Category Archives: Obstetrics

30,000 women have an untreated vesicovaginal fistula

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In Ethiopia about 30,000 women have an untreated vesicovaginal fistula. Most often this is the result of complications of neglected, prolonged or obstructed labour.

At our new Fistula Unit in Arba Minch we collaborate with the Fistula Hospital in Addis Ababa in Ethiopia. This hospital in Addis Ababa is dedicated only to the care of women with obstetric fistulae, and treating other physical and social injuries.

In their experience, this vesicovaginal fistula often results in other injuries. More than half of the patients will be divorced and excluded from religious activities, their home, public transport and health institutions. Patients with fistulas have more than a ‘hole’ between the bladder and vagina, and often have physical, psychological and social problems, stress and urge urinary incontinence, hydronephrosis, renal failure, rectovaginal fistulae, secondary infertility, vaginal scarring and damage to the nerves (foot drop).

You can read a review of the experiences from the Fistula Hospital in Addis Ababa in a paper in by Professor Gordon Williams in The Surgeon (February 2007 Vol 5 No 1).

About obstetric fistulas

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The vesico vaginal fistula (VVF) is as old as mankind, and has always been a source of misery of the affected women. Most communities consider these women as outcasts, because they leak urine down their legs, their clothes are wet, and the women smell.

The main case of VVF is obstructed labour which is not relieved in time by a caesarean section. The vagina and bladder walls become compressed between the foetal scull and the maternal pelvis, resulting in pressure necrosis. This results in obstetric fistula.

Obstetric fistulas have disappeared in the industrialized countries. In developing countries it is a public health problem, and 1-2 women per 1000 deliveries end in obstetric fistula.

In south-west Ethiopia we work on a programme to reduce maternal deaths and obstetric fistulas. With an estimated population of 2.6 million, and a crude birth rate of 38/1000, we have estimated that about 800 women die every year and 150 women get an obstetric fistula.

The main aim of our current work in south Ethiopia is to reduce these death and fistulas.

Obstetric fistula in Arba Minch

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In Ethiopia, obstetric fistula remains one of the most visible indicators of inadequate maternal health care. Obstetric fistula still exists because health care systems fail to provide accessible, quality maternal health care, including family planning, skilled birth attendance, and basic and emergency obstetric care, and affordable treatment of fistula.

Thankfully, prevention and treatment of obstetric fistula has during the last three years gained attention in South Ethiopia. In 2005, the Yirga Alem Fistula Hospital opened. This was build with Norwegian support, and Addis Ababa Fistula Hospital runs the unit.

This week, we opened the second Fistula Unit in Arba Minch in south Ethiopia. It is a private gift. Altogether it has a new delivery (16 beds) and gynaecological (40 beds) wards, new outpatient departments for women and children, and a 24-bed fistula unit, and two new operation theatres. Through this work we hope to reduce maternal deaths and reduce obstetric fistulas.

We have agreed with the local government and peasant associations to help us in finding women with fistulas.

During the past two years, 250 women from this area were operated in Yirga Alem. Now they do not need to travel 250 km to get treatment.

Our work shall be done in close collaboration the Addis Ababa Fistula Hospital and with the Unit in Yirga Alem.

Doctors and non-physician clinicians (NPC)

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There is a severe shortage of trained health staff in rural Africa. We try to solve this issue by using doctors and non-physician clinicians (NPC). A recent problem we have seen in south Ethiopia is that these two categories of health personnel do not collaborate.

As non-physician clinicians (NPC) take over doing surgical tasks, the doctors withdraw from this important part of the work. General practitioners work on internal medicine and paediatrics, leaving surgery and obstetrics to NPC. In one hospital we have also seen the physician, who has only one year of clinical experience, leave the hospital when the non-physician clinician (NPC) started work.

This is a trend that worries us, and we need to find mechanisms to promote the collaboration between the two professions.

Any suggestions to solve this unhealthy competition?

Sustainability and task shifting in Africa

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Recently Kathryn Chu and colleagues  wrote  a very good discussion on the topic of using non-physician clinician in emergency surgery (see Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078)

In a response to their paper, I wrote a comment on PLoSMedicine:

Kathryn Chu and colleagues are to be commended for their paper on “Surgical Task Shifting in Sub-Saharan Africa”.

I work on a project to train non-physician clinicians (NPC) in Emergency Obstetrics and surgery in south Ethiopia. The Ministry of Health collaborates and recognizes the training. It is a programme for public institutions, and it consists of four months basic training, followed by two months of supervisory visits to their home institutions. An important part of the project is also to support the peripheral institutions with essential equipment.

Our experience is similar to those from Mozambique and shows that using NPC for essential surgery and obstetrics is workable. Complication rates are low. As expected, we see that staff with some years of clinical experience perform better that those coming directly from school.

As many institutions have only one trained NPC, their sustainability is often threatened, and work might be discontinued during week-ends, vacations and needed travels. Each institution needs more than one team to become sustainable.

Too often, staff receive training and acquire basic skills to return to their home institution where it is not possible to do the tasks they trained for because of lack of follow up, surgical equipment or materials. For programmes to succeed, we think it is important to continue supporting the peripheral institutions.

As most peripheral hospitals and health centres are public, and to ensure sustainable performance, we believe the national or regional health authorities should own or be a part of the programme. This would allow for needed professional and political recognition, provision of necessary incentives and continued recruitment of essential staff.

Non-physician clinicians

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We have good experience from sub-Saharan Africa, that task shifting from doctors to non-physician clinicians can address the HIV/AIDS treatment, improve tuberculosis control and manage health problems in children (IMC). Similarly, some operations usually done by surgeons and anaesthesiologists can be safely done non- specialists.

Surgical care is the safe provision of preoperative, operative, and post-operative surgical and anaesthesia services. Unfortunately, there are too few surgeons in Africa, and it is unlikely that a modest increase in the number of surgeons and anaesthesiologists will occur.

In HIV care, we recognized the Western model of care with medical specialists in secondary and tertiary hospitals, could not be copied in Africa. By adapting and selecting treatment protocols and task shifting, it was possible to treat millions of patients received antiretroviral drugs. Similarly, it is important in the surgical fields to avoid creating “islands of excellence in a sea of under provision”.

By enabling non-physician clinicians to do some essential operations, we may increase benefits while lessening harm among populations where the unmet need of surgical care is great.

Please also see a very good discussion on this topic written by Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078

For more information about our training programme in Ethiopia click here.