involves sexual activity with a girl as young as eight. The girl’s parents choose, negotiate with and pay a man from their community to initiate sexual activity with their daughter at night as a way to “teach” her how to have sexual relationships. The girl is not told about this arrangement beforehand and, because it is dark, is not supposed to be able to identify the man. Given all of the inequities in gender relations, it is not surprising that there is also evidence of imbalance of power in issues related to transportation. In some locations, bicycle ambu- lances were considered a possible way to overcome the dearth of transportation options, but in many locations, women would not be allowed to ride a bicycle. In addition, because women could be seen on a bicycle, even if the bicycle were driven by a man, it is not considered an ideal choice for a woman in labour. Furthermore, the oxcarts which were designed to help some communities secure additional transportation had to be re-positioned to tilt, as anyone lying on a flat surface is often con- sidered dead. Despite these obstacles, many health centres now have telephones and some have radios to communicate with the referral hospital, which can dispatch a vehicle ambulance (if one is avail- able, working, etc.) In addition, the village health committees have helped to organize bicycle ambu- lances and oxcarts. Unfortunately, given the size of the districts, the many health centres (often 14 to 16) contained in each district and the tendency of the vehicle ambulances to break down, it can still easily take 24 hours for one to appear if called. As noted above, the bicycle ambulances and the oxcarts have faced some challenges, but are functioning effective- ly in some communities. Moreover, because of severe staffing shortages, a number of health centres have had to close and a brand new, fully equipped health centre has not been able to open. The nursing school has had little success getting their students licensed (75 out of 100 students failed this year), and 1,800 trained nurses in the country are not working as nurses because the pay is so low and the working conditions so poor. In addition, the nurs- ing council reports that 65 nurses have left Malawi over the past year for more lucrative employment elsewhere. There are 10 gynaecologists in the coun- try, including eight expatriates, and they are all located in the central and southern districts. Due to the staffing crisis, many stories were shared with the assessment team about less than ideal solutions to this difficult situation. Not surprisingly, the quality of care is compro- mised within the health facilities that continue to function. Nurses are in charge of as many as 140 patients per ward, and are often reported as treating the clients very poorly, a clear deterrent to seeking care at a facility. The team repeatedly heard stories of women being told immediately after giving birth to “clean up their mess” with their own chitenge cloths, a sari-like cloth wrapped around the lower body of a woman for reasons of modesty and custom. Supplies of medical equip- ment and other materials are not great, although in the case of fistula surgery, most staff report that they have what they need to conduct such operations. An exception occurs when supplies of materials also used for other operations, such as sutures and catheters, are depleted. Despite this challenging scenario, the sites conducting obstetric fistula repair (visited by the team) serve one to 12 clients per month. For example, the facility in Nkhoma was performing an average of 12 to 14 cases per year between 1997 and 1999, but since the arrival of a gynaecologist with interest in fistula, the numbers have risen 26 steadily to 35 in 2000, 40 in 2001 and 30 in the first six months of 2002. In Zomba, the physician has operated on 48 cases in the four months since hold- ing a training workshop. Although few providers in Malawi have had the opportunity to be trained at an official training centre, such as the hospital in Addis Ababa, through great initiative on their part they have formed a collegial network of interested parties. The physician in Zomba (as noted above) helped to organize a fistula training workshop in April, which brought in outside expertise in the form of two well-known fistula surgeons from Europe. During the workshop, eight fistula clients were operated on and the physicians and clinical officers had an opportunity to upgrade their skills. It should be noted that in Malawi, unlike some other countries in the region, any cadre of clinical or medical officers can be trained to do fistula repair. There is no policy limiting this training to specialists. “For us, competence is the only thing that matters,” commented a chief administrator at a hospital in Blantyre. While six sites were visited in central and southern Malawi where repairs are conducted, an additional four sites are known to have been conducting fistula surgery in the past, and there may be others with the capacity as well. In each of the mission and government hospitals, the providers stressed the fact that the number of fistula clients is increasing. Whenever a provider with the capacity to conduct repairs is present, “the women just know and they show up,” explained a provider in the southern district. When the providers leave, even for a holiday, the women stop coming. Providers have taken the initiative to travel to other districts to operate both to help a local provider who needs support in con- ducting fistula repair surgery and because fistula clients are often too poor to be able to fund their transportation to a service delivery site. In one hospital in the north, a provider was trained to do repairs at the hospital in Addis Ababa, but he is the only one at the facility and is not sufficiently comfortable with his skill level to perform fistula surgery alone. As in other locations, this situation points to the need to train more than one person per site. None of the sites visited require obstetric fistula clients to pay. In each of the government hospitals, clients were not expected to pay for services, as is customary in government sites. Although mission hospitals usually do require some form of payment, in one of the mission hospitals visited, the doctor pays for all of the surgeries out of her own pocket and, in the other, the doctor has been able to raise funds from an American organization to cover the costs of the repairs he does. Recommendations and Critical Needs • Support Zomba Central Hospital as a site for a national or regional fistula repair training centre. Zomba Central Hospital is well positioned to become a training centre for a number of reasons. They have already conducted an international level training workshop and have plans to conduct another one. They are doing on-the-job training in fistula repair among clinical officers and nursing sisters. The gynaecologist is currently going out to other districts to perform fistula surgery in support of a network of colleagues and hospitals, linkages that are now well established. In addition, the hospital is in the midst of constructing a theatre for gynaecological surgery, which could be used for fistula surgery training sessions. Unlike the other nearest central hospital, Zomba is not overwhelmed by a huge number of emergency surgeries, so there would not be a need to stop and start fistula operations when emergency cases appear. Finally, and perhaps most importantly, the chief administrator, a physician who does fistula surgery and other staff have planned this initiative on their own, so they already have ownership of the issue and are now working to make it a reality. • Conduct data gathering to assess the situation of girls and women with fistula at the commu- nity level and adapt the current health management information system to capture 27 28 fistula information at the national level. While much is known about women with fistula if and when they make it to a facility, little is known about their situation at the community level. Insight into the lives of girls and women from this perspective will be pivotal in initiating work to pre- vent fistula and to facilitate reintegration back into the community once they have been repaired. In addition, adapting the current health information management system to collect data on fistula will facilitate the ability of national level policy makers to create programmes and responses within the context of a reasonably accurate prevalence rate. • Standardize protocols and guidelines for fistula surgery, as well as pre-operative and post-operative care. As the needs assessment team conducted interviews with all levels of providers, it became apparent that a standardized set of guidelines or protocols would help to facilitate the use of best practices. Even sharing simple tips about how to help a fistu- la client train her bladder after surgery would help those caring for clients to do a better job. • Ensure that fistula training always includes more than one person per site. When conducting training on fistula repair, it is critical that at least two individuals per site are trained, preferably a doctor-nurse team. If only one person at a facility has been trained, s/he appears to be significantly less likely to feel comfortable conducting fistula repair surgeries, so is not likely to be able to maintain his/her skill level. If a deci- sion has to be made between training two people from one site or one person from two sites, the former option is more likely to create sustained change than the latter, an especially important lesson if a national or regional training centre is created. • Support the collegial network of providers already working on fistula. The physicians, medical and clinical officers, and nursing staff who are working on fistula have done much to find and support each other on this issue in Malawi. Finding ways to continue to support their initiative and enthusiasm is critical. Perhaps a card with a list of all the referral facilities and providers could be created and distributed throughout the country and kept updated. Some fundraising could also be done to secure equipment and supplies for providers and even furnish them with some money they could draw on for fistula clients. Any measures that would support these providers would go a long way toward engendering goodwill and ensuring that high quality fistula services remain available in Malawi. • Focus on prevention by increasing awareness of different aspects of reproductive health. Data indicate that approximately 91 per cent of pregnant women in Malawi have had some type of antenatal care. These visits would be an opportune time for providers to offer information on the potential complications of childbirth and the importance of emergency obstetric care. Giving culturally appropriate information to community members about the potential harm of some com- mon traditional practices and early marriage might also dispel misperceptions about obstructed labour. A . Queen Elizabeth Central Hospital, Blantyre, visited 7 August 2002 Size: Unclear. Most of the hospital is non-paying, but there is a paying ward, which operates at about 40 per cent of capacity most of the time. Medical staff: Three gynaecologists, but the only one doing fistula repairs is Dr. Rijken, who has performed more than 1,000 fistula repairs in his 20 years practicing in the tropics. Queen’s Hospital serves as a referral hospital for fistula due to Dr. Rijken’s skill level. Specialists are employees of the university rather than the hospital, and they have limited time for actual clinical practice because of their teaching duties. There is a critical nursing staff shortage; most nurses are charged with caring for more than 100 patients and work from 7:30 am to 5 pm. Queen’s is noted as the hospi- tal with the worst staffing shortage in the country. Caseload: At least 52 fistula clients per year are operated on; more are waiting for services, espe- cially when other gynaecological surgeries need to take precedence or Dr. Rijken is away. Provenance of clients: The clients come from all over; many are from Mozambique. Typical client profile: All ages of women, but the majority of clients are young—about age 18 is typi- cal, although most do not know exactly how old they are. Usually they experience a fistula with their first delivery. Assessment and screening process: Not available. Post-operative care: Not available. Rehabilitation/reintegration: Not available. Community outreach: None, except for a DfID- funded safe motherhood project working in the southern district. Support at the policy level: Fistula is not a priori- ty at the policy level. Estimated fully-loaded cost per procedure: Not clear. Clients do not have to pay. Resources: The Government of Malawi. Barriers: • Far more clients request services than can be operated on. • Only one specialist with skills is available and he has only one to two days of theatre time each week. • Transportation is difficult for women to manage. • Delays in getting to the facility are often pro- nounced. • Staffing shortage is critical. • Due to all of the above, women sometimes have their surgery postponed two or three times before it can take place. B. Mulanje Mission Hospital, Mulanje, visited 7 August 2002 Size: 160 beds. Medical staff: One American gynaecologist, two tropical doctors from the Netherlands, and clinical officers. The American gynaecologist, Dr. Sue Makin, was trained during six weeks at the Addis Ababa hospital in 1995 and performs “simple” VVF repairs. The more complicated fistula cases are referred to Dr. Rijken at Queen’s Hospital in Blantyre. “Need to have the imagination of a plas- tic surgeon for the difficult cases—I don’t have it!” Dr. Makin reports. She also does simple repairs for two other hospitals from time to time. Caseload: About 12 fistula clients per year. Provenance of clients: Most are from the area bordering Mozambique. Typical client profile: Most are young (around 18); most are pregnant for the first time and very poor. Occasionally, a woman has already had one to six children at home before running into a problem with obstructed labour and developing a fistula. Dr. Makin covers the cost of the procedure, which is about $15 USD. Assessment and screening process: Dr. Makin 29 Fact Sheets on Malawi Site Visits examines the women (without anaesthesia) to determine if she can do the repair. If she thinks she can and it has been three months since the fistula formed, she usually can operate on them within a couple of weeks. Otherwise, she sends clients home until it has been three months and refers the difficult cases to Queen’s, where there is a waiting list of about three to four months. No screening tests are done. Post-operative care: • Nurses are trained to care for fistula clients. • Clients tend to stay in ward for about two weeks following surgery. • Clients are counselled on HIV and family plan- ning methods and can get free methods at the hospital—Norplant, depo and tubal ligations are the most common. Rehabilitation/reintegration: No programmes were mentioned, and Dr. Makin covers the cost of the procedure and the food for the client and an attendant she may have. Dr. Makin’s perception is that about half of the time, the partner/husband stays with the woman; the other half of the time women are abandoned and end up returning to their parents’ house. Community outreach: None known. Support at the policy level: Although fistula is not perceived to be a priority, especially since the recent discovery of a great deal of cervical cancer, a group of doctors in the southern region communi- cate regularly about fistula and convened a workshop on the topic in March, during which they operated on eight cases the same week. Estimated fully-loaded cost per procedure: Hospital charges about $15 USD per procedure but it is not known what the actual cost to the facility is. Clients do not have to pay. Resources: • The Government of Malawi. • Presbyterian Church of the United States. • Presbyterian Church of Ireland. • Presbyterian Church of Scotland. • Dutch NGOs. • Project HOPE (Health Opportunity for Everyone) supports voluntary counselling and testing (VCT). Barriers: • No anaesthesiologist, so surgeries have to wait until one can come, usually about once every two weeks. • Inadequate supply of HIV/AIDS tests. The govern- ment is supposed to provide them, but they seem to “go missing”.Frequently, when the supply is low, the hospital saves the tests to use on poten- tial blood donors. • Fistula prevention messages in the community need to be created. • Famine is becoming more widespread. C. Maiwathu Hospital, Blantyre, visited 7 August 2002 Size: 60 beds. Medical staff: Five gynaecologists, one anaesthesi- ologist, and an ample number of nurses Caseload: Four fistula clients over the past three years, but fistulas were not obstetric in origin. Instead, the fistulas resulted from other procedures (hysterectomies, for example) or other conditions. Provenance of clients: Clients at this facility are from Blantyre and have the means to pay what are considered hefty sums locally for services. The cost of a C-section, for example, is 36,000 kwacha ($450 USD). Most women with fistula are from the border area with Mozambique; some are from inside Mozambique. One staff member noted, “There are many, many women living with fistulas in rural areas” but they are not seen in this hospi- tal. One doctor stated that the HIV prevalence rate at this private hospital and other hospitals is 20 per cent to 30 per cent of women of reproductive age. Typical client profile: Fistula clients at this pri- vate hospital are not the typical ones, as these clients have a fair amount of disposable income. They are older and their fistulas are from other causes, not obstructed labour. Assessment and screening process: Not available. Post-operative care: Not available. Rehabilitation/reintegration: Not available. 30 Community outreach: Not available. Support at the policy level: Not available. Estimated full-loaded cost per procedure: Not known. Resources: A private bank and an American organization helped to fund the hospital; all patients pay for services. Barriers: Not available. D. Zomba Central Hospital, Zomba, visited 8 August 2002 Size: 400 beds; currently, some patients are having to share beds. One major operating theatre, one small theatre and one more currently planned. Medical staff: Two OB/GYNs (expatriates from Austria who have been there two years and are leaving in October); and clinical officers. Caseload: The hospital has done 48 repairs in the last four months, of which two were RVFs; during the week that Dr. John Kelly was there for the workshop, they conducted eight repairs. Provenance of clients: Most were referred from other district hospitals; some come from Zomba catchment area as well, which serves 1.5 million people; Zomba has become a fistula referral centre. Typical client profile: The majority are young, and the fistula occurred with their first pregnancy. Some clients have been living with fistula for as long as 15 years. However, all are poor and many have been ostracized or are ashamed of their condi- tion so they won’t tell a nursing sister immediately why they are there: they might first mention “stomach pains”. Assessment and screening process: • Examination with anaesthesia to determine the position and size of the fistula. • Screening and treatment for any current illness- es/conditions. • No routine HIV screening. Post-operative care: • Dye is injected into the bladder to make sure that procedure was successful. • Clients are counselled on abstaining for three months; the husband is likely to hear in the com- munity that his wife is now healthy, so he tends to come back to her once she has been repaired. • Clients are counselled on family planning (injectables are most popular method), HIV/AIDS and the need to return to the hospital to give birth for any future pregnancies. • Clients tend to stay on the ward (with other female clients) for two weeks with catheter. • Bladder is trained for another several days. Rehabilitation/reintegration: None known. Community outreach: Some bicycle ambulances are bringing women in, so this link with the community has been at least partially successful. Nurses are trying to work with TBAs to help them to recognize signs of obstetric emergencies, yet they have found that they need to go back repeatedly to follow up to support the TBAs. Support at the policy level: The Department of Clinical Services at the MOH has been supportive. Estimated fully-loaded cost per procedure: Not known, but women do not have to pay. Resources: Funds from the Government of Malawi, as well as a few donations and equipment from expatriate visitors. Barriers: • Currently, space is a constraint, but a new build- ing is being constructed. The original building dates from 1938. • When the two Austrian OB/BGNs leave, the hospital will need to find another gynaecologist. • Although equipment and materials are sufficient for now, if Zomba becomes a fistula training cen- tre, the hospital will need to secure more supplies, as well as a steady source of staff and financial support. 31 E. Machinga District Hospital, Machinga, visited 8 August 2002 Size: 239 hospital beds. Medical staff: Two general doctors, one gynaecolo- gist (Egyptian), one surgeon, two anaesthetist clinical officers, one orthopedic clinical officer, four general clinical officers and 46 nurses. Caseload: Currently the facility handles about three cases a month. They refer many cases to Queen’s as well, since the doctor currently feels comfortable operating on simple cases only. Provenance of clients: Clients come from through- out the region. The hospital is newer than most and has a reputation for being very good and for having staff who treat clients well. The hospital is also in the president’s district. Typical client profile: Young (younger than 20 years old), first pregnancy, poor. Staff note that they are seeing pregnancies in girls as young as 12 in the region. There is a strong belief in rural areas about giving birth at home. Assessment and screening process: • Examination under anaesthesia. • Screened for schistosomiasis. • Haemoglobin. • Stool/urine checked. • No HIV tests. Post-operative care: • Clients are given counselling on abstaining, family planning and the need for subsequent deliveries to occur in a facility. • Women tend to stay in ward for about 14 days. Rehabilitation/reintegration: No information was available, but staff members feel that there is not much ostracizing of women with fistula in the community. Community outreach: Nurses are working in com- munities, but not on fistula specifically. They do talk with village health committees about how to identify obstetric emergencies and have given advice on how to create a makeshift “ambulance” using poles and cloth. The famine has had an impact in the area. Support at the policy level: Staff members feel that because the facility is located within the presi- dent’s district the perception is that they are well supported. Estimated fully-loaded cost per procedure: Not known. Resources: The Government of Malawi. Barriers: • The biggest obstacle is early childbearing. • The skill level of the OB/GYN is limited. He would like to get more practice in fistula repair. F. Nkhoma Mission Hospital, Nkhoma, visited 9 August 2002 Size: 220 beds; two operating theatres, only one of which can be used for fistula repairs. Medical staff: Three doctors, one of whom, Dr. Ter Haar, has experience and interest in gynae- cology, but is not a gynaecologist; three clinical officers. There is no anaesthesiologist, so the clini- cal officers supervise spinal anaesthesia. A severe shortage of nursing staff is currently a problem. Two VVF workshops were held this year: one with Dr. Kelly and one with Dr. Lydia Engelhart and Dr. Walter Hull from the United States. Caseload: Fourteen fistula clients in 1997; 10 in 1998; 14 in 1999; 35 in 2000; 45 in 2001; and in the first six months of 2002, the staff has performed 30 repairs. The problem is growing, and they are receiving more referrals. The hospital tends to do 1,500 to 2,000 deliveries each year. No advertising is done—the referrals spread by word of mouth for the most part, except for official ones that come from Lilongwe Central if they are backed up there. At Nkhoma, they reserve the really difficult cases for the visiting teams, which so far have been coming once a year. Provenance of clients: From the area, as well as from Mozambique. As mentioned above, many refer- rals are now coming from Lilongwe Central Hospital. Typical client profile: Young (about 15) and married at an early age. The belief that women must have their first baby at home gets in the way of coming to the facility to deliver. Often the women arrive too late. 32 Assessment and screening process: • A clinical exam is done to determine the position and size of the fistula and its degree of complication. • Exams under anaesthesia are performed for cases that would be difficult to examine otherwise. • Since the laboratory is not equipped for cultures, clients are not routinely screened for other infec- tions or complications. Occasionally a urine exam under microscopy is performed. Post-operative care: • Clients usually stay for 14 days, until the catheter comes out. • Bladder training is not routinely done. • Clients are counselled on coming back to hospital to deliver in the future. No specific counselling on family planning or HIV is done, but no restrictions against doing so are in place. Rehabilitation/reintegration: No information known. Community outreach: Antenatal care is “talked up” at the community level; 80 kwacha ($1 USD) is the cost for visits during the entire antenatal care period, but no one is turned away who cannot pay. In this area, there is not a strong culture of ante- natal care visits, so nurses go into communities. HIV/AIDS is very stigmatized. Support at the policy level: None known. One provider noted that it would be helpful if the Ministry of Education crafted a clear message on the problems of early marriage and childbearing. Estimated fully-loaded cost per procedure: Not known. Resources: • Dr. Ter Haar has organized a fistula fund (supported by an American organization) so fistula clients do not pay. • A variety of church organizations. • Two doctors are supported through the Dutch Reformed Church. • The Government of Malawi pays all salaries, except for doctors; visiting teams of doctors pay all of their own costs. Barriers: • Large number of clients. • May be hard for Dr. Ter Haar to keep up if numbers keep rising. • At a community level, there is much work to be done on HIV/AIDS. Key Contacts The needs assessment team is deeply grateful to the following individuals in Malawi for their assistance with this project: UNFPA Country Office Dr. Charlotte Gardiner, Country Representative, and staff EngenderHealth Ms. Deliwe Malema, Country Programme Manager Ministry of Health Ms. Jane Namasasu Machinga District Hospital Mr. Chisutu, Clinical Officer, and nursing staff Ms. Beata Zuzu Maiwathu Hospital Dr. Francis Sungani and nursing staff Mulanje Mission Hospital Dr. Sue Makin and nursing staff Nkhoma Mission Hospital Medical and nursing staff Dr. Ter Haar (communication via e-mail) Dr. Krueger Mr. Vincent Usiwa, Clinical Officer Queen Elizabeth Central Hospital Dr. Ibrahim Idana and staff Dr. Rijken (communication via e-mail) Safe Motherhood Project (DfID) Ms. Hannah Ashwood-Smith, Health Planner Zomba Central Hospital Dr. Austin Mnthambala and medical and nursing staff 33 Background Reproductive health in Mali is characterized by a total fertility rate of 7 and a modern contra- ceptive prevalence rate of 6 per cent,19 although 23 per cent of women surveyed between 1996 and 2001 reported that they had used a method of contraception at some point in their life.20 Another challenge to reproductive health in Mali is HIV. In addition, the maternal mortality ratio remains high despite a decrease in infant mortality over the past two decades. Increased antenatal care attendance during the last five years resulted in almost half of all preg- nant women receiving some kind of antenatal care. Sixty-three percent of women deliver at home, in part because health facilities are hard to reach. For 85 per cent of women living in rural areas, the nearest hospital is located at least 30 km away. When women are educated—and only 38 per cent of women in Mali have had the opportunity to receive formal education—they tend to live in urban areas and to deliver in health care facilities, the majority of which are found there. In contrast, 66 per cent of the women who deliver at home have no education at all. The circumstances surrounding labour and delivery dif- fer radically depending on location: 91 per cent of women in Bamako, the capital city, give birth in a facility; many of these women report having had the chance to make the decision themselves. Outside of Bamako, critical decisions about a birth are often made by a prominent family member. These conditions imply that many women are at risk for fistula in Mali and it is, indeed, recognized as a problem in the country, with both local and international groups working to find solutions. Part of the issue is connected to discovering how many women have fistulas. A recent survey spon- sored by Doctors of the World and conducted near Mopti suggests that out of 2,000 villages in the region, half have at least one woman living with fistula. No other surveys have been conducted to determine the number of cases existing nationwide, but based on information gathered by Doctors of the World, it is clear that the number of cases surfacing for treatment does not mirror the actual prevalence of the condition. Furthermore, because families often want to hide members with fistula, this finding is likely to represent an under- count. In addition, it appears that those with the condition are, in general, young. At one facility providing fistula repair, the average age of a fistula client is 15; at the other, it is 25. As elsewhere in the region, women who develop fistula tend to be poor, uneducated and often have neither support from their families nor ready access to a facility that might offer high quality labour and delivery care. Doctors of the World first organized missions to Mali to repair obstetric fistula in 1986. In November 1993, the first fistula programme was launched in Mopti with the help of Dr. Ouattara at the University Hospital of Point G in Bamako. The primary objective was to increase the number of service delivery sites outside the capital city, making fistula repair more readily available to women who could not reach Bamako. Until 2000, the programme was entirely funded by Doctors of the World, but supporters now include several other partners. Sixty-five percent of the current project, which will be completed in December 2003, is underwritten by private organizations. This project covers 90 per cent of the cost of each fistula repair, with clients contributing about $25 USD. Another facet of fistula care has been taken up by Delta Survie, a local NGO that collaborates with Doctors of the World. This group has initiated a project at the Regional Hospital of Mopti, Sominé Dolo, to improve the living conditions of women with fistula who have either received or are await- ing treatment at the facility. Efforts include building a shed on the hospital grounds where women can learn handicrafts that might allow them to earn an income. 34 M A L I Issues and Challenges The needs assessment team had the opportunity to participate in a two-day meeting that assembled several Malian health providers from around the country, all of whom are involved in fistula treat- ment and its accompanying social problems. The meeting, known as Journée des Femmes Fistuleuses de Mopti or the Day of Fistula in Mopti, was con- vened by Doctors of the World. At the meeting, the team was able to speak with members of Doctors of the World, the Ministry of Social Action and Delta Survie. In Bamako, the team also met with staff from the University Hospital of Point G in Bamako and the Director of the Reproductive Health Division of the MOH. Visits to two sites in Mali and discussions with providers indicated that there is a stark need for more local surgeons able to provide repair services. The only local doctors known to perform fistula surgery are concentrated in Bamako, at Point G. At that facility there are four urologists who all perform fistula surgery, but given that only one operating room is available for the entire hos- pital, it is very difficult to meet the demand: urology emergencies and other urgent operations take precedence over fistula repair. There is heavy reliance on visiting expatriate physicians. In addi- tion, the hospital of Mopti depends entirely on external support to carry out fistula repair. Their current programme, which ends in December 2003, will be capable of extending their efforts through to the next phase only if further resources are secured. Another issue Malians face is the fact that the majority of clinically trained midwives practice in Bamako. While this fact encourages many women there to deliver in a facility, as noted above, it also means that access to emergency obstetric care in rural areas is very difficult to locate. Women in these regions are already more likely to give birth at home, but the lack of health care resources near their communities contributes to their not seeking care, even if they experience a difficult labour. Further complicating the situation for women in these areas is that fact that mothers-in-law and other important family members are in charge of decisions about where a woman may give birth and what to do if the labour does not proceed as hoped. These relatives may not be aware of the morbidities possible from obstructed labour or know where to go to obtain care. In addition, community health centres, which are often understaffed and underequipped, tend to be the facilities that women seek, causing further critical delays during emergencies. If a woman does develop fistula, she may suffer from stigmatization and be vulnerable to social exclusion. Relatives often try to hide the presence of a family member with fistula, and often do not have the benefit of knowing what has caused the fistula in the first place. The affected women are often ashamed of their condition and isolate themselves, trying to hide from the community at large. No reproductive health programme that includes fistula repair is now in place at the national level. However, a new five-year plan includes mention of general reproductive health concerns and those of young adults in particular. Recommendations • Advocate at the national level for increased attention to fistula as a key reproductive health concern. Although some scattered support for the issue exists at the policy level, a strategic advocacy programme must be mounted to build commitment to the issue within Mali. Increased attention to reproductive health issues is the first step. Only with this commitment will policy makers be able to build a better platform from which to provide support for fistula repair. • Develop community-level awareness-raising campaigns. A widespread campaign to raise awareness about and explain fistula—both its causes and its treat- ment—among women and the key decision makers 35 in their lives would help to spread the word that the condition is both preventable and treatable. Doctors of the World has sponsored a play about the issue which has garnered significant attention in places where it has been performed; such efforts need to be continued and reinforced with other locally appropriate media, taking into account high rates of illiteracy. • Train additional providers and ensure skilled surgeons and providers are using best practices across the country. As part of their academic training, physicians must learn how to conduct fistula repairs. At least a handful of doctors at referral centres in different regions of the country need to learn the necessary skills to perform this type of surgery. In particular, it is important that a local surgeon in Mopti gets trained as a way to provide continuity if the exter- nal support diminishes. Another key piece of training involves the creation of an evidence-based protocol for repairs. This kind of training needs to be made available in medical training programmes across the country. Best practices may also extend to those providing antenatal care, which a large number of women in Mali seek. Providers could use these visits to offer women and their families information on fistula prevention and the importance of emergency obstetric care. • Increase collaboration between institutions providing repairs and improve communication with providers in other areas and countries. It is important to increase the communication between the two centres offering repairs, so that they can coordinate and, ideally, maximize the efficiency of their treatment plans. In addition, surgeons in Mali would welcome increased communication and exchanges with international colleagues to improve their technical skills and to learn new ones. • Create a social reintegration strategy for women following repair. Careful attention needs to be paid to how women reintegrate into society following fistula surgery. The Oasis at Point G has started to address these issues, but it could use assistance. Other models for re-integration also need to be developed to create an environment in Mali that actively encourages and supports women’s re-entry into communities. • Devise a fund or financial strategy to support women who need repairs. A critical obstacle to women seeking care in Mali is the need to provide even partial payment for fistu- la repairs. As is common in the other countries where the needs assessment took place, fistula clients in Mali have no means to pay. Some kind of financial support will be necessary if repairs are to be offered to the current roster of clients. Local NGOs such as Bengadi have made attempts to pro- vide this type of support at the Hospital of Point G by assuming transportation costs and subsidizing part of the operation for women in the town of Bla. • Consider creating a national fistula centre at University Hospital of Point G. This facility is able to perform hundreds of fistula operations each year. The 80–85 per cent success rate is evidence that the providers are technically skilled, but staff have reported that the number of repairs they perform does not reflect what they could be doing. With improved infrastructure, it would be possible for providers to dedicate more time to fistula repair and to offer higher quality care. Furthermore, no collaboration between the hospital and the Oasis centre is currently in place; but with improved partnership, the centre could help handle an increased number of fistula clients and keep the hospital at full capacity. 36 A. Hôpital Regional de Mopti, Sominé Dolo (Regional Hospital of Mopti, Sominé Dolo), Mopti, visited 17 October 2002 Size: Six out of 100 beds are reserved for fistula clients; two operating theatres, one of which has recently been remodelled by Doctors of the World and Doctors Without Borders. Medical staff: Four missions per year come to Sominé Dolo with Doctors of the World. Each mis- sion consists of several doctors from a pool of about 20, including Dr. Jean-Martin Zino, an expa- triate physician with Doctors of the World based in Mopti. There are currently no local surgeons available to operate on fistula and only one gener- al surgeon slated to serve the entire region of Mopti, with its 1,400,000 residents. Given this situation, it is understandable that this physician has many other responsibilities apart from fistula repair. Caseload: 150 operations per year since the 2000 project began, with at least a 78 per cent success rate. This success rate has been calculated on the basis that some women who have undergone fistula surgery have not returned for follow up and are therefore considered as failed repairs. There have been 55 cases of RVF since 1993, providing about 10 per cent of the total caseload. Provenance of clients: Most clients come from Mopti and the bordering regions. Some come from neighbouring countries. Typical client profile: The average age is 25 and most are primigravidus, but of those who have had children, they are generally of low parity. The majority of clients come from the countryside and are usually uneducated except for the few who have had one or two years of schooling at the most. They are always accompanied by someone; more and more with their husbands recently, thanks to awareness efforts initiated by Doctors of the World. Most of the women who come have spent an aver- age of three days in labour. In general, the women have been living with fistula for less than a year. Assessment and screening process: • Before the operation, the client and her attendant are counselled and given an explanation of what to expect, the specifics of the operation and its potential results. • A standard clinical exam is given (blood analyses, etc.). • The fistula is classified based on its complexity (simple, complex or serious) and surgical procedures to be used are determined. Post-operative care: • Counselling is given about sexual relations, STIs and appropriate actions for future deliveries. • Clients remain in the hospital for one month, and a post-op consultation is scheduled for a date three months later. • Some women prefer to stay at the hospital after their recovery and work in the artisan workshop located on the outer limits of the hospital grounds. Rehabilitation/reintegration: Doctors of the World works with Delta Survie, a local NGO, to help women to return to their communities with a set of skills they can use to generate an income. They are taught to make bogolon fabric and to dye and weave material, which they can sell to people in the community. Community outreach: Doctors of the World has organized a local theatre group to perform a play near Mopti about a woman who has developed obstetric fistula. Approximately 45 minutes long, the drama recounts the story of a woman from the day of her marriage through her difficult pregnan- cy, the development of obstetric fistula and the challenges she faces as a result. The play, which has already been produced in several sites, has encouraged many men to bring their wives to Mopti for treatment. Perceived support at the policy level: A statement of accord signed by the MOH and Doctors of the World in Mopti notes their mutual support. Estimated fully-loaded cost per procedure: The 37 Fact Sheets for Mali Site Visits actual intervention would cost the hospital about $260 USD per case. However, because of funding from a variety of sources via Doctors of the World (such as the Materra Foundation of Germany, a private foundation in France and others), clients are only responsible for $25 USD. This amount cov- ers everything from their first diagnosis to their month-long recovery, but it does not pay for their food. Resources: Funding obtained by Doctors of the World. Barriers: • If funding doesn’t continue, Doctors of the World will have to cease services. B. Centre Hôspitalier Universitaire du Point G (University Hospital of Point G), Bamako, visited 21 October 2002 Size: The Department of Urology handles fistula surgery. One operating theatre is available for the entire hospital, meaning none is specifically reserved for fistula clients. This theatre is extreme- ly busy, which limits the time available for surgery on fistula clients. There is one recovery room with seven beds for the Department of Urology. Also located on the grounds is a facility known as the Oasis, which houses clients who are awaiting their repairs. Medical staff: The Department of Urology consists of three state-certified nurses; two to three interns each year who serve as surgery assistants; and four surgeons, all of whom are urologists. Dr. Kalila Ouattara leads the team of four urologists, who perform all of the fistula repairs. Caseload: Each surgeon operates on at least two fistulas per week, which creates a caseload of about 416 operations per year. This number does not reflect their capacity, however; if more space, were available, more operations would be possible. A separate ward for fistula clients would be very helpful. Provenance of clients: Clients come from all over the country. Most have complex fistulas that have been referred from regional hospitals. Some come from other countries, like Côte d’Ivoire (where treatment is very expensive) and Guinea. Rarely is a client from the capital of Bamako, as most women there deliver in hospitals and are thus less likely to develop fistula. Typical client profile: The average age is 15; the extremes are 12 and 40. The older women are of high parity and their uteruses have ruptured during delivery. Clients usually come alone and most are poor, uneducated and rejected by their husbands. Most of the younger clients are primi- gravidus and married very early. Some have fistula as result of consequences of FGM. Four out of five women who come to the Department of Urology for treatment have fistula. Assessment and screening process: • Vaginal diagnosis is done after a client arrives leaking urine. • A gynaecological exam is done and a catheter is inserted. • Biological and radiological analysis are done, but often it is not possible to do a full exam because of lack of resources. • For a period of one week to seven days before the operation, the client is told to maintain personal hygiene to disinfect the vaginal area. A sitz bath is recommended, which most clients cannot afford. Post-operative care: • A catheter is inserted; antibiotics are given if necessary. • Sitz baths continues with permanganate, a disinfectant. • The catheter is removed 15 days after the opera- tion, and the client is examined for continence. • The catheter is then reinserted for 10 days. If she no longer leaks urine at that time, the client is discharged. Rehabilitation/reintegration: According to hospital staff, social reintegration activities are not necessary. If their fistula is closed, the women return to their husbands. Culturally, a woman is of little value if she is not married.21 Most of these 38 women already knew how to make soap, sew, weave, etc., before developing fistula, and used those skills to generate income before their treatment. Because staff claim that the women return to their normal lives once they are fully recovered, some providers feel that it does not help to teach clients these activ- ities as a means of instilling independence. The Oasis centre, which was originally conceived as a place to help women learn a useful skill, could be used as a recovery space as well as a hostel for women awaiting surgery. Community outreach: Rarely seen. It has been reported that sometimes if a woman who has devel- oped fistula moves to a different locale after total exclusion from her native community, a local mosque or a similar organization will help her get to a service delivery site where fistula surgery is performed and may raise money for her to have the operation. In addition, the local NGO Bengadi helps women in the town of Bla to receive treatment at Point G by assuming transportation costs as well as subsidizing the procedure. The Ministry of Social Development intervenes by signing an affidavit of indigence in extreme cases, allowing women with no means to receive treatment. Perceived support at the policy level: Apart from the construction of the Oasis by the First Lady, who is president of the NGO Fondation Partage, and the Ministry of Social Development, no political support is perceived. Estimated fully-loaded cost per procedure: The cost of the operation varies depending on the room a women decides to occupy. There are three vari- eties of accommodation: 1st class, which ensures a private air-conditioned room with an indoor toilet, costing roughly $100 USD for 15 days post-op hospi- talization; 2nd class, which gives her a private room with a ceiling fan and access to an outdoor toilet, costing $85 USD for 15 days; and 3rd class, which allows her to share a room that usually holds eight to 10 beds and a communal exterior toi- let, costing $65 USD for 15 days. Most fistula clients choose the last option. A medical kit (including the sitz bath) costs about $76 USD. Resources: Only what the hospital receives from clients for medical interventions. Barriers: • Inadequate funding. • Policy decisions are made at an administrative level, and clinicians are often not involved. It would be difficult, however, for administrators to fully grasp the problems facing providers without input from those in the field. • Inability to provide transportation to and from the hospital. Key Contacts The needs assessment team is deeply grateful to the following individuals in Mali for their assistance with this project: UNFPA Country Office Dr. Myriam Cissoko, Reproductive Health Unit Officer and National Project Professional Ministry of Health Dr. Zeïna Maïga, Director, Reproductive Health Division Ministry of Social Action Mr. Gaoussou Traoré, Director Doctors of the World (Mopti) Dr. Jean-Martin Zino, OB/GYN Programme Coordinator Dr. Catherine Loire, Medical Coordinator University Hospital of Point G Dr. Kalila Ouattara, Chief Urologist Dr. Ally Tembely, Assistant Surgeon of Urology Delta Survie Mr. Ibrahima Sankaré, Secretary General Dr. Fatoumata D. Diallo 39 Background It has been a decade since the end of the civil war in Mozambique and some basic health indi- cators appear to have improved while others have grown worse in this time period. The nation is vast in size and access to health services remains a challenge, especially in pockets of the country where the terrain makes transportation treacher- ous and vehicles are in short supply. Because of the population distribution in rural areas, the often fractured health care infrastructure in some provinces and the underlying poverty, many obstacles remain to providing access to basic health care for a large percentage of Mozambicans. Despite these challenges, however, there are some noteworthy achievements as well as some obvious needs. The percentage of the population with access to health care grew 10 per cent between 1992 and 1999; thirty-five percent of the popula- tion is considered to have access to quality health care. The percentage of individuals charac- terized as “new family planning clients” has grown from 2.3 per cent in 1996 to 7.2 per cent in 2000, yet the modern contraceptive prevalence rate remains low at 5 per cent, and only 60 per cent of women have knowledge of at least one method of family planning. 21 The total fertility rate is 5.86, with the majority of women giving birth at least once by the time they reach 20.22 Approximately 44 per cent of deliveries happen within institutions (far more in Maputo city than elsewhere), but the maternal mortality ratio and number of neonatal deaths within institutions is high, undoubtedly due to a number of factors: delays in getting to a facility, delays in referrals being made in a timely manner, overburdened staff within facilities, inadequate equipment within facilities, etc. Within institutions, the maternal mortality ratio is believed to vary between 175 and 600 per 100,000 live births, against a national average (including women giving birth in and outside of institutions) of approximately 980 maternal deaths per 100,000 live births. 23 For each maternal death, there are 17 report- ed stillbirths. Data from 1997 to 2002 suggest that out of every 100 stillbirths reported within an institution, 10 women were admitted to the hospital with a detectable foetal heartbeat. This fact, as well as a national C-section rate of 1.12 per cent, signals a need for further work on the quality of facility-based maternal care.24, 25 Rates of antenatal coverage are believed to be fairly high in most provinces and have grown in the last 10 years. Not as encouraging is the fact that the vast majori- ty of women who seek antenatal care do not begin doing so until their sixth month of pregnancy. As is true throughout the region, HIV/AIDS is already having far-reaching consequences and is expected to reduce average life expectancy consid- erably in the next 10 years if the incidence rate continues at the current pace. Prevalence of AIDS is currently thought to be a little more than 12 per cent among pregnant women, with women of all ages representing 52 per cent of new AIDS cases in 2001. Life expectancy among women is currently 38.6; among men, it is 37.3.26 Despite grinding poverty evident throughout most of the country—Mozambique remains one of the 10 poorest countries in the world according to the United Nations Development Programme’s (UNDP) Human Development Report—the significance of peace prevailing this past decade cannot be over- estimated. More than anything else, “that we can now expect to live,” explained a man in Quelimane, “fills us with light.” Ensuring that that expectation is met for everyone, including women with obstet- ric emergencies, remains a formidable challenge. Issues and Challenges In Mozambique, the needs assessment team met with the UNFPA country office staff, the Vice Minister of Health and the Deputy Director of the Community Health Department within the MOH. 40 M OZ A M B I Q U E In addition, in the province of Zambezia, the team met with the Provincial Director of Health and the director of the hospital as well as the surgeon pro- viding fistula repair services at Hospital Provincial de Quelimane in Quelimane. The team also had the opportunity to visit with six fistula clients in Quelimane, five of whom had been repaired and were receiving post-operative care and one of whom was waiting for her procedure. In Maputo, the team met with the urologist providing fistula repair services at Maputo Central Hospital, had the opportunity to observe a repair within the operat- ing theatre and met with other physicians assisting in the operating theatre. Although Mozambique is large, there are only three physicians known to have the skills who are actually providing fistula repairs through- out the whole country: a Mozambican urologist in the southern part of the country at Maputo Central Hospital, an Italian general surgeon in central Mozambique in Quelimane and a Tanzanian OB/GYN in Niassa province in the north.27 The annual caseload varies by facility—ranging from 15 in the northernmost facility to greater than 50 elsewhere—but each provider interviewed agreed that the numbers of women they were see- ing undoubtedly represent the tip of the iceberg. In addition to a considerable caseload at each of these three sites, each of the physicians goes out to per- form fistula repairs at other sites, but there is concern among them about their ability to main- tain this practice and the lack of other providers who might be interested in learning these skills and providing repairs. Two of the doctors went together to one province to perform 27 operations in three weeks. While this effort helped diminish the growing backlog, it is “not the smartest nor the most sustainable way to go, if we cannot be train- ing others while operating,” noted one of the providers. The fistula clients appear to face great stigma in their communities and their families. In central Mozambique, a woman with a fistula may become the servant of the next woman whom her husband takes as a wife and remain in this position for as long as she is leaking. If she is able to be successfully repaired, her chances increase either of going back to her husband as his wife or finding another husband. In either sce- nario, however, there will be strong pressure on her to become pregnant and, for safety reasons, the provider will have counselled her on the need to deliver the next (and all subsequent babies) within a facility. Indeed, the surgeon in Quelimane has done hundreds of C-sections on women whom he has previously repaired. The stigmatizing of girls and women appears to spread beyond their families and communities. All three of the physicians currently performing fis- tula repairs have offered to train others, notably OB/GYNs, but there has been little interest shown. The two providers interviewed noted that stigma is probably one reason, coupled with others. In fact, as part of their training, each student has a three- month rotation during which s/he is taught how to perform fistula repair, but none to date has wanted to continue learning these skills. The urologist in Maputo recently spent three months in additional training on another issue in Cape Town and, although his fellow providers within Maputo Central Hospital have the skills to do at least simple fistula repairs, they only performed one while he was away and waited for him to return to take on the others, even though they were not all complicated cases. In Quelimane, the provider who does repairs offered to train the physicians who were there with him for three years, but none was interested. The OB/GYN Department requested that fistula clients leave the maternity ward, so now women with fistula must use the surgery ward for pre- and post-operative care. Because of strong pressure to have a baby, it appears that counselling on family planning and HIV/AIDS is virtually nonexistent for fistula clients. Among the providers interviewed, the risk of contracting HIV/AIDS was considered secondary to a woman’s need to become pregnant again. Indeed, because there is such an emphasis on women having many children, there is currently a family planning campaign aimed at men in 41 Mozambique. The perception of women who go to family planning clinics is that they “have more than one man” or else they would not need such services, so women who do practice family plan- ning tend to do so secretly, going to the clinic under the guise of needing a consultation on a baby’s health. Probably because injectables can be practiced discreetly, these methods are the most popular choice. As in other countries, the transportation and communication system are often insufficient to get a woman experiencing obstructed labour to a facility quickly. Especially in the northern part of the country where the terrain is mountainous, wheelbarrows, oxcarts and bicycles have not met with success. Also in this part of the country, women tend to be very small and fistula appears to be more widespread than in other locations where women are of larger stature. For these reasons, in some places, waiting homes are being established as a mechanism to get women at high risk closer to facilities before giving birth. While the policy is nor- mally to ask women to come in at eight months to “wait” for a month, it is rare that women will do so, as their families often do not want them to be away from home for so long and they are often reluctant to leave their children for this period of time. Recommendations and Critical Needs • Maintain waiting homes as part—but not all—of the answer. As noted, there has been some success with estab- lishing waiting homes for women who are considered high risk, perhaps because of an earlier fistula and repair or for other reasons. Although the concept of the “high risk” label is controversial and a woman’s family may not want to allow her to be “waiting” for labour to ensue at a location other than her own home, waiting homes have met with some success in limited parts of the country. • Develop an incentive system for physicians to interest them in learning fistula repair and keep them motivated to provide services. One key concern has been the lack of interest in learning the skills to provide fistula repair, despite mandatory training as part of medical education within the country. For this reason, a variety of types of incentives (travel to international repro- ductive health conferences was suggested by some staff) needs to be provided to attract and maintain potential providers’ interest. • Secure short-term external support as the national government continues rebuilding the health care infrastructure. Mozambique has done a tremendous job restoring the health care infrastructure following the war, yet there is a long way still to go. For fistula repair to be “truly owned by Mozambicans”, in the words of one provider, the MOH needs to take over some kind of fistula initiative, following support of an outside donor for a limited period of time, such as three years. • Advocate for the government to describe fistula as a human rights issue. To build awareness about the issue, a campaign needs to be created that targets potential clients and potential providers (as well as other key stake- holders) with a message that posits a life free of fistula as a human rights issue. The MOH could play a key role in the creation of such a campaign. • Establish one or two training centres for repair of more complicated cases. Because the country is so large, it may be that more than one training centre is required to serve as a national referral centre. Such centre(s) would need a steady supply of support, equipment and materi- als. While Maputo Central Hospital might be the obvious candidate, the distance between Maputo and other parts of the country may suggest the need to establish another one as well. Providers note that a master plan should be created at a national level which outlines what level of facili- ties are able to provide what level and kinds of fistula repairs. This assessment process could also drive the selection of a national centre or centres. 42 A. Hospital Provincial de Quelimane, Quelimane, visited 13 August 2002 Size: 420 beds, one operating theatre with three rooms. The maternity ward has 60 beds, but fistula clients have been asked to leave the maternity ward (due to the smell) and are now housed in the surgery ward. Medical staff: 11 doctors, three surgery techni- cians, 16 nurses (in maternity ward only; more in the rest of the hospital). Caseload: 200+ deliveries each month, of which 25 to 30 are C-sections. Per year, 40 to 50 fistula clients, but there is a backlog. Six cases were waiting on the day the team visited. Dr. Aldo Marchesini also goes out to five other provincial hospitals to operate. All these facilities have gynaecologists, none of whom have taken the opportunity to be trained. Provenance of clients: Clients come from through- out Zambezia. There is a group called the Lilongwe tribe in the north where women are typically of very small stature (1m 50cm); among these women, there is a high prevalence of fistula. In addition, some clients are sent from other provinces: Nampula, Niassa and Capo Delgado. Typical client profile: Fistula clients are generally younger than 20, but some women are 30, 35 or 40 and have been living with fistula for 15 years. Of the six fistula clients interviewed by the research team, only two developed fistula with their first pregnancy; for the others, parity was three to eight. Assessment and screening process: • A manual exam is performed to determine if the woman’s condition is fistula. This is “adequate” for about 70 per cent. • For the remaining 30 per cent, a surgeon needs to examine the client in an operating theatre to determine the position and size of fistula, as well as its degree of complication. Some of these exams are performed with anaesthesia, some without. • Screening for anaemia. • If indicated, screening for renal function. • Since 85 per cent of population has schistosomiasis, every client is given single dose of praziquantel. • Time since delivery is determined—it must be two to three months. If a woman is from far away, she is admitted and waits at the hospital. If the waiting period is one month or less, a client is admitted. Otherwise, Dr. Marchesini gives her funds to return home and then tells her to return a week before the surgery. On average, 35 per cent don’t come back at all. The other 65 per cent, may come back, but later than the appointment date. Post-operative care: • Clients usually stay for 14 days, until catheter comes out. • Counselled on coming back to hospital to deliver in the future by elective C-section, so Dr. Marchesini has done many C-sections on former fistula clients. • Counselled on abstaining for two months. • No specific counselling on family planning or HIV. The sense among providers is that these women really want to get pregnant, so it is not necessary. “HIV is a secondary problem.” Rehabilitation/reintegration: No specific programmes; more than half of the women are abandoned by their husbands. Sometimes, the wife with fistula becomes the servant for the next wife whom the husband takes. If repair is successful, she may be taken back as an equivalent wife or may marry someone else Community outreach: No programmes doing community outreach to which fistula is linked. There is outreach, however, on family planning, immunization, etc. Support at the policy level: MOH is aware of the problem with fistula, as are people at the provin- cial level, but nothing specific is being done, except mention is made of fistula in the context of gener- al maternal health care policy for both adolescent sexual and reproductive health and general repro- ductive health. 43 Fact Sheets on Mozambique Site Visits Estimated fully-loaded cost per procedure: Not known, but fistula clients themselves do not pay if they satisfy a certain number of criteria. Obstetric services are free, services are free to those under 18 and older than 60 and transfers from districts are treated free of charge. Resources: • Dr. Marchesini’s friends in Italy provide materi- als, such as suture. They gave head lamps to two other doctors. • The Government of Mozambique provides the only other support that the hospital gets. Barriers: • Due to gender and economic inequities, women with fistula don’t have money, power, etc. and might not know services are available. • Fistula is not recognized at the low-level health facilities. • Sometimes fistulas are recognized, but are not considered important enough problems to refer. • Transportation—road network, distances to trav- el and difficult terrain—make it hard for women to access services. • Space for fistula clients pre-op and post-op is lim- ited. Dr. Marchesini bought 14 mattresses and 10 mats for surgery ward so clients could also stay on the floor. • Only one provider can do repairs at the facility, which contributes to the growth of a backlog of cases. A system as well as resources need to be in place to sustain supplies and materials. B. Maputo Central Hospital, Maputo, visited 14 August 2002 Size: 1,200 beds, only 800 of which are in use because of staff, especially nurse, shortages. There are theatre blocks in the maternity unit, casualty department and general surgery department. The general surgery department has the largest theatre block, with five operating rooms. However, one of the rooms is not in use due to staff shortages, while the other theatres sometimes have two dif- ferent clients under spinal anaesthesia being oper- ated on in the same room simultaneously. The urology team is looking for funding to be able to renovate a theatre and ward for special use by fis- tula clients. Some physical exams are performed in the Urology Outpatient Department, in addition to some minor prostate and hydrocoele surgery. Medical staff: The urology team consists of a sur- geon, a urologist, an anaesthetist and an OB/GYN resident. Caseload: The urology team performs an average of two repairs a week, and they are already booked to the end of the year. A much smaller number of sim- pler procedures, one or two a month, is performed in the maternity theatres. The urology team intends to visit regional hospitals to conduct on-the-job training and to set up model fistula repair teams. Provenance of clients: As this hospital serves as the country’s main referral and teaching hospital, clients come from all over Mozambique, although the ones near the Malawi border tend to cross over into Malawi. Many of the clients referred have complications requiring very skilled surgery and equipment in addition to basic fistula repair sup- plies and materials. Typical client profile: Fistula clients are generally young, sometimes just out of their teens, poor and of short stature. They usually developed the fistula with the first pregnancy. A few have had other pregnancies before and some, like the woman the team saw in the theatre, are in their late 20s and have undergone previous attempts at fistula repair. Assessment and screening: • Most repair procedures are performed at least three months after the pregnancy during which the woman experienced fistula. • Repairs are preceded by examination in the ward and also under anaesthesia pre-op. • Renal function tests are performed as indicated, but the urography unit is non-functional at present. • Routine praziquantel is given pre-op for endemic schistosomiasis • Ureteric catheterization is used for some compli- cated types of fistulas. 44 Post-operative care: • Clients usually have in-dwelling bladder catheter for 14 days. No bladder training. • Clients are advised to abstain and to avoid tam- pons and other foreign objects in the vagina for three months. • Clients are advised that a C-section is mandatory for next pregnancy. • Family planning needs and HIV risk are not routinely explored; these are perceived to be more of an OB/GYN responsibility. Rehabilitation/reintegration: No specific pro- grammes or follow-up in the community. Most fistula repairs are successful at the first attempt, but some have required as many as six attempts, and a couple have required sophisticated surgery, such as the recreation of a bladder out of intestinal tissue or the creation of a new vagina or urinary diversion. A few of the women are known to have come back for C-sections, but most would be seen in the maternity unit or in peripheral hospitals. It is not known how well the clients are later integrated into the community. Community outreach: There is none related to fistula work, except for the proposed fistula model team visits to peripheral sites. Support at the policy level: The MOH is committed to the general issues of safe motherhood, including fistula, but is severely hampered by lack of funds, not only for infrastructure, equipment and materi- als, but also for salaries. The urologist has to use his personal cystoscope and vicryl sutures for the MOH clients. Estimated cost per procedure: This has not been estimated. Fistula clients do not pay. Resources: The MOH supports the hospital. The urologist often uses some of his personal materials for clients. Barriers: • Lack of equipment and supplies. Due to the complexity of the type of surgery required for some of the referral cases, the hospital needs a couple of cystoscopes with three spare lenses each, a ring vaginal retractor to avoid the need for many assistant hands in the surgical field, expandables such as vicryl/ureteric catheters and a Liga-Sure set for easier control of bleeding dur- ing complex surgery. • Disempowerment of women with fistula, econom- ically and socially. • Staff shortages. Nurses are poorly paid, about $100 USD per month, and many have left and gone on to better paid non-medical work, includ- ing small business enterprise and horticulture. Doctors are paid about $300 USD per month, so many of them also have a private practice. • Poor infrastructure. • Lack of interest/motivation of many of the local doctors, including OB/GYNs in fistula work. One OB/GYN resident was in the theatre as part of the repair team. He admitted that he was not really interested in this work and was only taking this rotation to fulfill a requirement for qualification. Key Contacts The needs assessment team is deeply grateful to the following individuals in Mozambique for their assistance with this project: UNFPA Country Office Dr. Georges Gorgi, Country Representative Dr. Maria de Luz Vaz, National Project Professional Dr. Clara Santos, National Project Professional Ministry of Health Dr. Aida Libombo, Vice Minister of Health, Deputy Director of the Community Health Department Dr. Leonardo Chavane, Provincial Director of Health, Zambezia Province Hospital Provincial de Quelimane Dr. Helena Fernando Mula Chong, Medical Superintendent Dr. Aldo Marchesini and nursing staff Maputo Central Hospital Dr. Igor Vaz and nursing staff 45 Background Nigerien women have the highest fertility rate (8) in sub-Saharan Africa, with a modern con- traceptive prevalence rate of 4 per cent and a maternal mortality ratio of 920 per 100,000 live births. Eighty-five per cent of women deliver at home, either unassisted or without the help of a trained provider.28 Entrenched traditions some- times prevent women from leaving their homes, which may explain why only 30 per cent seek ante- natal care and the C-section rate is 2 per cent. In addition, women are invariably encouraged to deliver their first child at the home of their par- ents, which can result in especially problematic situations when women live in remote areas far from obstetric care. Other traditions, such as FGM, which is widespread, put women’s health at risk. Of the women with fistula who received repairs in the country last year, 22 per cent had also experi- enced some form of FGM. The total number of those with HIV/AIDS in Niger in 2001 was 64,000 and, although no statistics are available for rates of infection among women, it can be assumed that a significant number must also cope with this threat to their health. Early marriage is another common risk factor. Although DHS reports that the average age at marriage for women in Niger is 15, in cer- tain regions women are married as early as nine years old. Traditionally, girls are kept in the fami- ly home of the man they are to marry and sexual relations are not supposed to begin until the girls reach menarche. Unfortunately, this custom of waiting has slowly eroded. Young age at first pregnancy also predisposes women to fistula. Thirty-six per cent of girls ages 15 to 19 have either been pregnant or already have at least one child. All of these factors have made obstetric fistula exceptionally common in Niger. Other conditions further complicate women’s health care in this country, including the fact that two-thirds of the nation is desert, 85 per cent of its population lives in rural areas and illiteracy among women is 91 per cent. Despite the success of some of its initiatives, the government has not been able to maintain the budget allotted to health and education. NGOs have tried to help offset this situation. CARE Niger organized a workshop in August 2002 for those involved in women’s health and rights to discuss issues surrounding fistula in particular. At the workshop’s conclusion, participants planned to create a network of people to raise national aware- ness about obstetric fistula; to organize activities to prevent increased occurrence; and to develop a plan for the 47 women who have waited, sometimes for years, at the National Hospital to receive treat- ment and begin to reintegrate into the community. UNFPA Niger’s programmes include low-risk maternity; a youth initiative, which involves repro- ductive health for youth and adolescents; and a gender initiative to encourage girls to go to school. The prohibition of early marriage is also featured in this programme. A final project will involve an assessment of the results and effects of these attempts to improve reproductive health. The local organizations involved in the issue include Reproductive Health for Low-Risk Maternity (DIMOL), an NGO founded in 1998 by a Nigerien midwife who has worked with UNFPA’s low-risk maternity initiative. She devised a project to build a fistula operating/treatment centre for which Oxfam-Québec has provided the equipment and supplies. The United States Embassy has fund- ed the construction of the operating block and a hostel for pre- and post-operative clients. The site has been identified and construction of the centre is imminent. Plans to build a well and an appren- ticeship studio are also in the works. The Nigerien Committee on Traditional Practices (CONIPRAT), an NGO which promotes women’s health and rights, is working to raise awareness about the dangers of FGM and early marriage, both of which are factors that contribute directly to the 46 N I G E R development of obstetric fistula. They recently organized an exhaustive, nationwide survey to take an inventory of the prevalence of these practices, but the results have not yet been tabulated. They are also fighting for legal action that will prohibit early marriage and are promoting activities to reduce FGM by identifying those who perform the procedure and training them in other ways to earn a living. This has worked especially well in Couba, a small southwestern village, whose citizens have come together to expel excisors from Burkina Faso. A legal expert at CONIPRAT has presented a propos- al to the Ministry of Justice to pass a national law prohibiting excision. They are currently waiting for the parliament to decide on the matter. The Coordination of NGOs and Feminine Associations of Niger (CONGAFEN) lobbies against early marriage and has solicited local leaders of women’s associa- tions for support. Issues and Challenges In Niger, the needs assessment team met with staff from the UNFPA country office, who helped to set up meetings with organizations working for women’s health and rights, such as DIMOL, CONIPRAT, CONGAFEN, Oxfam-Québec and CARE Niger. The team also spoke with various representa- tives from specific divisions of the MOH, including the Director of Social Protection and National Solidarity, the Director of Reproductive Health and the Secretary General of Public Health. The team had the opportunity to visit fistula repair sites at Niamey National Hospital the University Hospital of Lamordé, the District Hospital of Loga, Zinder Maternity Hospital and Maradi Regional Hospital. Several facilities housed fistula clients who had recovered from surgery and were available for interviews. At the Niamey National Hospital, the team had the chance to speak with the group of 47 women living in the fistula repair pavilion. Visits to five sites and discussions with providers, district officials and NGO staff indicate that, as noted, obstetric fistula in Niger is an extremely common phenomenon. Its occurrence is frequently linked to traditional practices preva- lent in the rural areas where most fistula cases develop. A national survey conducted by two fistula surgeons in 1995 to acquire a clearer picture of the issue found that the average age of those polled was 13, and 58 per cent were primigravidus. Cultural concerns appear to be paramount in keeping women from receiving care before, during or after a birth. In some villages near the Nigerien border, women are not allowed to leave their homes at all and receive guests through a veil, which suggests that they are not likely to seek antenatal or emergency obstetric care. In addition, very young women who are pregnant for the first time often refuse antenatal care out of shame. Because little community support exists for such treatment, if these women suffer a complication during labour, they may turn to a local religious healer or an untrained older woman. The women receive no financial support from their husbands, who sometimes will not let them obtain assistance from a trained provider. A range of traditional practices can put women at risk for fistula. In some parts of the country, the practice of giving women water to drink to expel the baby during labour can lead to fistula, given that the baby’s head pushes against a full bladder. A custom known as cervical reposi- tioning involves putting a wooden spatula into the vagina if a woman experiences infections during pregnancy. It is said that her vagina has fallen and that the spatula will restore it to its correct posi- tion. TBAs may also press their elbows or knees on a woman’s belly to keep the baby from being expelled through the anus. Should a fistula develop and a woman decide to seek care, her choices will be few. In general, surgical resources for fistula repair are spotty. At the three sites that provide these services in Niger—Niamey, Maradi and Zinder—only six surgeons are known to have the technical abilities to handle fistula repair. Three of the six received some background in the procedure in Addis Ababa, and of the remaining three, one is known not to have had technical training and is 47 unable to repair complicated fistulas. More providers are desperately needed, as the current supply does not meet the demand. A siz- able backlog of clients exists, especially in Niamey, where fistulas that are difficult to repair are referred. Training is feasible within the country from the few specialists who have been trained in Addis Ababa, but providers must be made aware of the most updated surgical techniques. In addition, staff are reluctant to stay in certain locations because life in the “brush” is very difficult, as most of the remote villages are in the midst of the desert. Even if women do undergo a successful repair, they may not return to their husbands. Most are illiterate and lack skills for employment. Some turn to commercial sex work once their fistula is closed as a way to earn an income. This situation is of particular concern in crossroads cities, such as Dirkou in the northern Sahara, which is frequented by business travellers from various countries with high HIV/AIDS prevalence rates. Two other projects linked to government involvement also illuminate the situation. As a response to a national need for self-sufficiency, the President of the Republic inaugurated a programme to build schools, reservoirs of clean water and local health units staffed with a midwife and a nurse in 1,000 of Niger’s 9,000 villages. While 85 per cent of the project has been completed, the schools and dis- pensaries have had difficulty retaining health care workers in the most distant settings. An initiative funded by the World Bank and some partners mir- rors this outcome: in 1995, 30 hospitals were constructed, all well equipped to handle emergency cases. Many of these, however, suffer from a lack of qualified personnel and often do not offer suffi- ciently attractive salaries to retain well trained staff. More positively, a division of the MOH now pays for C-sections needed by women who have had fistula repair. A final example involves a programme intended to address obstetric fistula directly. After the 1995 survey, a project was designed to treat current and prevent future cases of fistula over the course of four years. Called Prévention et Traitement de la Fistule Obstétricale au Niger (the Prevention and Treatment of Obstetric Fistula in Niger), its strategies included building national and regional teams of doctors trained in fistula, educating providers, rebuilding hospital infrastruc- ture and spreading information, education and communication about the topic to the population, all at a cost of $385,000 USD. While the government found that the programme was useful, it was not able to provide financing for the launching of the work. La Coopération Française took on the task and proposed activities were carried out over a three-year period. Recommendations and Critical Needs • Provide better and more training to more fistula repair providers, with a focus on remote locations. This process may involve integrating emergency obstetric care into the training for fistula surgery, since part of the issue in Niger involves keeping qualified providers in remote areas where mastery of emergency techniques is of critical importance. But an effort must also be made to increase the sheer number of providers to better address the caseload of women already waiting for repairs. Work should be done, too, to improve health care workers’ treatment of women with fistula, who sometimes are referred to as “those women who smell of urine.” Finally, it may be necessary to implement some kind of incentive system for providers, such as adequate housing, better salaries, improved communication and transportation and/or the opportunity for continued education. • Create and disseminate community awareness campaigns. Advertising aimed at village chiefs and religious leaders, as well as TBAs and pregnant women, could counteract the notion that delivery becomes prob- lematic only after the second or third day of labour. 48 These campaigns would need to be in local languages and aired via radio, television and newspapers. It would be extremely effective to involve former fistula clients in these efforts on a national and district level. • Organize better transport and communication between health care sites. Transportation to appropriate care may be an obstacle. Women may have to travel by wagon or donkey if they are not picked up as hitchhikers. If they find an ambulance, they have to pay for gas. District hospitals urgently need more vehicles and a better radio network for referrals. • Explore ways to help make fistula clients more economically self-sufficient. Helping women learn new skills is a good means of assisting them after surgery and may prevent them from turning to more desperate measures, such as commercial sex work, as a way to earn a living. • Increase contact between funders and clinicians. Frequently, NGOs and foundation personnel negoti- ate with administrators and officials instead of with those directly implementing programmes, leading to projects getting stalled at the planning stage. Increasing communication between funders and those caring for fistula clients would help both parties to plan. • Advocate for increased funding for national projects. For Niger to be able to safeguard maternal health, more financial and political backing of projects aimed at preventing the decline in women’s health, and improving their social and physical status, are needed in the country. • Consider creating a fistula centre at Hôpital de Lamordé. Because of the interest and commitment of the chief urologist and the fact that this hospital is currently receiving all of the urology cases in the region surrounding Niamey, it is a strong candidate to become a fistula centre. The chief urologist was trained in Addis Ababa and is now eager to train other local physicians. 49 A. Hôpital National de Niamey (Niamey National Hospital), visited 8 October 2002 Size: 244 beds for the surgery ward, with 20 beds reserved for fistula clients. Six operating theatres, one of which is used for fistula operations. Medical staff: 15 surgeons, including expatriates; seven medical assistants; several nurses and anaesthesiologists who rotate through different departments. Dr. Amadou Deibou performs surgery on an increasingly small caseload each year (see below.) Caseload: In 2000, there were 92 admissions; 51 of these women underwent surgery. In 2001, 23 were admitted, and this year, 10 have been admitted. The reason for the decrease in numbers is the restruc- turing of three area hospitals; all clients with urological issues are now seen at one central hospi- tal, Lamordé. Provenance of clients: Mostly departments of Tillabéry, Dosso (a central crossroads city, also a department) and all over Niamey. Typical client profile: It depends on how long the client has had the fistula. If she is being seen just a few weeks after the fistula has developed, she is usually depressed, limping due to partial paralysis from labour complications, in wet skirts and usual- ly smelling of urine and/or faeces. If it has been several months after the fistula has developed, the client has had time to take control of the leaking, by wearing pads or other forms of protection. These women are often also very depressed after the still- birth of their child. Eighty per cent of the women have been married by age 16 and have become preg- nant by age 18. The fistula typically has developed in that time. Clients are usually accompanied by their mothers, rarely by their husbands. Assessment and screening process: • Physical exam is done. • Clinical assessment done (blood type determined, blood count taken to check for anaemia). • Electrocardiogram. • Sometimes x-rays are taken, if necessary. • Type and dimensions of fistula are also deter- mined. Post-operative care: • Clients are hospitalized for 10 to 14 days after the operation. • A catheter is inserted to make sure urine exits though the catheter and not from the vagina; client is observed to ensure no further complica- tions arise. • Antibiotics given. • Advised to abstain for at least two months, and to return to the hospital if they get pregnant to seek antenatal counselling and care from the gynaecol- ogist. They are told to make sure their next birth occurs in a hospital setting. Rehabilitation/reintegration: None noted. Husband almost invariably takes them back once fistula is closed. Community outreach: Women’s NGOs intervene at various levels. Perceived support at the policy level: The Ministries of Public Health and Social Development organize visits to see fistula clients. They also make efforts to sensitize others by visiting centres with members of national NGOs and sometimes with members of embassies, including Canada, France and the United States. These visits usually result in donations of food and clothing. Estimated fully-loaded cost per procedure: $55 USD is the quoted price, fully loaded is likely to be more. Resources: Costs of procedure (hospitalization, operation and medication) used to be fully funded by a French cooperative, Falandry, which received more than $150,000 from the French government some years ago. The money has since been exhaust- ed, and women now pay for the procedures themselves, financing it any way that they can. Barriers: • Before intervention from CARE Africa in the form of a fistula workshop, doctors worked alone, with- 50 Fact Sheets on Niger Site Visits out support of others doing the same repairs. The situation is somewhat better now that there is more collaboration. • Financing for repairs must be made available. Initiatives to advocate for funds for fistula repair need to be in place. Additional Notes on Niamey National Hospital Fistula Pavilion This situation is a very special case. In an isolated p a rt of the hospital grounds a pavilion holds about 50 women, many of whom who have been wa i t i n g for several years to be treated. These women live within the walls of this enclave, where they are ostracized by other female residents of the hospital, who consider them to be unclean. They all have fis- tula, some for the second or third time. They are all waiting for help. They are all waiting to go home. To date, they have still not been treated because they have no money to pay for the surgery. It was remarkable to talk with these women, who, despite the suffering they live with every day, laugh and remain hopeful that they will one day be able to lead normal lives again. One recently broadcast radio programme labelled them as totally abandoned, without family and friends, tired and depressed; but in reality, most of them have family whom they visit occasionally. They are taught vari- ous activities to pass the time. They cook for each other, sew and braid each other’s hair. They live together, waiting. Encouragingly, the NGO DIMOL has received funding from Oxfam-Québec to build a fistula repair centre in Niamey. Construction has not yet begun, but they have taken action to begin financ- ing surgery for the women at the pavilion. Operations, which will take place at Lamordé and at the National Hospital, are scheduled to begin in November 2002. B. Hôpital de Lamordé (Lamordé Hospital), visite d 8 October 2002 Size: 72 beds, six of which are reserved for fistula clients; two operating theatres and one recovery room. Medical staff: Dr. Oumourou Sanda, the head fistula surgeon, leads a team of five surgeons, including two urologists, one general surgeon, one pediatric surgeon, and one trauma surgeon. Six surgery nurses and 11 hospitalization nurses, four of whom are involved in post-operative care. Caseload: Three to four operations per week, and as many as 200 per year. Last year, there were about six cases of RVF. However, on 7 October 2002, Dr. Sanda operated on a nurse from a hospital in Zinder, a large city in the southeastern part of the country. She had both VVF and RVF. She was oper- ated on in Zinder, and the VVF was repaired. But when they tried to repair the RVF, four attempts proved unsuccessful. She was then referred to Lamordé where the RVF was repaired. Provenance of clients: All over the country. Some from Burkina Faso, Mali and Nigeria. Most Nigerien women are from the department of Tillabéry, because Lamordé is easy to get to from there. There are also referrals from the maternity hospital in Niamey. Women are put on a waiting list to receive service. There is a huge backlog. Typical client profile: Impoverished, the majority (89 per cent) are illiterate; most are housewives with an age range of 15 to 35. It was explained that the older cases are usually of very high parity, resulting in fragile uteruses that rupture during pregnancy or labour. Most women are accompanied by their mothers, a sister or an aunt. Almost all are divorced, which in Niger does not consist of paperwork and lawyers but rather a separation. 51 Assessment and screening process: • Standard clinical assessment; the urinary area is sterilized in preparation for the procedure in case of infection. • Operation is then scheduled. • Blood type is determined. • Other tests performed if needed. Post-operative care: • A catheter is inserted for two weeks, and clients are observed. The catheter is then removed to check for incontinence. If a woman continues to be incontinent, she is watched closely for about a week. Sometimes, this is enough time for the wound to continue healing on its own. • Clients are counselled by a social worker about contraception, what to do in the event of future pregnancies and to abstain from sexual relations for three months. • Clients are advised to return in three months to consult with the urologist, who asks them if they want to return to their husband. Most choose not to go back because they are hurt and angry about being abandoned. Some women do not return for a consultation after the three months, and later get pregnant again, deliver at home again and return to the hospital, their fistula reopened. Of these cases, there is a 16 per cent failure rate. Rehabilitation/reintegration: Only the help of the social worker, who counsels them and answers any questions clients may have. Community outreach: The European Union runs a social service that gives affidavits to women who can- not afford the procedure. This helps some women. Perceived support at the policy level: None. It was explained that to date no one from the govern- ment has visited the site, or acknowledged the work being done there. Members of the surgical team are concerned because Niamey National Hospital receives support. However, at Lamordé, where the caseload is larger, there is no support at all. Estimated fully-loaded cost per procedure: 30,000 CFA, about $45 USD. Women also pay 2,500 CFA, approximately $4 USD, for a hospitalization of up to one month, sometimes more. Clients pay for their own medications. Resources: Support from the state, which covers salaries; internal resources, which is income generat- ed from clients; and donations from various sources. Barriers: • Lack of political support. The work they are doing needs to be better recognized on a national level so that specific initiatives can be taken by the government to help clients and the providers who treat them. • Insufficient medication and equipment. • Inadequate facilities. Designating or constructing a new building exclusively for fistula clients would help alleviate the current backlog. • Bureaucratic slowdown. Any outside funding propositions or programme plans need to be presented directly to the clinicians in charge, who understand and manage the situation day to day. Too often when plans are made by adminis- trators, the information stays at the top and does not involve those whom the plans directly affect. C. District Sanitaire de Loga (District Hospital of Loga), visited 10 October 2002 Size: 28 beds; two operating theatres, only one of which is currently functional. Medical staff: 18 in total, including two doctors, though only one OB/GYN, Dr. Moustapha Diahllo, does fistula repair; two midwives; one medical/sur- geon’s assistant; one anaesthetist; and three laboratory technicians. The rest are nurses and contractual workers. Caseload: Not very large. Since November 2001, only three cases have been seen. Because the oper- ating theatre is not always usable, many women are not aware that fistula repair can be done here. The surgical team spoke with a woman named Barakatou who was married at 17 and developed fis- tula at 20. She claims that there are many women in the region who are suffering, but don’t know that they can be cured at Loga. Many of them have no home life and live as she did before having her operation. Being abandoned by her husband pushed 52 her to seek help. She was repaired, returned to her husband, got pregnant several months later and came to Loga to have a C-section. Provenance of clients: They come from the villages surrounding Loga. In one case, a woman who was in prolonged labour at one of the cases de santé (health huts) was brought by ambulance (provided for by UNFPA Niger) because that hut had radio contact with the district hospital. Typical client profile: Most are housewives whose husbands are agriculturists. They are very young. Only in one of the three cases mentioned above was the woman separated/divorced from her husband. Another one of the women had fistula for 10 years and her condition was too complicated to repair. She was referred to Niamey. Community outreach: Information is usually spread by word of mouth. UNFPA finances certain awareness campaigns. For example, these cam- paigns may include meeting with women in the community to give them health messages about HIV, immunizations or available delivery services. Perceived support at the policy level: None. Estimated fully-loaded cost per procedure: The cost quoted was the same as for other operations, about $15 USD. This amount covers all costs. Resources: Federal funding. UNFPA provided funding to construct the new operating centre and also provides technical assistance such as supplies and training. Barriers: • Existing personnel need to be trained. The doctor who currently performs fistula repair does not operate on complex fistulas, but refers them to Niamey. If he and a surgical team were trained properly, this delay would not be necessary. • A system needs to be in place to inform the com- munity that fistula repair is possible at Loga. • The current budget is not sufficient for necessary supplies such as suture materials, anaesthesia and oxygen. • Lack of space. There are only eight beds—four for women and four for men—available for recovery. More beds are necessary, especially in the event that more fistula cases arrive. D. Maternité Centrale de Zinder (Central Maternity Hospital of Zinder), visited 11 October 2002 Size: 45 beds; one operating theatre specifically for fistula repair, which was converted from some sort of examination room; one delivery room. A new fis- tula treatment centre funded by La Coopération Française and located next door was constructed in 2001. However, because the operating equipment ordered has not yet arrived from Europe, the cen- tre is not yet running. Fistula repair is currently performed in the maternity hospital. Medical staff: 60 agents: two OB/GYNs, six midwives, two anaesthesiologists and one med- ical/surgery assistant, with the remainder being nurses and laboratory technicians. Both Dr. Lucien Djangnikpo and his associate have been trained in fistula repair at the Katsina Centre in Nigeria. Caseload: According to Solidarité, the NGO created by health providers at the maternity hospital to mobilize funding for the new fistula centre, 259 sur- geries were performed between 1998 and 2001. There are an estimated 10,000 cases nationwide. However, it is thought that the actual number is much high- er: as many as 25–30 per cent of Nigerien women with fistula go to Nigeria to be treated. Provenance of clients: Mostly from the region of Zinder (32 per cent); some are from Nigeria. There are also some women who come from the Diffa and Maradi regions of Niger. Typical client profile: Women who live in rural zones make up 90–100 per cent of the cases that are seen. Most are younger than 17 and are primi- gravidus. The surgeons have operated on some women who have undergone FGM. Two years ago, one young woman, her name unknown, came to the hospital to receive treatment for her first fistula, which developed when she was fifteen. She had been abandoned by her husband and had spent over a year looking for help. After her recovery, her family pushed to get her husband to take her back. He did, but he had already taken another wife. She rejoined the family as the second wife and got preg- nant shortly after. Although advised during her post-operative care to return to the hospital during 53 the seventh month of her next pregnancy to pre- pare for a C-section, she could not come because her husband had travelled and had not returned. When she delivered at home, labour complications ensued and a fistula once again occurred. Assessment and screening process: • Exam conducted to determine that fistula is the source of the incontinence. • The fistula’s location assessed, and its type and size are determined. • Clients are examined using instruments that are exposed to open air. • A catheter is inserted as soon as a diagnosis has been made. If the fistula developed less than three months earlier, it is possible to see a signifi- cant reduction or total closure approximately one week after the catheter is inserted. • The operation is performed vaginally; no abdomi- nal cutting is necessary. Post-operative care: • Clients remain in the hospital for at least one month. • The catheter remains in during this period. Clients are instructed by the OB/GYN to drink lots of water so that there is a continuous stream of urine through the catheter inserted after surgery and left in for four weeks. According to the surgeon, this practice reduces the likelihood of infection and removes the need for antibiotics (despite information that the risk of infection increases 10 per cent every day the catheter is left in over seven days). • No antibiotics are administered during the post- operative phase. • Personal hygiene of the vaginal area is recommended. • Removable sutures are left in for four weeks, after which they are removed without anaesthesia. • Despite the presence of 26 beds in a newly con- structed fistula centre, women recover in a shed outside the hospital. Mats on the floor serve as places to sleep. • Six months of abstinence is recommended. • Clients are advised to return during the seventh month of their next pregnancy to receive antenatal care and to prepare for a C-section. Rehabilitation/reintegration: An action plan written by Solidarité specifies that these services will be provided for women who have been treated at the fistula centre. They have yet to start, howev- er, since the centre is waiting for the arrival of equipment before initiating any of these kinds of activities. The centre also hopes to train women in a skill that will allow them to provide for them- selves. Women who have had fistula for 10 to 15 years are likely to have lived in terrible shame and may resort to commercial sex work once they are repaired as a way to seek an immediate income to survive. Community outreach: A lot of outreach is done on the radio, with the message that fistula is a repairable problem broadcast in local languages. Perceived support at the policy level: Local officials are aware of the problem. The mayor of Zinder donated the land for the new fistula centre. Zinder’s Sultan visits often, as does the First Lady. Estimated fully-loaded cost per procedure: Solidarité covers the cost of the entire procedure. Costs to the hospital listed in the action plan budg- et include: room and board, $750 USD a year; client reinsertion at $15,000 USD a year; and medications at $23,400 USD a year. Given that the number of cases treated a year is roughly 75, it can be estimat- ed that the cost for a single procedure would run to about $750 USD, although the surgery is free to clients. Resources: Solidarité. No state subsidy. They want to see the centre integrated in the state budget. Barriers: • They are still at the beginning. The centre is not yet operational, though its beds could be used for women in recovery. Currently, clients recover in an open shed outside the hospital and sleep on mats. • Staff could receive updates on infection preven- tion practices, such as the development of a protocol on the use of post-operative antibiotics and the maintenance of a sterile field in the operating theatre. 54 E. Hôpital Regional de Maradi (Regional Hospital of Maradi), visited 13 October 2002 Size: 330 beds, 14 of which are reserved for post- operative care; three operating theatres, one of which is reserved for fistula surgery. Medical staff: 143 agents, 81 of whom are medical professionals. One Nigerien surgeon and three Chinese surgeons, one of whom performs fistula repair. According to Dr. Ousseini Boulama, the Hospital Director, there are no local fistula surgeons at the moment. Providers from the Katsina centre in Nigeria were frequent support- ers, coming twice a week to help with fistula operations. Because of some difficulties, however, the Katsina physicians stopped coming. They are expected to return after this season’s harvest. Caseload: During the first half of 2002, only one case was operated on. When the Nigerians were assisting the staff in Maradi, the caseload was much higher. In 2001, 17 cases were seen and not all were operated on. Provenance of clients: Women come from all over the region and also from Nigeria, whose border is 70 km away. Typical client profile: Young, usually abandoned by their husbands. They are often hopeless and alone, as they may also have been abandoned by their families. They are often malnourished; how- ever this is not necessarily specific to the women who come for fistula repair, as it is not unusual for Nigerien women to be undernourished. Many have undergone FGM as excision is very common in the region of Maradi. Assessment and screening process: • Surgery is usually performed during the week that a woman arrives. • A general clinical assessment is done. Post-operative care: • Clients generally remain at the hospital for three to four weeks. • During this time, client hygiene is monitored, antibiotics are given and the catheter is checked every morning to make sure it is not leaking or blocked. It is possible to inject blue ink into the bladder in the case of leaking to determine where the leak is coming from. • Clients are also encouraged to get up and walk around every day to regain muscular strength. Rehabilitation/reintegration: None noted. There is no problem of reinsertion after the fistula is closed, but the hospital does not intervene at that level. Community outreach: A forum of village chiefs and religious leaders organized by UNICEF was held to raise awareness about the need to fight against early marriage. The hospital recommended that a committee be created at a political level to manage such an effort, but to date nothing has been done. Perceived support at the policy level: Not available. Estimated fully-loaded cost per procedure: The oper- ation is free. Women pay for their own medications. Resources: Only the state support that is required for a regional hospital. Barriers: • Must find a way to help the hospital pay for medications, which would substantially relieve financial pressure on clients seeking care. • Women often go back to their husbands because they cannot support themselves. Training in income-generating skills at the hospital might help clients make post-operative decisions out of personal choice, not economic need. • No community level investment in the impor- tance of antenatal care. Women who are very young and forced to marry are often ashamed to show their pregnancy in the village and resort to staying home instead of consulting health profes- sionals for antenatal recommendations. • UNICEF did a study in 1998 to see why so many women were still delivering at home, and the results showed that: 1) Women are cloistered at home for religious reasons; 2) They receive no financial help from their husbands to seek hospi- tal care; 3) Socially, the subordinate position of women makes it difficult for them to make their own decisions; and 4) They were ashamed to emerge pregnant in the village. 55 Key Contacts The needs assessment team is deeply grateful to the following individuals in Niger for their assistance with this project. UNFPA Country Office Nathalie Maulet, UN Volunteer Ministry of Health Mr. Issa Boubacar, Director, Division of Social Protection and National Solidarity Dr. Adamou Hassane, Director of Public Health District Hospital of Loga Dr. Moustapha Diahllo, OB/GYN Issaka Gazobi Maternity Hospital of Niamey Dr. Madi Nayama, Chief OB/GYN Lamordé Hospital Dr. Oumourou Ganda, Head Urologist and fistula surgeon Mr. Adoumou Aziz, Head Nurse Mr. Salifou Boubacar, Head Surgical Nurse Dr. Fatima Djaharou, Anaesthesiologist Dr. Amadou Soumana, Assistant Urologist Maradi Regional Hospital Dr. Ousseini Boulama, Hospital Director Niamey National Hospital Dr. Amadou Seïbou, Chief Surgeon Zinder Central Maternity Hospital Dr. Lucien Djangnikpo, Chief OB/GYN DIMOL Ms. Salamatou Traoré, President CARE Niger Mr. Omar Tankari, Coordinator, Civil Society and Education Sector CONGAFEN Ms. Maémouna Niendou, Permanent Secretary CONIPRAT Ms. Ouassa Djataou, Vice President OB/GYN Society of Niger Dr. Nafio Idi, President Oxfam-Québec Ms. Fatima Ibrahïma, Organizational Adviser of Development Solidarité Ms. Hadizhatou Ibraïm, Vice President 56 Background Nigeria boasts an abundance of natural and human resources. Yet the country’s per capita income of $350 USD is one of the lowest in the world. With an estimated 120 million citizens, Nigeria is Africa’s most populous country. Its citizens, however, come from diverse backgrounds and live in very different cultures, so some have noted that Nigeria feels more like a combination of many countries, with especially notable differences between the North and South. This division is echoed in the way fistula appears to occur across the country: far more cases seem to develop in the North than in the South. It should be noted, however, that information about prevalence is very hard to capture at the communi- ty level and the data available come from hospital records. Nonetheless, no matter where and how fistula occurs in Nigeria, it is clear that it is a large and growing problem across the country. The fertility rate has dropped from 6.0 in 1990 to the current 5.42. In addition, UNFPA’s State of World Population 2002 reports a maternal mortality ratio of 1,100 deaths for every 100,000 live births. Throughout the country, it appears that Nigerians favour large families, with 66 per cent of women and 71 per cent of men indi- cating a desire to have more children. Knowledge about family planning is on the rise, with 65 per cent of women and 82 per cent of men aware of at least one kind of birth control. In practice, 15 per cent of married women now use some form of contraception, with 9 per cent of women choosing a modern method. Sixty-four per cent of women receive antenatal care, with the median number of visits, six. However, the first visit generally occurs as late as the fifth month of pregnancy.29 In addition, 30 per cent of women receive no antenatal treatment at all, with adolescent mothers and those who live in rural areas particularly unlikely to receive care. Many women in the north seek antenatal care, but deliv- er at home in part because they report finding the squatting position more comfortable for delivery than the supine position preferred at health facili- ties. While, across the country, many women still deliver at home, since 1990 the percentage of births in facilities has increased from 31 per cent to 37 per cent. Nonetheless, 58 per cent of women are not attended at all during labour and delivery.30 The following information may create an even clearer sense of who these mothers are. Forty-one per cent of women have had no formal education at all, compared to 25 per cent of men. As of 2001, 5.83 per cent of Nigerian women live with HIV/AIDS, with 1,700,000 women between the ages of 15 and 49 carrying the virus. The median age at first marriage is 19 for urban women and 17 for rural women, higher for more educated women and varying from 15 years in the northeast and northwest regions to 20 in the southeast and southwest regions. In some communities, it is taboo for a girl to reach menarche in her mother’s house; it is seen as imperative that she be married before this event occurs. In the North, if her vagina has been found to be too narrow and immature to allow consum- mation of the marriage, it may be widened via the Gishiri cut, which may be used not only for this purpose but as a cure for other medical ailments, such as a cold. In the south and central regions of the country, one in four Nigerian women aged 15 to 49 reported FGM. Issues and Challenges Visits to 12 sites around the country produced an alarming and complex picture of the frequency, prevention and treatment of fistula in Nigeria. While exact prevalence rates are not known, it is estimated that between 100,000 and 1,000,000 Nigerian women live with the condi- tion. Even the training of new fistula surgeons has not reduced the number of cases awaiting repair, as 57 N I G E R I A new cases occur faster than existing ones can be treated. The educational, economic, cultural and religious divide that exists between the northern and southern regions of the country extends when it applies to fistula as well: far more women are treated in the North than in the South. However, fistula develops in both areas for many of the same reasons: most are obstetric in origin and occur during deliveries that are handled by TBAs, relatives and friends or without any assis- tance at all. The majority of women in the country suffer fistula at a young age, most often in conjunction with their first vaginal delivery, with stillbirth a common result. They are usual- ly poor, of small stature and unmarried or get divorced/separated as soon as their husband real- izes that their condition is complicated, lingering and costly to treat. However, more and more frequently, especially in the southern regions of the country, a previously atypical picture is emerging: 25 to 45-year-old married women, who have had previously successful vaginal deliveries, are developing fistula. These women tend to stay mar- ried and cared for. In fact, at a few sites, hostels for men have been set up so that they can be nearby to give assistance and comfort. It is unclear why this is occurring, but it may be that since subsequent babies tend to be heavier, mothers are more vulner- able to obstructed labours. In addition, some fistulas reportedly occur in facilities, as noted in other countries as well. Another notable feature is that, especially in northern states, some women have successful fistula surgery, but do not return for delivery in a hospital and suffer another fistula. More than 5 per cent of fistulas at one northern site are reported to be recurrences. Some women have had four or even five repairs after an initial successful one. Although it is tempting to point to poor infrastructure or inadequate access to facilities as explanations, most of these women come from a radius of less than 10 km from the hospital, so one reason may be the need for many women to obtain the approval of their husbands before seeking care. The overwhelming cultural preference for giving birth at home (especially for the first baby) coupled with a strong dislike of delivery by C-section could be another. Some surgeons also report that a C-sec- tion may not be necessary after a successful repair. However, a new phenomenon may also be responsible. Over the last 10 years, poverty has engendered a spiritual revival, which has resulted in many women choosing to deliver their babies in churches. While this practice is not entirely new, it has recently become more com- mon. Although the delivery care they receive here is unskilled, women sometimes believe that they will be protected from satanic forces or witchcraft enacted by jealous or wicked neighbours. The government has created a national task force on fistula and supported initiatives to train nurses and surgeons, advocate for women, create community awareness programmes, rehabilitate and reintegrate fistula patients back into the community and gather data about fistula. However, the fistula situation in Nigeria remains critical and is only growing more

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