Fistula Care Plus Associate Cooperative Agreement AID-OAA-A14-00013 Annual Report October 1, 2016 to September 30, 2017
Managing Partner: EngenderHealth; Associate Partners: The Population Council, Dimagi, Direct Relief, Fistula Foundation, Maternal Health Task Force, TERREWODE
Submitted to United States Agency for International Development Washington, D.C.
November 30, 2017
EngenderHealth 440 Ninth Avenue, New York, NY 10001, USA Telephone: 212-561-8000 Fax: 212-561-8067 E-mail: [email protected]
Copyright 2017. EngenderHealth/Fistula Care Plus. All rights reserved.
Fistula Care Plus (FC+) c/o EngenderHealth 440 Ninth Avenue New York, NY 10001 U.S.A. Telephone: 212-561-8000 Fax: 212-561-8067 E-mail:[email protected] www.fistulacare.org
This publication is made possible by the generous support of the American people through the Office of Maternal and Child Health, U.S. Agency for International Development (USAID), under the terms of cooperative agreement AID-OAA-A14-00013. The contents are the responsibility of the Fistula Care Plus project and do not necessarily reflect the views of USAID or the United States Government.
TABLE OF CONTENTS
TABLE OF CONTENTS ...... 2 ACRONYMS AND ABBREVIATIONS ...... 4 TABLES ...... 6 FIGURES ...... 7 EXECUTIVE SUMMARY ...... 8 INTRODUCTION ...... 10 SECTION I: MANAGEMENT ACTIVITIES ...... 11 OVERVIEW...... 11 STAFFING AND RECRUITMENT ...... 11 PROJECT MANAGEMENT ...... 11 PARTNERSHIP: GLOBAL AND COUNTRY-LEVEL ...... 12 LEVERAGING FC+ FOR ADDITIONAL FISTULA PROGRAMMING ...... 15 INTERNATIONAL CLINICAL SUPPORT AND TECHNICAL ASSISTANCE (TA) TRAVEL ...... 16 MEETINGS ...... 17 FUNDING ...... 21 SECTION II: GLOBAL ACCOMPLISHMENTS ...... 22 FISTULA CARE PLUS ACHIEVEMENTS ...... 22 OBJECTIVE 1: STRENGTHENED ENABLING ENVIRONMENT TO INSTITUTIONALIZE FISTULA PREVENTION, TREATMENT, AND REINTEGRATION IN THE PUBLIC AND PRIVATE SECTORS ...... 23 OBJECTIVE 2: ENHANCED COMMUNITY UNDERSTANDING AND PRACTICES TO PREVENT FISTULA, IMPROVE ACCESS TO FISTULA TREATMENT, REDUCE STIGMA, AND SUPPORT REINTEGRATION OF WOMEN AND GIRLS WITH FISTULA ...... 32 OBJECTIVE 3: REDUCED TRANSPORTATION, COMMUNICATIONS, AND FINANCIAL BARRIERS TO ACCESSING PREVENTIVE CARE, DETECTION, TREATMENT, AND REINTEGRATION SUPPORT ...... 34 OBJECTIVE 4: STRENGTHENED PROVIDER AND HEALTH FACILITY CAPACITY TO PROVIDE AND SUSTAIN QUALITY SERVICES FOR FISTULA PREVENTION, DETECTION, AND TREATMENT...... 36 OBJECTIVE 5: STRENGTHENED EVIDENCE BASE FOR APPROACHES TO IMPROVE FISTULA CARE AND SCALED UP APPLICATION OF STANDARD MONITORING AND EVALUATION (M&E) INDICATORS FOR PREVENTION AND TREATMENT...... 48 SECTION III: COUNTRY REPORTS ...... 55 BANGLADESH ...... 55 DEMOCRATIC REPUBLIC OF CONGO ...... 65 NIGERIA...... 74 UGANDA ...... 90 WEST AFRICA/NIGER (WAN) ...... 106 APPENDIX A: FC+ PLANNED AND ACTUAL SUPPORTED SITES, FY 16/17...... 113 APPENDIX B: FC+ PARTNERSHIPS, BY COUNTRY ...... 115 APPENDIX C: NUMBER OF USAID-SUPPORTED FISTULA REPAIR SURGERIES BY COUNTRY, SITE AND YEAR ...... 117 APPENDIX E: FC/FC+ PUBLICATION READERSHIP METRICS ...... 139
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APPENDIX F: FC+ PRESENCE AT 2016 IOFWG AND ISOFS ...... 141 APPENDIX G: FC+ CLINICAL MEETING AGENDA AND PARTICIPANT LIST ...... 144 APPENDIX H: CATHETERIZATION FOR FISTULA PREVENTION AND TREATMENT: OPPORTUNITIES FOR PARTNERSHIP ...... 146 APPENDIX I: CESAREAN SECTION TECHNICAL CONSULTATION EXECUTIVE SUMMARY ...... 148 APPENDIX J: CESAREAN SECTION TECHNICAL CONSULTATION MEETING AGENDA ...... 149 APPENDIX K: CESAREAN SECTION TECHNICAL CONSULTATION PARTICIPANTS ..... 151 APPENDIX L: LANDSCAPE OF CAESAREAN SECTIONS IN SUB-SAHARAN AFRICA AND SOUTH/SOUTHEAST ASIA - DRAFT EXECUTIVE SUMMARY ...... 153 APPENDIX M: HRH FORUM PROGRAM FLYER ...... 159 APPENDIX N: SBA SURVEY ANNOUNCEMENT...... 160 APPENDIX O: ICM 2017 PANEL ADVERTISEMENT ...... 162 APPENDIX P: 31ST ANNUAL ICM CONGRESS PANEL ...... 163 APPENDIX Q: ICM PANEL PRESENTATION: PROLONGED/ OBSTRUCTED LABOR...... 168 APPENDIX R: BRIEFING ON LINKAGES BETWEEN FISTULA AND FGM/C ...... 174 APPENDIX S: PRIMARY HEALTH FACILITY SCREENING FISTULA JOB AID...... 184 APPENDIX T: COMMUNITY AGENT FISTULA SCREENING JOB AID ...... 185 APPENDIX U: FISTULA SCREENING HOTLINE ALGORITHM ...... 186 APPENDIX V: BARRIER REDUCTION STUDY BRIEF: EBONYI ...... 190 APPENDIX W: BARRIER REDUCTION STUDY BRIEF: KATSINA ...... 193 APPENDIX X: BARRIER REDUCTION STUDY BRIEF: UGANDA ...... 196 APPENDIX Y: FC+ CALL FOR CONCEPT PAPERS ON SECONDARY ANALYSIS OF CLINICAL DATA ...... 199 APPENDIX Z: FC+ ANNUAL PARTOGRAPH MONITORING: FY 14/15 ...... 201 APPENDIX AA: FC+ ANNUAL PARTOGRAPH MONITORING: FY 15/16 ...... 204 APPENDIX BB: FC+ ANNUAL PARTOGRAPH MONITORING: FY 16/17 ...... 207 APPENDIX CC: EH ANNUAL CDDM MEETING AGENDA ...... 210 APPENDIX DD: FC+ SUPPORTED TREATMENT SITES MEETING TO DISCUSS DATA ... 215 APPENDIX EE: MEDIA COVERAGE IN FC+ COUNTRIES, FY 16/17 ...... 217 APPENDIX FF: FY 16/17 FC+ COUNTRY REPAIR DATA VISUALIZATIONS ...... 220 APPENDIX GG: FC+ CORE INDICATORS: ANNUAL ACHIEVEMENTS ...... 223
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ACRONYMS AND ABBREVIATIONS ACOG ...... American College of Obstetricians and Gynecologists ANC ...... Antenatal Care BMGF ...... Bill and Melinda Gates Foundation BMMMS ...... Bangladesh Maternal Mortality Survey brac ...... Bangladesh Rural Advancement Committee BSMMU ...... Bangabandhu Sheikh Mujib Medical University C-Section ...... Cesarean Section CBO ...... Community Based Organization CCBRT ...... Comprehensive Community Based Rehabilitation in Tanzania CE ...... Community engagement COSECSA ...... College of Surgeons of East, Central and Southern Africa CPR ...... Country program review CSME ...... Maternal and Child Health Center (Centre de Santé Mère / Enfant) CNRFO ...... Centre National de Référence pour la Fistules Obstétricales CYP ...... Couple-Years of Protection DDM ...... Data for Decision Making DGHS ...... Directorate General of Health Services DHIS ...... District Health Information System DHS ...... Demographic and Health Survey DOVENET ...... Daughter of Virtue and Empowerment Initiative DRC ...... Democratic Republic of the Congo ECOWAS ...... Economic Community of West African States ECSA ...... East, Central and Southern Africa ECSACOGS ...... East, Central and Southern Association College of Obstetricians and Gynecologists EmOC ...... Emergency Obstetric Care EmONC ...... Emergency Obstetric and Neonatal Care ESOG ...... Ethiopian Society of Obstetrics and Gynecology FBO ...... Faith Based Organization FC ...... Fistula Care FC+ ...... Fistula Care Plus FCoP ...... Fistula Community of Practice FF ...... Fistula Foundation FIGO ...... International Federation of Gynecology and Obstetrics FMOH ...... Federal Ministry of Health (Nigeria) FP ...... Family planning FY ...... Fiscal year GOB ...... Government of Bangladesh HC ...... Health Center HGR ...... General Reference Hospital HMIS ...... Health Management Information System HSD ...... Health Services Delivery ICM ...... International Confederation of Midwives IDB ...... Islamic Development Bank IGL ...... Imagerie des Grand Lacs IMAN ...... Islamic Medical Association of Nigeria IOFWG ...... International Obstetric Fistula Working Group IRB ...... Institutional Review Board ISOFS ...... International Society of Obstetric Fistula Surgeons
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IUCD ...... Intrauterine contraceptive device IVR ...... Interactive voice response LARC ...... Long acting reversible contraceptives LGA ...... Local Government Area MAF ...... Medical Aid Films MCH ...... Maternal and Child Health MCSP ...... Maternal and Child Survival Program ME&R ...... Monitoring, evaluation and research M&E ...... Monitoring and evaluation MHTF ...... Maternal Health Task Force MNCH ...... Maternal, Newborn and Child Health MOH ...... Ministry of Health MOHFW ...... Ministry of Health and Family Welfare MSRK ...... Maternité Sans Risque de Kindu NOFIC ...... National Obstetric Fistula Center NFTWG ...... National Fistula Technical Working Group OBGYN ...... Obstetricians and gynecologists OF ...... Obstetric fistula OGSB ...... Obstetrical and Gynaecological Society of Bangladesh PHC ...... Primary Health Center PMP ...... Performance Management Plan PNM ...... Provider Network Meeting POP ...... Pelvic organ prolapse PPP ...... Public Private Partnership PRH ...... Population and reproductive health PROSANI ...... Le Projet de Santé Intégré PT ...... Physical therapy QIS ...... Quality Improvement Secretariat RCOG ...... Royal College of Obstetricians and Gynecologists RCT ...... Randomized Controlled Trial REF ...... Réseau pour l’Eradication des Fistules (Niger) SBCC ...... Social and behavior change communication SDI ...... Service delivery improvement SJH ...... St. Joseph Hospital (DRC) SMNE ...... Santé de la mère, du nouveau né et de l‘enfant SOO ...... Structured Operative Obstetrics SST ...... Surgical safety toolkit SWT ...... Site Walk-Through TA ...... Technical Assistance TOT ...... Training of trainers TF ...... Traumatic fistula TSHIP ...... Targeted States High Impact Project (Nigeria) UNFPA ...... United Nations Population Fund USAID ...... United States Agency for International Development USAID/W ...... USAID/Washington VHT ...... Village health team volunteer VVF ...... Vesico Vaginal Fistula WA ...... West Africa WDI ...... Women Deemed Incurable
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TABLES
Title Page Table 1: Active Subawards as of September 30, 2017 13 Table 2: International Technical Assistance Travel, FY16/17 16 Table 3: Meetings and Presentations, FY16/17 18 Table 4: Select Fistula Care Plus Achievements and Benchmarks, FY16/17 22 Table 5: Total Number of Clinical Training Participants, by Country, by Topic, FY16/17 23 Table 6: FC+ Twitter Account Metrics, FY16/17 31 Table 7: Community Outreach/Education Events, by Country, FY16/17 33 Table 8: Community Volunteer/Educator Training, Participants by Country, FY 16/17 34 Table 9: Number of USAID-Supported Surgical Fistula Repairs, by Country, FY 16/17 41 Table 10: Training in Surgical Fistula Repair, Participants by Quarter, FY 16/17 43 Table 11: Training for Health System Personnel (excluding fistula/POP surgery), Participants 43 by Quarter, FY 16/17 Table 12: Family Planning Rapid Assessment Interviews 45 Table 13: Number Seeking, Requiring, and Receiving POP Treatment, by Country, FY16/17 47 Table 14: Peer-Reviewed Articles Published, FY 16/17 51 Table 15: FC+ Blog Posts in FY 16/17 52 Table BGD1: Community Outreach/Education/Advocacy Events, FY 16/17 58 Table BGD2: Community Volunteer/Educator Training, Participants by Topic, FY 16/17 59 Table BGD3: USAID-Supported Surgical Fistula Repairs, by Site, FY 16/17 60 Table BGD4: Surgical Fistula Repair Training, Participants by Trainee Institution, FY 16/17 61 Table BGD5: Non-Surgical Health System Personnel Training, Participants by Topic, FY 16/17 62 Table BGD6: Family Planning Counseling Sessions and CYP, by Site, FY 16/17 62 Table DRC1: Community Outreach/Education/Advocacy Events, FY 16/17 68 Table DRC2: Community Volunteer/Educator Training, Participants by Topic, FY FY16/17 68 Table DRC3: USAID-Supported Surgical Fistula Repairs, by Site, FY 16/17 70 Table DRC4: Surgical Repair Training, by Trainee Institution, FY 16/17 71 Table DRC5:Non-Surgical Health System Personnel Training, Participants by Topic, FY 16/17 71 Table DRC6: Family Planning Counseling Sessions and CYP, by Site, FY 16/17 72 Table NGA1: Community Outreach/Education/Advocacy Events, FY 16/17 80 Table NGA2: Community Volunteer/Educator Training, Participants by Topic, FY 16/17 81 Table NGA3: USAID-Supported Surgical Fistula Repairs, by Site, FY 16/17 84 Table NGA4: Surgical Fistula Repair Training, Participants by Trainee Institution, FY 16/17 86 Table NGA5: Non-Surgical Health System Personnel Training, Participants by Topic, FY 16/17 88 Table NGA6: Family Planning Counseling Sessions and CYP, by Site, FY 16/17 88 Table UGA1: Community Outreach/Education/Advocacy Events, FY 16/17 93 Table UGA2: Community Volunteer/Educator Training, FY 16/17 95 Table UGA3: USAID-Supported Surgical Fistula Repairs, by Site, FY 16/17 99 Table UGA4: Surgical Fistula Repair Training, By Quarter, FY 16/17 100 Table UGA5: Non-Surgical Health System Personnel Training, Participants by Topic, FY 16/17 101 Table UGA6: Family Planning Counseling Sessions and CYP, by Site, FY 16/17 102 Table WAN1: Community Outreach/Education/Advocacy Events, FY 16/17 108 Table WAN2: Community Volunteer/Educator Training, Participants by Topic, FY 16/17 108 Table WAN3: USAID-Supported Surgical Fistula Repairs, by Site, FY 16/17 109 Table WAN4: Non-Surgical Health System Personnel Training, Participants by Topic, FY 110 16/17 Table WAN5: Family Planning Counseling Sessions and CYP, by Site, FY 16/17 111
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FIGURES
Title Page Figure 1: Fistula Care Plus Project Framework 10 Figure 2: Fistula Care Plus Website Views, by Month 32 Figure 3: Cesarean Section Rates, by Country, FY16/17 38 Figure 4: Number of Women Seeking and Requiring Fistula Treatment, and Number of 40 Surgical Repairs, By Country, FY16/17 Figure 5: USAID-Supported Surgical Fistula Repairs, by Quarter, FY 16/17 41 Figure 6: Outcome Rates for Fistula Surgical Repairs, by Country, FY16/17 42 Figure 7: Family Planning Counseling Sessions, by Country, FY16/17 46 Figure 8: Family Planning CYP, Short-Term vs. Long-Term/Permanent Methods, by 47 Country, FY16/17 Figure BGD1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 60 Surgical Repairs, by Site, FY16/17 Figure BGD2: Outcome Rates for Surgical Repairs, by Site, FY16/17 61 Figure BGD3: Number of Obstetric Deliveries, by Site, FY16/17 63 Figure BGD4: Cesarean Section Rates, by Site, FY16/17 63 Figure DRC1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 69 Surgical Repairs, by Site, FY16/17 Figure DRC2: Outcome Rates for Surgical Repairs, by Site, FY16/17 70 Figure DRC3: Number of Obstetric Deliveries, by Site, FY16/17 72 Figure DRC4: Cesarean Section Rates, by Site, FY16/17 72 Figure NGA1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 83 Surgical Repairs, by Site, FY16/17 Figure NGA2: Outcome Rates for Surgical Repairs, by Site, FY16/17 85 Figure UGA1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 98 Surgical Repairs, by Site, FY16/17 Figure UGA2: Outcome Rates for Surgical Repairs, by Site, FY16/17 100 Figure UGA3: Number of Obstetric Deliveries, by Site, FY16/17 103 Figure UGA4: Cesarean Section Rates, by Site, FY16/17 104 Figure WAN1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 109 Surgical Repairs, by Site, FY16/17 Figure WAN2: Outcome Rates for Surgical Repairs, by Site, FY16/17 110 Figure WAN3: Number of Obstetric Deliveries, by Site, FY16/17 111 Figure WAN4: Cesarean Section Rates, by Site, FY16/17 111
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EXECUTIVE SUMMARY
The annual report presents key accomplishments and activities for the fourth fiscal year (October 1, 2016 to September 30, 2017) of Fistula Care Plus (FC+). EngenderHealth manages the project in collaboration with international and national partners. During FY 16/17, USAID supported fistula treatment and prevention services through the FC+ project in five countries—Bangladesh, the Democratic Republic of the Congo (DRC), Niger, Nigeria, and Uganda. FC+ is finalizing plans to add Mozambique as a supported country in FY 17/18, in collaboration with Focus Fistula. USAID also supports fistula activities in DRC, Ethiopia, Guinea, Mali, Pakistan, and Tanzania through bilateral funding. EngenderHealth also implements fistula prevention and care activities in Guinea with funds from other sources, including the Jhpiego-implemented, USAID-funded Health Services Delivery (HSD) project. Key accomplishments during the October 1, 2016 to September 30, 2017 period included: Objective 1: Strengthened enabling environment Technical Consultation on cesarean section safety and quality co-convened with Maternal Health Task Force Public Private Partnerships established with LABORIE, Inc.to strengthen urodynamics capacity and services and Gradian Health systems to improve anesthesia quality of care FC+/Royal College of Obstetricians and Gynecologists working group established to develop integrated female pelvic medicine training manual National guideline on catheterization for fistula treatment and prevention launched in Nigeria FC+ supported sites reviewed by Fistula Foundation for potential sustainability support following end of FC+ Eight sites received Direct Relief Fistula Repair Module distribution Successful inauguration of College of Obstetricians and Gynecologists (OBGYN) within East, Central and Southern Africa (ECSA) through FC+ facilitated collaboration between ECSA Association of OBGYN and College of Surgeons of ECSA South Asia and West Africa regional obstetric fistula working groups established
Objective 2: Enhanced community understanding and practices 850 community volunteers/educators trained in tools and approaches to raise awareness regarding fistula prevention and repair Community stakeholders, including adolescent groups, religious leaders, village committees in Uganda and Nigeria; cured fistula patients, schoolgirls and married couples in Bangladesh; and community relais in Niger, trained and supported for outreach and awareness-raising activities 33,425 in-person community awareness-raising activities/events conducted by program partners, reaching 557,186 participants Mass media awareness-raising efforts reached an estimated 15 million people Completion of Gender 101 trainings and development of action plans for all country programs
Objective 3: Reduced transportation, communications, and financial barriers Pilot testing and launch of interactive voice response (IVR) hotline for fistula screening and referral Development and dissemination of job aids for screening for primary health facility workers and community agents for fistula screening and referral Development and launch of transportation partners and vouchers system Initiation of Fistula Treatment Barrier Reduction Intervention in Nigeria and Uganda, incorporating IVR, job aid, and transportation voucher elements; as of September 30, 2017, 26 positively screened
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women in the intervention areas have used the transportation voucher to reach fistula treatment centers. Findings of Nigeria formative research for Fistula Treatment Barrier Reduction Intervention presented to national, state, and local stakeholders, along with overview of planned intervention Findings of Nigeria Communications Needs Assessment applied to update communications strategy and materials in Nigeria
Objective 4: Strengthened provider and health facility capacity 33 sites supported by FC+ for fistula treatment and prevention activities; 17 sites supported through other USAID bilateral support 3,250 surgical fistula repairs and 294 non-surgical repairs supported through FC+; 1,515 surgical repairs and 32 non-surgical repairs supported by other bilateral USAID programs; this has brought the total USAID-supported surgical fistula repairs since 2005 to 49,320 and the total EngenderHealth- supported surgical fistula repairs to 38,994 252 sites supported by FC+ for prevention-only activities, as well as 500 former Targeted States High Impact Project (TSHIP) sites in Nigeria where FC+ provides temporary data collection; 45 sites supported through other USAID bilateral support 423,736 family planning (FP) counseling sessions provided at supported sites (205,048 at FC+ supported sites, and 218,688 through former TSHIP sites), with FP services resulting in 263,206 Couple Years of Protection (170,019 through FC+ sites and 93,187 through former TSHIP sites) 24 surgeons trained in fistula repair; four surgeons trained in pelvic organ prolapse repair 1,391 health system personnel trained in non-surgical fistula repair and prevention topics Rapid clinical assessment of family planning in DRC, Nigeria and Uganda resulting in programmatic efforts towards long-acting reversible contraceptives training (Uganda) and development of a pre- service curriculum for nurses and midwives on non-surgical treatment of fistula (Nigeria)
Objective 5: Strengthened evidence base Presentation of 34 panel presentations and posters and several plenary sessions disseminating research and program evidence at 2016 IOFWG and ISOFS meetings Fistula Community of Practice webinars hosted on gender-based violence and fistula, and client needs post-repair Panel at International Confederation of Midwives Congress held on neglected aspects of care for women who have experienced prolonged/obstructed labor Global survey of intrapartum and postpartum practices related to prolonged/obstructed labor and bladder care management launched, with responses from 174 participants from 34 countries as of September 30, 2017 92% of all supported sites regularly reviewing and utilizing data for decision making HMIS process documentation data collection completed in two countries (Nigeria and Uganda) and underway in three countries (Bangladesh, Guinea, and Niger) FC+/Nigeria efforts to sustainably improve national data collection and quality resulted in improvement in HMIS FP reporting rates from less than 50% to 98% and availability of fistula etiology data from 56% to 77%
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INTRODUCTION
This annual report provides a summary of accomplishments for the fourth fiscal year (October 1, 2016 – September 30, 2017) of Fistula Care Plus (FC+), a five-year Associate Cooperative Agreement (No. AID- OAA-A14-00013) supported by USAID. In this report, we present data on quantitative project indicators as well as narrative updates organized into: Section I: Management Activities, Section II: Global Accomplishments, and Section III: Country Accomplishments. Global and country accomplishments are reported against the objectives of the FC+ Project Framework (see Figure 1 and Appendix GG) and in alignment with the USAID-approved Project Monitoring Plan (PMP). Section II is further organized by sub-objective. USAID support to EngenderHealth for fistula services began in FY 04/05 under the Access, Quality, and Use in Reproductive Health (ACQUIRE) and Action for West Africa Region (AWARE) Projects and continued through the Fistula Care (FC) project, which ended on December 31, 2013. USAID/Washington (USAID/W) awarded the FC+ project to EngenderHealth, in partnership with the Population Council, Dimagi, Direct Relief, Fistula Foundation, Maternal Health Task Force, and TERREWODE, on December 12, 2013. FC+ seeks to strengthen health system capacity for fistula prevention, detection, treatment, and reintegration in priority countries in Sub-Saharan Africa and South Asia. As of September 30, 2017, FC+ is supporting fistula prevention and treatment activities with USAID funding at a total of 285 sites in Bangladesh, the Democratic Republic of the Congo (DRC), Niger, Nigeria, and Uganda: 33 treatment and prevention sites and 252 prevention-only sites. FC+ is also supporting temporary data collection at an additional 500 former TSHIP sites in Nigeria. See Appendix A for a full list of FC+ planned and actual supported sites. In addition to the support provided via FC+, USAID provides bilateral support to fistula work carried out at 62 sites (17 treatment, 45 prevention-only) in DRC (through ProSani); Ethiopia (through Pathfinder); Guinea (through Jhpiego); Mali (through IntraHealth); Pakistan (through the Jinnah Post Graduate Medical Center); and Tanzania (through Vodafone/CCBRT). In FY 16/17, EngenderHealth continued fistula-related activities in Guinea through the Jhpiego Health Services Delivery (HSD) project, as well as support from the Alcoa Foundation. Conversations with Fistula Foundation led to consideration of re-establishing funding support for fistula services with EngenderHealth Guinea, without funding from IDB, as had been the previous collaboration. A proposal for funding from EngenderHealth Guinea to Fistula Foundation was submitted to the EngenderHealth Business Development Division for analysis.
Figure 1: Fistula Care Plus Project Framework
GOAL: To strengthen health system capacity for fistula prevention, detection, treatment, and reintegration in priority countries in sub-Saharan Africa and South Asia Obj. 1: Strengthened Obj. 2: Enhanced Obj. 3: Reduced Obj. 4: Strengthened Obj. 5: Strengthened evidence enabling environment to community understanding transportation, provider and health facility base for approaches to improve institutionalize fistula and practices to prevent communications, and capacity to provide and fistula care and scaled up prevention, treatment, and fistula, improve access to financial barriers to sustain quality services for application of standard reintegration in the public fistula treatment, reduce accessing preventive care, fistula prevention, detection, monitoring and evaluation (M&E) and private sectors stigma, and support detection, treatment, and and treatment indicators for prevention and reintegration of women and reintegration support treatment girls with fistula
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SECTION I: MANAGEMENT ACTIVITIES Overview During FY 16/17, the global FC+ team’s management activities focused on recruitment and orientation of outstanding staff positions, finalization and implementation of project subawards, workplan and budget development, and continued refinement of the project’s clinical and programmatic data collection and monitoring systems. Management activities provided the oversight and operational framework that enabled the achievements described in Sections II and III. Staffing and Recruitment During FY 16/17, the FC+/Global team was comprised of the following staff: Lauri Romanzi: Project Director Vandana Tripathi: Deputy Director Bethany Cole: Global Projects Manager Alpha Koroma: Finance and Administration Manager (October 2016 – February 2017) Isaac Achwal: Senior Clinical Associate (25% LOE) Lauren Bellhouse: Program Associate Elly Arnoff: Program Associate – Evaluation and Research Altiné Diop: Program Associate Karen Levin: Senior Program Associate, Monitoring and Evaluation (50% LOE) Mark Barone: Senior Clinical Advisor – short-term technical assistance
Project Management FC+ leadership oversaw project management through participation in meetings with USAID/W; finalization of FY 16/17 workplans and budgets and development of FY17/18 workplans and budgets; securing USAID Mission concurrence and USAID/W approvals for subawards; and working with partners and country-level staff to facilitate FC+ finance and M&E systems, and staffing and program support. FC+ developed a low-cost, flexible, and robust data collection and management system using the DHIS2 platform. The system has been continually updated, most recently to provide country level dashboards for review during monthly country program review meetings. At the request of USAID/Washington, FC+ has continued to work with several projects supporting fistula-related work through USAID-supported bilateral funding in order to coordinate reporting of fistula-related data to USAID. FC+ was able to gather data from five bilateral projects during FY16/17: ProSani in DRC, Pathfinder in Ethiopia, Jhpiego in Guinea, IntraHealth in Mali, and Vodafone/CCBRT in Tanzania. The USAID-supported fistula work in Ethiopia has transitioned to the TRANSFORM Project and FC+ is working to establish a reporting mechanism with the new project leadership. Throughout FY 16/17, FC+ continued to hold coordinated country program reviews (CPR), a process initiated in FY 15/16, involving monthly teleconferences between Clinical, Program Management, M&E, and Finance staff from global and country offices to streamline and harmonize staff and programmatic functions in relation to objectives, indicators, and program innovations. During an FC+ clinical meeting held in November 2016, the team observed that FP compliance plans were not carefully harmonized across all country programs. The FC+/Global Project Manager worked with the FP compliance point persons in each office to update and harmonize the plans. They are stored centrally on EngenderHealth’s intranet. This activity is ongoing and taking place in coordination with the
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rapid FP assessment implemented in three countries (Uganda, Nigeria, and DRC) by consultant Pandora Hardtman (see Section II, Objective 4.3). Drafts will be finalized after the recommendation from the rapid assessment. All staff and partners completed the online training courses for Protecting Life in Global Health Assistance (PLGHA) and US Abortion and Family Planning Requirements. These certificates are also stored on the project intranet. In January 2017, FC+ leadership participated in two USAID processes: an FC+ Management Review and the FC+ Midterm Evaluation debrief, which included the project AORs, evaluators, and other members of USAID PRH and gender teams. FC+ management also participated in an internal EngenderHealth portfolio review. Following concerns identified regarding management and administration processes in Nigeria, a formal staff and office review process was undertaken. A restructuring followed this process, in which some positions were eliminated and a new Country Program Manager was recruited. During this transition period, FC+ global management staff provided intensive on-the-ground support and supervision to the Nigeria office, and the Nigeria Senior M&E Advisor, Babafemi Dare, played the role of Acting Country Program Manager. Current Country Program Manager Iyeme Efem joined the project in the third quarter of FY 16/17. Following the January 25, 2017 Executive Order reinstating the Mexico City Policy and the later expansion to Protecting Life in Global Health Assistance (PLGHA), the FC+ global team has been working with EngenderHealth’s senior leadership and Grants and Contracts teams to assess impact for project subawards, partners, and activities and ensure compliance. In July 2017, the USAID Mission in Maputo, Mozambique contacted FC+ to explore collaboration in FY 17/18. The goal is for FC+ to partner with Maputo-based local NGO Focus Fistula, to build the NGO’s administrative capacity, support fistula repair, and reinforce clinical capacity at partner facilities through the leadership of Dr. Igor Vaz. In September 2017, Global Projects Manager Bethany Cole traveled to Mozambique. This trip included courtesy meetings with the USAID mission, relevant ministry officials, UNFPA bilateral projects, and potential partner sites to introduce the project and learn about current work to address fistula in Mozambique. A site visit to a district hospital and a health center III in Gaza province provided important context for how women access services. She was also able to attend selected sessions of the UroMap conference to ensure the project’s Public Private Partnership (PPP) partner Laborie was integrated into the program. A subaward package with Focus Fistula is under development. While the intention is to receive multiyear funding from USAID, the subaward will cover seven months, November 2017 through June 2018, and be extended if further support is provided.
Partnership: Global and Country-Level As the fourth project year of FC+ ends, creative engagement with collaborative partners to avoid end-of- project gaps in fistula services is a top priority for the project’s “sustainability and legacy” platform. In February 2017, the FC+ Project Director met with Fistula Foundation staff to discuss plans for sustainable support to various fistula treatment facilities to ensure continued services after the FC+ project has ended. Fistula Foundation is a resource partner of the project and to date the partnership has centered on facilitation of purchase of pharmaceutical supplies for fistula surgery that are currently restricted under USAID regulations. Fistula Foundation has suspended the active review of FC+ supported treatment sites to determine the feasibility of taking over the funding and general support of fistula services and visiting surgical consultants at selected sites when the FC+ Project ends in 2018. FC+ will re-engage with Fistula Foundation in FY 17/18 to determine whether this support of selected facilities is possible.
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In February 2017, EngenderHealth declined to renew membership in the G4 Alliance due to organizational determination that the safe surgery community of practice is not aligned with EngenderHealth’s Strategic Plan 2020 to empower women and girls through all-sector advocacy for access to safe family planning. In addition, the G4 Alliance leadership development and transition to permanent council status is unclear. FC+ continues to contribute to the safe surgery community of practice through our webinars, technical consultation activities, and collaboration with the WHO Global Initiative for Essential and Emergency Surgical Care (GIEESC). During FY 16/17, FC+ continued to work with global partners to strengthen and disseminate the evidence base for improved fistula care. For instance, FC+ has continued to work with the Population Council to carry out research to build knowledge about the effectiveness of interventions to reduce barriers faced by women seeking fistula repair services in Nigeria and Uganda. This work is described in detail in Section II, Objectives 3 and 5 as well as in Section III: Nigeria and Uganda. FC+ has also continued partnership with the American College of Obstetricians and Gynecologists, to provide technical assistance for monitoring and evaluation of a program to strengthen surgical obstetrics in Uganda (see Section II, Objective 4 as well as Section III: Uganda). During FY 16/17, FC+ global and country staff continued to finalize and implement in-country partnerships and subawards for facilities that receive FC+ support. As of September 30, 2017, there are 14 active subawards approved by USAID, see Table 1 for detail. Please refer to Appendix B for a complete list of current FC+ partnerships.
Table 1: Active Subawards as of September 30, 2017
Institution Start End Date Number Amount Description Date
Global
Population 1-Oct-14 31-Dec-17 SUBA094 $687,244 To build institutional knowledge about interventions Council to reduce financial barriers, particularly related to transportation, by women seeking fistula repair services with a focus on Nigeria and Uganda.
Bangladesh
Ad-Din 1-Oct-16 31-Mar-18 SABD009 $62,256 To continue providing obstetric fistula prevention, Hospital detection, treatment, and reintegration services at Ad-Din Hospital, Dhaka and to continue organizing periodic fistula repair concentrated efforts at Ad-Din Hospital in Jessore.
LAMB 16-Jun-16 30-Jun-18 SABD011 $138,471 To enable LAMB Hospital to further strengthen and Hospital develop its capacity to perform surgical repair of fistula, and to increase staff and public awareness of the problem and its prevention.
Kumudini 1-Oct-16 31-Mar-18 SABD010 $69,280 To provide support to build the capacity of Hospital Kumudini Hospital to improve the quality and availability of fistula treatment services, and to prevent fistula through strengthening maternal health services and increasing access to family planning.
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Institution Start End Date Number Amount Description Date
BSMMU 1-Oct-16 31-Mar-18 SABD012 $104,528.00 To develop and strengthen BSMMU’s capacity to perform surgical repair of fistula, and its prevention; to support the “University Fistula Center” and fistula surgery and management training for doctors and nurses.
DRC
St. Joseph 1-Sept-14 15-Nov-17 SACD002 $766,705 To improve access to quality fistula services Hospital through improved fistula service delivery, training of (SJH) providers and strengthening quality assurance mechanisms.
HEAL Africa 1-Sept -14 15-Nov-17 SACD001 $487,631 To strengthen the capacity of HEAL Africa and its staff to provide accessible, high quality obstetric fistula repairs and prevention services.
Imagerie Des 1-Oct-14 30-Sep-17 SACD004 $342,497 To build the capacity of IGL staff to prevent Grands Lacs obstetric fistula through strengthening maternal (IGL) health services and family planning.
Maternité 1-Oct-14 30-Sep-17 SACD005 $404,940 To build the capacity of MSRK staff to prevent Sans Risque obstetric fistula through the strengthening of de Kindu maternal health services and family planning. (MSRK)
Panzi Hospital 1-Sep-14 15-Nov-17 SACD003 $664,348.95 To improve access to fistula care, build the capacity of General Reference Hospital Panzi to repair obstetric fistula, improve the clinical services provided in the hospital, and prevent fistula through strengthening maternal health services including increasing access to family planning.
Niger
Réseau pour 1-Apr-17 28-Feb-18 SANE002 $68,047 Under this subaward, REF will strengthen the l’Eradication enabling environment to institutionalize fistula des fistules prevention, treatment, and reintegration in the (REF) public and private sectors. REF will enhance community understanding and practices to prevent fistula, improve access to fistula treatment, reduce stigma, and support reintegration of women and girls with fistula
Nigeria Daughter of 1-Oct-16 31-May-18 SANG001 $150,393 To strengthen work falling under FC+ Objective 2: Virtue and enhance community understanding and practices to Empowerment prevent fistula, improve access to treatment, reduce Initiative stigma and support reintegration of women with (DOVENET) fistula, including those whose fistula is deemed incurable and whose fistula is the result of sexual violence in Ebonyi State. To enhance community level knowledge around fistula prevention, stigma reduction, and access to treatment services.
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Institution Start End Date Number Amount Description Date
Uganda
Kitovu 1-Mar-17 28-Feb-18 SAUG004 $182,004.23 To enhance community understanding and Hospital practices to prevent fistula, improve access to treatment, reduce stigma and support reintegration of women with fistula, including those whose fistula is deemed incurable and those fistula is the result of sexual violence; To reduce transportation, communication and financial barriers to accessing preventive care, detection, treatment and reintegration support; and To strengthen provider and health facility capacity to improve and sustain quality services for fistula prevention, detection and treatment.
Kamuli 1-Jul-17 30-Jun-18 SAUG005 $80,344.04 To provide repairs to 100 women with fistula, Mission enhance community understanding and practices Hospital to prevent fistula, reduce barriers to accessing preventive care, treatment and reintegration support, and strengthen facility level capacity for fistula management.
In addition to work with project partners, FC+ staff participated in several meetings and coordination processes led by USAID and its flagship projects. These include meetings of the USAID PRH Gender Cooperating Agencies (CAs), the PRH Service Delivery Improvement (SDI) CAs, the USAID ASSIST Project Quarterly Review Meeting, USAID GH/MCHN PLGHA briefings for implementing partners, and the social and behavior change and communications (SBCC) and Service Delivery Integration (SDI) Working Group. FC+ staff, including the Project Director, also attended the Reproductive Health Office West Africa Partners’ Meeting in Accra. FC+ sought opportunities to support USAID-led and global initiatives addressing maternal health. The FC+ Deputy Director participated in a stakeholders meeting of the WHO Maternal Morbidity Measurement Initiative Group (see Table 3) in Geneva in February 2017, during which she provided feedback on the WHO maternal morbidity measurement framework and proposed next steps for research as well as presenting at the WHO QED Network Monitoring Working Group meeting in June 2017. The FC+ Project Director participated in a UN Congressional Staff Learning Tour in May 2017. FC+ staff also attended the Innovations for Maternal Newborn and Child Health (MNCH) Projects Results Dissemination meeting convened by UNICEF and Concern Worldwide in October 2016. The project has also partnered with Jhpiego and the Maternal and Child Survival Program (MCSP), including through an ICM Congress panel on obstructed labor, the technical consultation on cesarean section safety and quality, and dissemination activities following the consultation (See Section II, Objective 5).
Leveraging FC+ for Additional Fistula Programming In January 1, 2015, EngenderHealth reopened an office in Guinea to continue work toward a fistula free generation in the country. EngenderHealth invested much effort to develop resources to continue the work begun under the FC project, including the provision of FP services. Challenges of reopening were compounded by the 2014-2016 Ebola outbreak that necessitated careful strategy to facilitate continuation
Annual Report • October 2016 – September 2017 Fistula Care Plus 15
of this work in an Ebola context. EngenderHealth successfully raised funds from the Alcoa Foundation, which has significant mining interests in Guinea, as well as the Islamic Development Bank/Islamic Solidarity Fund for Development. In January 2016, the USAID Guinea RFA-OAA-15-000024 Guinea Health Service Delivery (HSD) project for FP and MNCH was awarded to the Jhpiego-led consortium. EngenderHealth and Save the Children are partners on the five-year project and EngenderHealth leads fistula prevention and repair activities for a “fistula free generation” in Guinea. HSD staff have been oriented to the FC+ PMP and are reporting through the FC+ DHIS2 platform. From December 2016 to March 2017, the FC+ Deputy Director held discussions with IDInsight, a nonprofit organization that helps clients generate and use rigorous evidence to improve their social impact. IDInsight currently supports GiveWell's efforts to assist charities to improve their monitoring systems and the evidence of their impact. GiveWell has identified fistula surgery as a priority intervention to investigate. The conversations included both FC+ current activities and impact measurement efforts, including efforts to strengthen routine/national-level monitoring of fistula services, as well as the Deputy Director’s experience with facility quality assessment measures. GiveWell is exploring the possibility of funding an expansion of fistula work beyond a study of effectiveness and impact of fistula services to be implemented by IDInsight. There has been no further update on programming possibilities from IDInsight or GiveWell in this fiscal year.
International Clinical Support and Technical Assistance (TA) Travel FC+ global staff and consultants have carried out international clinical support and TA visits to seven countries during FY 16/17 (see Table 2). This travel included:
Management visits, partner meetings (Bangladesh, DRC, Niger, Nigeria, Mozambique, Uganda); Training and support for fistula and POP surgery (Nigeria, DRC, Uganda); Strengthening family planning service provision (Bangladesh, DRC, Uganda); Research (DRC, Nigeria, Uganda); Gender training (Nigeria, Uganda); and Peer educator training and programmatic advising (Uganda).
Table 2: International Technical Assistance Travel, FY16/17
Traveler Dates/Location Purpose Bethany Cole Oct 29–Nov 1, 2016 Develop country action plan and provide program management Nigeria support Igor Vaz Oct 30-Nov 7, 2016 Provide training on complex fistula surgery in selected sites in (consultant) Nigeria Nigeria Lauren Bellhouse Nov 2-4, 2016 Facilitation of training-of-trainers for the FC+ Gender Working Nigeria Group of the Nigeria office. Isaac Achwal Nov 6-20, 2016 Support DRC team to perform the needs assessment for new DRC sites and the evaluation of COPE and FP activities in existing sites Altine Diop Dec 3-10, 2016 Provide management review to Niger country programs and Niger provide technical assistance to finalize REF subaward process Lauri Romanzi Dec 11-23, 2016 Provide Nigeria country program management and accompany Alpha Koroma Nigeria EngenderHealth HR director and EngenderHealth new Chief Operation Officer Alpha Koroma Jan 7-20, 2017 Provide coverage for the Finance and Operations Manager Nigeria including recruitment of a new Finance and Operations Manager Lauren Bellhouse Jan 23-Feb 3, 2017 Provide program management support Nigeria Alpha Koroma Feb 3-10, 2017 Provide financial management support to Niger Country Program
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Traveler Dates/Location Purpose Niger Vandana Tripathi Feb 11-17, 2017 Provide management support to Niger Country Program Altine Diop Niger Shannon Rauh Feb 10-17, 2017 Conduct training on peer educators on the Aflateen PLUS Uganda curriculum for out of school youth Pandora Hardtman Feb 12-18, 2017 Conduct a rapid assessment of selected partner family planning Uganda sites and make recommendations for strengthening services Lauren Bellhouse Feb 28-Mar 3, 2017 Support and co-facilitate a three day gender training workshop in Uganda Kampala for all FC+/Uganda staff and visiting DRC participants; project management Paul Wondergem Mar 8-15, 2017 Oversee project management, project finance performance plan (consultant) Nigeria for Finance Manager, reduce bottle necks, maintain project Joyce Chinembiri activities and improve the office burn rate. Elly Arnoff Mar 13-24, 2017 Provide technical assistance to the community engagement team Nigeria on the barrier’s intervention study and support facilitation of trainings for community agents and primary health workers in Ebonyi and Katsina as part of the barrier intervention study. Alexandre Delamou Mar 18-26, 2017 Conduct a workshop finalizing the research protocol. (consultant) DRC Macka Barry Mar 29-Apr 3, 2017 Provide financial reporting training to new subawardee REF Niger Bethany Cole May 15-26, 2017 Provide orientation and updates on FP compliance to staff; Uganda, Rwanda Participate in year five workplanning sessions with Uganda office; Participate in year five workplanning discussions with DRC’s program manager; Meet with COSECSA steering committee members in Rwanda Lauren Bellhouse May 27–Jun 10, Launch year 5 work planning in Nigeria through strategic 2017 discussion; attend 2017 Provider Network Meeting; work with Nigeria finance and community teams on updates to subawards. Pandora Hartman June 6-11, 2017 Work with Nursing and Midwifery Council Expert Group to review (consultant) Nigeria the catheterization guideline and develop a module for this collaboration with other partners, including FMOH and UNFPA. Alexandre Delamou July 2-9, 2017 Conduct a workshop to finalize the research protocol and train (consultant) DRC local investigators. Steve Arrowsmith July 26-29, 2017 Conduct orientation and training for use of Urodynamic Machine (consultant) Nigeria for Pooled Effort Fistula Repairs, with Honorable Minister of Health participation. Lauri Romanzi Sept 17-26, 2017 Provide clinical monitoring at Panzi and HEAL. DRC Lauren Bellhouse Sept 13-24, 2017 Attend partners’ meeting; updated orientation on PLHHA and Bangladesh USAID FP rules and regulations; provide program management support to finalize year five workplan. Bethany Cole Sept 6-17, 2017 Establish FC+ in Mozambique, develop scope of work, budget, Mozambique budget notes, and share subaward documentation with Focus Fistula, meet with the USAID Mission, partners, and ministry colleagues, and attend UroMap and facilitate engagement of Laborie with local partners. Judith Goh Sept 5-16, 2017 Participate in the POP Camp at Kagando Hospital. (consultant) Uganda Elly Arnoff Sept 19-30, 2017 Conduct mid-point monitoring of the barrier intervention study in Nigeria Ebonyi and present summary of findings from the baseline data collection to staff at USAID Nigeria mission.
Meetings FC+/Global staff convened, attended, and presented at numerous meetings in FY 16/17, as summarized in Table 3.
Table 3: Meetings and Presentations, FY16/17
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Meeting Dates/Location Convened Attending FC+ Inputs / Presentations by FC+? Innovations for Oct 5, 2016 No Lauren Bellhouse Participation MNCH Project New York Results Dissemination International Oct 24-25, 2016 No Isaac Achwal Participation, Presentation Obstetric Working Abuja, Nigeria Elly Arnoff See Appendix F for list of FC+ Group Meeting Lauren Bellhouse Contributions (IOFWG) Bethany Cole Altine Diop Lauri Romanzi Vandana Tripathi International Oct 26-28, 2016 No Isaac Achwal Participation, Presentation Society of Abuja, Nigeria Elly Arnoff See Appendix F for list of FC+ Obstetric Fistula Lauren Bellhouse Contributions Surgeons (ISOFS) Bethany Cole 6th International Altine Diop Scientific Lauri Romanzi Conference Vandana Tripathi Health Systems Nov 14-18, 2016 No Vandana Tripathi Presentation on intervention designed Research Vancouver, in response to Population Council Symposium Canada formative research on barriers to fistula treatment; poster on POP integration capacity/demand/need DHIS2: Helping Nov 17, 2016 No Karen Levin Participation People in their Webinar Daily Work College of Dec 7-9, 2016 No Isaac Achwal Participation Surgeons of East Mombasa, Kenya Central and Southern Africa (COSECSA) 17th Annual Scientific Conference Community Care Dec 13, 2016 No Lauren Bellhouse Participation Management Webinar Indicators Closing the Gaps Dec 18, 2016 No Lauren Bellhouse Participation of Maternal Health Webinar in Conflict and Crises Mango Mobile Jan 10, 2017 No Karen Levin Participation Application Webinar Platform USAID/PRH Jan 12, 2017 No Lauri Romanzi Participation Partners Meeting Washington DC Vandana Tripathi USAID ASSIST Jan 25-26, 2017 No Vandana Tripathi Participation Project Quarterly Washington DC Review Meeting The WHO Global Feb 1, 2017 No Vandana Tripathi Participation Learning Webinar Laboratory for Quality Universal Health Coverage WHO Maternal Feb 9-10, 2017 No Vandana Tripathi Participation Morbidity Geneva, Measurement Switzerland Initiative Group Royal College of Feb 17-19, 2017 No Lauri Romanzi Participation Obstetricians and London, England
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Meeting Dates/Location Convened Attending FC+ Inputs / Presentations by FC+? Gynaecologists (RCOG) Integrated Manual Working Group RCOG World Mar 17-23, 2017 No Lauri Romanzi Participation and panel: “Eradication Congress Cape Town, of Fistula: Lessons from History.” South Africa SBCC and Mar 22, 2017 No Lauren Bellhouse Participation Service Delivery Washington DC Integration (Attended Working Group remotely) Service Delivery Mar 22, 2017 No Bethany Cole Participation Improvement Washington DC (SDI) CA Meeting Strengthening Mar 23, 2017 No Lauren Bellhouse Participation National SBCC Webinar Capacity to Improve Health Outcomes 2017 DHIS2 Mar 23-24, 2017 No Karen Levin Participation Symposium Washington DC 17th Annual Nepal Apr 9, 2017 No Lauri Romanzi Presentations: “Ending fistula within a Society of Kathmandu, SK Nazmul Huda generation: Lesson from history”; Obstetricians and Nepal Sayeba Akhter An integrated training manual for Gynaecologists “Fistula, prolapse and incontinence – updates from RCOG” ; “Ending Fistula within generation- Challenges for Bangladesh”; “Emerging Issues in Fistula prevention”. FC+ Webinar Apr 10, 2017 Yes FC+ Global Team See: “After Fistula New York, NY https://fistulacare.org/blog/2017/06/aft Repair” Webinar er-fistula-repair-webinar/ East, Central and Apr 10-12, 2017 No Isaac Achwal Presentation, participation. See Southern Africa Dar Es Salaam, Section II, Objective 1 for additional Health Community Tanzania detail. 10th Best Practices Forum and 26th Directors Joint Consultative Meeting DHIS Apr 20, 2017 No Karen Levin Participation Interoperability Webinar Too Much Too Apr 24, 2017 No Lauri Romanzi Participation Soon: Addressing Washington, DC Vandana Tripathi Over-Intervention in Maternity Care Task Sharing: Apr 27, 2017 No Lauren Bellhouse Participation Expanding Access Webinar in Family Planning Regional Health May 15-20, 2017 No Lauri Romanzi Poster presentation: “Historical Office West Africa Accra, Ghana Altine Diop Lessons Learned Concerning Ending Partners’ Meeting Fistula Within a Generation” UN Congressional May 12, 2017 No Lauri Romanzi Overview presentation of FC+ staff learning tour: New York, NY program UN response to humanitarian crises with focus
Annual Report • October 2016 – September 2017 Fistula Care Plus 19
Meeting Dates/Location Convened Attending FC+ Inputs / Presentations by FC+? on girls and women EngenderHealth May 20-27,2017 No Karen Levin Multiple presentations, participation, CDDM Meeting Dar Es Salaam, Isaac Achwal see Appendix CC for detail. Tanzania The Critical Role Jun 8, 2017 No Bethany Cole Participation of Social and Webinar Behavior Change across the Service Delivery Continuum WHO QED Jun 14, 2017 No Vandana Tripathi Presentation “The Labor and Delivery Network Geneva, Quality of Care Short Observational Monitoring Switzerland Index: A User Guide “; Participation Working Group Meeting 31st Triennial Jun 18-22, 2017 No Lauri Romanzi Sponsored breakfast panel; chaired Congress of the Toronto, Canada Vandana Tripathi panel, oral and poster presentations. International Elly Arnoff See Section II and Appendices O, P, Confederation of SK Nazmul Huda and Q for additional details. Midwives Men as More than Jun 21, 2017 No Lauren Bellhouse Participation Partners: Webinar Increasing Men’s use of SRH 42nd Annual Jun 22-25, 2017 No Lauri Romanzi Participation, Environmental scan Meeting of the Vancouver, presentation to FIUGA Board International Canada Urogynecological Association Human Centered Jun 27, 2017 No Lauren Bellhouse Participation Design Webinar UroDAK 2017 Jul 9- 12, 2017 No Lauri Romanzi Sponsored urodynamics training Annual Workshop Dakar, Senegal Bethany Cole workshops Maternal and Jul 14, 2017 No Elly Arnoff Participation Women’s Health, Webinar Two Years In: Measuring Progress Towards Meeting the SDGs Technical Jul 27-28, 2017 Yes Lauri Romanzi Co-sponsor of consultation, See Consultation on Boston, MA Vandana Tripathi https://fistulacare.org/resources/progr Cesarean Section Lauren Bellhouse am-reports/cesarean-section- Safety and Quality technical-consultation/ for materials in Low Resource and inputs Settings UroMAP September 11- No Bethany Cole Participation, coordination with 15, 2017 project partner Laborie to present and Maputo, showcase urodynamics equipment Mozambique Launch meeting of Sep 11-15, 2017 No Lauri Romanzi Participation, Vice-Chair of Working the International Florence, Italy Group Urogynecological Association International Continence Society - International Continence
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Meeting Dates/Location Convened Attending FC+ Inputs / Presentations by FC+? Society (IUGA- ICS) USAID SDI CAs Sep 13, 2017 No Lauren Bellhouse Participation Meeting Arlington, VA Gynuity – Lessons Sep 14, 2017 No Vandana Tripathi Participation Learned from Webinar Karen Levin Evaluating the Scale-Up of PPH Technolog ies in Maternal Health Programs Wilson Center Sep 14, 2017 No Vandana Tripathi Participation Maternal Health Washington, DC Elly Arnoff Initiative – Webinar Reaching the Farthest Behind: Facility-level Innovations in Maternal Health Securing Health, Sep 18, 2017 No Lauri Romanzi Participation Hope, & Dignity New York, NY for All to Achieve the SDGs: Ending Obstetric Fistula within a Generation PRH Webinar Sep 18, 2017 No Vandana Tripathi Participation Webinar RHINO Forum on Sep 27, 2017 No Karen Levin Participation the Data Quality Webinar Review (DQR) Framework Launch of the Sep 27-29, 2017 No Lauri Romanzi Participation East, Central and Kigali, Rwanda Isaac Achwal Southern Africa College of Obstetrics and Gynecology Implementing a Sep 28, 2017 No Karen Levin Participation Low Budget Webinar DHIS2 System
Funding The FC+ project was awarded on December 12, 2013 with a ceiling of $74,490,086. In FY 16/17, $2.35M (17%) was received by November 2016, $6.2M (49%) was received by December 2016, and 2.5M (23%) by April 2017 to bring the total FY 16/17 obligations to $11.09M. Total life of project obligation is $37.997M and total expenses through September 30, 2017 is $32.33M. Cumulative expenditures and subaward commitments (see Table 1) for FY 17/18 as of September 30, 2018 are projected to be $9.74M, leaving an obligated pipeline of $2.86M.
Annual Report • October 2016 – September 2017 Fistula Care Plus 21
SECTION II: GLOBAL ACCOMPLISHMENTS Fistula Care Plus Achievements In its fourth fiscal year, FC+ made significant achievements in line with the aims and targets of its global workplan. Table 4 provides a snapshot of FC+ achievements in FY 16/17. Full reporting on FC+ benchmarks for core indicators can be found in Appendix GG. Appendix C provides information on all USAID-supported fistula repair surgeries from 2005-present.
Table 4: Select Fistula Care Plus Achievements and Benchmarks as of September 30, 2017
FY13/14 FY14/15 FY15/16 FY16/17 FY16/17 Actual Actual Actual Benchmark Actual
Number of countries supported by FC+ 5 6 6 6 51
Number of sites supported by FC+ for fistula repair and 25 31 37 36 332 prevention
Number of prevention-only sites supported by FC+ 16 249 289 291 2523 500 former 500 former 500 former 500 former TSHIP TSHIP TSHIP TSHIP
Number of participants in community volunteer/educator 114 776 679 725 850 training in tools and approaches to raise awareness regarding fistula prevention and repair
Number of community awareness-raising 12 1,990 10,352 6,130 33,425 activities/events conducted by program partners (in person) (in person) 41 659 (mass media) (mass media)
Number of participants reached through community 10,745 414,067 2,862,124 327,000 557,186 awareness-raising events/activities conducted by (in person) (in person) (in person) program partners 3,676,406 102,150,000 15,289,736 (mass media) (mass media) (mass media)
Number of surgical fistula repairs 873 2,876 3,514 3,780 3,250
Number of participants in health systems personnel 161 1,065 1,414 1,041 1,391 training, by topic, for fistula and/or POP prevention and treatment (disaggregated by training topic, sex and cadre of provider)4
Number of FP counseling sessions provided 38,373 149,610 167,424 (FC+) 186,232 205,048(FC+) 198,614 218,688 (Former TSHIP) (Former TSHIP)
Number of CYP provided 40,039 107,986 106,645 (FC+) 145,496 170,019(FC+) 89,341 93,187 (Former TSHIP) (Former TSHIP)
1 The number of countries has decreased to five due to lack of project activity in Togo, activity in Mozambique will begin in FY 17/18. 2 33 sites supported during the fiscal year. 32 sites receiving support as of September 30, 2017. The number of supported sites changed due to end of support for one site in Bangladesh (Ad-din Jessore) and one state in Nigeria (Jigawa),re-evaluation of support to two facilities in Nigeria (Evangel and Pope John Paul), and the addition of a state in Nigeria (Osun). 3 Support to sites in Jigawa State in Nigeria was discontinued in the third quarter of the FY. 4 Does not include training of surgeons to provide fistula repair.
Annual Report • October 2016 – September 2017 Fistula Care Plus 22
Clinical training outputs are summarized in Table 5. Training accomplishments are described in greater detail in Objective 4, and in Section III, by country. With USAID bilateral support, Pathfinder also carried out training in Ethiopia for 842 clinicians,5 focusing on fistula identification and referral, and IntraHealth trained 763 health clinicians in Mali in quality assurance, surgical skills for fistula repair, data for decision making and fistula prevention topics.
Table 5: Total Number of Clinical Training Participants, by Country, by Topic, FY16/17
Bangladesh DRC WA/Niger Nigeria Uganda Total First Training in Surgical 1 2 0 1 0 4 Fistula Repair Continuing Training in Surgical 9 2 0 7 2 156 Fistula Repair Surgical Fistula TOT 0 0 0 6 0 6 First Training in Surgical POP 0 4 0 0 0 4 Repair Continuing Training in Surgical 0 2 0 0 0 2 POP Repair ANC 0 0 0 0 0 0 Community, outreach and 0 0 0 0 272 272 advocacy Data management 36 20 0 38 0 94 EmONC 0 31 15 0 0 46 EmONC and labor monitoring 0 46 13 0 54 113 FP counseling 0 0 0 31 31 62 FP methods 0 78 0 148 195 421 FP and fistula counseling 0 0 0 0 0 0 Fistula counseling 0 0 0 0 0 0 Gender 0 0 0 0 0 0 Infection Prevention 0 117 65 0 0 182 Non-surgical POP treatment 0 0 0 0 0 0 Pre- and Post-Operative Care 6 26 6 109 42 189 Quality Assurance 0 0 0 0 0 0 Other 0 0 0 0 12 12 TOTAL 52 3257 99 340 608 1,419
Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors FC+ strengthens the enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors by improving country and facility policies, guidelines, and resources allocated to fistula prevention and treatment, including addressing the needs of particularly vulnerable women (e.g., women deemed incurable (WDI) and those with traumatic fistula (TF)). Sub-Objective 1.1: Establish sustainability plans: from policy to implementation During FC+ 16/17, FC+ continued to develop Public Private Partnerships (PPPs) with a focus on ensuring the sustainability of these efforts beyond the project.
5 Pathfinder’s E2A project ended in June 2017, figures reported here are through April 2017. 6 Surgeons participating in multiple trainings during the fiscal year are only counted once in the FY total, therefore the sum of each quarter may not equal the FY total. 7 Total is slightly less than the addition of all training categories as surgeons trained multiple times during the fiscal year are only counted once in the total.
Annual Report • October 2016 – September 2017 Fistula Care Plus 23
FC+ collaborates with LABORIE Inc., a urodynamics and pelvic floor therapy company with emerging interest in pessary supply chain strengthening in sub-Saharan Africa. Since executing a MoU CESAREAN with FC+ to strengthen the role of academia in the sustainability SECTION platform of the project, LABORIE has supported several TECHNICAL international events. This PPP has included funding application to Heineken Africa Foundation to support the creation of the UCH CONSULTATION Ibadan Continence Center in Nigeria. Women with incontinence In July 2017, FC+ hosted a after fistula will be able to undergo the complex evaluation they global technical consultation need to formulate individualized, effective medical and surgical with the Maternal Health treatment plans for residual incontinence. Task Force at the Harvard Using Nigeria as the showcase, the PPP scope will expand School of Public Health, to regionally in Nigeria where LABORIE has existing units in Evangel draw attention to the and Abakaliki, and then into the ECOWAS region, where growing challenges to LABORIE already has distribution in academic fistula centers in women’s health posed by a Senegal and Ghana, eventually to create a West African rapidly increasing volume of Urodynamics Society among senior fistula surgeons. Through the cesarean delivery in low- MoU, the PPP will strengthen the quality of fistula care services resource settings where through provision of favored partner pricing for urodynamics and minimum standards of related patient evaluation patient therapy equipment that LABORIE safety and quality of care distributes. Currently the agreed-upon pricing is 30% below North cannot be attained. American prices and 15% below standard Low/Middle Income Country (LMIC) prices. FC+ worked with LABORIE to support a The consultation was half-day urodynamics workshop run by Dr. Steve Arrowsmith that aculmination of FC+ took place at the ISOFS meeting in October 2016 in Abuja, Nigeria, leadership in gathering data see Objective 4 for more detail. Laborie was also engaged at the and conducting research on UroDak and UroMap conferences for urodynamics capacity cesarean section provision building for evaluation complex fistula cases. and iatrogenic fistula over the past several years. As part of efforts to strengthen PPP related to anesthesia quality of care, FC+ initiated discussions with Gradian Health Systems during FC+ will work with partners FY 15/16, following the implementation of an anesthesia machine to disseminate and needs assessment survey at all supported repair sites. The survey implement the consensus results allowed stratification of sites according to need. As a result, action agenda developed at highest-need sites were balanced against budget for prioritization of the consultation, starting partnership with Gradian. Saint Joseph Hospital in Kinshasa, DRC with a Fistula Community of was chosen as the first site to receive the Universal Anesthesia Practice webinar on Machine (UAM) and the procurement process is underway in November 9, 2017 and a Nigeria. panel at the Fourth Global Forum on Human Resources Through referral from USAID’s Susan Rae Ross, FC+ has begun negotiations with representatives of Bard Medical a renowned for Health on November 16, distributor of high quality bladder catheters, towards a potential PPP 2017. Read more about this MOU, to promote task shifting of catheter treatment of fistula to technical consultation be in National Midwifery Societies in LMIC generally, piloting the Section II: Objective 1.3 and concept in FC+ supported countries. FC+ has shared opportunities Appendices I-K. for partnership with Bard Medical, see Appendix H. FC+ has also
Annual Report • October 2016 – September 2017 Fistula Care Plus 24
been in discussion with Bioteque, a medical device distributor, to develop a potential MoU to establish sustainable pessary supply chains in supported countries. During the fiscal year, FC+ engaged the principles of the emerging Safe Surgery community of practice set forth by the WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) and Lancet Global Surgery, through participation in national and global advocacy for safe surgery and project promotion of clinical quality of care. FC+ initiated engagement with the Royal College of Obstetricians and Gynecologists (RCOG) Global Health Division in London at the end of FY 15/16, as well as UNFPA and ISOFS, to support the drafting of a training manual for evaluation and surgical and nonsurgical treatment of fistula, POP, incontinence and related pelvic floor disorders. FC+ and RCOG convened a global working group for the development of an integrated training manual. Invitees included RCOG, UNFPA, and sub-Saharan Africa and South Asia region professional organizations. This group held its first progress review meeting in London during the second quarter of FY 16/17. RCOG provided the cost of lodging that enabled Dr. Rene Genadry to participate in the meeting. The manual will be designed to support academic, credentialed urogynecology and female pelvic medicine fellowships emerging in sub-Saharan Africa (Ghana, Nigeria, Ethiopia) and South Asia (Nepal, Bangladesh), all of which were founded by senior fistula surgeons working in renowned fistula facilities. The development of the manual will contribute to the sustainability and legacy of the FC+ project. As of the end of FY 16/17, the RCOG working group continues work on a draft manual to be introduced in a stakeholder session in mid-2018, and negotiations for a final MoU between EngenderHealth and RCOG are underway In March 2017, the FC+ Project Director attended the RCOG World Congress held in Cape Town, South Africa. She participated in an African Federation of Obstetricians and Gynecologists (AFOG) panel on the “Eradication of Fistula: Lessons from History.” She was also able to meet with RCOG leadership regarding the continuing development of a MOU for the development of the manual described above. Beginning in the final year of the prior Fistula Care (FC) Project through the first three years of FC+, the project worked with the Nigeria Federal Ministry of Health (FMOH) and convened meetings and discussions to develop a national policy and guidance on the use of catheterization to prevent and non- surgically treat fistula, reducing the need for surgery. In March 2016, the draft guidelines, developed through meetings and discussions convened by FC+, were approved by the FMOH. FC+/Nigeria provided both technical support for the development of these guidelines and financial support for their publication. In October 2016, at the opening ceremony of the ISOFS conference in Abuja, Nigeria Federal Minister of Health Professor Isaac F. Adewole launched the Guidelines on Urethral Catheterization for Prevention and Management of Obstetric Fistula in Nigeria. FC+ received permission from the Government of Nigeria to translate and disseminate these official guidelines in other countries. The guidelines have been translated into French and introduced at supported sites in DRC and Niger. FC+ had a substantial presence at the October 2016 ISOFS meeting held in Abuja, Nigeria. The ISOFS 6th Biennial General Meeting and Scientific Congress brought together fistula surgeons, programmers, and M&E specialists from 33 countries. The theme of the conference was restoring the past and securing the future for obstetric fistula patients and covered the sub-themes: management options for patients deemed incurable, management of post repair urinary incontinence, management of severe vaginal occlusion, and sexuality and reproductive experience of obstetric fistula clients. Twenty-eight members from the FC+ team attended (seven global; ten Nigeria, two Niger, three Uganda, three DRC, and three Bangladesh) as well as one partner from Guinea, where EngenderHealth supports additional fistula
Annual Report • October 2016 – September 2017 Fistula Care Plus 25
programming. Additionally, four FC+ consultants attended with support from the project (Jessica McKinney, Laura Keyser, Alex Delamou, and Renee Fiorentino). FC+ team members submitted a total of 28 abstracts to the conference, all of which were accepted (21 as oral presentations and seven as posters). Additionally, FC+ partners submitted five oral and one poster presentations, all of which were reviewed by FC+ team members before submission. Overall, FC+ contributed 26 of the conference’s 74 oral presentations and 8 of the conference’s 22 poster presentations. FC+ also gave two plenary presentations and chaired multiple panel sessions. See Appendix F for a complete list of FC+ ISOFS and IOFWG involvement. Immediately following ISOFS, FC+ held a meeting for project clinical staff who attended the conference, to discuss issues that have emerged from routine FC+ data for decision-making (DDM) discussions as well as planning for the dissemination and implementation of the FC+ Surgical Safety Toolkit (SST). See Appendix G for the clinical meeting agenda and participant list. FC+ commissioned Medical Aid Films (MAF) to create a 20-minute orientation video to complement the formal roll-out of the FC+ SST during the first half of FY 16/17. MAF shot the film with longtime FC+ partner surgeons as well as at a partner site in Ibadan, Nigeria during the ISOFS conference. The final video blends this footage with graphics to recap main points. It is being used to orient facility clinical staff to the principles and to the global community of practice related to surgical and anesthesia safety, as an introduction to the SST. Bangladesh has had the strongest engagement of the SST thus far, and the video was used during the March 2017 SST orientation stakeholder meeting in Dhaka. More information on the SST can be found in Section II, Objective 4. In May 2017, the FC+ Project Director attended the WHO scoping meeting on creating a guideline based on the FC Project RCT for non-inferiority of seven day catheterization after surgical repair of simple fistula. The guideline rough draft was circulated in July 2017 and publication of the final guideline on the WHO website is expected in the first quarter of FY 17/18 (see Section II, Objective 5). During FY 16/17, FC+ continued advocacy and participation in the renewals of the National Fistula Policy in Uganda and the National Fistula Strategy in Bangladesh, the next iteration of the National Fistula Strategy in Nigeria, as well as efforts to establish a national strategic plan for fistula in DRC. As described in Section 1: Partnership: Global and Country-Level, responding to mid-term evaluation recommendations, FC+ is engaging with project partner Fistula Foundation to review supported facilities in all countries for potential funding support after FC+, through Fistula Foundation grants. The Fistula Foundation also directly provided funds to FC+ that were used in Nigeria during the second quarter to procure restricted pharmaceuticals for fistula surgery. Fistula Foundation has postponed final determination on future site support due to strategic shifts in their emerging primary geographic base in Kenya and staff sabbaticals. FC+ remains in contact to continue discussion on transitional funding for FC+ supported sites at the end of project. FC+ is working with project partner Direct Relief to streamline enrollment, MOUs, and materials receipt so that all FC+ supported sites may benefit from Direct Relief donation of disposable supplies in Fistula Repair Modules to facilitate best-quality fistula services worldwide. A Fistula Repair Module is a standardized pack of high-quality medicines and disposable surgical and anesthesia supplies necessary for fistula repair surgery. These modules are available to qualified health facilities providing fistula care services at no cost. This donation process requires FC+ supported sites to first register with Direct Relief via an online application prior to receiving the modules. As of the end of FY 16/17, eight supported sites have received fistula modules from Direct Relief: five in DRC, two in Uganda, and one in Niger. In
Annual Report • October 2016 – September 2017 Fistula Care Plus 26
addition, Direct Relief has approved all applications from Bangladesh, Niger and Uganda, but distribution is delayed as there is a shortage of supplies to process shipments. Nigeria applications were approved but identification of an in-country expeditor has proved difficult thus far. In January 2017, the FC+ Project Director held discussions with Dr. Igor Vaz related to possible collaboration with the newly launched NGO Focus Fistula in Mozambique (FFM, http://focusfistula.org/en/). FFM would benefit from funding as well as mentoring for implementation monitoring at the aggregate and clinical levels. As described in Section I, the FC+ Global Projects Manager traveled to Mozambique in September 2017 to further develop the scope of work, budget, and subaward documentation with Focus Fistula Mozambique, as well as meet with the local USAID Mission, partners, and ministry colleagues. A subaward package with Focus Fistula is under development. While the intention is to receive multiyear funding from USAID, the subaward will cover seven months, November 2017 – June 2018 and will be extended if further support is provided. At the country level, FC+ teams continue to maintain and expand partnerships with private entities, such as media outlets, for cost share and other support to FC+ activities. See Section III, by country. Other project efforts building sustainability are described in Objective 4 (COSECSA activities) and in Section III: Bangladesh country activities (PACOM). In addition to FC+ activities in DRC and Uganda, EngenderHealth is implementing ExpandFP, a two year, $3 million Bill and Melinda Gates Foundation (BMGF) funded project. This FP project focuses on increasing sustainable access to quality hormonal implant services in a context of informed choice and volunteerism in Tanzania, DRC, and Uganda with a focus on training and support for clinicians.
Sub-Objective 1.2: Improve data available on OF to facilitate planning FC+ has carried out several activities during FY 16/17 to promote improved availability of fistula data for programmatic implementation. In collaboration with USAID/W, FC+ launched the Fistula Community of Practice (FCoP) in May 2016. The purpose of the FCoP is to facilitate collective learning, knowledge sharing, coordination, and technical resource development related to preventive care, detection, treatment, and reintegration support for women and their families and communities and to leverage that within the global conversation and activity around fistula. FCoP membership is extended to USAID Missions and organizations funded to work on fistula. FC+ continues to provide global leadership through the FCoP for sharing lessons learned and convening meetings for technical exchange. FC+ convenes an FCoP webinar series that is open to all individuals and organizations interested in these topics. In February 2017, the FCoP held its second webinar, entitled “Obstetric fistula and gender-based violence: Examining the linkages” and in April 2017, its third webinar, entitled “After fistula repair: Understanding women’s needs.” More detail on these webinars is included under Objective 5.3. Sub-Objective 1.3: Advocate for a fistula-free generation Activities to strengthen the enabling environment for fistula services and advocate for prevention and treatment needed to achieve a fistula-free generation have been taking place across countries throughout the fiscal year. National working groups have met with FC+ support and participation in the first half of FY 16/17 in Bangladesh, DRC, Nigeria, and Uganda to revise and update national strategies for the elimination of fistula.
Annual Report • October 2016 – September 2017 Fistula Care Plus 27
FC+ partnered with professional organizations and other actors in the international maternal and child health community to plan and carry out advocacy efforts towards the eradication of fistula. FC+ continues our work with the Safe Surgery community of practice through the WHO Global Initiative for Essential and Emergency Surgical Care (GIEESC). In 2017, EH declined to renew membership in the Global Alliance for Surgical, Obstetric, Trauma, and Anesthesia Care (G4 Alliance www.g4alliance.org) due to organizational priority shifts and concerns related G4 Alliance structural transitions. During FY 15/16 and FY 16/17, FC+ has successfully facilitated an initiative to support ECSA-region obstetrician-gynecologist society (ECSAOGS) leaders’ efforts to establish a College of OBGYN within ECSA (ECSACOGS), commensurate and in collaboration with the ECSA College of Surgeons of East, Central and Southern Africa (COSECSA, www.cosecsa.org). This COSECSA/ECSACOGS collaboration is founded on annual cost share of conferences during which fellows take written and oral examinations that allow them to be credentialed at the regional level. With support and funding from FC+ and USAID, COSECSA offered to guide the ECSAOGS to either become a college of the East, Central and Southern African Health Community (ECSA-HC) or to combine fully with COSECSA. In December 2016, the FC+/Global Senior Clinical Associate participated in the17th Annual Scientific Conference of COSECSA during which he learned the history of how COSECSA became a college of ECSA-HC with the capacity to give internationally recognized surgical professional memberships and fellowships. This linkage to ECSA-HC Health Systems and Capacity Development (HSCD) helped to subsequently develop a plan for ECSAOGS to follow the same course. During this conference, a constitution for this college was developed, along with guidelines for membership and sub-specialty fellowships. In April 2017, FC+ participated in the East, Central and Southern Africa Health Community 10th Best Practices Forum and 26th Directors Joint Consultative Meeting held in Tanzania as part of continued efforts to further the formation of ECSACOG. FC+ made a presentation and carried out advocacy meetings with various stakeholders to garner support and share information about proposed plans. In July 2017, official approval for formation of the college was granted by ECSA-HC. In September 2017, the formal launch of ECSACOG took place, in conjunction with the 5th Annual Scientific Conference of the Rwanda Society of Obstetricians and Gynecologists. The FC+ Project Director and Senior Clinical Advisor were in attendance, along with three other FC+ project staff from Uganda and DRC. It is anticipated that the legacy impact of the launch of ECSACOG will include the creation of regional credentialing for OBGYN through a uniform educational curriculum for residency training and for subspecialty fellowship training (maternal fetal medicine, reproductive health/infertility, female pelvic medicine and reconstructive surgery/urogynaecology, gynecologic oncology, etc). This level of regional credentialing is commensurate with current credentialing functions of the COSECSA and with the West African College of Surgeons (WACS) in the ECOWAS region. Credentialing functions will be enumerated in the five year strategic plan currently under development, and are conceptually contained within the Constitution of ECSACOG filed with the ECSA Health Community. To facilitate the growth of the college, the FC+ project will continue to foster collaboration between ECSACOG and COSECSA in the East African Region, between ECSACOG and the OBGYN division of the WACS in the West African Region, and between ECSACOG and the American College of Obstetricians and Gynecologists (ACOG) Global Women’s Health office. In addition to this regional development in Africa, the South Asian Group on Fistula and Related Morbidities (SAGFRM) held its inaugural meeting bringing together experts from leading agencies representing public and private sectors, civil society, health care associations and academic institutions.
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The Nepal Society of Obstetricians and Gynecologists and FC+ co-hosted the meeting in Kathmandu on April 8, 2017. The group committed to developing a dynamic, multi-sectoral strategy with the goal of ending obstetric fistula in South Asia by 2030. Based on the 2030 Sustainable Development Goals, SAGFRM will advocate for and serve as a hub for integrating the public, private, civil society, and academic approaches, to fully realize the United Nations Secretary General’s 2016 call to “End Fistula within a Generation.” One of the key actions identified at the meeting is for stakeholders to enhance the capacity of national health systems and academic and medical institutions to provide credentialed training for iatrogenic and obstetric fistula prevention and fistula treatment in the South Asian region. This is one of several action areas to be reflected in the new strategy that aims to be measurable and accountable to ministries of health and of education, engage principles of safe surgery, and promote respectful maternity care and safe anesthesia. SAGFRM participants included the Nepal Society of Obstetricians and Gynecologists, EngenderHealth, UNFPA (Nepal, Asia Pacific Region, and New York City), World Health Organization, South Asian Federation of Urogynecology, South Asian Federation of Obstetrics and Gynecology, International Society of Obstetric Fistula Surgeons, Royal College of Obstetrics and Gynaecology, Advancing Reduction in Mortality and Morbidity of Mothers and Neonates, International Federation of Gynecology and Obstetrics, and the International Urogynecological Association. SAGFRM plans to identify participant organizations in Afghanistan, Bhutan, Maldives, Myanmar, and Sri Lanka to ensure their voices and experiences are represented. In addition to this South Asian initiative, FC+ has catalyzed launch of a West and Central African Regional Working Group initiative to engage the UNSG’s 2016 call to action to “end fistula within a generation.” In collaboration with the WA/USAID mission and the FC+, a communication plan was set up with the WAHO regional office and UNFPA to
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have a common understanding of the regional strategy harmonization process. Immediately following the end of UroDak in July 2017, FC+ held a two-day launch meeting for the West and Central African Group to End Obstetric Fistula (WCAGEOF) on July 14-15, 2017. Mary Ellen Stanton, USAID Maternal Health Advisor, attended and participated in this meeting. A follow-on meeting is planned for the first quarter of FY 17/18 together with WAHO and UNFPA. These two working groups (South Asia and West/Central Africa) are two of three launched by FC+ in collaboration with UNFPA as part of the FC+ sustainability and impact platform. The remaining working group is the East and South African Group to End Obstetric Fistula that will launch in December 2017. The mission of all the three working groups is to bring the public, private and academic sectors to the policy and advocacy arenas towards realizing the UN Secretary General’s 2016 Call to Action to end obstetric fistula within a generation. During FY 16/17, FC+ and ACOG continued collaboration on ACOG Global Program’s cesarean section/EmONC training in Uganda, known as the Structured Operative Obstetrics (SOO) pilot. This ACOG Global Programs (http://www.acog.org/About-ACOG/ACOG-Departments/Global-Womens- Health) initiative builds on the Canadian Network for International Surgeons (www.CNIS.ca) cesarean skills program in Uganda and is geared toward assuring minimum acceptable levels of cesarean delivery skills among clinical trainees. An MOU between FC+ and ACOG was finalized and the FC+ Deputy Director has provided ongoing M&E support to the pilot, including drafting the SOO pilot M&E plan for ACOG. In the second quarter, the FC+/Uganda M&E officer provided an M&E orientation to the ACOG Global Program Associates responsible for supervising training. The FC+ Deputy Director also developed an online survey tool to ensure that data on outcomes/impact for trainees is collected on an ongoing basis after they are placed at rural hospitals. The FC+ Project Director has also provided a linkage between ACOG and Johns Hopkins University to pursue the possible expansion of this program into Rwanda. As the pilot continues its second phase, FC+ remains on hand for M&E technical assistance as needed. FC+ organized a panel for the International Confederation of Midwives (ICM) Congress, held in Toronto in June 2017, on neglected aspects of care for women who have experienced prolonged/obstructed labor. More information on this panel and other sponsors and presenters is described under Objective 5, as well as in Appendices O, P, and Q. The FC+ Project Director and Deputy Director attended a Wilson Center Maternal Health Initiative panel event, “Too Much Too Soon: Addressing Over-Intervention in Maternity Care”, in April 2017. The event provided an excellent environmental scanning opportunity for FC+ in relation to prevention of both obstetric and iatrogenic genital fistula. A major component of the project’s advocacy efforts during the fiscal year was a technical consultation on cesarean section safety and quality in low-resource settings, a co-convened with the Maternal Health Task Force (MHTF) at the Harvard T H Chan School of Public Health on July 27-28, 2017. The full meeting report, presentations and other materials are available at: https://fistulacare.org/resources/program-reports/cesarean-section-technical-consultation/. Appendices I, J, and K provide a summary of the meeting, meeting agenda and participant list. On the first day of the consultation, presenters summarized current evidence related to cesarean section provision, including an assessment of global trends, flashpoints that affect safety and quality, and country-level insights. These presentations demonstrated that cesarean section services are often provided in settings where minimum standards for clinical decision-making, surgical safety, and counseling and consent cannot be attained due to severe resource gaps. Participants from sub-Saharan Africa and South Asia provided examples of the effects of gaps in workforce, infrastructure, and quality assurance (QA) on
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service delivery. While the focus of the meeting was not on cesarean section rates, presentations clearly demonstrated that both underuse and overuse are problems with significant implications for maternal and newborn health – and that “too much” and “too little” often coexist in the same country and sometimes even the same facility. The discussion also highlighted important gaps in knowledge, such as the lack of evidence-based guidelines for labor monitoring and intrapartum risk assessment to facilitate appropriate decision-making for cesarean section. On the second day of the consultation, participants synthesized these findings, developing a consensus action agenda to improve cesarean section safety and quality. Participants also identified immediate actions that the maternal health and OBGYN communities can undertake to collaborate with the safe surgery community and disseminate the recommendations of this consultation to local, regional, and global stakeholders. Since the meeting, FC+ has begun a range of activities to disseminate the meeting findings and action agenda. In addition to providing the meeting report on the FC+ and MHTF websites, this will be the topic of the next FCOP webinar (November 9). FC+ will also convene a panel focusing on the workforce aspects of the consultation and agenda at the WHO Human Resources for Health (HRH) Symposium (November 16). Other dissemination opportunities have been identified for 2018, including the Institute for Healthcare Improvement First Annual Africa Forum on Quality and Safety in Healthcare (February 2018) and the FIGO World Congress (November 2018). During the fiscal year, FC+ has also responded to requests from partners and USAID to provide information on fistula and female genital mutilation/cutting (FGM/C). At USAID’s request, the FC+ Deputy Director prepared a briefing on the linkages between fistula and FGM/C, and the potential synergies and conflict in programming that address both (see Appendix R). The FC+ Deputy Director was also asked by the Population Council to provide technical review to a DFID-supported report on fistula and FGM/C in March 2017. As part of a coordinated external relations strategy, the FC+ blog and Twitter account have been updated regularly throughout FY 16/17. During the fiscal year, the blog has featured 19 postings highlighting current issues in maternal health and FC+ activities, authored by FC+ global and country staff as well as FC+ partners (see Objective 5 for a list of postings). Overall, the FC+ website had a total of 24,283 page views during the fiscal year (see Figure 2 for views by month). The FC+ Twitter account metrics are presented in Table 6.
Table 6. FC+ Twitter Account Metrics, FY16/17
Metric Current period Total since April 2015 Twitter Followers 167 new 630 Impressions (number of times tweets appear on 68,582 364,770 feeds) Link clicks 91 409 Retweets 364 1,141 Favorites/Likes 398 1,018 Mentions 268 711 Total Engagements (number of times someone 1,244 3,973 interacts with a tweet)
Figure 2. Fistula Care Plus Website Views by Month
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4115 4500 3889 4000 3544 3276 3500 2993 2949 2973 2864 2690 2789 3000 2473 2446 2293 2500 2071 1849 1808 1891 1773 1862 1802 2000 1633 1529 1593 1500 1001 1000 500
0
Jul-16 Jul-17
Jan-16 Jan-17
Jun-16 Jun-17
Oct-15 Oct-16
Sep-16 Feb-16 Feb-17 Sep-17
Apr-16 Apr-17
Dec-15 Dec-16
Mar-16 Mar-17
Aug-17 Nov-15 Aug-16 Nov-16 May-17 May-16
Objective 2: Enhanced community understanding and practices to prevent fistula, improve access to fistula treatment, reduce stigma, and support reintegration of women and girls with fistula FC+ enhances community understanding and practices to prevent fistula, improve access to fistula treatment, reduce stigma, and support reintegration of women and girls with fistula by building community awareness, skills, and mobilization regarding the behaviors and services that can prevent fistula, as well as those that enable treatment. The FC+ project aims to address gender inequalities as a root cause of fistula, for instance through barriers to prevention and care, and maximize overall impact. The FC+ Gender Focal Point, Lauren Bellhouse, worked with the EngenderHealth Gender team to develop a Gender Action Plan to address the training, capacity, and programmatic needs of the project and ensure gender mainstreaming. The action plan is based on input from country programs, documented best practices, USAID guidance and gender priorities, and recommendations from the EngenderHealth Gender team. During FY 16/17, FC+ continued implementation of the project’s global Gender Action Plan and provided technical support to country-specific action plans working towards a gender transformative approach to programming. FC+ provides ongoing technical support and training on gender mainstreaming and promotion of reproductive empowerment across the life course to all FC+ staff and select partners. As part of capacity building activities, country programs identified items for immediate action. During FY 16/17, a Gender 101 orientation was conducted in the final remaining country of Uganda, where FC+ staff were joined by colleagues working across other sexual and reproductive health and rights (SRHR) and MNCH projects. Additionally, DRC staff from supported subaward sites Panzi and HEAL Africa joined the Uganda training, contributing to cross-border learning. By the end of the fiscal year, 81 total individuals (FC+ and external) had been trained through FC+ gender mainstreaming initiative. Additionally, 10 staff from the Nigeria office elected to form an internal “Gender Working Group” during FY 15/16. During FY 16/17, this Gender Working Group received a training-of-trainers and thereafter provided multiple orientations on the gender action plan to new staff, both internal to FC+ and external partners. Over the course of FY 16/17, FC+/Global and the Gender Focal Point continued to monitor progress of country-level action plans drafted during each of the orientations, working with country programs towards a transformative approach to activities and messaging. Support provided during the fiscal year included: continued capacity building on gender mainstreaming for staff of partner organizations (DRC, Nigeria, Uganda); inclusion of gender components in a youth empowerment and sexual and reproductive health (SRH) curriculum (Uganda); review of project-supported local and national media activities to ensure
Annual Report • October 2016 – September 2017 Fistula Care Plus 32
gender transformative messaging (Bangladesh, Nigeria); support to partner sites Panzi and HEAL Africa to utilize best practices in their programs to engage men as supportive partners in MNCH, and to document these activities for future partnership and funding opportunities (DRC); and finalization of an SBCC strategy and review of SBCC materials and messages, drafted with a gender lens and based on findings of a project-conducted assessment (Nigeria).
Sub-Objective 2.1 Create awareness and reduce stigma about OF Country-level activities to increase community understanding and practices related to preventing fistula and the availability of fistula repair services were undertaken in Bangladesh, DRC, Niger, Nigeria, and Uganda in FY 16/17. A total of 34,084 community outreach/education/advocacy events were carried out, reaching over an estimated 15.8 million people. Of these events, 33,425 were in-person community activities that reached over 550,000 people. 659 mass media activities were also supported, estimated to reach over 15 million people. Additional detail by country can be found in Table 7 below, as well as in Section III. A compiled list of media coverage around fistula in supported countries can be found in Appendix EE.
Table 7: Community Outreach/Education Events, by Country, FY 16/17
Country Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Bangladesh -in person 18 958 22 1,103 31 2,461 11 800 82 5,322 -mass media 0 0 0 0 34 33,007 0 0 34 33,007 DRC -in person 7 115 69 1,564 9 513 3 243 88 2,435 -mass media 0 0 6 305,000 3 185 0 0 9 305,185 WA/Niger -in person 2,332 67,414 2,196 55,710 2,139 51,146 1,037 27,008 7,704 201,278 Nigeria -in person 7 2,174 69 8,286 110 49,322 319 163,216 505 222,998 Uganda -in person 4 30,587 1 5,692 8,144 38,640 16,897 50,234 25,046 125,153 -mass media 0 0 1 1,175,772 613 9,100,000 2 4,675,772 616 14,951,544 Total 2,368 101,248 2,364 1,553,127 11,083 9,275,274 18,269 4,917,273 34,084 15,846,922 -in person - 2,368 -101,248 -2,357 -72,355 -10,433 -142,082 -18,267 -241,501 -33,425 -557,186 -mass media - 0 - 0 - 7 -1,480,772 -650 -9,133,192 -2 -4,675,772 -659 -15,289,736
Additionally, a total of 850 community volunteers and educators were trained in Bangladesh, DRC, Niger, Nigeria, and Uganda in FY 16/17. Participants included cured fistula patients, community partners, adolescent peer outreach volunteers and local religious leaders; see Table 8 and Section III, by country, for more information. In the first half of the project, emphasis was on the identification and training of community volunteers. Beginning in FY 15/16 and continuing in FY 16/17, efforts have shifted focus from training towards increased outreach activity in communities and with media, community structures, and religious institutions.
Table 8: Community Volunteer/Educator Training, Participants by Country, FY 16/17
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Country Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total FY 16/17 2016 2017 2017 2017 Bangladesh 0 10 0 10 20 DRC 6 0 0 0 6 WA/Niger 0 0 360 0 360 Nigeria 0 252 153 0 405 Uganda 0 29 30 0 59 Total 6 291 543 10 850
Sub-Objective 2.2 Establish partnerships to facilitate achievable, holistic goals for reintegration to meet the needs of women with fistula Global staff provided management support to TERREWODE, a resource partner on the FC+ project, for the implementation of a study to understand the needs of WDI as well as the effects of social reintegration services for this group, see Objective 5 and Section III: Uganda for additional details. FC+ has also completed a partnership with UCSF/Makerere University to provide support for a study on reintegration after fistula repair in Uganda, see also Objectives 1 and 5. This study was completed at the end of FY 15/16; Makerere University researchers presented preliminary findings at ISOFS in Abuja in October 2016. Findings were shared more comprehensively in an FCoP webinar in April 2017 and a UCSF-supported manuscript. As described in Objective 1, FC+ is exploring potential PPPs that may increase access to products that can help women with fistula, particularly WDI, better integrate into the community by mitigating the impact of their symptoms.
Objective 3: Reduced transportation, communications, and financial barriers to accessing preventive care, detection, treatment, and reintegration support Efforts to reduce transportation, communications, and financial barriers to accessing preventive care, detection, treatment, and reintegration support target the challenges that keep women from being able to access and use fistula services, particularly for repair, and will involve testing innovative incentives and enablers to help women overcome these obstacles.
Sub-Objective 3.1 Reduce transportation barriers for prevention and treatment of obstetric fistula Sub-Objective 3.3 Reduce financial barriers to fistula prevention, treatment, and reintegration In 2014, FC+ partnered with the Population Council to conduct a literature review on barriers affecting women’s access to genital fistula treatment in low-income countries. The review identified numerous barriers women often face and categorized these barriers as psychosocial, cultural, awareness, social, financial, transportation, facility shortages, and quality of care factors. Building on this, the Population Council conducted formative, qualitative research in 2015 to understand the specific barriers women face in Nigeria and Uganda and to identify enabling mechanisms that mitigate the most salient barriers. Reports from the literature review and formative research are available on both the FC+ and Population Council websites (https://fistulacare.org/resources/publications/research-reports and http://www.popcouncil.org/research/fistula-care-plus). Findings from these studies informed FC+ in the design of a comprehensive information, screening and referral intervention aimed at reducing the awareness, financial, and transportation barriers that impede
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women’s access to fistula treatment in Nigeria and Uganda. Formative research findings and the process of developing a responsive intervention were showcased at a panel event at the fourth Global Symposium on Health Systems Research in Vancouver in November 2016, convened by the Population Council. Findings were also presented to national, state, and community stakeholders in Nigeria in September 2017. A similar debriefing will be held for stakeholders in Uganda in the first quarter of FY 17/18. The Fistula Treatment Barrier Reduction Intervention utilizes a consistent fistula screening algorithm across multiple communication and referral channels, including communities, primary health facilities, and mass media; and a transportation voucher to enable positively screened women to travel for free to and from an accredited fistula treatment facility. The Population Council is conducting implementation research to evaluate the effects of this Intervention. The Intervention is taking place in the catchment areas of two fistula treatment facilities in Nigeria (NOFIC Abakaliki and NOFIC Babbar Ruga) and one facility in Uganda (Kitovu Mission Hospital). Within each of the three catchment areas, FC+ supports activities that seek to strengthen community- based screening and referral to the treatment facility. The intervention focuses on screening and referral mechanisms through three channels: primary health facilities, community engagement activities, and phone-based communication. FC+ is training community agents and health workers (doctors, midwives, nurses, and community health care workers) at primary health facilities across each catchment area to identify potential fistula clients and refer these women for treatment. Job aids for screening were developed for both primary health facility workers and community agents (see Appendices S and T). As part of this Intervention, FC+ collaborated with VOTO Mobile, now known as Viamo, to design a free interactive voice response (IVR) fistula screening hotline that also collects data on positively screened callers. The fistula hotline is being widely advertised through graphic flyers disseminated by the community agents and primary health facility workers at community venues. Community agents follow- up with women who call into the hotline and facilitate their free transport to the fistula treatment facility using a transportation voucher designed for the intervention. Community agents also use the fistula hotline to screen women using their own phones during their community mobilization activities (home visits, community forums, etc.), while primary health facility workers use a paper-based job aid to screen patients at primary health facilities. Community agents and primary health workers follow up with positively screened women and facilitate their free transport to the fistula treatment facility using the transportation voucher. All three screening channels – community agents, health workers, and the hotline - collect the same data, using the same screening algorithm (see Appendix U). The key fistula symptom question within this algorithm is, “Do you currently experience constant leakage of urine or feces from your vagina during the day and night even when you are not urinating or trying to urinate?“ During FY 16/17, FC+ community mobilization specialists in Nigeria and Uganda conducted trainings to strengthen fistula screening and referral for primary health care (PHC) workers (doctors, midwives, nurses, and community health care workers) and community agents participating in the barrier intervention study by the end of the third quarter. PHC workers participated in three-day trainings that included overviews of the FC+ project, maternal mortality and morbidity, antenatal care and birth preparedness, genital fistula focusing on obstetric fistula, family planning/child spacing, management of normal labor and delivery, infection prevention, and prolonged/obstructed labor (P/OL); and provided PHC workers with practical tools for participating in the barrier intervention. A total of 94 PHC workers from 41 facilities were trained across Ikwo and Katsina LGAs in Nigeria and 42 PHC workers were trained from 21 facilities across Kalungu District in Uganda. Community volunteers participated in two-
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day trainings on identifying fistula patients, promoting healthy pregnancies, and community engagement activities. A total of 82 volunteers were trained across Ikwo and Katsina LGAs in Nigeria and 275 volunteers were trained across Kalungu District in Uganda. Upon the completion of the trainings, FC+ community mobilization specialists in Nigeria and Uganda ensured that the flyers advertising the hotline were widely disseminated throughout the catchment areas by community agents and PHC worker, and the transportation voucher mechanism was fully operational (i.e. transport provider contracts executed and PHC workers and community volunteers had vouchers to initiate the transport mechanism). By July 2017, the barrier intervention was fully launched in all three intervention sites (Ebonyi and Katsina States in Nigeria and Kalungu District Uganda). Out of 233 callers to the hotline from the three catchment areas between June – September, 165 screened positively for fistula; a total of 26 women who screened positively, have utilized the transport voucher mechanism across the three catchment areas. A monitoring visit was conducted in Nigeria the fourth quarter of FY 16/17 to assess implementation fidelity, identify problems for course correction, and collect process documentation data, as well as to present baseline findings to National and State-level stakeholders. A similar visit will be conducted in Uganda in the first quarter of FY 17/18.
Sub-Objective 3.2 Improve communication in support of fistula prevention, treatment, and reintegration During FY 15/16, FC+/Nigeria conducted a communications needs assessment with technical guidance from FC+/Global. The findings from this assessment were disseminated through presentations at the ISOFS conference in Abuja in October 2016 and summarized in reports available on the FC+ website. The findings were also used to design an updated SBCC strategy in Nigeria that began implementation in FY 16/17. Please see Section III, Nigeria for more information. Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment FC+ strengthens clinician and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment, supporting health facilities and their staff to deliver effective clinical care and monitoring of topics ranging from FP counseling to fistula repair outcomes. Sub-Objective 4.1 Strengthen facility-level capacity to prevent fistula Good quality obstetric care, including timely recognition and management of prolonged/obstructed labor, is the cornerstone of fistula prevention. FC+ efforts to strengthen fistula prevention at the facility level primarily relate to increasing capacity for FP, labor monitoring, and EmONC. Training efforts and provision of FP counseling and services are described below. To assess the quality of labor monitoring and management of prolonged/obstructed labor, FC+ conducts partograph reviews annually at facilities that receive FC+ support for labor and delivery care. When possible, reviews are also conducted at facilities where FC+ plans to provide such support during the life of the project, even if the support is not currently being provided. Such support may include training, supervision or other inputs related to EmONC, BEmONC, partograph/labor monitoring, and cesarean section. Support may also include provision of supplies, equipment and/or expendables, through a formal agreement, for labor and delivery services as well as improving infrastructure and/or systems (i.e. data capture, supervision, monitoring). During FY 16/17, FC+ supported training for 113 health personnel in DRC, Niger and Uganda in use of the partograph.
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A record review tool was developed by FC+ M&E and clinical staff, during FY 14/15, to be completed as either a stand-alone data collection activity or in conjunction with clinical visits/medical monitoring visits at facilities supported for L&D services and treatment. The review focuses on the partograph as a labor monitoring tool, for the purpose of identification of and timely response to obstructed labor specifically. The review looks at a sampling of patient files to determine whether essential elements of the partograph form have been completed correctly and utilized in decision making for the patient. The tool also includes questions related to facility and workforce labor and delivery capacity. Records review summaries from FY 14/15 and FY 15/16 can be found in Appendices Z and AA. A total of 708 records from FY 16/17 were reviewed at a total of 29 facilities in four countries (Bangladesh, DRC, Niger, and Uganda), see Appendix BB for detailed scored by site. Reviews were not carried out in Nigeria where partograph support has not been implemented. In Niger, a review was completed at only one supported site: a new clinical consultant was recently deployed and only one review could be completed by the end of the fiscal year. Record review indicated wide variety in rates and quality of partograph completion between sites, and between countries. In Uganda, there was an improvement over the previous fiscal year: 94% of patient files reviewed this year contained partographs (compared to 51% in FY 15/16). In Bangladesh and DRC, rates of completion were nearly identical to the previous year: for Bangladesh 57% compared to 59% in FY 15/16, for DRC 73% compared to 74% in FY 15/16. In Niger, completion rates were 84% (compared to 100% in FY 15/16). In Bangladesh, when partographs were not present in a patient file, relevant data was still often recorded, just not using the partograph form. The majority of records reviewed were not referral cases, or not clearly identified as referral cases, which made it difficult to measure the number of records that included a partograph from the referring facility. The review tool examined four specific parts of the partograph for completion: Contractions monitored half-hourly; fetal heart rate monitored half-hourly; and maternal blood pressure and pulse monitored either at admission or throughout labor. In Bangladesh, contractions were monitored in 55% of records, with the other components recorded in 82-99% of records, which reflects no change from the previous year. In Niger, contractions were monitored in 32% of records, with the other components recorded in 72- 80% of records (as only one site was monitored this year, comparisons to the previous fiscal year are not meaningful). In DRC, contractions and fetal heart rate monitoring were found in less than 50% of records (46% and 44% respectively, a slight decrease for contractions and slight increase for fetal heart monitoring, compared to FY 15/16), while maternal blood pressure and pulse were recorded more frequently (72% and 66%). Finally, in Uganda, contractions and fetal heart rate were present in about 83% and 80% of the records (continued improvement from 70% in FY 15/16 and 60% in FY 14/15), while maternal blood pressure and pulse were present in 50-55% of records (compared to ~40% in FY 15/16). Records were also assessed to determine whether the partograph included a crossed action line, and if so, whether action was taken to address the prolonged or obstructed labor. Very few records included partographs with crossed action lines, but in nearly all those cases, action was taken. Overall, the record review for FY 16/17 indicated that the partograph implementation at supported sites greatly varies in terms of completeness and correctness, as it has in previous years. It is notable that the Uganda record reviews have shown the greatest consistent improvement in completion, as FC+/Uganda has implemented ongoing training, supervision and monitoring in partograph use at supported sites over the life of the project. FC+ will continue to utilize these findings in programmatic activities for FY 17/18.
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The FC+ M&E/research team designed a web-based survey of intrapartum and postpartum clinical practices related to bladder care and management of prolonged and obstructed labor. The draft survey was shared with technical reviewers, including FC+ consultants and technical experts at Jhpiego, and their input was incorporated into the survey that was then programmed on Survey Monkey. FC+ launched the online global survey targeting birth attendants in May 2017 (see announcement in Appendix N). The FC+ Deputy Director presented the preliminary findings from the survey’s pilot phase at the ICM Congress, highlighting the considerable variation in responses on how respondents defined P/OL, the criteria they use to assess it, and the amount of time they catheterize after P/OL. Findings were also shared on the FC+ blog: https://fistulacare.org/blog/2017/07/icm-postpartum-care-panel/. During FY 16/17, FC+ supported sites reported a total of 82,367 deliveries in four program countries (Bangladesh, DRC, Niger and Uganda). Data was not available from Nigeria, where the project is not working directly to support obstetric services. FC+ supported sites tend to be higher-level facilities that are more likely to receive referrals and complications; this contributes to a high proportion of cesarean section deliveries relative to the national average cesarean section rates in these countries. The total cesarean section rate across all FC+ supported sites was 43.3% (Figure 3). Cesarean section rates at supported sites vary widely at the country level (from 27% in Uganda to 68% in Bangladesh) and at the facility level, due to the varied patient profiles and clinical mandates of different facilities. Across supported sites, 2.3% of all deliveries were reported as prolonged/obstructed labors, with 46% of those prolonged/obstructed labors receiving catheterization for fistula prevention. The reported numbers range widely by country and by site, with a high of 15% of labors reported as prolonged/obstructed in Niger and less than <1% reported in Bangladesh. Sites in Niger also reported high levels of catheterization for fistula prevention (95%), with DRC reported a low of 12%. Site-level data can be found in Section III, by country.
Figure 3: Cesarean Section Rates, by Country, FY 16/17 (n=82,367 deliveries)
Bangladesh 31.7 68.3
DRC 69.5 30.5
Vaginal delivery Nigeria 44.6 55.4 C-Section
Uganda 73.1 26.9
FC+ Total 56.7 43.3
Sub-Objective 4.2 Increase capacity for treatment FC+ has developed a Surgical Safety Toolkit (SST), a set of clinical trackers and quality assurance checklists. The SST is a compendium of resources for surgeons and allied clinicians to improve fistula repair services and support the provision of surgical care at a minimum acceptable standard, as outlined by global actors such as the World Health Organization and the G4 Alliance. The SST addresses gaps in
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clinical record keeping and monitoring that have been identified by FC+, and provides resources that build a platform for ongoing quality assurance in fistula services past the duration of the project. The SST is a novel, integrated package that includes a client tracker of clinical outcomes for surgical and non-surgical care for fistula, pelvic organ prolapse (POP), and incontinence; a surgical skills tracker designed to document return on investment of funded clinician training, for fistula, prolapse, and incontinence; a sentinel event tracker designed to identify time trends of near-miss morbidity events that will augment the existing system of mortality review and help target quality improvement support to facilities. The SST also guides and supports staff teamwork behaviors with seven surgical safety checklists covering topics ranging from candidacy for surgery to daily post-operative care and discharge follow-up planning. The checklists are integrated into the client tracker and were designed to meet specific requests from supported sites that shared internally identified gaps within facility care systems. As described under Objective 1, FC+ commissioned MAF to create a 20-minute orientation video to complement the formal roll-out of the FC+ SST during the first half of FY 16/17. The film demonstrates the principles of safe surgery/safe anesthesia that underpin the SST, showing that the culture of safe surgery is an emerging global community, and demonstrating the positive impact that SST implementation can have on staff time and workload. The film will also serve as an advocacy tool for health policy makers, reflecting the principles of the global surgery communities of practice (G4 Alliance, Lancet Global Surgery, WHO GIEESC). The FC+ Project Director was able to hold in-depth discussions with in-country FC+ clinical staff about the SST during the clinical meeting held immediately after ISOFS. During the second quarter, FC+ global staff carried out two webinars for in-country FC+ clinical staff to orient them and discuss roll out of the SST. FC+ country clinical staff are now introducing SST at partner sites. Data is submitted monthly and an analysis framework is under development. Thus far, only the Bangladesh team has submitted regular SST information. The engagement in Bangladesh began with a stakeholder introductory meeting in March 2017 at one of the supported facilities. The implementation of the “triage to discharge” set of seven safety checklists is well documented for all facilities, with facilities either using the system as is, or not using because the site already has an equivalent procedure or checklist system in place. The skills tracker was well utilized during one pooled effort in April 2017, with clear documentation of skills used to gauge organic scale-up of fistula services. The Sentinel Events system has been utilized in most but not all facilities, and no clusters of morbidity events have occurred that would mandate an audit. In October 2016, immediately preceding the IOFWG/ISOFS meeting in Abuja, Nigeria, Medical Simulation International held a fistula repair training of trainers (TOT) using a video fistula repair simulator. Fistula surgeons and trainers were oriented in use of the fistula video simulator for teaching and training. FC+ shared the cost of travel for selected participants with ISOFS organizers. As described under Objective 1, in October 2016 at ISOFS, as part of the LABORIE PPP MOU, 60 participants attended a six-hour LABORIE-sponsored seminar on continence after fistula repair and the use of urodynamic studies in guiding effective treatment, led by a LABORIE representative and Dr. Steve Arrowsmith. On the following day, ISOFS President Dr. Ojengbede requested the leaders of the seminar to repeat the seminar for those unable to fit in the room the first day. A second session was held with about 40 people in attendance. Throughout the remainder of the week, a total of seven hands-on small group sessions were held, demonstrating the use of an actual urodynamics unit. FC+ shared a portion of the cost for Dr. Arrowsmith’s lodging with LABORIE. LABORIE also held FC+ co-sponsored training workshops on the use of urodynamics to evaluate complex bladder symptoms at the UroDAK and UroMAP workshops in 2017, described later in this section of the report. FC+-sponsored participants
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reported that these skills were of greater impact in learning and increasing fistula service capacity than the surgical components of the workshop. During FY 16/17, a total of 5,637 women with severe incontinence symptoms sought fistula care services at FC+ supported sites, compared with 6,380 in FY 15/16. Of these women, 4,031 were diagnosed with fistula (72% of those seeking, compared with 83% in FY 15/16). Of those diagnosed, 3,910 were medically eligible for surgical repair (97%, compared with 91% in FY 15/16). FC+ supported the provision of 3,250 surgical fistula repairs in FY 16/17 (83% of those eligible, compared with 81% in FY 15/16). See Figure 4 for data on women seeking and requiring fistula treatment and the number of surgical repairs supported, by country. Site level information is presented in Section III, by country. Some women may be diagnosed with fistula in one quarter, and repaired in the next. Because FC+ does not track individual women through established monitoring and evaluation data collection, we are unable to present a definitive percentage of women requiring repair who receive it. We are also unable to report the number of women repaired because women may have multiple repairs over the life of project, or repairs at multiple sites. However, within a given quarter, the number of repairs generally reflects the number of women.
Figure 4: Number of Women Seeking and Requiring Fistula Treatment, and Number of Surgical Repairs, By Country, FY 16/17
3500 3000 2500 2000 Seeking 1500 Eligible 1000 Repairs 500 0 Bangladesh DRC Niger Nigeria Uganda Including projects receiving bilateral funding, a total of 4,765 surgical repairs were supported by USAID in eight countries (Bangladesh, DRC, Guinea, Mali, Niger, Nigeria, Tanzania, and Uganda) during FY 16/17, of which 3,250 (68%) were supported through FC+ (see Figure 5 and Table 9 for detail). The remaining 1,515 surgical repairs were supported by USAID bilateral projects. Site level repair data is presented in Section III, by country. In addition to the surgical repairs described above, FC+ supported non-surgical treatment of fistula using catheterization for a total of 294 women during FY 16/17. The vast majority of these treatments were performed in Nigeria (261, 89%). ProSani also supported non-surgical treatment for 32 women in DRC during the fiscal year. It is important to note that, as identified at the 2016 FC+ clinical meeting, much prevention and early treatment of fistula using catheterization is likely to occur outside of fistula treatment centers, in maternity service sites.
Figure 5: USAID-Supported Surgical Fistula Repairs, by Quarter, FY 16/17 (n=4,556)
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1400 1287 1185 1112 1200 1181 FC+ 1000 822 845 794 800 789 Bilateral 600 493 400 340 323 359 Total USAID 200 supported 0 Q1 Q2 Q3 Q4
Table 9: Number of USAID-Supported Surgical Fistula Repairs, by Country, FY 16/17
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sept Total 2016 2017 2017 2017 FY 16/17 Bangladesh 91 58 47 47 243 DRC 108 114 221 104 547 WAR/Niger 47 67 74 14 202 Nigeria 527 557 314 555 1,953 Uganda 49 49 138 69 305 Total FC+ 822 845 794 789 3,250 DRC: ProSani (bilateral) 60 48 51 48 207 Mali: IntraHealth (bilateral) 8 53 85 35 181 Tanzania: Vodafone/CCBRT (bilateral) 211 177 288 209 885 Guinea: Jhpiego HSD project 80 62 69 31 242 Total USAID bilateral 359 340 493 323 1,515 Total All USAID-supported 1,181 1,185 1,287 1,112 4,765
Since FY 15/16, FC+ has collected aggregate data regarding the etiology of fistula diagnosed at supported sites. In FY 16/17, FC+ was able to collect this etiology data for 85% (n=3,438) of all diagnosed cases, a significant improvement of the 56% of cases where data was available in FY 15/16. This improvement is primarily due to the Nigerian MoH’s implementation of a national client record booklet, on which FC+ collaborated. Data reported during this period indicate that, of cases with available data, the etiology of the diagnosed fistula was: obstructed/prolonged labor 79% (n=2,707, compared to 72% in FY 15/16); iatrogenic 17% (n=583, compared to 20% in FY 15/16); traumatic 2% (n=69, 6% in FY 15/16); and other causes (primarily cancer or congenital) 2% (n=79, also 2% in FY 15/16). Clinician error during medical procedures has emerged as an important contributor to the fistula burden, causing a higher proportion of cases than traumatic fistula in most settings. FC+ collected data from supported sites on the number of cases deemed by the operating surgeon to be iatrogenic fistula. During this reporting period, all 33 supported sites reported this data, though it was incomplete at some sites; as noted above, reporting that 17% of all diagnosed fistula cases where etiology data were available were identified as iatrogenic in nature. However, a higher percent of cases was identified as iatrogenic in Bangladesh (39%) and DRC (25%) (see Section III, by country). Increasing discussion with country and site teams is required to ensure all sites are identifying probable iatrogenic fistula cases with consistent criteria. FC+ has considered recommending the algorithm proposed in an FC+ co-authored paper on iatrogenic fistula;8 however, there continues to be debate about
8 Raassen TJ, Ngongo CJ, Mahendeka MM. Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries. Int Urogynecol J. 2014 Dec;25(12):1699-706. http://www.ncbi.nlm.nih.gov/pubmed/25062654
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the anatomical signs and clinical history that are indicative of iatrogenic fistula. FC+ is participating in the IUGA-ICS Joint Report on the Terminology for Female Pelvic Floor Fistulae that will create consensus definitions of all terminology related to genital tract fistulae, including but not limited to etiology. FC+ has inserted the working definitions used by the project at this time, included in the client tracker of the SST, in the zero-draft of the IUGA-ICS document. During FY 16/17, 89% of all discharged FC+ repair cases were closed at the time of discharge. 78% of all cases were closed and continent (i.e., dry in the case of fistula resulting in leakage of urine) at discharge, 11% were closed with remaining incontinence, and 11% were not closed, see Figure 6 for outcome rates by country. Closed and continent rates are a potentially non-informative indicator for quality of care, in that a patient can have suboptimal outcome even when the quality of fistula care meets or exceeds an acceptable standard. This is exacerbated by variations in case mix, i.e., if some facilities are caring for many more patients with complex fistulas and complicating incontinence co-morbidities. However, in tandem with other clinical indicators (e.g., complications), this indicator may be useful in identifying settings where audit and analysis of the case mix, skills and materials that underpin evaluation and management of post- fistula incontinence, overall quality of care, and other issues may be warranted. Historically, the project has set a benchmark of 75% for the proportion of discharged cases deemed closed and continent. When rates fall below benchmarks, FC+ investigates the causes to determine whether follow-up action is necessary. Appendix FF presents data visualizations that illustrate the available country-level data on whether repairs were conducted through routine or concentrated efforts, how many previous repairs clients had undergone, whether repairs were categorized as simple or complex, and discharge outcomes.
Figure 6. Outcome Rates for Fistula Surgical Repairs, by Country, FY 16/17
100% 90% 80% 70% Not closed 60% 50% Closed with remaining 40% incontinence 30% Closed and continent 20% 10% Benchmark closed and 0% continent (75%)
Of the 2,885 discharged cases during the fiscal year, data on level of fistula complexity were available for 2,273 cases (79% of cases, compared with 44% in FY 15/16, again with the increase primarily due to the introduction of the Nigerian client record booklet). Of these, 41% were classified as simple fistula and 59% were not simple. This is a marked change from the percentages seen in FY 15/16 where 65% of cases where classification was available were simple fistula and 35% were not simple. It is difficult to know whether this reflects a true change or is just reflective of the increased number of cases for which data was available in FY 16/17. In FY 16/17, simple fistula made up 30% of reported cases in Nigeria,
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approximately half of the reported cases in Bangladesh, DRC, and Niger; and 100% of those reported in Uganda. Reported complication rates for surgically repaired fistula cases at supported sites were generally low (2.1% project-wide), with countries reporting rates ranging from 0% in Niger to 4.5% in DRC, all well below the defined project benchmark for acceptable complication rates (<20%). Country-specific data on complication rates can be found in Section III. To strengthen capacity for fistula repair, during FY 16/17, FC+ trained a total of 24 surgeons in four countries (Bangladesh, DRC, Nigeria, and Uganda) in fistula surgical repair, based on the FIGO training curriculum. Four surgeons participated in first training in fistula surgical repair and 15 took part in continuing training (see Table 10). Six surgeons in Nigeria participated in a training of trainers (TOT). An additional four surgeons were trained in surgical POP repair. Four surgeons participated in first training in surgical POP repair, and two of those surgeons also received continuing training. More detailed training information can be found in Section III, by country.
Table 10: Training in Surgical Repair, Participants by Quarter, FY 16/17
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total 2016 2017 2017 2017 FY 16/17 First Training in Surgical Fistula Repair 0 1 1 2 4 Continuing Training in Surgical Fistula Repair 10 2 6 8 159 Training to be a Fistula Trainer 6 0 0 0 6 First Training in Surgical POP Repair 0 2 0 2 4 Continuing Training in Surgical POP Repair 0 0 0 2 2 Total 16 5 7 14 2810
A total of 1,391 health system personnel in five countries (Bangladesh, DRC, Niger, Nigeria, and Uganda) participated in training in non-surgical topics during FY 16/17, including data management, EmONC, FP methods and counseling, anesthesia, data management and infection prevention (see Table 11). These trainings contribute to fistula and POP prevention, identification, referral, treatment, and post- repair services as well as clinical data management.
Table 11: Training for Health System Personnel (excluding fistula/POP surgery), Participants by Quarter, FY 16/17
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total 2016 2017 2017 2017 FY 16/17 ANC 0 0 0 0 0 Community, outreach and advocacy 0 0 272 0 0 Data management 0 48 26 20 94 EmONC 31 0 0 15 46 EmONC and labor monitoring 59 20 10 24 113 FP counseling 14 0 48 0 62 FP methods 67 209 35 110 421 FP and fistula counseling 0 0 0 0 0 Fistula counseling 0 0 0 0 0 Gender 0 0 0 0 0 Infection Prevention 0 86 0 96 182 Labor monitoring 0 0 0 0 0
9 Surgeons receiving multiple trainings during the fiscal year are only counted once in the annual total. 10 Some surgeons received both first and continuing training, or multiple continuing trainings during the fiscal year. They are only counted once in the annual total, therefore the rows do not always add up to the FY total column.
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Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total 2016 2017 2017 2017 FY 16/17 Non-surgical POP treatment 0 0 0 0 0 Pre- and Post-Operative Care 15 109 48 17 189 Quality Assurance 0 0 0 0 0 Other 0 12 0 0 12 Total 186 484 439 282 1,391
FC+ sponsored ten surgeons from DRC, Guinea, Uganda, Niger, Nigeria, and Mozambique to attend the UroDak workshop in Dakar, Senegal in July 2017. UroDak is organized by IFRU-SF (Institution de formation et de Recherche en Urology-Santé Familiale), chaired by Professor Serigne Magueye Gueye, in Senegal. The goal of the conference is to provide opportunities for urologists, obstetricians-gynecologists, surgeons, nurses, midwifes and other health professionals to share surgical experiences and develop partnerships in the field of urology and reproductive health research, training, and care. The workshop this year provided specific training for complex fistula and complications of fistula (vaginal fibrosis, genito-urinary reconstructive surgeries, urodynamics, female genital mutilations, sexual medicine and obstetric fistula). FC+ co-sponsored training workshops over two days on the use of urodynamics to evaluate complex bladder symptoms. Many women remain incontinent after fistula surgery. The factors contributing to the incontinence are usually complex, mandating precise diagnosis in order to reduce or cure symptoms. Urodynamics is mandatory for precision in diagnosis and treatment planning. FC+’s public-private partnership with Laborie, Inc. is part of these efforts. FC+ was also able to engage the collaborative support of a new fistula service partner, Humani-Terra (www.humani-terra.org). Humani-Terra is a foundation based in Marseille that has been active in humanitarian crisis-zone surgery for trauma and burns for over 20 years, mostly in Francophone West Africa. For the past several years, they have been supporting fistula surgery through collaboration with Professor F. Aristide Kabore of the Department of Urodynamics workshop at 2017 UroDAK meeting. Credit: FC+/Global. Urology at the University of OUAGUI in remote and urban regions of Burkina Faso. Humani-Terra provided no-cost support for Prof Kabore to attend both UroDak and the launch of the WCAGEOF. Discussions to potentially implement a capacity building, no cost MOU between FC+/Engenderhealth and Humani-Terra were continued in Dakar.
Sub-Objective 4.3 Integrate family planning (FP) services to respond to client needs FC+ supports efforts to strengthen integration of FP in fistula treatment services and broader maternal health care at supported sites. The FC+ Global Project Manager works with the FP compliance point persons in each office to update and harmonize plans. During the first two quarters of FY 16/17, FC+ conducted a rapid clinical assessment of family planning (FP) service quality through international consultant and midwife Pandora Hardtman. This included multiple visits to Nigeria and Uganda and a desk review of DRC. The assessment included using a standardized FP tool adapted for FC+ FP implementation, details on those interviewed in Nigeria and Uganda can be found in Table 12.
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FP based audits were commissioned and an environmental scan aimed at midwifery associations was also simultaneously planned to explore possibilities for expansion of midwifery and nursing practice to include non-surgical treatment of fistula, loosely structured around the ECSA curriculum and FMOH Nigeria guidelines for the prevention and conservative management of fistula by midwives and nurses. Areas of specific concern in the FP audit included provider bias and barriers to IUD insertion.
Table 12: Family Planning Rapid Assessment Interviews
Nigeria Interviews Registered Midwife NOFIC Abakaliki Nigerian Nurses & Midwives Council Deputy Registrar (2) Registered Midwife MCH Nigerian Nurses & Midwives Council Education Officer Registered Midwife FETHA (4) Nigerian Nurses & Midwives Association President Registered Midwife in Charge FETHA Clinical Medical Director Katsina NOFIC FC+ Nigeria Country Program Staff Director of Nursing Katsina NOFIC FC+ Nigeria FP/RH Advisor FP Director FMOH Uganda Interviews Clinical Medical Director Federal Ministry of Health General Secretary Uganda Nurses and Midwives (FMOH) Federal Teaching Hospital Abakaliki (FETHA) Union Nurse in Charge of VVF Desk FMOH President Uganda Nurse and Midwives Union State FP Coordinator Eboyni Senior Principal Nursing Officer Hoima Regional Hospital State FP Coordinator Kano Hospital Director Hoima Regional Referral Hospital Clinical Medical Director NOFIC Abakaliki Uganda Private Midwives Association (UPMA) Registered Midwife In Charge NOFIC Abakaliki UPMA Project Coordinator Registered Midwife in Charge NOFIC Katsina Female Midwife Registered Midwife Abakaliki District Senior Nursing Officer Registered Midwife in Charge MCH Abakaliki Registered Midwife (10) Community Health Worker (2) Senior Nursing Officer Registered Midwife In Charge of FP Federal Psychiatric Nurse Registered Midwife Federal 10 FC+ Uganda Country Program Staff Registered Midwife FP Unit Katsina NOFIC (2) FC+ Uganda FP/RH Advisor
In both Nigeria and Uganda, there was concern noted during the rapid assessment that attempts to provide a balanced counseling strategy for clients were impeded by lack of IEC materials and the use of generic large group health education sessions without further individualized client follow- up. Also of note were issues surrounding compromised privacy and confidentiality in client counseling sessions and procedures. There was also room for improvement in the overall infection prevention and control/cleanliness and appearance of FP sites with lack of provider recognition for the interconnectedness of site appearance and increased uptake of FP methods. Provider bias was noted as a barrier to IUD insertion due in part to lack of knowledge/skills in insertion of IUD, lack of materials for procedures, and cultural opinions about method. For example, quotes from providers included: “When I don't know how to do it, I did not talk about it.” “The women prefer FP after they see their menses.” “It's the patients’ choice- I should not try to convince them.” When asked about the male influence on uptake of contraceptive methods the following statements were given: “The men in the community they don't want a vasectomy so I don't talk about it much.” “There are many immediate implant removals reported cause the men don't like them.”
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The FP audit clearly revealed that EH/FC+ has had a positive impact on technical practice and commodities related to FP. For many health workers, EH/FC+ trainings were the only source of the basic skill set to be able to provide FP services. Comments were made freely by a wide range of health care workers to support this impact. For example: “Before EH/FC+ came, we had less knowledge, now people are taking implant, people were not taking before the training.” “EH/FC+ has done a good job.” “We only practiced FP knowledge for the sake of a school exam before, but now we do it because we like doing the procedures.” The rapid assessment also positively noted that commodities for the provision of a full range of FP options was found at all sites, attributed to EH FC+, with no incidence of expired pills, implants or IUDs. A post-rapid assessment response in country has focused on reinforcement of long-acting, reversible contraceptives (LARC) skills in the areas of quality assurance in counselling and infection prevention and control. Systems to incorporate more robust client exit interviews as a means to capture information on efficacy of EH/FC+ trained providers in counseling have been implemented. There has also been incorporation of strong reinforcement of tenets of respectful care and privacy into on-site FP supervision, mentoring, and coaching strategies in all countries. The environmental scan of midwifery associations found a large degree of interest in scale-up of non- surgical treatment of fistula and integration into pre-service and in-service health worker education in both countries assessed. As described further in Section III: Nigeria, FC+/Nigeria rapidly utilized the findings of the environmental scan of the Nigerian Midwifery and Nursing Council to convene a stakeholder working group resulting in a draft outline for the implementation of a pre-service curriculum for the Nigeria FMOH guidelines within the Nursing and Midwifery training institutions. During FY 16/17, a total of 423,736 counseling sessions were provided at supported sites, and FP services resulted in a total of 263,206 Couple Years of Protection (CYP). The method mix contributing to this total CYP includes implants (52%), injectables (15%), IUCD (12%), tubal ligation (7%), and oral pills (4%). Country specific counseling information is provided in Figure 7 and CYP information in Figure 8, with additional country- and site-specific information provided in Section III.
Figure 7. Family Planning Counseling Sessions, by Country, FY 16/17 (n=423,736)
Bangladesh 29,268 Number of Counseling Sessions DRC 4,084 Niger 1,199 Nigeria 143,113 Nigeria former TSHIP 218,688 Uganda 27,384
Figure 8. Family Planning CYP, Short-Term vs. Long-Term/Permanent Methods, by Country, FY 16/17 (n=263,206)
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Bangladesh STM LTM+PM
DRC
Niger
Nigeria
Nigeria Former TSHIP
Uganda
Sub-Objective 4.4 Support and establish treatment/care programs for WDI and POP During FY 16/17, FC+ has worked to develop program plans for the establishment and support of treatment for WDI and women suffering from POP. As referenced in Table 10, four surgeons in DRC participated in training for surgical and non-surgical POP treatment through both pessaries and physical therapy. The results from an FC+ physical therapy questionnaire for partner sites in DRC and Nigeria, to better understand existing site capacities and efforts needed to address gaps, were presented at the October 2016 ISOFS conference (see Appendix F). FC+ has been working to establish functioning supply chains for pessaries in supported countries. A pessary supply chain was established in DRC and Uganda after competitive bidding among suppliers meeting standards for quality and vetting for donor procurement compliance. Panzi and St. Joseph Hospital have received pessaries. In July 2017, both teams gathered for clinical pessary training in Kinshasa. The project continues to work with the Mission to secure sustainable supply chain for ring-plate pessaries post-project. As September 30, 2017, 15 FC+ supported sites (three in Bangladesh, five in DRC, two in Niger and five in Uganda) provide routine data on non-surgical and surgical POP treatment. During the fiscal year, these sites reported that 1,683 women sought treatment for possible POP symptoms with 1,461 women diagnosed with and requiring treatment for POP (87% of those seeking). A total of 1,052 women received POP treatment during this period (72% of those diagnosed). Supported sites reported providing 1,859 non-surgical POP treatments and 1,025 surgical POP treatments (some women may receive both non- surgical and surgical treatment). Non-surgical POP treatments at reporting sites presently overwhelmingly consist of counseling and physical therapy with only six pessaries reported (at Panzi and SJH in DRC). This evidence strengthens the rationale for FC+ efforts to increase the availability of pessaries. POP treatment data is presented by country in Table 13.
Table 13. Number Seeking, Requiring, and Receiving POP Treatment, by Country, FY16/17
Country #Seeking #Eligible % of Seeking #Receiving % of Eligible Bangladesh 12 12 100% 12 100% DRC 1,504 1,286 86% 900 70% Niger 97 93 96% 70 75% Uganda 70 70 100% 70 100% Total 1,683 1,461 87% 1,052 72% None of the women receiving surgical POP treatment experienced complications. Given the nature of surgical POP repair, it is to be expected that all treated women would be considered “cured” at the time of discharge. The project is not currently able to gather longer term follow up data to monitor repair breakdown after discharge.
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Objective 5: Strengthened evidence base for approaches to improve fistula care and scaled up application of standard monitoring and evaluation (M&E) indicators for prevention and treatment FC+ strengthens the evidence base for approaches to improve fistula care and promotes M&E scale-up by ensuring that FC+ activities are appropriately documented and disseminated and by learning from and contributing to the knowledge of the fistula community as well as the broader maternal health sector. Throughout the fiscal year, FC+ ensured compliance with USAID and EngenderHealth policies and procedures for research and evaluation dissemination by including all studies and reports on internal and external databases.
Sub-Objective 5.1 Increase standardization in terminology, classification, and indicators FC+ is overseeing a study to document the process by which standard indicators for fistula treatment, developed and promoted under the previous FC project, are being integrated and adopted in the Health Management Information Systems (HMIS) of select FC+ countries (Bangladesh, Niger, Nigeria, and Uganda) and in Guinea, where EngenderHealth implements fistula programming as a sub-awardee. The process documentation seeks to understand the degree to which recently selected fistula indicators have been adopted and/or operationalized by national HMIS and the use of HMIS fistula data by health workers/managers at facility, regional and national levels. Key informants for this process documentation include national, regional and sub-regional health office staff involved in reviewing, synthesizing, and acting on data on HMIS fistula indicators, and health facility staff involved in monitoring, collecting, and reporting data on these indicators. As of the end of FY 16/17, FC+ completed data collection in Nigeria and Uganda. Data collection in Bangladesh, Guinea, and Niger is still ongoing and is planned to be completed by the end of first quarter of FY 17/18. Analysis and summary of the findings is planned to be completed by the second quarter of FY 17/18. Since the distribution and adoption of the FIGO Global Competency-Based Fistula Surgery Training Manual in 2009, the fistula community of practice has realized and defined gaps in terminology definitions, from etiology to evaluation and management to surgery and reintegration. In March 2017, the International Continence Society (ICS) Standardization Committee published a scoping document on the need for standardized terminology for female pelvic floor fistula. This review and discussion resulted in the creation of the fistula terminology working group, of which the FC+ Project Director was elected vice-chair. In September 2017, the FC+ Project Director participated in the launch of the International Urogynecological Association – ICS (IUGA-ICS) Joint Report on the Terminology for Female Pelvic Floor Fistulae. The ICS, often in multidisciplinary collaboration with partner organizations, has published a series of 29 international terminology standardization documents on pelvic floor dysfunction in men, women and children (https://www.ics.org/committees/standardisation#currenticsreports). These documents have backstopped the definition of terms in peer-review clinical and epidemiological research, in textbooks, monographs and reviews, and in educational curricula for clinicians.
Sub-Objective 5.2 Strengthen monitoring and evaluation/research (ME&R) systems and use of data To operationalize the FC+ PMP, a key activity through the life of the project has been developing and updating FC+ M&E and data management and review systems. FC+ has built a DHIS2 platform to function as the global M&E database for the current project. The FC+ Senior M&E Associate has
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continued to be active in the global DHIS2 community during FY 16/17, participating in webinars and the annual DHIS2 Symposium in Washington DC to share FC+/EngenderHealth experience and learn about the latest developments in the field. Seven FC+ staff participated in the Annual EngenderHealth Clinical Data for Decision Making (CDDM) meeting, held in Tanzania in May 2017. Staff from FC+’s global team as well as Nigeria, DRC, and Uganda participated. FC+ shared and learned from identified DDM best practices across the organization as well participated in training on implementation of a rights’ based approach in sexual and reproductive health. The meeting agenda can be found in Appendix CC. FC+ conducts internal DDM exercises after the close of each quarter to discuss program data and identify issues in need of follow-up. Country programs implement similar processes. This practice is being carried out in Bangladesh, Nigeria, and Uganda as well, both within the FC+ country office and with partner sites through annual clinician and partner network meetings, generally convened by FC+ and the MOH, which provide opportunity to reflect on both national and site level data trends. FC+ works with supported treatment sites to encourage ongoing review of site-specific data to identify and act upon areas of clinical and programmatic concern and opportunities to improve fistula services. While it is ideal for sites to review data on a monthly or quarterly basis, depending on service volume, experience from the original FC project indicates that this is very difficult for sites to achieve, given shortages in human and other resources. In FY 16/17, 94% of FC+ supported treatment sites met at least twice during the fiscal year to review their data, compared to 68% in FY 15/16; 97% (the same as in FY 15/16) met at least once (See Appendix DD for country and site details). In addition to facilitating such reviews, FC+ has also trained 94 health personnel throughout the fiscal year in data management and DDM.
Sub-Objective 5.3 Use research findings to improve practice In February 2017, FC+ held its second FCoP webinar, as described in Objective 1, on the subject of “Obstetric fistula and gender-based violence: Examining the linkages.” The webinar discussed findings from the recent multi-country analysis of data from the Demographic and Health Surveys (DHS) which found that women reporting symptoms of gynecological fistula are also more likely to report experience of physical and sexual violence (see Objective 5.4). The webinar presenters were the FC+ Project Director and Deputy Director, and Lindsay Mallick, Senior Research Associate at the DHS Program. A recording of the webinar can be viewed at https://www.youtube.com/watch?v=sW2MFnDWHzw. One hundred people registered and 40 attended. In April 2017, the FCoP held its third webinar, as described in Objective 1, on the subject of understanding women’s needs after fistula repair in Uganda. Presenter Alison El Ayadi of the University of California, San Francisco reviewed the results from a one year longitudinal study, partly supported by FC+, to develop a measure of postsurgical reintegration success and document physical and mental health changes among repaired fistula clients in Uganda (see Objective 5.4). Commentators Moustapha Diallo and Rose Mukisa discussed the implications of these findings for FC+, and the Global Projects Manager moderated a discussion with questions from webinar attendants. Due to the volume of questions, a follow- up blog post was provided to respond to questions that could be not be addressed during the webinar. A recording of the webinar can be viewed at: https://www.youtube.com/watch?v=r76PUoQBekk&feature=em-share_video_user. The follow-up blog post is available at: https://fistulacare.org/blog/2017/06/after-fistula-repair-webinar/. 84 people registered and 44 attended.
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During FY 15/16, FC+ worked with the Population Council to review and build on findings from the formative research on barriers to fistula treatment carried out in Uganda and Nigeria in FY 14/15. Based on the research findings, a responsive intervention and evaluation plan were developed and implementation began during this fiscal year, as described in detail in Objective 3. In September 2017, FC+ presented baseline findings and intervention progress updates to representatives from USAID/Nigeria, the Nigeria FMOH, and Ebonyi State stakeholders. During this trip, mid-line monitoring was conducted including in-depth interviews with key program implements and beneficiaries of the study. In FY 15/16, FC+ also continued to share results from the FC project RCT on the non-inferiority of shortened duration of catheterization after surgical repair and has been in contact with WHO regarding their plans to create a guideline based on the RCT. FC+ collaboration with WHO on the RCT has resulted in an invitation to partner on a systematic review of the literature on catheterization, leading to a scoping meeting and issuance of a formal guideline in support of short duration catheterization. The scoping meeting took place in May 2017 with WHO covering costs. A draft guideline was circulated to the working group in July 2017, entitled “WHO recommendation on duration of bladder catheterization after surgical repair of simple obstetric fistula.” A final version is expected to be published by WHO in the first quarter of FY 17/18. Conference presentations and publications continue to foster evidence-based change in research and FC+ program practices. Throughout the fiscal year, FC+ convened and presented at multiple meetings and conferences to disseminate findings from research and program evaluations; see Table 3 for details as well as Appendix F for details on the extensive FC+ presence at the 2016 IOFWG and ISOFS meetings in Abuja, Nigeria, Appendices O-Q for FC+ involvement at the International Confederation of Midwives (ICM) Triennial Congress, and Appendices I-L for detail on the cesarean section technical consultation. FC+/EngenderHealth organized a panel, “Obstructed labor does not end at delivery: Strengthening postpartum care following prolonged/obstructed labor,” for the 31st ICM Triennial Congress held in Toronto in June 2017. Congress participants included midwives from ICM’s 116 member associations, representing 102 countries, as well as representatives of non-governmental, bilateral, and multilateral organizations such as WHO and other UN Agencies; global professional associations such as International Federation of Gynaecology and Obstetrics; and USAID. The panel on postpartum care after obstructed labor was an important project activity for FY 16/17, enabling FC+ to disseminate new guidelines related to urinary catheterization (UC) after prolonged and obstructed labor (P/OL) to prevent fistula, and to link our work on fistula prevention to other aspects of P/OL care. The panel was very well- attended, with 50 registrants in advance but more attending and standing room only throughout the event. The panel discussion was co-sponsored by Bard Medical and moderated by the FC+ Project Director. Panelists included the FC+ Deputy Director; Pandora Hardtman, International Midwifery Consultant; Ekpoanwan Esienumoh, Senior Lecturer and Professor of Midwifery at University of Calabar, Nigeria; and Jeffrey M. Smith, Vice President, Jhpiego. Panelists discussed gaps in guidelines for intrapartum and postpartum care, and highlighted practices to prevent and manage morbidity, focusing on bladder care and urinary catheterization, as well as sepsis prevention, recognition, and treatment. In additional to the panel, FC+ presented at the Congress on “Feasibility of Task Sharing in Primary Screening of Obstetric Fistula clients by Midwives – Lessons learnt from a Fistula Treatment Site, Uganda;” chaired a panel entitled “Cultural influences on practice;” and presented two posters entitled “Use of partograph in tertiary hospitals in Bangladesh: Opportunities for making a difference through midwives” and “Urinary catheterization after prolonged and obstructed labor: Current practices and potential leadership by midwives.” FC+ also used the Congress as an opportunity to disseminate
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information about a new global survey to midwives from low- and middle-income countries (LMIC), see Objective 5.4. Abstracts have been prepared and submitted to disseminate the action agenda resulting from the Technical Consultation held in July 2017, on cesarean section safety and quality (see Objective 1.3). These include an accepted panel at the HRH Forum (November 2017), an accepted poster at the IHI 1st Africa Forum on Quality and Safety in Healthcare (February 2018), and a submitted presentation for the ACOG Annual Meeting (April 2018). FC+ has also sought to contribute to the evidence informing fistula and related programs through the continued publication of reports, briefs, and journal articles. During FY 16/17, four articles related to FC+ support activity were accepted or published in peer-reviewed journals (see Table 14); three are FC+ products and one was supported by UCSF (El Ayadi, et al.). FC+ ensures that all articles supported with project resources and included in approved workplans are published open-access, in line with USAID policy on research.
Table 14: Peer-Reviewed Articles Published, FY 16/17
Authors Title Journal Delamou, A et al Pregnancy and childbirth after repair Tropical Medicine and International of obstetric fistula in sub-Saharan Health. 2016 Nov; 21(11): 1348-1365. Africa: Scoping Review http://onlinelibrary.wiley.com/doi/10.11 11/tmi.12771/abstract;jsessionid=17E 26CAAB1427E8B96E6E075416BDB6 3.f04t04 Bedwell C, Levin K, Pett C, A realist review of the partograph: BMC Pregnancy and Childbirth. 2017. and Lavender when and how does it work for labour 17:31. monitoring? https://bmcpregnancychildbirth.biomed central.com/articles/10.1186/s12884- 016-1213-4 Delamou, A et al11 Fistula recurrence, pregnancy, and The Lancet Global Health.2017. 5(11): childbirth following successful closure e1152–e1160. of female genital fistula in Guinea: a http://www.thelancet.com/journals/lang longitudinal study. lo/article/PIIS2214-109X(17)30366- 2/fulltext El Ayadi A, Nalubwama H, Development and preliminary Reproductive Health. 2017. Barageine J, Neilands TB, validation of a post-fistula repair Sep:2;14(1):109. Obore S, Byamugisha J, reintegration instrument among https://www.ncbi.nlm.nih.gov/pubmed/ Kakaire O, Mwanje H, Korn A, Ugandan women. 28865473 Lester F, Miller S.12
Three additional peer-reviewed manuscripts are currently under review at journals: “Research to action: Incorporating qualitative findings to promote access to fistula screening and treatment;” “Poverty is the big thing”: exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda;” and “The association between female genital fistula symptoms and gender-based violence: A multi-country secondary analysis of household survey data.” Appendix D provides a list of FC/FC+ peer-reviewed journal publications and Appendix E provides metrics for readership of articles published by FC/FC+. While metrics are only available for some FC/FC+ articles, these have been viewed more than 33,000 times.
11 Manuscript accepted for epublication in the Lancet Global Health and available in the first quarter of FY 17/18. 12 Published through the UCSF Library Open Access Fund.
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In addition to these peer-reviewed journal publications, the FC+ Project Director was a co-author on a commentary in Lancet Global Health as part of IDEOF commemoration efforts, together with partners UNFPA and the Fistula Foundation: “Ending fistula within a generation: making the dream a reality” (http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30226-7/fulltext). FC+ also authored a media article on the Safe Surgery Toolkit: How a Simple Checklist Can Save Women’s Lives (https://medium.com/@EngenderHealth/how-a-simple-checklist-can-save-womens-lives-64b96ee6fd26). Research briefs on the barrier intervention studies in Nigeria and Uganda were also completed in September 2017 and approved by USAID. Formative research findings and the process of developing a responsive intervention were showcased at a panel event at the fourth Global Symposium on Health Systems Research in Vancouver in November 2016, convened by the Population Council. Findings were also presented to national, state, and community stakeholders in Nigeria in September 2017. A similar debriefing will be held for stakeholders in Uganda in the first quarter of FY 17/18. The briefs are also available on the FC+ and Population Council websites. The project’s online presence has helped foster relationships with peer organizations, including resource partners such as MHTF. FC+ is increasingly engaged by partner organizations to participate in Twitter chats and other forms of online discourse focused on maternal health and morbidity. During FY 16/17, the project shared 19 posts on the FC+ blog (https://fistulacare.org/blog), see Table 15.
Table 15: FC+ Blog Posts in FY 16/17
Blog Title Date Bixby Center at UCSF publishes preliminary validation of post-fistula repair September 13, 2017 reintegration instrument Fatima’s Story August 29, 2017 Obstructed labor does not end at delivery: Strengthening postpartum care following July 29, 2017 prolonged/obstructed labor Village Health Workers: Delivering Critical Maternal Health Information to the Last Mile June 13, 2017 After Fistula Repair: Understanding Women’s Needs in Uganda June 1, 2017 MHTF Blog [Part 3] Obstetric Fistula: Innovative Interventions and the Way Forward May 29, 2017 MHTF Blog [Part 2] Obstetric Fistula: Women’s Voices May 29, 2017 MHTF Blog [Part 1] Obstetric Fistula: A Global Maternal Health Challenge May 24, 2017 Fistula in Her Words May 23, 2017 How a Simple Checklist Can Save Women’s Lives May 22, 2017 Nigeria to Mark International Day to End Obstetric Fistula May 18, 2017 New Resource Advances Safe Surgery for Women Affected by Fistula April 20, 2017 A New Film about Safety in Fistula Surgery March 20, 2017 Nigeria Launches Guidelines on Catheterization for Prevention and Management of February 7, 2017 Obstetric Fistula EngenderHealth Hosts Media Round Table on Fistula Prevention in Nigeria January 31, 2017 2016 In Review December 30, 2016 Research to Action: Intervention to Reduce Barriers to Access Fistula Treatment in November 23, 2016 Nigeria and Uganda Putting The Lancet Maternal Health Series Into Action: Five Next Steps November 4, 2017 Men as Partners in the Fight to End Fistula in Nigeria September 26, 2016
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Several of the FC+ blog postings were cross-posted with the MHTF blog and the Kupona Foundation blog. FC+ Program Associate Lauren Bellhouse was also featured on the K4Health and FP2020 FP Voices blog during the fiscal year: http://fpvoices.tumblr.com/post/160981084404/lauren-bellhouse- program-associate-fistula-care.
Sub-Objective 5.4 Contribute to the evidence for improved programming and care Following a meeting of FC+ clinical staff and clinicians from supported sites at the ISOFS conference in Abuja, FC+ determined that the best way to support country-level research interests and capacity building would be to issue a call for concepts for the analysis of existing clinical data. FC+ issued this call for concepts in late 2016 (see Appendix Y), and collected 13 concepts from four FC+ countries. FC+ selected three concepts from supported sites (two in DRC and one in Uganda) for provision of technical assistance from the global team. Examples of technical assistance include support in defining research objectives, writing analysis plans, conducting secondary analysis of qualitative or quantitative data, and support in reporting and disseminating findings. Based on initial discussion and data review, the two concepts from DRC have been prioritized – one examining factors associated with barriers to fistula treatment, as defined by duration of fistula symptoms prior to treatment seeking; and one examining factors associated with fistula recurrence. Both analyses will examine data from the database at Panzi Hospital. Full descriptions of the proposed research/analysis were developed and shared with USAID for review and approval. In-country ethical review and approval is currently being finalized, and the secondary data analysis will occur in the first quarter of FY 17/18. Since the previous DHS comparative analysis on questions related to incontinence was published in 2008, numerous surveys have used the DHS fistula module. In FY 14/15, the Deputy Director requested the DHS Program to conduct an updated secondary analysis of the data from all surveys using the fistula module; the resulting report is available on the DHS program website (http://dhsprogram.com/publications/publication-OD67-Other-Documents.cfm). The FC+ Deputy Director and DHS Program analyst Lindsay Mallick co-authored a manuscript based on this secondary analysis in FY 15/16. The manuscript describes increased risk for sexual/physical violence among women with fistula symptoms and the possibility that this violence may be aggravated by fistula, rather than only being a cause. The manuscript was revised and resubmitted during the first half of FY 16/17, after technical review and suggestions from Cynthia Stanton. FC+ and DHS have submitted the revised manuscript to Tropical Medicine and International Health (TMIH). A revise and resubmit was received from TMIH, and the authors have responded. As described under Objective 2, the Deputy Director has continued working with project partner TERREWODE to apply validated quality of life (QoL) assessment tools and develop indicators and data collection tools for a joint study on the psychosocial reintegration of women deemed incurable (WDI). In the first two quarters of FY 16/17, TERREWODE completed providing intervention services to enrolled WDI, and completed data collection. Initial datasets have been shared with FC+ by TERREWODE, and data analysis is ongoing. Study findings, including recommendations regarding optimal tools for Quality of Life assessment among fistula clients and WDI, are expected to be available by January 2018. In partnership with UCSF/Makarere University, FC+ completed a study on reintegration after fistula repair in Uganda at the end of FY 15/16. Makerere University researchers presented preliminary findings at ISOFS in Abuja in October 2016. Complete findings were shared in the FCoP webinar held in April 2017, see Objective 1 for additional detail. The first publication from this study has been published through the UCSF Library Open Access Fund (see Table 14).
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As part of the July 2017 Technical Consultation on cesarean section in low-resource settings, convened by FC+ and Maternal Health Task Force, FC+ commissioned an analysis of DHS and SPA data from the London School for Hygiene and Tropical Medicine to synthesize as much information as possible about the current profile of cesarean section services. The resulting report was submitted to USAID for review at the end of FY 16/17. The report assesses the landscape of caesarean sections in LMICs using recent, comparable, nationally representative survey data. Data from Demographic and Health Surveys (DHS) conducted in 34 countries in sub-Saharan Africa and 10 in South/Southeast Asia between 2002 and 2016 were analyzed. Estimates of caesarean section rates were based on most recent live births in the survey recall period and all information about the delivery (location, assistance, and mode) is based on women’s self-report. Additional data were available about the circumstances surrounding women’s caesarean section in Bangladesh (DHS) and the facility-level care provision in Tanzania from the Service Provision Assessment (SPA) survey. These two countries are presented as case studies, accompanied by an in-depth review of time trends in the level and provision of caesarean sections. The final report is expected to be published in November 2017. To understand the range of postpartum practices that SBAs employ, FC+ launched an online global survey targeting SBAs from LMIC on intrapartum and postpartum practices related to P/OL and bladder care management (see announcement in Appendix N). The FC+ Deputy Director presented the preliminary findings from the survey’s pilot phase at the ICM Congress, highlighting the considerable variation in responses on how SBAs define P/OL, the criteria they use to assess it, and the amount of time they catheterize after P/OL. These preliminary findings were also shared on the FC+ blog: https://fistulacare.org/blog/2017/07/icm-postpartum-care-panel/. As of September 30 2017, the global survey of intrapartum and postpartum practices related to P/OL and bladder care management has collected data from 174 SBA respondents from 34 countries.
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SECTION III: COUNTRY REPORTS
Please note: reports are provided only for objectives that were actively addressed in FY 16/17. All sub- objectives are consolidated for reporting. Bangladesh USAID-supported fistula repair services in Bangladesh began in July 2005 through the previous FC project and continue through FC+ in seven hospitals providing fistula treatment and three providing prevention only services as of September 30, 2017. In Bangladesh, FC+ works with private hospitals and public sector institutions, including Medical College Hospitals and District Hospitals. The FC+ project is working in partnership with the Bangabandhu Sheikh Mujib Medical University (BSMMU) to set up a Fistula Prevention, Treatment and Training Center on-site. The project also provides support to three prevention-only facilities. All currently supported fistula treatment sites in Bangladesh provide referrals to fistula clients for social and medical services and five provide reintegration services. In the fourth quarter of the fiscal year, massive floods in the northern districts of the country prevented some program activities from occurring. Additionally, in August and September 2017, Bangladesh received a very large influx of Rohingya refugees from Myanmar. These two situations engaged many of our partners, which resulted in a slowdown of project work as partners and the national government prioritized emergency responses. Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors FC+/Bangladesh has been working nationally and regionally to strengthen the enabling environment for fistula prevention, treatment and reintegration. Regionally, FC+ cohosted, with the Nepal Society of Obstetricians and Gynecologists, the South Asian Group on Fistula and Related Morbidities (SAGFRM) inaugural meeting in Kathmandu, Nepal on April 8, 2017. Section II, Objective 1.3 provides additional detail on this meeting, in which the FC+/Bangladesh Country Director presented and participated. In September 2017, FC+/Bangladesh hosted their annual Partners’ Forum in Cox’s Bazar. Project leaders and key clinical staff of all supported sites participated in the forum. Other participants included representatives from the MOH, DGHS, UNFPA, UNICEF, the HOPE foundation, and members of the press. Among the many topics of discussion, there was a focus on evidence-based fistula care, Annual Partners’ Forum, September 2017. epidemiological transitions in fistula etiology Credit: FC+/Bangladesh. and national trends related to provision of cesarean section. FC+ collaborates in Bangladesh with UNFPA and the National Fistula Task Force Working Group (NFTWG) to strengthen the enabling environment and support institutionalization of fistula services in both the public and private sectors. During the first quarter, FC+/Bangladesh met with counterparts at UNFPA to discuss convening a meeting of the National Fistula Task Force to address the upcoming expiration of the current national fistula strategy and draft a new strategy. In January, May, and
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September 2017, FC+ participated in National Fistula Task Force Meetings at the office of the Directorate General of Health Services (DGHS) to continue the momentum on developing a new fistula strategy. The Country Project Director participated in a debriefing meeting at DGHS in May 2017 during which decisions were made to pursue a centralized approach in the country to delivering fistula services through a few key fistula centers, all including a community outreach program. UNFPA agreed to provide a consultant to work with FC+ and an initial draft of the strategy was prepared by September 2017. There was also agreement on developing a community-based fistula registry, for which UNFPA expressed interest in providing resource support. In the September 2017 meeting, the initial draft of the National Strategy was presented for discussion. FC+/Bangladesh has continued working with various arms of the Government of Bangladesh (GOB), holding multiple meetings with government officials throughout the year. In the first and third quarters, the FC+/Bangladesh Project Manager met with key staff from the Ministry of Health and Family Welfare (MOHFW), the Assistant Director of the Directorate General of Health Services (DGHS), health facility officials and USAID representatives to continue briefings and coordination on the United States Pacific Command (PACOM) mission in Bangladesh. PACOM mission clinical outputs are described under Objective 4 below. The Project Manager also met with the Director General of the Health Economics Unit of the Ministry of Health and Family Welfare (MOHFW) to brief him on FC+ engagement with the Quality Improvement Secretariat (QIS). FC+/Bangladesh is working with QIS to increase in-country capacity of local institutions to provide fistula care. The QIS is responsible for setting standards of clinical and preventive care in the country. FC+ will facilitate three meetings of the fistula technical committee of QIS over the next year. Activities under discussion include quality monitoring activities, strategies for prevention of iatrogenic fistula and the current status of incorporation of fistula indicators into the national HMIS. FC+/Bangladesh has also continued close collaboration with the Obstetrical and Gynecological Society of Bangladesh (OGSB) throughout the fiscal year. In the beginning of the year, the new Secretary General of the OGSB, Professor Firoza Begum, met with FC+/Bangladesh to learn more about the project’s activities. On behalf of OGSB, she expressed interested in supporting the project’s safe surgery advocacy, and prevention and care of POP/ fistula, through a dedicated center called “Center for Neglected Women Disease.” In May 2017, the FC+/Bangladesh participated in a meeting with the fistula committee of the OGSB during which FC+ shared information with the OGSB about increasing rates of iatrogenic fistula in Bangladesh. FC+ and the OGSB discussed their mutual concern and as a result, the OGSB committed to organizing a Continuing Medical Education (CME) program focusing on safe surgery and ethics in practice. OGSB also issued a position paper on iatrogenic fistula, released on May 23, 2017 the International Day to End Fistula. During the third quarter, as part of efforts to celebrate the International Day to End Obstetric Fistula International Day to End Fistula, The University Fistula activities at LAMB Hospital. Credit: Center (UFC), the Press Institute of Bangladesh (PIB), Isharab Hossain. the Dhaka Sub-Editors Council, the Bangladesh Health Reporters Forum, and the Ministry of Information cohosted a workshop for media leaders on female
Annual Report • October 2016 – September 2017 Fistula Care Plus 56
genital fistula. Twelve articles were published in national news outlets following the workshop, see Appendix EE for a list of FC+ media coverage by country. Other International Day to End Fistula activities in Bangladesh included an event for 250 gynecologists at Dhaka Medical College and Hospital, jointly organized with UNFPA and OGSB, with the theme of “Hope, Healing and Dignity for All”. LAMB Hospital also observed International Day to End Obstetric Fistula, organizing a rally around the hospital campus and the local bazaar. Participants included hospital staff, doctors, nurses, community members and local administration. The University Fistula Center of BSMMU has published a yearly planner to be used for promoting referral and fistula case identification by health clinicians. The USAID-funded NGO Health Service Delivery Project (NHSDP) will help in distributing these yearly planners to all of their “Smiling Sun” clinics (clinics funded through NHSDP to provide a package of essential health services) throughout the country. FC+/Bangladesh and NHSDP are working to schedule fistula orientations for Smiling Sun clinic operators as well.
Objective 2: Enhanced community understanding and practices to prevent fistula, improve access to fistula treatment, reduce stigma, and support reintegration of women and girls with fistula During the first quarter of the fiscal year, FC+/Bangladesh held a quarterly review meeting with in- country partner Bangladesh Rural Advancement Committee (brac) to review progress on fistula case identification and referral efforts. The partnership with brac innovated fistula case finding through the use of a four question (4Q) checklist as a job aid used by brac community health workers to conduct house-to- house screening to identify and refer suspected fistula and complete perineal tear (CPT) cases. The house- to-house approach uses context-appropriate methods to address the realities of women’s lives, particularly barriers women with fistula face including stigma, isolation, limited mobility, and limited literacy. The house-to-house screening is sensitive to the physical, economic, and sociocultural barriers to mobility that many women face, particularly in rural or underserved areas. In Bangladesh, there is anecdotal evidence that fistula may be additionally stigmatized due to perceived association with sexual violence, further depressing care-seeking. By deploying female community screeners knowledgeable on both the 4Q checklist and the local context, information and referral can be brought to women in their own homes, to identify previously isolated women with fistula symptoms and provide linkages to care. Building on community networks to reach every house in a community, the Bangladesh activity may also enable local, population-level estimates of fistula and complete perineal tear burden for the first time. FC+/Bangladesh shared the 4Q checklist and the screening approach at the ISOFS conference in Abuja, Nigeria in October 2016. During the first half of the fiscal year, FC+/Bangladesh worked with brac to ensure that diagnosis and repair services were available for those who need it, including scheduling concentrated diagnosis and repair events (CFDE) where needed. In order to ensure compliance with the Protecting Life in Global Health Assistance (PLGHA), partnership with brac ended as of June 30, 4Q launch in Satkhira District. 2017. This, along with dramatic staff turnover at brac Credit: PK Poddar.
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in the wake of PLGHA, stymied FC+’s ability to collect the final, complete data from brac on 4Q checklist use in Faridpur district. FC+ anticipates being able to obtain these data in the first quarter of FY 17/18, and will analyze these for summary estimates of fistula/POP prevalence and the sensitivity/specificity of this screening tool. In line with government priorities, FC+ has shifted its approach to examining opportunities for scaling the 4Q checklist through community clinics. As part of pilot exploration of the feasibility and acceptability of this approach, in the third quarter, community health care providers (CHCP) in Satkhira district were oriented to the 4Q checklist. Throughout the fiscal year, 18 fistula and POP CFDEs were held in Faridpur, Gaibandha, Habiganj, and Moulvibazar Districts during which 104 fistula cases and 110 prolapse cases were identified and referred. Referred repairs took place at BSMMU, Mamms Hospital, Muttalib Community Hospital and Kumudini Hospital. During FY 16/17, a total of 82 in-person community outreach events were carried out for community members, health clinicians, and local officials. These activities included orientation programs for community health workers and volunteers, community skilled birth attendants, female students, pregnant women, and newly married couples, covering topics related to early marriage, fistula prevention (including FP), identification, treatment and reintegration. Over 5,300 participants were reached through these in person School girls’ orientation at Nalta Girls High community outreach, education, and advocacy events, School in Kaligonj. Credit: PK Poddar. information is presented, by type, in Table BGD1.
Table BGD1: Community Outreach/Education/Advocacy Events, By Quarter, FY 16/17
Type of Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 Event # # # # # # # # # # Reached Events Reached Events Reached Events Reached Events Reached Events Existing 8 435 9 516 13 1,160 1 46 31 2,157 community activity Health 8 413 4 233 0 0 2 121 14 767 facility Health 20 110 3 118 9 460 3 171 17 859 clinicians Policy 0 0 1 60 1 35 1 40 3 135 makers Maternal 0 0 5 176 8 806 4 422 17 1,404 health/ fistula- focused Radio/TV 0 0 0 0 34 33,007 0 0 34 33,007 Total 18 958 22 1,103 65 35,468 11 800 116 38,329
-in person 18 958 22 1,103 31 2,461 11 800 82 5,322 -mass 0 0 0 0 34 33,007 0 0 34 33,007 media
As part of efforts to increase media attention to fistula-related issues, FC+/Bangladesh met with the News Editor of Medivoice in the first quarter and agreed to provide content to the publication on fistula and
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reproductive health related issues, as well inviting Medivoice to future events to allow for media coverage. In the second quarter, FC+/Bangladesh met with the Bikrampur Community radio station in Munshigonj to provide an orientation on fistula related issues and discuss collaboration on producing community radio shows. FC+/Bangladesh also produced two community radio talk shows on female genital fistula, with participants from DGHS, OGSB, QIS, DMCH, UFC, BSMMU and media outlets. A total of 34 radio programs were aired during the third quarter, reaching an estimated listening audience of over 33,000 (see Table BGD1). During the second and fourth quarters of FY 16/17, LAMB provided training for a total of 20 cured fistula clients, who will work with their communities to provide information on fistula prevention and treatment; see Table BGD2.
Table BGD2: Community Volunteer/Educator Training, Participants by Topic, FY 16/17
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total FY 16/17 2016 2017 2017 2017 Cured fistula patients 0 10 0 10 20 Total 0 10 0 10 20
Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment FC+/Bangladesh has oriented supported sites to the FC+ Surgical Safety Toolkit (SST). The FC+/Bangladesh Clinical Associate works monthly with supported sites to collect information and review findings from the checklists and clinical tracker in the SST (see Section II, Sub-objective 4.2). A system of SST client data correlation to M&E aggregate trends data has not yet been devised in FY 16/17, but is a top priority for FY 17/18. SST implementation research, likewise, did not launch in FY 16/17 but is a top priority for FY 17/18. During FY 16/17, PACOM carried out two fistula missions in Bangladesh, with significant logistical and coordination support from FC+. The first concentrated repair effort took place in November and December 2016, when a medical team of US military surgeons and one anesthesia clinician conducted surgical fistula and POP repairs at three supported facilities: Kumudini Hospital in the Tangail District, Ad-Din Hospital in Khulna, and BSMMU in Dhaka. The second mission took place in April 2017 with a similarly comprised team. In addition, the team provided a cystoscopy training workshop for six obstetricians/gynecologists and participated in an FC+ training for six nurses (see Table BGD5). In FY 16/17, 465 women with severe incontinence symptoms sought fistula care services at FC+ supported sites, of which 279 were diagnosed with fistula (60%, compared to 56% in the previous year). FC+ supported 243 surgical fistula repairs during this period (92% of the 263 women who were diagnosed with fistula and medically eligible for surgery). This represents a 9% decrease in repairs from FY 15/16, primarily due to challenges related to national crises including flooding and a refugee influx. In Bangladesh, a high proportion of women seeking care for severe incontinence have 3rd or 4th degree perineal tears – a condition with symptoms virtually identical to fistula. During FY 16/17, FC+ supported surgical repairs for 93 3rd and 4th degree perineal tears. Some women may be diagnosed with fistula in one quarter and repaired in the next. Because FC+ does not track individual women through our data collection, we are unable to present a definitive percentage of women requiring repair who receive it. We are also unable to report the number of women repaired because women may have multiple repairs over the life of project, or repairs at multiple sites. However, within a given quarter, the number of repairs generally reflects the number of women. Figure BGD1
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presents data on women seeking and eligible for fistula treatment, and the number of fistula surgeries supported, by site.
Figure BGD1: Number of Women Seeking and Requiring Fistula Treatment, and Number of Surgical Repairs, by Site, FY 16/17
150
100 Seeking Eligible 50 Repairs
0 Ad-Din Ad-Din BSMMU Dr. Kumudini LAMB Mamm's Dhaka Khulna Muttalib Institute
These 243 fistula repair surgeries were conducted at seven FC+ supported hospitals: Ad-Din Dhaka, Ad- Din Khulna, BSMMU, Dr. Muttalib Community Hospital, Kumudini, LAMB, and Mamm’s Institute of Fistula and Women’s Health (see Table BGD3 for detail by quarter).13 In addition to the surgical repairs supported, three women received non-surgical catheter treatment (catheterization) for fistula during the fiscal year at LAMB (two) and Kumudini (one). The outcome of these cases were: one closed and continent, one not closed and one outcome not available at the time of reporting. Ad-din Khulna, LAMB and Kumudini (via PACOM) held concentrated repair efforts during the reporting period, during which some of the more complicated cases were able to undergo repair surgery. 27% (n=65) of all surgeries performed during this time period occurred during concentrated efforts.
Table BGD3: USAID-Supported Surgical Fistula Repairs, by Site, By Quarter, FY 16/17
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 16/17 2016 2017 2017 2017 Ad-Din Dhaka 4 2 4 0 10 Ad-Din Khulna 4 0 0 0 4 BSMMU 10 6 5 2 23 Dr. Muttalib 9 4 2 7 22 Kumudini 10 3 19 1 33 LAMB 36 26 6 15 83 Mamm’s Institute 18 17 11 22 68 Total 91 58 47 47 243
Etiology data was available for all 558 diagnosed fistula cases. Just over half of fistulas diagnosed were the result of prolonged/obstructed labor (53%), followed by iatrogenic causes (39%). 3% of diagnosed fistula were the result of trauma and the remaining “other” etiology (5%) was cancer-related. The proportion of fistula deemed iatrogenic was high at all supported sites, with variation: from a low of 26%
13 Ad-Din Jessore screened and referred women for repairs, but did not conduct any fistula surgical repairs.
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at Kumudini Hospital to highs of 75% at Ad-Din Khulna, 70% at Ad-Din Dhaka, 59% at BSMMU, and 42% at LAMB. Discharged fistula repairs during FY 16/17 were slightly more often classified as simple cases (48%) than not simple (42%, with 10% not available). 86% of all fistula surgery cases discharged in this time period were closed at discharge; with 78% closed and continent and 8% closed and incontinent. 14% were not closed at discharge. Appendix FF presents data visualizations that illustrate the available country-level data on whether repairs were conducted through routine or concentrated efforts, how many previous repairs clients had undergone, whether repairs were categorized as simple or complex, and discharge outcomes. Outcomes for discharged patients are presented, by site, in Figure BGD2. Reported complications were low at supported sites (3.5% overall) with BSMMU reporting 16% complications, LAMB 4%, Mamm’s 1.5% and all other sites reporting 0%.
Figure BGD2. Outcome Rates for Surgical Repairs, by Site, FY16/17
100% 90% 80% 70% Not closed 60% 50% 40% Closed with remaining 30% incontinence 20% 10% Closed and continent 0% Benchmark closed and continent (75%)
Three sites in Bangladesh report providing a total of 12 surgical POP treatments during FY 16/17. During FY 16/17, FC+ Bangladesh supported training of nine surgeons from six facilities in fistula repair. One surgeon received first training and nine surgeons participated in continuing training (including the surgeon who also received their first training during the fiscal year), see Table BGD4 for details.
Table BGD4: Surgical Fistula Repair Training, Participants by Trainee Institution, FY 16/17
Institution Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total Total # 2016 2017 2017 2017 FY 16/17 surgeons trained 1st Cont 1st Cont 1st Cont 1st Cont 1st Cont Total BSMMU 0 1 0 0 0 1 0 0 0 2 2 Shaheed 0 1 0 0 0 0 0 0 0 1 1 Suhrawady Medical College Sir Salimullah 0 1 0 0 0 0 0 0 0 1 1 Medical College
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Institution Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total Total # 2016 2017 2017 2017 FY 16/17 surgeons trained LAMB 0 2 1 2 0 2 0 3 1 314 3 Sylhet Medical 0 0 0 0 0 1 0 0 0 1 1 College Rajshahi 0 0 0 0 0 1 0 0 0 1 1 Medical College Total 0 5 1 2 0 5 0 3 1 9 9
As part of fistula prevention efforts, FC+/Bangladesh provided training to 42 health system personnel during FY 16/17. These trainings included use of the SST at MAMMS Hospital, training of brac personnel in data record keeping, and a fistula training for nurses. Table BGD5 provides detail on non- surgical trainings for health system personnel.
Table BGD5: Non-Surgical Health System Personnel Training, Participants by Topic, By Quarter, FY 16/17
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2016 2017 2017 2017 FY 16/17 Data management 0 36 0 0 36 Pre- and post-operative fistula care 0 0 6 0 6 Total 0 0 6 0 42
FC+ supports FP counseling and service provision at most supported sites in Bangladesh. During FY 16/17, 29,268 counseling sessions took place at supported sites and 27,364 CYP were provided; see Table BGD6 for detail, by site. Method mix in Bangladesh during this period was primarily comprised of tubal ligation (42% of CYP), oral contraceptives (8%), Implanon (7%), Depo (6%) and IUCD (Copper T- 5%). Standard Days method makes up 29% of the total CYP, all of which are reported from Dr. Muttalib Community Hospital.
Table BGD6: Family Planning Counseling Sessions and CYP, by Site, By Quarter, FY 16/17
Site Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP15 Ad-Din 4,300 2,147 3,820 1,777 2,953 2,112 3,265 2,285 14,338 8,320 Dhaka Ad-Din 469 629 501 390 339 446 251 482 1,560 1,947 Khulna BSMMU 3,000 989 400 695 814 532 2,000 686 6,214 2,901 Dr. 79 189 60 7,776 70 264 NA NA 209 8,229 Muttalib Hope 775 2 422 1 NA NA NA NA 1,197 3 Kumudini 560 710 689 725 1,024 626 258 669 2,531 2,730 LAMB 644 794 1,289 774 800 709 486 957 3,219 3,234 Total 9.827 5,459 7,181 12,137 6,000 4,689 6,260 5,079 29,268 27,364
14 One surgeon received first training at LAMB in the second quarter, and then continuing training in the fourth quarter. Two additional surgeons from LAMB received continuing training in the first and second and fourth quarters, and are only counted once in the fiscal total. 15 Due to rounding, totals may differ slightly from the sum of individual quarters.
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FC+ supported sites reported 28,618 total obstetric deliveries with an overall cesarean section rate of 68% during the fiscal year. Information on number of deliveries, by site, is represented in Figure BGD3 and cesarean section rates, by site, are presented in Figure BGD4. Six FC+ supported facilities report current use of catheterization as a prevention intervention following prolonged/obstructed labor. Due to record keeping at the facilities, it is difficult to collect accurate data on the number of prolonged and obstructed labors.
Figure BGD3. Number of Obstetric Figure BGD4. Cesarean Section Rates, by Site, FY Deliveries, by Site, FY 16/17 (n=28,618) 16/17 0% 100%
Ad-din Dhaka 14,534 Ad-din Dhaka 73.4 Ad-Din Khulna 76.2 Ad-Din Khulna 6,010 BSSMU 77.7 BSMMU 1893 Dr. Muttalib 86.8
Dr. Muttalib 1,159 Kumudini 62.1 LAMB 21.5 Kumudini 3,166 Bangladesh Total 68.3 LAMB 2,704 Vaginal delivery C-Section
Obj. 5: Strengthened evidence base for approaches to improve fistula care and scaled up application of standard monitoring and evaluation (M&E) indicators for prevention and treatment As the key implementation partner of the Bangladesh Maternal Morbidity Verification Study (MMVS), FC+/Bangladesh has completed series of community-based Fistula and Prolapse Diagnosis Event (CFPDE – see Obj. 2) during the fiscal year. The data collected will support development of a national estimate of the current fistula burden in Bangladesh. FC+/Bangladesh conducted Data Quality Assessment (DQA) visits at all supported sites throughout FY 16/17. These visits included cross checking reported data with site files and registers and files to check consistency as well as collecting, reviewing and discussing the data for the Surgical Safety Toolkit with site staff. All supported treatment sites in Bangladesh met twice during the fiscal year to review their fistula data. Internal data for decision making (DDM) reports are also prepared for all supported sites using the most recent available data for review meetings. Two FC+/Bangladesh staff members presented at the ISOFS conference in Abuja, Nigeria in October 2016. Their presentations addressed, “The Source of Injury in Iatrogenic Fistula Cases in Bangladesh” and “Meeting Fistula Clients’ Health Care Needs Through Community-Based Fistula Diagnosis.” The FC+/Bangladesh Country Director presented at the 13th International Conference of the Nepal Society of Obstetrics and Gynecology in April 2017 in Kathmandu, Nepal. At the conference, he presented a paper on “Emerging Issues in Prevention and Care of Female Genital Fistula-Reflections from
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Fistula Care Plus Project in Bangladesh”. He also facilitated a meeting of regional fistula stakeholders for creating a dedicated group for addressing fistula and related disorders in South Asia (see Objective 1). The Country Director also presented a poster at the 31st Triennial Congress of International Confederation of Midwives (ICM) in June 2017 in Toronto, Canada: “Use of partograph in tertiary hospitals in Bangladesh: Opportunities for making a difference through midwives”.
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Democratic Republic of Congo USAID-supported fistula services in DRC began in 2008 through the previous FC project and continue through FC+ in five hospitals as of September 30, 2017. USAID also provides bilateral support to the Projet de Santé Integré (ProSani) for mobile outreach fistula repair efforts in DRC. The EngenderHealth office in Kinshasa is shared with the BMGF-funded project, ExpandFP. In DRC, FC+ has partnered with health centers and hospitals to support fistula repairs, train doctors and nurses in fistula-related skills and topics, improve EmONC, and conduct outreach to rural clinics to ensure that women in need of medical attention are referred to the hospitals for repair. Throughout the fiscal year, the city of Beni and its surroundings have remained subject to insecurity due to violence in the area. This permanent instability and insecurity causes frequent displacements of the population. The security situation in the country in general has remained unstable, with recurrent insecurity due to elections, the escape of prisoners in several cities of the country, and killings in the Kasai area.
Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors FC+/DRC continues to participate in the Santé de la Mère, du Nouveau né et de L‘Enfant – Maternal, Newborn and Infant Health, MNCH Task Force (SMNE Task Force)along with experts from the MOH and professionals working in the field of MNCH and fistula. The Task Force has provided a platform for reflection, designing standards and guidelines, and monitoring activities and progress. FC+/DRC has printed 500 copies of the standards and guidelines developed and will be distributing them in FC+ supported sites as well as in the Provincial Health Divisions in which supported sites are located. FC+/DRC has led efforts to create a specific working group within the Task Force, focused on the fight against fistula. The Task Force will also work towards establishing a national strategic plan in the fight against fistula and try to reach consensus on various definitions in fistula classification. FC+/DRC held meetings with a UNFPA consultant charged with finalizing the national strategy for the elimination of obstetric fistula. This was followed by a meeting with the Director of the National Reproductive Health Program to finalize the terms of reference for the fistula working group that will now be called the National Multidisciplinary Working Group for the Elimination of Obstetric Fistula. FC+/DRC provided financial and technical support to the 10th Health Directorate: Family and Specific Groups (D10) and the National Program for Reproductive Health (PNSR) for a literature review to be used as a catalyst for the first national review of reproductive health. Document review took place in January 2017 and the literature review and draft national review report were completed in the third quarter. The planned national review meeting has been delayed until FY 17/18. In September 2017, FC+/DRC Technical Advisor of FC +, together with Panzi’s FC+ Project Manager, participated in the international meeting in Kigali for the establishment of the Regional College of Gynecology and Obstetrics for Eastern, Central and Southern Africa (ECSACOG). Throughout FY 16/17, supported sites have directly leveraged funds from their own partners to complement the activities they are able to do with FC+ funds. In Kinshasa, partner repair site Hospital St. Joseph (SJH) received drugs, supplies, and direct technical and logistical support for a fistula concentrated effort from the Belgian NGO "Doctors Without Vacation" as well as food, clothing, and hospital gowns donated by private individuals. Also at SJH, the Belgian NGO “Fistula Aid” has funded a six months practical training in Urology for Dr. Paulin Kapaya of SJH, at the University Hospital of
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Sousse in Tunisia and has donated a four-wheel ambulance vehicle to the fistula clinic of the hospital for transportation of clients. Panzi has a partnership with the radio station SVEN to support awareness raising in the community and outreach efforts and SJH received free air time for a program on Radio Okapi dedicated to obstetric fistula in the DRC and available repair services. Supported sites have also adapted/created tools based on FC+ models during the fiscal year: SJH has developed a patient card for the collection of patient data as well as formal procedures for surgical practice. At Panzi, the gynecology department has integrated a set of procedures for service provision including procedures for fistula prevention with the support of the French Development Association.
FC+/DRC supported multiple activities IDEOF celebration at Heal Africa. Credit: E. Kitambala. in celebration of the International Day to End of Obstetric Fistula in May 2017. The theme of the celebration was "Hope, Healing and Dignity for All". All FC+ supported sites, including the local office, participated in the celebration and organized events. In collaboration with the Programme National la Santé de la Reproduction (PNSR), UNFPA and Doctors Without Vacation, FC+/DRC celebrated at SJH where two cured fistula patients gave emotional testimonies about their experiences. Over 60 cured and current fistula clients were in attendance. Dr. Paulin Kapaya who accompanies clients with fistula on their journey to care at SJH shared his experience and the constraints of displacement of these women, after their recruitment in remote villages. He shared some of the painful experiences he witnessed where fistula clients using public transportation were met with stigma, refusal and lack of compassion. He was able to use the experience as an opportunity to explain and provide sensitization on obstetric fistula to the drivers and passengers of the bus that brought them to Kinshasa. Another IDEOF commemoration took place at HEAL Africa, with support from FC+/DRC, where a conference with community relays, representatives of hospitals, two health zones in Goma city and obstetric fistula clients was organized. After a brief history of the IDEOF, presentations were made by a psychologist who addressed the fistula related psycho-mental problems and the healing process and a pastor who spoke of the biblical foundations of hope, healing and dignity. Three clients were also able to give testimonies of their experience living with fistula. The activity reached 79 people, including women suffering from fistula, counsellors, community relays, representatives of few hospitals, representatives of health zones in Goma. The FC+/DRC Program Manager participated in a meeting at Panzi in Bukavu, where he gave a speech on IDEOF. It was also an opportunity for him to discuss the merits of the recent introduction of the SST at fistula treatment sites.
Objective 2: Enhanced community understanding and practices to prevent fistula, improve access to fistula treatment, reduce stigma, and support reintegration of women and girls with fistula
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During FY 16/17, all five supported fistula treatment sites have conducted awareness raising campaigns in their communities to improve knowledge about fistula, access to treatment, male involvement, family planning, and the fight against stigma. FC+ supported sites in DRC carried out 99 in-person community outreach efforts reaching over 2,400 people, see Table DRC1. An additional nine mass media outreach efforts were undertaken, with estimated reach of over 300,000 people. HEAL Africa conducted multiple awareness activities for both health facility staff and community members including school and religious leaders, community volunteers, and village chiefs in Goma and its surrounding areas. The outreach efforts included information related to pregnancy complications, safe delivery practices, fistula and POP identification, prevention, and treatment, and the role of male involvement in the management of fistula and POP. HEAL also organized an exchange session students three universities and two higher institutes in Goma around the theme "mother and daughter's health." The discussion centered on unwanted teenage pregnancy, use of contraception, and complications of childbirth and was facilitated by the PNSR manager and a team from HEAL Africa. It is expected that these small groups from higher education settings will continue to raise awareness within their student communities. SJH carried out many community outreach and awareness building activities including radio broadcasts and a television program that aired on TVS1, a private TV channel in Kinshasa, covering themes including antenatal care, pregnancy and safe delivery. The program was re-broadcast several times. Community meetings were held with varied groups including women at the Camp Luka market in Kinshasa, female gardeners in Kinkole, a suburb of Kinshasa, maternity officials of the Diocesan Bureau of Medical Works (BDOM) and the CBO Vivre et Travailler Autrement (VTA - Living and Working Alternatively). These events covered many topics including fistula prevention and treatment, safe pregnancy and delivery, and the importance of male involvement in fistula and POP care. Maternité Sans Risque de Kindu (MSRK) and SJH have both held community awareness-raising meeting that addressed fistula prevention as swell as the availability of free fistula care. SJH also worked with members of the "Florylège" Association, a women’s organization that fights against poverty, to share information about access to free obstetric fistula treatment, reimbursement of transportation costs and the harms of stigma related to fistula. Imagerie des Grands Lacs (IGL) has reached out to inform communities, schools, and churches about the FC+ Project Director visiting HEAL Africa’s resumption of family planning activities at reintegration center. Credit: M. Mpunga. the facility. This awareness raising campaign has helped "boost" the demand for FP services with 127 new acceptors at the site following the campaign. The IGL team also conducted several community meetings with female merchants and students at various local institutions. Throughout the fiscal year, Panzi worked in partnership with Radio Sven to conduct community awareness raising activities related to gender norms and roles. Radio Sven has an estimated listening
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audience of over 300,000 people. Panzi also conducts community meetings and works with health professionals to improve service provision.
Table DRC1: Community Outreach/Education/Advocacy Events, By Quarter, FY 16/17
Type of Event Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Existing 0 0 21 372 1 129 0 0 22 501 community activity Health facility 1 50 0 0 0 0 0 0 1 50 Health 0 0 18 41 1 24 0 0 19 65 clinicians Policy makers 2 10 0 0 1 38 0 0 3 48 Maternal 4 55 30 1,151 6 322 3 243 43 1,771 health/ fistula- focused Radio/TV 0 0 6 305,000 3 185 0 0 9 305,185 Total 7 115 75 306,564 12 698 3 243 97 307,620
-in person 7 115 69 1,564 9 513 3 243 88 2,435 -mass media 0 0 6 305,000 3 185 0 0 9 305,185
During the first quarter of the fiscal year, six community volunteers participated in a training at SJH that covered EmONC and emergency/essential newborn care (see Table DRC2 as well as Objective 4).
Table DRC2: Community Volunteer/Educator Training, Participants by Topic, By Quarter, FY 16/17
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total 2016 2017 2017 2017 FY 16/17 EmONC and emergency newborn care 6 0 0 0 6 Total 6 0 0 6 6
Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment FC+/DRC carried out a needs assessment in Lubumbashi during the second quarter, and in the third quarter, assessments continued in South-Ubangi, Gemena and Bwamanda. Assessment findings indicate that Beniker Polyclinic in Lubumbashi is ready to be added as a supported fistula treatment site if accepted by the Mission. HGR Gemena would require some technical and material support before integration, if it is approved to move forward. During the fiscal year, site assessments were carried out at all supported treatment sites and the integration of the SST is being integrated into all FC+ supported sites in DRC. SJH has already developed its first patient follow-up register and is reporting electronically. Panzi and Heal Africa are discussing the integration of data from the surgical safety kit that is currently missing During FY 16/17, 982 women with severe incontinence symptoms arrived seeking fistula care at FC+ supported sites, of which 740 were diagnosed with fistula (75%, compared to 80% in FY 15/16). Of these diagnosed cases, 699 were medically eligible for surgical repair (94%). FC+ supported 547 fistula repair surgeries during this period (78% of those eligible, compared to 85% in FY 15/16). This represents a 46% decrease in repairs when compared to the previous fiscal year. fiscal year. The aforementioned political
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instability and the inability of outreach teams to access more remote parts of the country contributed to this decrease. Some women may be diagnosed with fistula in one quarter, and repaired in the next. Because FC+ does not track individual women through our data collection, we are unable to present a definitive percentage of women requiring repair who receive it. We are also unable to report the number of women repaired because women may have multiple repairs over the life of project, or repairs at multiple sites. However, within a given quarter, the number of repairs generally reflects the number of women. Figure DRC1 presents data on women seeking and requiring fistula treatment, and the number of fistula surgeries supported, by site. Figure DRC1 highlights a general trend of women eligible for fistula repair but unable to access FC+- supported care given the current funding levels. MSRK’s outreach teams have identified cases but cannot provide repair services and suggests continued backlog especially outside the catchment areas of partner facilities.
Figure DRC1: Number of Women Seeking and Eligible for Fistula Treatment, and Number of Surgical Repairs, by Site, FY 16/17
250
200
150 Seeking Eligible 100 Repairs 50
0 HEAL Africa IGL MSRK Panzi SJH These 547 fistula repair surgeries were conducted at five FC+ supported hospitals: HEAL Africa, IGL, MSRK, Panzi, and SJH, see Table DRC3 for detail by quarter. 279 of these repairs (51%) were provided via routine service provision, with 268 repairs (49%) carried out via outreach efforts. HEAL, IGL, Panzi and St. Joseph performed repairs via outreach efforts. Panzi also provided repairs to clients using other funds, which are not reported here. In addition to the surgical repairs reported here, three women received non-surgical catheter treatment for fistula: one at HEAL Africa and two at SJH, all of whom were closed and continent at discharge. In addition to these FC+ supported repairs, during FY 16/17, Hôpital General de Référence (HGR) Kaziba provided 207 surgical repairs and 32 non-surgical catheter treatments through the ProSani project, bilaterally funded by USAID. Information on the etiology of diagnosed fistula was available for 98% of diagnosed cases. Of those cases, 65% were identified as being caused by obstructed or prolonged labor; 25% identified as iatrogenic in nature; 6% identified as having a traumatic etiology; and 2% due to cancer. It was noted that SJH reported a high number of iatrogenic fistulas throughout the fiscal year (42%). This included two women from the same region with very complex fistulae, including total destruction of the urethra after
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symphysiotomy. Their surgeries have been scheduled to ensure treatment from a surgeon with adequate training to address them.
Table DRC3: USAID-Supported Surgical Fistula Repairs, by Site, By Quarter, FY 16/17
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2016 2017 2017 2017 FY 16/17 HEAL Africa 28 22 28 50 128 IGL 25 20 20 10 75 MSRK 6 31 9 0 46 Panzi 27 0 127 3 157 SJH 22 41 37 41 141 FC+ Total 108 114 221 104 547 HGR Kaziba (ProSani) 60 48 51 48 207 USAID-supported Total 168 162 272 152 754
A total of 509 fistula cases were discharged during FY 16/17. 59% (n=301) were classified as simple fistula and 41% (n=208) as not simple. 95% of all discharged fistula surgery cases were closed at time of discharge: 92% were closed and continent and 3% were closed and incontinent. Outcomes for discharged patients are presented, by site, in Figure DRC2. Appendix FF presents data visualizations that illustrate the available country-level data on whether repairs were conducted through routine or concentrated efforts, how many previous repairs clients had undergone, whether repairs were categorized as simple or complex, and discharge outcomes. Reported complications were low at supported sites (4.5% overall) with a range of 15% at HEAL, related to anesthesia, to less than 3% at the other supported sites.
Figure DRC2. Outcome Rates for Surgical Repairs, by Site, FY 16/17
100%
90% Not closed 80% 70% Closed with remaining incontinence 60% Closed and continent 50% 40% Benchmark closed and continent (75%) 30% 20% 10% 0% HEAL IGL MSRK Panzi SJH DRC Africa Total During FY 16/17, four sites (HEAL Africa, MSRK, Panzi, and SJH) reported providing POP treatment to 900 women. The sites reported 873 surgical POP treatments and 1,812 non-surgical treatments, six of which were pessaries. SJH has developed a client card and a protocol for surgical practice for the care of women with POP.
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A total of seven surgeons received training in fistula and POP repair during the fiscal year, see Table DRC4. FC+ supported two surgeons from SJH to travel from Kinshasa to Bukavu/Panzi Hospital and participate in south-south skills exchange training between senior fistula surgeons for surgical POP treatment. This site-to-site collaboration is part of a planned south-south exchange series for POP integration that did in this instance, and will continue to, result in increased treatment capacity at SJH, and in increased POP outreach activities and impact. These cases will receive treatment during the third quarter. Panzi and SJH surgeons received POP and fistula training from the FC+ Project Director during the fourth quarter. FC+ also supported the participation of four people from FC+/DRC and supported sites at the video TOT at ISOFS in Abuja, Nigeria during the first quarter (See Section II, Objective 4 for additional information).
Table DRC4: Surgical Repair Training, Participants by Trainee Institution, By Quarter, FY 16/17
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total Total # 2016 2017 2017 2017 FY 16/17 surgeons 1st Cont 1st Cont 1st Cont 1st Cont 1st Cont Fistula 0 1 0 0 1 0 1 1 2 2 316 surgical training POP 0 0 2 0 0 0 2 2 4 2 417 surgical training Total 0 1 2 0 1 0 3 3 6 4 7
As part of fistula prevention and treatment efforts, FC+/DRC has provided training on a variety of topics to 318 health care clinicians during the fiscal year; see Table DRC5. Training covered infection prevention, EmONC, catheterization for fistula prevention, antenatal care, FP methods and counseling, use of data for decision-making and pre- and post-operative fistula care, including counseling.
Obstetric fistula prevention and management training at HEAL Africa. Credit: M. Mpunga.
Table DRC5: Non-Surgical Health System Personnel Training, Participants by Topic, By Quarter, FY 16/17
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2016 2017 2017 2017 FY 16/17 EmONC, partograph, catheterization for 46 0 0 0 46 fistula prevention Pre- and post-operative care 15 0 0 11 26 EmONC and emergency newborn care 31 0 0 0 31
16 One surgeon received both first training and continuing training within the fiscal year, and is only counted once in the annual total. 17 Two surgeons received both first and continuing training within the fiscal year and are only counted once in the annual total.
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Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2016 2017 2017 2017 FY 16/17 FP counseling and methods 0 78 0 0 78 Infection prevention 0 86 0 31 117 Data for Decision Making 0 0 0 20 20 Total 92 164 0 62 318
During FY 16/17, FC+/DRC focused support to ensure that FP services are being provided and integrated with fistula service provision at supported sites. FP activities have been integrated into all five supported sites, including SJH which is a Catholic facility. As part of these efforts, FP refresher training was carried out for a total of 78 clinicians, see Table DRC5. During FY 16/17, over 4,000 counseling sessions took place at these supported sites and 7,288 CYP were provided (see Table DRC6 for detail, by site).
Table DRC6: Family Planning Counseling Sessions and CYP, by Site, By Quarter, FY 16/17
Site Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP18 HEAL 24 422 65 371 36 238 36 377 161 1,408 Africa IGL 0 0 0 358 12 263 12 200 24 820 MSRK 0 0 149 87 153 136 69 176 371 399 Panzi 46 640 335 473 232 432 354 639 967 2,184 SJH 240 45 692 450 925 812 704 1,170 2,561 2,477 Total 310 1,107 1,241 1,739 1,358 1,881 1,175 2,561 4,084 7,288
FC+ supported sites reported an overall cesarean section rate of 31% in FY 16/17, with a total of 9,638 deliveries. Information on number of deliveries, by site, is presented in Figure DRC3 and cesarean section rates, by site, are presented in Figure DRC4. 3.6% of reported deliveries were prolonged/obstructed labor and of those, 12% received catheterization for fistula prevention.
Figure DRC3. Number of Obstetric Figure DRC4. Cesarean Section Rates, by Site, FY Deliveries, by Site, FY 16/17 (n=9,638) 16/17
0% 100% HEAL Africa 1,626 HEAL Africa 66.2 33.8 IGL 210 IGL 55.7 44.3
MSRK 773 MSRK 84.6 15.4
Panzi 3,623 Panzi 72.4 27.6
SJH 3,406 SJH 65.3 34.7 DRC Total 69.5 30.5
Vaginal delivery C-Section
18 Due to rounding, totals may differ slightly from the sum of individual quarters.
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Obj. 5: Strengthened evidence base for approaches to improve fistula care and scaled up application of standard monitoring and evaluation (M&E) indicators for prevention and treatment FC+/DRC organized a workshop to finalize the research protocol on the frequency and management of non-obstetric fistula in DRC. The workshop was held in July 2017 in Kinshasa, facilitated by Dr Alex DeLamou (FC+ M&E Consultant). The workshop participants included staff from Panzi, HEAL, SJH and FC+. The research protocol has been approved by the local USAID Mission, USAID/Washington, and the local ethics committee. FC+/DRC sponsored three attendees from supported sites and two FC+ staff members to attend the ISOFS conference held in October 2016 in Abuja, Nigeria. In addition to the video TOT participation described under Objective 4, an attendee from Panzi gave a presentation on "The challenges faced by women with lower urogenital and gastrointestinal fistula: A case study from Kongolo and Kabalo in the DRC" and an attendee from SJH presented on the “Impact of Fistula on the Sexual Life of Women” in addition to a poster presentation on “Uretero-vaginal fistulas of obstetric origin: epidemiological profile, circumstances of childbirth, diagnosis and treatment outcomes.” The FC+/DRC Technical Advisor participated in EngenderHealth’s Third Annual Meeting on Clinical Data for Decision Making held in May 2017 in Dar Es Salaam, Tanzania. FC+/DRC intends to complement clinical quality assurance data reviews that will occur with the implementation of the SST with targeted facility-level special studies to address knowledge gaps identified by the SST process. As noted in Table DRC5, 20 staff at supported sites took part in data for decision-making training that included introduction of the SST.
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Nigeria USAID-supported fistula services in Nigeria began in 2007 through the previous FC project and continued under FC+ in FY 16/17 in 1419 treatment and prevention sites and 730 prevention-only sites, including 500 sites inherited from the former TSHIP project. FC+ currently works in 12 states in Nigeria: Bauchi, Cross River, Ebonyi, Kaduna, Kano, Katsina, Kebbi, Kwara, Osun, Oyo, Sokoto, and Zamfara. FC+ fistula prevention and treatment efforts in Nigeria have focused on support for repairs, clinical training, improving emergency and basic obstetric care, integration of FP services, community awareness efforts, and advocacy at the national and state levels. Support to sites in the state of Jigawa ended in the third quarter of FY 16/17. Osun State was added in the fourth quarter of the fiscal year. As of the September 30, 2017, 13 sites are being supported for treatment.
Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors In FY 16/17, FC+/Nigeria continued efforts to reach out to key stakeholders at various levels of government and traditional institutions to advocate for improved quality, increased attention, and increased resource allocation for fistula prevention, treatment, and reintegration in Nigeria. These efforts have included advocacy and collaboration with the Federal Ministry of Health (FMOH) as well as many key national ministries and state level ministries in all supported states. In the fourth quarter, FC+/Nigeria and the FMOH collaborated to ensure smooth implementation of the initiation of support to Wesley Guild Teaching Hospital Ilesha in Osun State. Preparations for the first pooled effort at the site included advocacy, site preparation, scoping mission, logistics requirements, client mobilization, and participation of the Osun State Governor and the Honorable Minster for Health. The pooled effort will also provide opportunity for on-the job mentoring of the resident surgical team. FC+/Nigeria is supporting all fistula centers to complete their application to Direct Relief, a FC+ resource partner, for serial donations of medical supplies required for treatment of fistula clients at no cost. Direct Relief enrollment of facilities is a key component of the FC+ sustainability and legacy platform, as it will ensure fistula centers are able to access high-quality disposable supplies after project closeout. All applications have been approved by Direct Relief, but it has been difficult to identify an in-country expeditor to proceed with shipment. Efforts continue to address this issue. The document, “Guidelines on Urethral Catheterization for Prevention and Management of Obstetric Fistula in Nigeria,” building on work initiated under the FC Project and continued by FC+, was launched by the Honorable Minister of Health, Prof. Isaac Adewole, during the 2016 ISOFS Conference in Abuja. The launch was the result of consistent engagement with the FMOH and other stakeholders to develop, approve, and disseminate a policy on conservative management of obstetric fistula in Nigeria. FC+/Nigeria printed 200 copies of the guidelines, whose final copy editing and formatting was supported by the global FC+ team, for dissemination at the launch. The Honorable Minister of Health launched two technical working committees in which FC+ is actively involved: one to review the national strategic framework for elimination of fistula in Nigeria (2011-2015), and one to coordinate national mapping of fistula facilities. The two committees will facilitate the development of a five-year national roadmap for the elimination of fistula.
19 As of September 30, 2017, 13 treatment sites were receiving support in Nigeria. A total of 14 sites were supported during the fiscal year, but support to Jigawa ended during the fiscal year.
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Following the launch of the guidelines, FC+/Nigeria and the FMOH (Family Health Department) began planning for the dissemination of the catheter guidelines to health institutions, working with the two main in-country regulatory institutions: the Nursing and Midwifery Council of Nigeria and the Community Health Practitioners Board of Nigeria. Plans are under development for dissemination and incorporation of the guidelines into the curricula of the regulatory institutions. FC+/Nigeria also provided technical and financial support to develop strategies for the Technical Working Group (TWG) of the Federal Ministry of Women Affairs and Social Development Campaign on Ending Child Marriage, which was launched in November 2016. FC+/Nigeria has worked throughout the fiscal year to ensure Cover of the Nigerian FMOH continual engagement of all fistula stakeholders with in the publication of the National Guidelines country. During the second quarter, FC+/Nigeria organized a on Urethral Catheterization for two-day stakeholders meeting as a follow-on activity to site Prevention and Management of Obstetric Fistula in Nigeria. assessments conducted earlier, to review current status and challenges of fistula service delivery. The meeting included fistula surgeons, matrons, and managers from all supported fistula centers, except Jigawa State, whose supported site representatives could not attend. The overarching goal of the meeting was to develop a strategy to engage sustainable, routine repairs of fistula through a framework of quality assurance and surgical safety at all sites. At the end of the meeting, each facility developed an action plan to address challenges limiting capacity to provide quality fistula treatment. The stakeholders requested cross-cutting support to strengthen the new action plans of each site through FC+/Nigeria meetings with relevant governments, State House of Assemblies, Supervising Ministries, First Ladies, and other decision-makers. During the third quarter of the fiscal year, FC+/Nigeria held its annual Providers Network Meeting (PNM). The PNM brings together fistula professionals, stakeholders at the national, state and community levels in Nigeria to discuss progress, issues affecting fistula service provision, and ways to improve fistula service delivery in the country. The 2017 PNM focused on engaging stakeholders “to understand the needs of the fistula constituencies, the constituents, service providers and mobilizers and to identify how to FC+/Nigeria Country Project Manager meeting with work together to meet those needs.” Most Commissioners of Health from supported states during annual PNM. Credit: FC+/Nigeria. prominently, the meeting discussed ways to sustain fistula intervention at the various state levels beyond the FC+ project lifespan. All the represented states confirmed their intention to continue to support the project and fistula intervention in Nigeria. The representative of the Federal Ministry of Women Affairs and Social Development reiterated its commitment to continued collaboration with FC+ and that the Ministry had
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made budgetary proposals for awareness raising and sensitization support for fistula in six states, one from each geo-political zone. He also noted that the ECOWAS Gender Development Center was supporting the ministry with USD 62,000 to support fistula activities in Kaduna and Katsina states. Other topics of discussion and highlights from the PNM included: the desire to have agreed upon criteria for establishing new fistula treatment centers; ensuring the viability and capacity to sustain services without the support of external partners; the role of FC+ as a catalyst and complement to government efforts; and the need to have fistula indicators further incorporated in the national HMIS. FC+/Nigeria has also emphasized the need to plan for and promote sustainability in the support of fistula treatment in all project sites during the fourth project year. FC+/Nigeria is engaging in environmental scan for development partners to continue strengthening the capacities of the supported fistula centers for sustainable surgeries for fistula clients even beyond the life span of the project. FC+ has signed MoUs with two major partners in Nigeria towards this end: the Islamic Medical Association of Nigeria (IMAN) and Sun of Hope Foundation (SHF). IMAN is an faith-based non-profit professional association. A key objective of the organization is to liaise with other organizations on matters of mutual interest and coordinate individual activities of health care professionals. The organization recently pledged to support the repairs of 100 fistula clients across the country. IMAN has been working with FC+ to provide fistula services at some supported centers. SHF, headquartered in Abuja, is a non-governmental, non-religious, non-political and not for profit organization whose vision is to attain a “developed and self-sustained society with equal opportunity for all.” Its mission is to improve maternal health care services. The organization has been providing support to National Obstetric Fistula Centre in Ningi since 2016 in the form of consumables supplies, medical equipment, office equipment and furniture, feeding of clients and provision of clothing. During the fiscal year, FC+/Nigeria continued its strategy of engaging with in-country media outlets through roundtable discussions to support the creation of awareness on fistula via mass media and enable journalists to accurately report on the condition and put fistula on national discussion platforms. Participants at the roundtable in the second quarter also traveled to two communities in Ebonyi where they met two women who had undergone fistula repair. See Appendix EE for a list of FC+ media coverage by country. FC+/Nigeria collaborated with the FMOH, SMOH, fistula service providers and community partners to broadcast national and state radio programs as well as town hall meetings to celebrate IDEOF in May 2017. These platforms provided an opportunity to engage stakeholders and broader society in a discussion about the problem of obstetric fistula and available treatment, rehabilitation and reintegration and to spread educational messaging through town hall meetings, rallies and radio programs. FC+/Nigeria supported 12 in-person IDEOF events reaching over 5500 people in IDEOF Rally in Ebonyi. Credit: FC+/Nigeria. Sokoto, Katsina, Oyo, Ebonyi and Cross River States.
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IDEOF Radio outreach efforts on Radio Nigeria and other state radio stations reached an estimated 20 million people. Radio program participants included the First Lady of Ebonyi State, Commissioners of Health and Women Affairs, senior fistula surgeons, fistula clients, CBOs, traditional and religious leaders, heads of fistula facilities, nurses, and community members. Listeners called in and sent text messages to ask questions from Katsina, Ebonyi, Kano, Sokoto, Zamfara, and Oyo States. FC+/EngenderHealth executed a public-private partnership (PPP) MoU with LABORIE, Inc., as discussed in Section II, Objective 1. This PPP is designed to support the creation of a University College Hospital (UCH) Ibadan Continence Center, to be run by Professor Oladosu Ojengbede of the department of Obstetrics and Gynecology who is also the Director of the Center for Population and Reproductive Health at the University. Women with residual incontinence after fistula repair will be able to undergo the complex evaluation they need to formulate individualized, effective medical and surgical treatment plans. Using this first site as the showcase, the PPP scope will expand regionally in Nigeria where LABORIE has existing units in Evangel and Abakaliki, and then into the ECOWAS region, where LABORIE already has distribution in academic fistula centers in Senegal and Ghana, to create a West African Urodynamics Society among senior fistula surgeons. Laborie’s platform is predicated on locating and engaging strong, transparent distributors in each country. Once this is achieved and Laborie’s success in the marketplaces secured, funding for a West African Urodynamics Society will be proposed to corporate leadership, most likely post-project in 2020. During the fourth quarter, FC+/Nigeria met with CBM International, a German mission funded by the Australian Government through CBM Australia to discuss areas of possible collaboration. CBM has been funding ECWA Evangel Hospital in Jos from 2008 to 2017 to provide surgical obstetric fistula repairs. CBM will continue to fund ECWA Evangel to provide fistula services in Jos and plans to fund comprehensive fistula services in at least two additional states in Nigeria. FC+/Nigeria participated in and sponsored partners to attend the ISOFS conference in October 2016. The EngenderHealth CEO and President at the time, Ms. Ulla Muller, and the FC+ Project Director were in attendance, along with many FC+ staff and partners from other countries (See Section II, Objective 1 and Appendix F). Abstracts included review of fistula surgery outcomes in Nigeria, conservative treatment of fistula, mortalities in fistula centers, and quality of care measures. FC+ also hosted an FC+/EngenderHealth Nigeria booth to showcase FC+ work, knowledge materials, and to display crafts by fistula clients. Branded T-shirts, badges and other communications materials were also distributed.
Objective 2: Enhanced community understanding and practices to prevent fistula, improve access to fistula treatment, reduce stigma, and support reintegration of women and girls with fistula Based on the findings of the communication needs assessment study conducted in early 2016, FC+/Nigeria created a refined community communications and engagement strategy. Community mobilization efforts support community structures to conduct community-based SBCC activities by reaching households with messages about the dangers of prolonged/obstructed labor and encouraging skilled birth attendance at health facilities. The strategy includes strengthening the use of community volunteers to conduct house-to-house pregnancy monitoring and of community structures to conduct awareness-raising community dialogues and forums. Men as Partners groups are being strengthened to encourage male involvement to address harmful gender norms that prevent women’s access to maternal health services. In states where FC+ does not directly support community mobilization, FC+ prioritizes strategic engagement of and advocacy to community leaders local mass media to reach wider, grass roots audiences. FC+ Nigeria has finalized partnerships with CBOs in Ebonyi, Sokoto, Zamfara, Kebbi, Jigawa,
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Cross River, and Katsina States as of the third quarter and community volunteers have commenced house- to-house visits and pregnancy monitoring. FC+/Nigeria supported a total of 505 in-person community outreach events, reaching nearly 223,000 people during FY 16/17, see Table NGA1. Events included home visits, community dialogues, church outreaches, and townhall meetings. These activities raised community awareness about fistula prevention, identified and mobilized women with fistula symptoms for treatment, discouraged stigmatization against women with fistula, and provided reintegration support for repaired clients. In its efforts to reach households with fistula prevention and treatment messages and ensure pregnant women access to ANC services and skilled delivery, FC+/Nigeria commenced home visits during the FY 16/17. Community volunteers were recruited and trained on community outreach tools and approaches. Community volunteers conducted visits to households to monitor pregnant women, sensitize household members on fistula prevention, and make appropriate referrals for ANC, skilled deliveries, FP, and fistula treatment. They also provided useful information to household members about the importance of birth preparedness and postpartum care. During the second and third quarters of the year, the community volunteers and Ward Development Committees (WDCs) were trained across six supported states. By the end of the fiscal year, the community volunteers had conducted a total of 8,082 household visits. During these household visits, 1,325 women were referred for services including ANC, FP and skilled delivery. This activity is crucial to efforts to prevent prolonged or obstructed labor, and to promote early detection of pregnancy-related complications and referral of women with fistula. FC+/Nigeria provided technical support to community structures for sensitization and awareness-raising activities. Events included information on family planning and fistula treatment and prevention. Through supported CBOs, FC+/Nigeria conducts advocacy visits to relevant stakeholders, policy makers at state and local government area (LGA) levels, traditional rulers and community leaders. These visits provide an opportunity to sensitize community leaders about fistula prevention and treatment and other interventions. Outcomes of Community member dialogue in Zamfara State. Credit: FC+/Nigeria. this outreach have included donation of free training halls at the LGAs for training of community advocates and commitments by community leaders to support fistula interventions in their various communities. The CBOs also held various meetings with fistula centers in their respective states to strengthen collaboration between the CBOs and the facilities to ensure optimal client mobilization and referrals. During the fourth quarter of the fiscal year, FC+ intensified efforts to mobilize women with fistula for surgical repairs, both through the Fistula Treatment Barrier Reduction Intervention describes in Objective 3 below, and through state-wide efforts. CBOs prioritized client mobilization through home visits by community volunteers, community dialogues, town hall meetings, and other community outreach avenues. They were encouraged to strengthen collaboration with fistula facilities in their respective states to identify and refer potential fistula clients to the treatment facilities. In Ebonyi state, where DOVENET is carrying out client mobilization efforts throughout the state (including in one Fistula Treatment Barrier Reduction Intervention LGA), the NOFIC saw an increase in the number of clients, attributed to their
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efforts, particularly in hard-to-reach communities. Through various community outreach activities, the CBO mobilized 253 women with fistula to the fistula center for repairs during the fiscal year. FC+/Nigeria supported WDCs and Religious Leaders Advocacy Champions (RLACs) to conduct awareness-raising activities in Kebbi, Ebonyi and Sokoto States. Activities conducted included advocacy visits to district and village heads, community dialogue with gate-keepers and key influencers, and community outreach events. Outreaches were conducted by the RLACs in mosques and other Islamic gatherings in Kebbi and Sokoto State. During the fiscal year, Christian religious leaders from Cross River and Ebonyi States and Muslim religious leaders in Northern states were trained on tools and approaches to create awareness about fistula prevention and treatment. RLACs also worked to help reintegrate women who have received repairs back to their families and communities in Ebonyi and Sokoto States, also supporting reconciliation of clients who suffered divorce due to their condition. As part of continued efforts to reach people at the community level, a one-hour call-in radio program was organized in the Yoruba language at Radio Kwara in llorin during the first quarter. The program was also used to raise awareness about an upcoming concentrated repair effort at SOBI Specialist Hospital in Ilorin. In addition, FC+/Nigeria continued to participate in the Health Watch radio program on Radio Nigeria, the largest radio network in Africa. Radio Nigeria covers the entire country, reaching 14 million people. FC+/Nigeria and partners also Community drama enactment. Credit: FC+/Nigeria. held two call-in radio programs on Ebonyi Broadcasting Corporation and Unity FM, with an estimated listening audience of 800,000 people. As noted in Objective 1, radio outreach played a role in IDEOF celebrations as well. Due to difficulties obtaining accurate estimated audiences for many of the radio programs, this data is not included in Table NGA1. During the fiscal year, FC+/Nigeria employed screenings of the film DRY and community drama performances as strategies for community education. Screening of the movie DRY was conducted in Ebonyi State and will be extended across other supported states in FY 17/18. Community dramas were conducted mainly in the Northern states in village squares. In FY 16/17, FC+/Nigeria implemented the Site Walk Through (SWT) approach for the first time. This community engagement approach aims to strengthen linkages between health facilities and the communities they serve. It consists of a guided tour of a health facility that provides an opportunity for community representatives to learn about the health services provided at the site and to discuss important community health concerns with PHC provider presenting facility utilization data to community members during SWT. Credit: FC+/Nigeria.
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the staff. The SWT was piloted in Enyibuchiri Model PHC in Ikwo LGA of Ebonyi state during the fourth quarter. A total of 37 participants attended the event, hosted by facility staff. Community members were taken on a tour of the various units of the facility. Action points were agreed upon to address some of the challenges identified through the event. FC+/Nigeria is monitoring their implementation, and will conduct a follow up meeting after three months to evaluate the impact of the SWT. Further implementation of the SWT approach in Nigeria will be informed by experiences in the FC+ Niger and Uganda programs, where the approach and its impact are currently being evaluated. FC+/Nigeria has partnered with the Institute of Social Works of Nigeria (ISOWN) to support community engagement activities, particularly in the areas of rehabilitation and reintegration of repaired fistula clients, as part of efforts to ensure sustainability of project interventions. ISOWN is a national body working in rehabilitation and reintegration with nationwide reach and structures at local levels. During FY 16/17, FC+ provided financial and technical support to the institute to conduct activities in Osun State including follow up ISOWN staff facilitating inaugural meeting of fistula of repaired clients and provision of reintegration Champions in Osun State. Credit: FC+/Nigeria. support. The group also established a network of fistula champions to become fistula advocates in their communities, leading community-based sensitization and peer education on fistula prevention.
Table NGA1: Community Outreach/Education/Advocacy Events, By Quarter, FY 16/17
Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Existing 7 2,174 0 0 110 49,322 319 163,216 436 214,712 community events Maternal 0 0 69 8,286 0 0 0 0 69 8,286 health/ fistula- focused event Total 7 2,174 69 8,286 110 49,322 319 163,216 505 222,998
Given low use of preventive maternal health services, including FP, in many of the FC+ focal states in Nigeria, efforts continue to cultivate champions for social change, with a focus on existing community development structures such as WDCs and other influential social leaders. During the fiscal year, FC+/Nigeria conducted training of 405 community volunteers and educators not formally affiliated with a health facility, see Table NGA2. The community volunteer trainings included training for staff from the seven newly-engaged CBOs to orient them to the FC+ communication and community engagement strategy. Sixteen staff were trained on maternal health, FC+ community engagement strategy and approaches, monitoring and evaluation, and financial policies and procedures. The CBOs from Ebonyi and Katsina were further trained as part of the barriers to fistula treatment intervention, described further under Objective 3. Community advocates were trained in 78 wards across six LGAs in Ebonyi State through a step down training by DOVENET. Training included the identification of women who may be suffering from fistula, methods of referral,
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awareness on dangers of prolonged obstructed labor, and benefits of ANC, skilled birth attendance at health facilities, birth preparedness, FP, and male involvement. During the third quarter, 36 volunteers in Katsina LGA were trained as part of the barrier intervention. This training focused on improving community-level fistula screening and referrals as well as maternal health, obstetric fistula prevention and treatment.
Table NGA2: Community Volunteer/Educator Training, Participants, By Quarter, FY 16/17
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total FY 16/17 2016 2017 2017 2017 Community volunteers 0 252 153 0 405 Total 0 252 153 0 405
In early November 2016, a gender TOT was organized for the Nigeria Gender Working Group to build gender training capacity. The training was facilitated by the FC+ global Gender Focal Point and co- facilitated by a resource person in Nigeria. This training transferred skills and tools to facilitate gender related trainings and to provide technical support for gender mainstreaming within FC+ Nigeria activities. The team has met regularly to review progress on the Nigeria specific action plan and guide the implementation of gender activities in Nigeria.
Objective 3: Reduced transportation, communications, and financial barriers to accessing preventive care, detection, treatment, and reintegration support As discussed in greater detail in Section II, Objective 3, FC+/Nigeria worked with the Population Council to carry out formative qualitative research to understand barriers to accessing fistula care services in Kano and Ebonyi States during FY 15/16. Findings from these studies informed FC+ in the design of a comprehensive information, screening and referral intervention aimed at reducing the awareness, financial and transportation barriers that impede women’s access to fistula treatment in Nigeria and Uganda. FC+ is piloting this intervention in two sites in Nigeria and one site in Uganda. The Population Council is conducting implementation research to evaluate the effects of this intervention. In Nigeria, the Fistula Treatment Barrier Reduction Intervention is taking place in the catchment areas of two fistula treatment facilities - NOFIC Abakaliki and NOFIC Babbar Ruga. Within each of the catchment areas, FC+ supports activities that seek to strengthen community-based screening and referral to the treatment facility. The intervention focuses on screening and referral mechanisms through primary health facilities, community engagement activities, and mass media/phone-based communication. FC+ is training community agents and health workers (doctors, midwives, nurses, and community health care workers) at primary health facilities across each catchment area to identify potential fistula clients and refer these women for treatment. Community volunteers are selected and trained by the project partners DOVENET in Ikwo LGA of Ebonyi State and FOMWAN in Katsina LGA of Katsina State. Flyer advertising the IVR screening hotline. During the second and third quarters of FY 16/17, 82 community agents and 94 primary health care workers were trained in Ikwo and Katsina LGAs. Numerous materials were developed for the trainings, including job aids for screening for both primary health facility workers and community agents (see Appendices S and T). An interactive voice response
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(IVR) phone screening hotline was pretested during the first quarter in Ebonyi, and in the second quarter in Katsina. The project has finalized engagement of two transport companies (National Union of Road Transport Workers and Aba Jamil Car Hire Services) to provide free transport services to positively screened clients in the two catchment areas. By the end of FY 16/17, the hotline received 260 calls from women seeking care through the IVR hotline, of which 172 screened positively for fistula symptoms. Thus far, 14 women from the intervention LGAs have benefitted from the free transportation mechanism, and an additional 15 women from within Katsina State but outside the intervention LGA, have utilized the free transport voucher. Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment At the beginning of the second quarter of FY 16/17, FC+/Nigeria conducted site assessments in ten states including Bauchi, Ebonyi, Kaduna, Kano, Katsina, Kebbi, Kwara, Oyo, Sokoto, and Zamfara using the EngenderHealth Clinical Monitoring Checklist. A number of critical gaps were identified and strategies outlined to address the gaps. As described in Section II, Objective 1, during the first quarter of FY 16/17, an FC+/Nigeria supported facility hosted Medical Aid Films to develop a short film that provides an orientation to the FC+ surgical safety toolkit which includes clinical trackers and checklists that will help strengthen clinical quality of fistula repair service provision. FC+ currently supports 13 designated fistula repair centers in 12 states in Nigeria, of which eight conduct regular routine fistula repairs. Conscious efforts are being made to maximize routine fistula surgery in all supported treatment sites in order to promote sustainability through consistent supply of medical consumables for repairs, capacity building for the health providers, investment in instruments and equipment, and other quality improvement activities. During the fourth quarter, a national strike hampered ability to conduct repairs. During FY 16/17, 3,217 women with severe incontinence symptoms arrived seeking fistula care at FC+ supported sites, of which 2,501 were diagnosed with fistula (78%, compared to 86% in FY 15/16). 100% of those diagnosed with fistula were medically eligible to receive treatment. FC+ supported 1,953 fistula repair surgeries during this period (78% of those eligible, compared to 77% in FY 15/16). Some women may be diagnosed with fistula in one quarter, and repaired in the next. Because FC+ does not track individual women through our data collection, we are unable to present a definitive percentage of women requiring repair who receive it. See Figure NGA1 for data on women seeking and requiring fistula treatment and the number of repairs supported, by country. We are also unable to report the number of women repaired because women may have multiple repairs over the life of project, or repairs at multiple sites. However, within a given quarter, the number of repairs generally reflects the number of women. All supported repair sites in Nigeria offer non- surgical catheter treatment of obstetric fistula. In addition to those fistula repair surgeries reported above, 261 women received catheter treatment for Fistula clients in Ogoja. Credit: FC+/Nigeria.
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fistula at ten supported sites (compared to 8 sites providing the same number of treatments in FY 15/16), the majority of which took place at Laure VVF Center, NOFIC Babbar Ruga and Maryam Abatcha. 62% of catheter-treated cases were closed and continent at discharge, and 7% were closed and incontinent.
Figure NGA1: Number of Women Seeking and Eligible for Fistula Treatment, and Number of Surgical Repairs, FY 16/17
0 100 200 300 400 500 600 700 800 900 Adeoyo Faridat GH Ningi GH Ogoja Gesse Hajiya Gambo Sawaba Seeking Jahun Eligible Laure Repairs Maryam Abatcha NOFIC Abakaliki NOFIC Babbar Ruga Sobi Specialist UCH Ibadan Wesley Guilds
Data on the etiology of diagnosed fistula was available for 1,934 (77%) cases. Of those cases where etiology was identified, the majority (85%) were due to prolonged/obstructed labor. 12.5% were diagnosed as iatrogenic fistula, <1% as traumatic and 2% attributed to cancer and congenital fistula. In Nigeria, the data on iatrogenic fistula diagnosis is sourced from operation notes across supported facilities where the assumption is that all ureteric fistulas are iatrogenic in origin. Because the surgeons are often absent at the time of reporting, it has been difficult to confirm these data. Tools such as the revised fistula registers and the SST have already greatly improved the availability of fistula etiology data (77% this fiscal year compared to 56% in FY 15/16). The 1,953 fistula repair surgeries supported during FY 16/17 were conducted at 14 FC+ supported hospitals, see Table NGA3. FC+/Nigeria supported a combination of routine services and pooled efforts at supported sites to both eliminate the backlog of fistula cases and provide ongoing services. It has become clear that some sites are reluctant to establish routine services and prefer to only employ the pooled effort model, which does not strengthen routine service provision of fistula services. The project emphasizes the importance of routine, high quality service provision, and has scaled down its support for the pooled effort approach. FC+ continues to encourage and support all efforts in each facility towards the optimal model of routine repairs year round for cases that are well within the surgeon skill set and facility spectrum of care, combined with pooled efforts for cases that require master surgeon consultants and/or require transfer to higher level facility for anticipated complex peri-operative care beyond the scope of the home facility. In general, progress has been made across the program, but some facilities still have not been able to engage any level of routine fistula services due to financial and human resource obstacles. Concentrated repair efforts continued to be utilized as a strategic approach to address the overwhelming backlog of clients and provide repair for particularly complex cases. During FY 16/17, FC+/Nigeria
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organized a total of 14 concentrated fistula repair efforts across project sites, repairing a total of 557 fistula clients. Pooled repairs accounted for 28% of all surgical fistula repairs during FY 16/17 (compared to 47% of all cases in FY 15/16).
Table NGA3: USAID-Supported Surgical Fistula Repairs, By Quarter, FY 16/17
Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 2016 2017 2017 2017 16/17 Adeoyo GH 13 1 15 27 56 Faridat GH 14 20 13 30 77 GH Ningi 24 72 22 68 186 GH Ogoja 25 0 12 26 63 Gesse VVF Center 55 56 13 29 153 Hajiya Gambo Sawaba 25 40 13 35 113 Jahun VVF Center 79 100 0 0 179 Laure VVF Center 82 93 56 62 293 Maryam Abatcha 55 42 28 61 186 NOFIC Abakaliki 44 28 59 66 197 NOFIC Babbar Ruga 93 101 63 100 357 Sobi Specialist Hospital 18 4 0 28 50 UCH Ibadan 0 0 20 0 20 Wesley Guilds 0 0 0 23 23 Total 527 557 314 555 1,953
Data on the classification of simple/not simple repairs discharged during the quarter has been challenging to obtain, for reasons similar to those reported above regarding etiology. Roll out of the revised fistula registers developed together with the FMOH, as well as the collection of data from the client tracker component of the SST, will allow for more complete data on the clinical profile of all fistula patients in the future. Of all fistula repair surgeries discharged during FY 16/17, 85% were closed at discharge: 71.5% were closed and continent and 13.7% were closed and incontinent. In FY 16/17, FC+ was unable to implement the client tracker component of the surgical safety toolkit adequately in order to better understand the not closed rates in each facility. In FY 17/18, with the assistance of a consultant FC+ will focus efforts on this roll out that will provide more information on that cases that are not closed. It is hoped that the ongoing efforts to ratify a national policy on women whose fistulas have been deemed incurable (WDI) will help to ensure that those women who remain not closed receive appropriate treatment and support. Outcomes for discharged patients are presented, by site, in Figure NGA2. Clinical and program staff have designed a tool for follow up with relevant sites to gain clarity on the causes of low closed rates, and what steps, if any, are necessary to address the issue. Appendix FF presents data visualizations that illustrate the available country-level data on whether repairs were conducted through routine or concentrated efforts, how many previous repairs clients had undergone, whether repairs were categorized as simple or complex, and discharge outcomes. Reported complications were low at supported sites (1.8% overall) with most sites reporting very low rates ranging from zero to 12% (Jahun VVF Center).
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Figure NGA2. Outcome Rates for Surgical Repairs, by Site, FY 16/17
100% Not closed
Closed with remaining incontinence Closed and continent
Benchmark closed and 0% continent (75%)
Immediately following the 2016 ISOFS meeting, FC+/Nigeria hosted and participated in a global FC+ clinical meeting in Abuja. Participants from Bangladesh, DRC, Niger, and Uganda also attended the meeting along with FC+ global team members. Discussions relevant to strengthening clinical data review of the new surgical safety toolkit of clinical trackers for quality assurance, checklists for surgical safety, and input from the M&E/R team related to data collection methods and inclusion of toolkit data in DDM analyses. Action plans were developed to support all country programs to ensure focus on goal and objectives, quality improvement and sustainability. FC+/Nigeria conducted clinical supervision visits at all supported treatment sites during the fourth quarter of the fiscal year that included assessment of waste management and infection prevention practices. Cross cutting challenges observed at supported sites include:
- Lack of infection prevention and waste management equipment and supplies, such as lidded waste containers for sharps, incinerators. - Lack of existing protocols and guidelines on infection prevention and waste management. - Inadequate waste management handling staff. - Lack of standard on-site final waste disposal unit - Inadequate capacity building on infection prevention & waste management
Actions taken to address the observed challenges include:
- Provision of infection prevention and waste management equipment and supplies to sites with acute shortage. - Sharing of EngenderHealth Standard Infection Prevention Guide with facility management. - On-the-job mentoring Meeting with key unit in-charges to discuss modalities for quality improvements.
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Dr. Igor Jose Vaz, from Maputo, Mozambique, was engaged by FC+ to participate in ISOFS and remain in Nigeria after the conference to repair very complex cases of fistula at supported site UCH Ibadan, under the supervision of Prof. Oladosu Ojengbede. Dr. Vaz demonstrated the latest surgical innovations for complex fistula repair and treatment of fistula repair complications. The complex surgery training series is necessary to successfully address the low closed rates at certain supported facilities and to address the backlog of Surgical fistula repair at UCH Ibadan. Credit: FC+/Nigeria complex cases throughout the FC+ project. The training, by design, involves selected senior Nigerian surgeons in a TOT format for efficient organic scale-up for complex case management throughout Nigeria. Four surgeons participated in a continuing training in surgical fistula repair in December 2016 at NOFIC Abakaliki and four surgeons were trained at Sobi Specialist Hospital in August 2017. Table NGA4 provides information on surgical repair trainings during the reporting period. Two resident facility surgeons also received further training on advance surgical procedures including urethroplasty, ureteric implantation and vaginaplasty. FC+ has focused efforts in addressing the increasing number of WDI. In Nigeria it has been noted that these women often have a long term complication characterized by partial or complete obliteration of the vaginal cavity resulting from the obstetric injury itself or from multiple unsuccessful repair attempts. To address the needs of this group of women, the project has been investing in building the capacity of indigenous fistula surgeons in advanced vaginal reconstructive surgeries. During the fourth quarter, in collaboration with the Fistula Foundation, FC+ supported a five-day workshop on vaginal reconstructive surgery organized by Dr. Kees Waaldjik. FC+ supported the participation of eight fistula surgeons and 14 nurses (ward nurses, theatre nurses and anesthetists) in the workshop which was held in Hajia Gambo Sawaba General Hospital, Zaria, Kaduna state.
Table NGA4: Surgical Fistula Repair Training, By Quarter, FY 16/17
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 16/17 2016 2017 2017 2017 1st Cont 1st Cont 1st Cont 1st Cont 1st Cont Training of Trainers 0 6 0 0 0 0 0 0 0 6 Fistula surgical repair 0 4 0 0 0 0 1 3 1 7 Total 0 10 0 0 0 0 1 3 1 13
As part of fistula treatment and prevention efforts, FC+/Nigeria provided training to 326 health care clinicians during the fiscal year, see Table NGA5. Trainings covered topics including FP methods and counseling, pre- and post-operative care, and anesthesia.
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Over the last two fiscal years, FC+ has promoted surgical and anesthesia safety in the care of fistula clients across all project supported sites. Building capacity of surgical teams in anesthesia for fistula surgery has been identified as key to sustaining provision of quality and safety in fistula surgery. During this fiscal year trainings took place in for doctors and nurses from supported sites in Bauchi, Jigawa, Kaduna, Kano, Katsina, Kwara, Osun, Ogoja, and Abakaliki. Family planning service provision has also been a focus of training efforts for the project. In FY 16/17, Supportive supervision visit in Bauchi State. 35 nurses and midwives have been trained in Kebbi, Credit: FC+/Nigeria. Kano, Jigawa, Kwara, and Oyo states to provide LARC services. 91 Nurse/CHEWs were trained in FP counseling skills. In Bauchi, 75 nurse/midwives and CHEWs from 201 health facilities counseling methods as well as use of the NHMIS to report routine family planning data. FC+ supported the implementation of these trainings with supportive supervisory visits conducted together with the SMOH, covering sites in Bauchi, Cross River, Sokoto, Ebonyi, Oyo, and Kwara States. Members of the USAID/Nigeria Health, Population and Nutrition team also participated in some supportive supervisory visits. As part of the efforts to promote the use of catheterization for the prevention and non-surgical treatment of obstetric fistula (described in Objective 1), FC+ is working with the FMOH and the Nursing and Midwifery Council of Nigeria (NMCN), to encourage task shifting in the health system and mainstream this process in pre- and in-service curriculum. This will ensure that current and new graduates will have the prerequisite skills to manage postpartum care after prolonged and obstructed labor with catheterization, especially at lower level centers. The use of the urethral catheter for this purpose is a cost- effective and efficient intervention that will widen the scope of care to primary and secondary health care levels. As described in greater detail in Section II, Objective 4.3, Nigeria was one of the countries included in FC+’s rapid assessment of FP service quality in FY 16/17. In Nigeria, FC+ rapidly utilized the findings of an environmental scan conducted by the NMCN to convene a stakeholder working group resulting in a draft pre-service curriculum within the Nursing and Midwifery training institutions that includes FP material. A key challenge requiring focused response is the reinforcement of quality assurance and infection prevention control skills related to long-acting reversible contraceptives (LARC). Discussions are underway exploring systems to incorporate client exit interviews as a means to capture information on efficacy of EH training on provider counseling. Moreover, unification of FP with state/local government level IPC/WA teams will add to the sustainable impact of the FP program. Additionally, there are plans for the incorporation of strong reinforcement of tenets of respectful care and privacy into on the site FP supervision, mentoring, and coaching strategies. Ongoing support for quality assurance will continue to address this gap and barrier to provision of quality services. The goal includes reduction of high staff turnover rates that is clearly contributing to this gap at supported facilities.
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Table NGA5: Non-Surgical Health System Personnel Training, Participants by Topic, By Quarter, FY 16/17
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2016 2017 2017 2017 FY 16/17 FP methods 57 91 0 0 148 FP counseling 0 0 31 0 31 Anesthesia (pre- and post-operative care) 0 15 0 0 15 Pre- and post-operative care 0 94 0 0 94 Data management/ DDM 0 12 26 0 38 Total 57 212 57 0 326
During FY 16/17, nearly 362,000 family planning counseling sessions took place at supported sites in 12 States, and over 187,900 CYP were provided, see Table NGA6 for detail, by state.
Table NGA6: Family Planning Counseling Sessions and CYP, By Quarter, FY 16/1720
Site Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP21 Bauchi Former 20,017 9,441 21,469 8,332 26,833 11,330 28,218 14,761 96,537 43,865 TSHIP Cross 839 1,708 1,222 1,672 362 1,504 829 1,633 3,252 6,518 River Ebonyi 20,437 4,161 20,446 3,533 18,526 7,614 12,173 17,540 71,582 32,848 Jigawa 4,451 2,100 4,261 1,560 6,064 2,104 NS NS 14,776 5,764 Kaduna NA NA NA NA NA NA 1,950 3,184 1,950 3,184 Kano NA NA 1,162 621 1,351 1,648 6,359 4,431 8,872 6,700 Katsina NA NA NA NA NA NA 381 281 381 281 Kebbi NA NA NA NA NA NA 3,975 2,027 3,975 2,027 Kwara 3,319 2,264 4,513 3,126 2,774 2,990 1,631 2,078 12,237 10,462 Oyo 6,190 6,962 5,811 4,842 5,422 7,045 6,219 6,045 23,642 24,893 Sokoto Former 34,408 10,725 31,077 10,281 28,497 12,356 28,169 15,961 122,151 49,322 TSHIP Zamfara 638 527 578 434 656 599 574 496 2,446 2,047 Total 90,299 37,887 90,539 34,405 90,485 47,182 90478 68,437 361,801 187,911 NA: Not Available NS: Not Supported
FC+ was tasked with maintaining and sustaining 300 selected FP sites inherited from TSHIP in Bauchi and Sokoto when that project ended. In order to increase access and strengthen their capacity to provide high quality FP services, FC+ is paying particular attention to capacity of the sites which are greatly affected by inadequate resources and untrained manpower. During the fourth quarter of the fiscal year, a follow up and assessment visit of the FP sites inherited from TSHIP was jointly planned and conducted by a team from the Sokoto State Primary Health Care Development Agency and Amina Bala, the FC+/Nigeria FP Advisor. Findings from the assessment indicated that the majority of providers lack counseling and other FP skills, and even those trained by TSHIP had had no recent skills updates. Other notable findings include poor physical conditions of facilities and high need for equipment and basic instruments for FP services (e.g.
20 Data for Kaduna, Katsina and Kebbi States were not available in the first three quarters. The data presented in the fourth quarter is actually the annual total for the States, with all four quarters aggregated into one once data was available. 21 Due to rounding, totals may differ slightly from the sum of individual quarters.
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blood pressure machines, weighing scales, FP SBCC materials and job aids). FC+ will select actionable strategies to address the current FP gaps and move towards addressing them. The assessment has also helped the management of the centers to understand that donor support is intended to initially reduce disparities and income gaps, and is not meant to be used as a long-term maintenance solution; therefore, management needs to move towards mobilizing resources in support of FP, taking full responsibility and ownership for interventions in the state.
Obj. 5: Strengthened evidence base for approaches to improve fistula care and scaled up application of standard monitoring and evaluation (M&E) indicators for prevention and treatment FC+/Nigeria has focused during FY 16/17 on strengthening the capacity of health facilities, LGAs, and states to generate quality service provision data, report the data accurately and in a timely manner on the national reporting platform, and analyze and use the data for planning and decision making. All state HMIS officers in the 12 project implementation states were trained in data management, as well as four state family planning coordinators from Bauchi, Ebonyi, Jigawa, and Sokoto. An additional two FMOH staff, 12 service providers, 12 medical record staff and seven M&E staff from seven supported CBOs were also trained (see Table NGA5). By the fourth quarter of the fiscal year, these efforts were yielding results with data reporting rates in the national system up to 98% in the fourth quarter (compared to less than 50% in the first quarter of the year). Quarterly data review meetings have been institutionalized in Bauchi, Ebonyi and Sokoto States through FC+ support. Two FC+/Nigeria staff participated in the EH CDDM meeting in Dar Es Salaam, Tanzania in May 2017. FC+ staff have tried to carry this emphasis on data use over to project partners. During the most recent providers’ network meeting, all stakeholders were encouraged to build a culture of using data for planning and decision-making. Data quality audits were carried out during the fiscal year in Bauchi, Ebonyi, Kebbi and Sokoto. During these visits, FC+ conducted post training follow-up, data validation, and capacity building and mentoring of service providers. Revised HMIS tools for fistula were also disseminated and training in their use was provided. FC+/Nigeria is collaborating with the government of Nigeria to increase the reporting rate of fistula and FP interventions in Nigeria. During the first quarter, at the request of the FMoH, FC+/Nigeria submitted 27 indicators to be included on the FMoH DHIS2 database. The M&E team has progressively tracked activities implemented to contribute to evidence and accountability. Twelve fistula program indicators were approved for inclusion on the list of national health indicators. During the fourth quarter, FC+ participated in a meeting of stakeholders to develop a national health indicators dictionary. As noted in Objective 2, FC+/Nigeria applied the findings of a 2016 communications needs assessment study to update its community communications and engagement strategy.
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Uganda USAID-supported fistula services in Uganda began in 2004 through the previous FC project and continue through FC+ in four treatment22 and prevention sites and 13 prevention-only sites as of September 30, 2017. The Kampala office is shared with the BMGF-funded project, ExpandFP. In Uganda, FC+ supports fistula repair services, POP treatment services, clinical training, efforts to improve the quality of obstetric care and FP services, and building community awareness. The project is increasing emphasis on the integration of FP services with fistula and maternal health care and piloting efforts to meet the reintegration needs of women who have undergone fistula repair.
Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors FC+/Uganda works to strengthen the enabling environment for fistula services through cultivation of partnerships with governmental and non-governmental agencies, participation in technical working groups and professional meetings and conferences, and by convening relevant stakeholders in Uganda through partner meetings and updates. During the third and fourth quarters of the fiscal year, FC+/Uganda supported meetings of the National Ugandan Fistula Technical Working Group (FTWG). The FTWG is comprised of select fistula surgeons, officials from the Ministry of Health, and representatives from implementing partners supporting fistula work in the country. The aims of these meetings were to strengthen stakeholder co-ordination as well as review progress made in fistula prevention, repair, and re-integration services. Dr. Fred Kirya of Soroti Referral Hospital, one of the expert fistula surgeons working with FC+, was chosen to lead a team to develop the new costed fistula strategy. Alice Emasu of TERREWODE also joined this team in the fourth quarter. A draft is expected by the end of 2017. FC+ presented project data and highlighted the backlog of patients at all supported sites and the emerging high rate of iatrogenic fistula at some supported facilities. In the fourth quarter of FY 16/17, FC+/Uganda held a partners’ meeting with the objective of “Fostering sustainable approaches to fistula prevention, detection, treatment and reintegration in Uganda”. The meeting took place in Jinja and was attended by over 100 participants, including MoH officials, Directors of Regional Referral Hospitals, FC+ supported sites, implementing partners, youths, District Health Officials Partners’ meeting on “Fostering sustainable approaches to fistula (DHOs), religious leaders and prevention, detection and reintegration in Uganda”. Credit: officials from community FC+/Uganda. departments such as Community Development Officers (CDOs) and Education Officers. During the meeting, project FC+ and partners presented achievements and discussed challenges. Participants expressed concern over the increasing
22Does not include Mbarara where a joint concentrated repair effort with UNFPA took place during FY 16/17.
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number of fresh fistula cases and called for exploring creative ways of “closing the tap” while at the same time “mopping the floor” to clear the backlog. Meeting attendees were challenged to ensure the sustainability and continuity of fistula care, even after the FC+ project has ended and by the end of the meeting, partnership commitments were sought from all participants, including implementing partners, districts, regional referral hospitals, community leaders, youths and religious leaders. Some committed to incorporate fistula care in their programming while others promised to utilize the current trained pool of medical professionals to see how best to address continuity of fistula care, treatment and prevention. Districts were also encouraged to include issues of fistula care in their development and health plans. As described in Section II, Objective 1, FC+ is also participating in regional initiatives to foster and promote collaboration. FC+ supported attendance of 16 participants at the launch of the East, Central and Southern African College of Obstetrics and Gynaecology (ECSACOG) in Rwanda, and supports participation in the East, Central and Southern Africa Health Community (ECSA-HC) which is an inter- governmental health organization that fosters and promotes regional cooperation in health among member states. Member states of the ECSA Health Community are Kenya, Lesotho, Malawi, Mauritius, Swaziland, United Republic of Tanzania, Uganda, Zambia and Zimbabwe. FC+/Uganda also facilitated the participation of nine representatives from East, Central, and Southern Africa at a COSECSA meeting in December 2016. FC+/Uganda was well represented at the 2016 ISOFS meeting in Abuja, Nigeria. Eight participants (three FC+ and five from partner organizations, including two senior surgeons) were supported to attend the conference where 16 abstracts from EngenderHealth Uganda staff and partners were represented at both oral (14) and poster (two) presentations (see Appendix F, and Section II for more detail). Two of the participants also participated in urodynamics training and three participated in a pre-conference video training of trainers (TOT) for obstetric fistula repair. The FC+/Uganda Senior Clinical Associate also joined the FC+ clinical meeting immediately following ISOFS. FC+ continued its collaboration with ACOG (American College of Obstetricians and Gynecologists) and the CNIS (Canadian Network for International Surgery) in FY 16/17 to strengthen Maternal and Child Health (MCH) care services in the country. In November 2016, FC+ jointly held a Surgical Operative Obstetrics (SOO) Stakeholder meeting. FC+ presented the monitoring and evaluation component of this partnership program geared towards improving skills of attending doctors at doing cesarean section. An SOO course for residents and intern doctors is being piloted at Mulago National Referral Hospital and Mbarara Regional Referral Hospital. Gynecologists and obstetricians from both institutions were given refresher training that involved theoretical and practical sessions for caesarian section and other emergency procedures. This will provide a basis for them to cascade the training to residents and intern doctors. See Objectives 4 and 5 as well as Section II, Objective 1 for additional information on this partnership. During the first quarter of FY 16/17, the FC+/Uganda Senior Clinical Associate participated in the Scientific Meeting of the Association of Obstetricians and Gynecologists of Uganda where current research and developments in women’s health were shared with attendees from the Ministry of Health, obstetricians, gynecologists and midwives. During the fourth quarter, FC+/Uganda participated in the 2nd Uganda National Conference on Family Planning in Kampala, supporting participation of 30 individuals including district leaders and youth peer educators. As described in Section II, Objective 1, FC+’s partnership with Direct Relief has resulted in successful distribution of fistula kits in Uganda. The first shipment to Kitovu Hospital occurred at the end of FY
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15/16, and a second shipment to Hoima Regional Referral Hospital, following application and registration by the hospital administration, was received during the first quarter of FY 16/17. The kit sent to Hoima Hospital can support repair of 50-140 patients, depending on case complexity. FC+/Uganda works to cultivate partnerships aimed at reaching underserved groups. In the first half of FY 16/17, FC+/Uganda carried out some activities with StrongMinds Uganda, an NGO focused on treating depression among women. These included continuing training of staff at supported sites, screening of obstetric fistula clients for depression and provision of counseling to women identified as needing services at supported treatment sites, and are described further under the relevant objectives in this section. Plans to move forward with a more formal partnership with Strong Minds have been delayed as part of EngenderHealth efforts to ensure full compliance with PLGHA.
Objective 2: Enhanced community understanding and practices to prevent fistula, improve access to fistula treatment, reduce stigma, and support reintegration of women and girls with fistula As part of efforts to increase public awareness of fistula prevention and treatment, FC+/Uganda carried out over 25,000 in-person community outreach/education/advocacy events reaching over 125,000 participants during FY 16/17, see Table UGA1. The majority of these activities were part of the project’s youth initiative, described below. Mass media efforts during this period reached an estimated 15 million people through radio programs. In addition to youth-focused activities described below, in-person community outreach has primarily worked with village health teams (VHTs) and local religious leaders to increase awareness and health- seeking behaviors among more rural communities, while mass media has utilized radio programs as a means of connecting with broader audiences, particularly in harder to reach areas. During the third and fourth quarters, several radio stations with large estimated listening audiences were utilized to broadcast fistula messages prior to concentrated repair efforts at Kitovu and Jinja (see Table UGA1). FC+/Uganda has also worked with Buganda radio as part of the Barriers’ study to make daily announcements for the Hotline to identify fistula clients in Kalungu and other districts. Following recommendations from the midterm evaluation, in the first quarter the FC+/Uganda community engagement and monitoring and evaluation teams met with FHI 360, implementers of the Obulamu (How’s your love life?) campaign. This campaign features a series of innovative health communication interventions developed by the Communication for Healthy Communities (CHC) project, funded by USAID and implemented by FHI 360, the Uganda Ministry of Health and other implementing partners. The meeting helped initiate discussions on including fistula messaging in the behavior change and communication campaigns conducted across the country. In the second quarter, CHC, FC+/Uganda and the Ministry of Health organized a fistula communication campaign design workshop on messaging to be included in the campaign. The workshop had 30 participants including representatives from Walter Reed Project Makerere, TERREWODE, Mildmay Uganda, Jinja Regional Referral Hospital, Kitovu Hospital, Kagando Hospital, Rakai Health Sciences, DREAMS Jinja, Soroti Regional Referral Hospital, Uganda Private Midwives Association, and MAAD advertising.
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Table UGA1: Community Outreach/Education/Advocacy Events, By Quarter, FY 16/17
Type of Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 Event # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Existing 3 30,509 1 5,692 8,144 38,640 16,895 49,436 25,043 124,277 community activity Maternal 1 78 0 0 0 0 0 0 1 78 health/ fistula- focused Health facility 0 0 0 0 0 0 2 798 2 798 Radio/TV 0 0 1 1,175,772 613 9,100,000 2 4,675,772 616 14,951,544 Total 4 30,587 2 1,181,464 8,757 9,138,640 16,899 4,726,006 25,662 15,076,697
-in person 4 30,587 1 5,692 8,144 38,640 16,897 50,234 25,046 125,153 -mass media 0 0 1 1,175,772 613 9,100,000 2 4,675,772 616 14,951,544
FC+/Uganda collaborates with institutions to strengthen the link between community members and health care institutions using both the Site Walk Through (SWT) approach and by training VHTs to promote maternal health service use and FP uptake. This model has been implemented in Hoima, Kamuli, Jinja, Masaka and Kasese districts. The model incorporates quarterly meetings between health care facility staff and VHTs during which achievements and barriers are discussed. Throughout FY 16/17, FC+/Uganda continued holding quarterly meetings with VHTs, reviewing maternal and FP service data and progress made to date in mobilizing communities in the health facility catchment areas as well as providing technical support to address challenges within their work. During the first quarter, FC+/Uganda participated in a fistula awareness campaign organized by two local religious leaders in Hoima, the first of its kind in that parish. The event covered topics related to fistula awareness, birth preparedness, family planning and male involvement in maternal and child health. During the fiscal year, a total of 148 religious leaders who had been trained previously were followed-up to gather information on what sensitization activities they had conducted and how many individuals had participated. These leaders included Catholics, Anglican and Muslims from the two districts of Hoima and Masaka, and the follow-up exercise covered a period of three years (2014-2016). FC+/Uganda has embarked on implementation of a youth component as part of its community engagement portfolio, aimed at empowering young people with knowledge and skills to make responsible SRH choices. FC+ is partnering with the Private Education Development Network (PEDN), an NGO that has been implementing youth-focused activities, to leverage their skills to address youth social and financial education in partnership with FC+’s efforts to address sexual and reproductive health. Initially, a total of 44 participants from the Ministry of Health, FC+/EngenderHealth and the Uganda AIDS Commission participated in a Health/HIV Technical Working Group meeting during which the FC+ team sought guidance and input from the working group to scale-up fistula interventions in schools. After presentation of the intended activities, an agreement was made that both materials and rollout should be approved by the Ministry, particularly in order to avoid creation and dissemination of controversial materials. FC+’s request for partnership with the Ministry’s TWG was granted, pending the vetting/approval of the training modules/materials. Following that meeting, FC+/Uganda has undertaken extensive programming to work with youth populations in Jinja and Kamuli. In partnership with the Private Education Development Network (PEDN) and Aflatoun International, EngenderHealth adapted the evidence-based Aflateen curriculum, combining its social and financial education for youth with modules on SRH and rights. By connecting
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the Aflateen learner-centered, social and financial approach with EngenderHealth’s gender-transformative SRH interventions, the enhanced Aflateen PLUS curriculum seeks to enhance the capacity of young people to empower themselves to make positive decisions about their education, health, social, and financial well-being through Alfateen youth clubs. The goal of the Aflateen club model is for youth to work as peer educators, helping others make responsible financial and social entrepreneurial decisions that will reduce out-of-school youth’s vulnerability to sexual and reproductive challenges such as unwanted pregnancies, morbidities such as obstetric fistula, and maternal deaths. In technical collaboration with PEDN, FC+/Uganda supported the implementation of the Aflateen PLUS curriculum in Jinja and Kamuli districts. In the first quarter, FC+/Uganda conducted a mapping exercise for out-of-school youth groups in Kamuli and Jinja districts and supported the training of 19 teachers to rollout the Aflateen PLUS curriculum with 10 in-school youth groups and the training of 29 peer- educators to teach the curriculum to 10 out-of-school youth groups in the second quarter. FC+ also provided refresher trainings and supportive supervision to the facilitators throughout the rollout of the Aflateen PLUS curriculum with in- and out-of-school youth in Jinja and Kamuli Districts. Additionally, FC+/Uganda trained nine school nurses and 10 community health workers on adolescent/youth friendly SRH services to be able to respond to any increase in demand for SRH services by youth participating in the Aflateen PLUS clubs (see Table UGA2). In the third quarter, peer educators trained by the FC+ project mobilized other youth in the communities to participate in a sports gala, as well as sharing messages about SRH issues using music, dance and drama skits. An expert client (and a youth herself) discussed her experience of living with fistula that resulted from her pregnancy as a teenager. Over 1,070 people were reached with information during the exercise, and 555 received health services (241 receiving FP methods and 314 received HIV counselling and testing). In addition to sessions with in and out of school groups, meetings were held to garner buy in and to work with teachers that were trained, during which head teachers made personal commitments towards ensuring time and physical space to for teachers carrying out anticipated adolescent sexual and reproductive health activities. Data is being collected to monitor the activity levels of the club members including their participation in the clubs, whether they were able to pass on information to their communities and whether those reached were able to seek out Mapping of youth group in Buwagi Village in health care, if needed. Data is also being collected Kamuli. Credit: A. Kyajumbuka to monitor whether they were able to start business enterprises and whether they were saving money informally or in a bank. A plan to document the process and outputs of the Aflateen Plus pilot has been developed by the FC+ global M&E/research team, in collaboration with FC+ Uganda staff, and data collection in line with this process documentation will begin in FY 17/18.
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Table UGA2: Community Volunteer/Educator Training, Participants by Topic, By Quarter, FY 16/17
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total FY 16/17 2016 2017 2017 2017 Aflateen volunteers 0 29 0 0 29 Taxi drivers association 0 0 30 0 30 Total 0 29 30 0 59
During the first quarter of FY 16/17, FC+/Uganda held two meetings with Jinja Hospital and the Uganda Village Project (UVP) to initiate a partnership that would support introduction of community level outreach for Jinja Regional Referral Hospital. A MoU between the two has been executed and FC+ and UVP successfully supported Jinja Regional Referral Hospital during the concentrated repair effort in July 2017. UVP contributed to the feeding, transport refund and is doing patient follow up. As described under Objective 1, to strengthen the mental health component of fistula care, FC+/Uganda worked with Strong Minds to provide screening and treatment to post-repair clients in Jinja, Kitovu and Hoima during fiscal year. Strong Minds had previously provided training to midwives in June 2016 in depression diagnosis procedure and skills for psychotherapeutic intervention. In the second quarter of FY 16/17, Strong Minds provided supportive mentoring and coaching to trained staff at Kitovu. An additional two-day training was provided for one of the midwives that had been trained previously (see Table UGA4) to provide a more in depth introduction to interpersonal psychotherapy as a means of building her capacity to provide support to women identified with severe depression through the screening. In order to ensure that different groups of women and men, boys and girls, have equal opportunities to achieve their full health potential, FC+ global staff conducted a gender training for 17 FC+ staff in Uganda and DRC. The training was held during the second quarter in Kampala and was conducted jointly by the FC+ Gender Focal Point and a Ministry of Gender resource person. This training addressed concepts such as what gender is, the difference between gender and sex, gender norms, gender roles, etc. After the training, participants suggested ideas for gender indicators.
Obj. 3: Reduced transportation, communications, and financial barriers to accessing preventive care, detection, treatment, and reintegration support FC+/Uganda continued working with the Population Council during FY 16/17 to implement an intervention package designed using the results of the formative research on barriers to fistula treatment conducted during FY 15/16 (see Section II, Objective 3). This intervention seeks to address the barriers identified through formative research, specifically low awareness, high stigma, high cost of accessing services, and clinician “gate-keeping” at lower levels of the health system. The intervention is being piloted in Kalungu District and offers treatment services to women at Kitovu Mission Hospital in the neighboring Masaka District. The intervention utilizes multiple communication channels for fistula messaging, screening, and referral, a consistent screening algorithm for fistula screening, and a transportation voucher to enable positively screened women to travel to and from the fistula treatment facility for free. At primary health care facilities, health workers identify potential fistula clients for referral and facilitate free transportation to appropriate treatment facilities. At the community level, village health team (VHT) volunteers circulate targeted messages about fistula symptoms and available treatment services; and a free hotline service, widely advertised by VHTs, radio messages, and through flyers, screens women for fistula via their mobile device using interactive voice response (IVR) technology. Positively screened
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women identified through primary health care workers, VHTs and the hotline all receive a voucher for free transportation to and from the fistula treatment facility as well as case-management support from either the VHT or primary health care worker. In partnership with FC+, VOTO Mobile (now Viamo) developed the IVR hotline, whereby VHTs and women from the community call to find out about fistula – its causes, prevention, and services available. This hotline was pretested with 27 women in three health facilities in Kalungu district. Those participating in the testing showed great enthusiasm for the innovation and its potential to help reach out to women in more remote areas, who have not been able to access services. During the third quarter of FY 16/17, FC+ supported training for 272 VHTs (see Table UGA4) to equip them with the knowledge, skills, and tools to promote healthy practices before, during, and after childbirth, to monitor maternal healthcare seeking and pregnancy outcomes in their communities, as well as identify women with fistula and link them to health care facilities for screening and treatment. The trainers were selected from the district to facilitate training in the local language. Training was also organized for primary health care (PHC) workers from 21 health facilities in Kalungu district. The training strengthened the capacity of clinicians, including doctors, midwives, clinical nurses, to provide quality essential and emergency obstetric care that prevents maternal and neonatal mortality and morbidities, such as neonatal hypoxia, infertility, drop-foot, and both obstetric and iatrogenic fistula. The training was also aimed at orienting the PHC workers on the IVR hotline. These PHC staff were followed Health workers in Kalungu district receiving FP supplies, a need up in the fourth quarter and identified through the barriers’ study. Credit: FC+/Uganda. oriented to the transportation voucher system and provided voucher books, IEC materials/job aids and FP products with the aim of raising awareness within their catchment areas. These job aids (see Appendices S and T) include information on how to recognize risk factors for obstetric fistula, ANC protocol, and conservative management of obstetric fistula and how to recognize obstructed labor. The FP commodities were provided through support from the Uganda Health Marketing Group (UHMG) after realizing that there was a stock out of methods. In June 2017, the project worked with the Lukaya Taxi Operators and Drivers Association (LUTOCS) to sensitive 30 drivers on the importance and availability of maternal health care. These drivers were identified to participate in the barrier study’s transportation voucher system, transporting women from Kalungu district to Kitovu Mission Hospital for treatment. The drivers were oriented to the transportation voucher and were eager to get started. During the fourth quarter, 12 clients utilized the free transportation voucher mechanism to go to Kitovu Mission Hospital for treatment.
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The Population Council will be evaluating the effectiveness of this intervention in reducing barriers to fistula treatment, starting with a baseline study. IRB approval for this baseline data collection and overall evaluation study was secured from Makerere School of Medicine. In the first quarter of FY 16/17, nine research assistants were identified and trained by the Population Council and FC+. The training covered the study background, methodology, tools and ethical procedures. Pretesting took place at three health facilities: Nabweru HC III, Wakiso HC IV, and Epicenter HC III. Focus group discussion guides were pretested in Lukwanga Village in Wakiso district. Data collection began after the training with assessments of health facilities, interviews with health facility clinicians and post-repaired clients and conducting focus group discussions. Data collection continued in the second quarter until the target number of post-repair client participants for baseline data collection was achieved. In order to be able to collect data routinely about implementation of the treatment barrier intervention, an exit interview tool was developed by the team for use at concentrated repair efforts. A focal person who not directly involved in fistula care was identified from the records department to support the exit interviews. She received orientation on the study and the tool and passed the online course on protecting human subjects. Routine data collection commenced in the fourth quarter of the fiscal year.
Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment FC+/Uganda currently supports four treatment sites in Uganda: Kitovu and Kamuli Mission Hospitals and Hoima and Jinja Regional Referral Hospitals are supported for fistula prevention and treatment services. A fifth fistula treatment site (Kisiizi Mission Hospital) is being considered for a sub award in FY 17/18. A concentrated repair effort took place at Mbarara Regional Referral Hospital during this fiscal year jointly supported by FC+ and UNFPA. FC+ supported surgical staff and the transport of clients. In order to improve maternal and child health outcomes in South-Western Uganda, the USAID Regional Health Integration to Enhance Services South West (RHITES/SW) and FC+ are collaborating to provide a comprehensive package including fistula prevention, detection, treatment, and reintegration that can lead to improvement in maternal and child health outcomes. In May 2016, health facility assessments were conducted at five RHITES/SW supported hospitals to identify areas for possible FC+ support. Areas identified include capacity building of health workers, equipment, fistula treatment and reintegration, infection prevention, FP, community sensitization and data management. Kisiizi Hospital was selected to be a fistula treatment site for support in the South Western region. In the fourth quarter of the fiscal year, a team from FC+ and RHITES-SW visited the hospital to guide the development of a scope of work and workplan and give insight into other prerequisite requirements for the facility to be supported. During the fourth quarter, an assessment was conducted at four district hospitals in the Bunyoro sub region: Kagadi, Kiboga, Masindi, and Kirandongo, to identify a possible outreach site for Hoima Regional Referral Hospital in order to extend fistula services to the most in need populations. The assessment focused on four areas: treatment, clinical prevention, community engagement, and data management. Kagadi and Kiryandongo Hospitals were identified as the most optimal choices for future investment. FC+ also conducted a health facility assessment in the first quarter at Jinja Regional Referral Hospital, focusing on the MCH department. Based on findings, infection prevention and FP integration trainings were conducted during the first quarter and partograph training took place during the second quarter (see Table UGA4). FC+ also supported meetings of Infection Prevention and Control (IPC) Committees in Kasese and Hoima districts during which national guidelines were reviewed and action plans made to
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address gaps. In all the meetings immediate actions were made such as agreeing on assessment tools, purchasing supplies for cleaning, and reproducing IPC Protocols and making them accessible to providers. Waste management and partograph monitoring were conducted at supported sites with support from the IPC committees, the results of which are summarized in Section II of this report, as well as in FC+’s annual waste management monitoring report. Political unrest in Kasese during the first quarter led to temporary suspension of FC+ supported activities in that area, including a planned concentrated POP repair effort at Kagando Hospital planned for December 2016. Subaward delays also negatively affected the ability to support fistula repairs during the first half of FY 16/17. During FY 16/17, FC+ supported seven concentrated repair efforts: one at Kitovu Hospital, two at Jinja Regional Referral Hospital, three at Kitovu Mission Hospital and one at Mbarara Hospital. During the Jinja effort, two expert surgeons and an anesthesiologist were able to provide mentoring and coaching to two local surgeons. Kitovu Hospital carried out two additional concentrated repair efforts with other support, and Hoima Regional Referral Hospital carried out two concentrated efforts with support from UNFPA and World Vision. FC+ and UNFPA jointly supported the concentrated repair effort Mbarara Regional Referral Hospital. Mbarara is not an officially supported site in the project, FC+ contributed support to four fistula surgeons as well as transportation of patients. Some women may be diagnosed with fistula in one quarter and repaired in the next. Because FC+ does not track individual women through our monitoring and evaluation data collection, we are unable to present a definitive percentage of women requiring repair who receive it. See Figure UGA1 for data on women seeking and requiring fistula treatment and the number of repairs supported, by country. We are also unable to report the number of women repaired because some women may have multiple repairs over the life of project, or repairs at multiple sites. However, within a given quarter, the number of repairs generally reflects the number of women.
Figure UGA1: Number of Women Seeking and Eligible for Fistula Treatment, and Number of Surgical Repairs, by Site, FY 16/17
300
250
200 Seeking
150 Eligible Repairs 100
50
0 Hoima RRH Jinja RRH Kamuli Kitovu Mbarara
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During FY 16/17, 783 women with severe incontinence symptoms arrived seeking fistula care at FC+ supported sites, of which 366 were diagnosed with fistula (47%, compared with 46% in FY 15/16). Of those diagnosed, 314 were medically eligible for services. A total of 305 surgical fistula repairs were supported during FY 16/17 at four supported sites in Uganda, as well as Mbarara Regional Referral Hospital (97% of those eligible, compared with 96% in FY 15/16). The number of surgeries provided is a decrease of 13% from the previous fiscal year due to delays in the implementation of the subaward with Kamuli. The majority of these surgical repairs (86%) were carried out during concentrated repair efforts with a smaller number of routine repairs also provided at all four supported sites (see Table UGA3 for detail by quarter). Dr. Moses Baraine of Kamuli Mission Hospital providing FC+/Uganda has made a concerted effort with supported sites to fistula repair surgery. Credit: institute and support routine repair services; this fiscal year those J. Nabaggala efforts have begun to bear fruit, with this small but meaningful number of routine repairs. During the third and fourth quarters, despite the absence of a subaward for a period of time, Kamuli Mission Hospital continued to repair fistula patients on a routine basis, which is a great accomplishment towards achieving sustainability of repairs at a private, not for profit facility.
Table UGA3: USAID-Supported Surgical Fistula Repairs, by Site, By Quarter, FY 16/17
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 16/17 2016 2017 2017 2017 Hoima Regional Referral Hospital 2 0 42 0 44 Jinja Regional Referral Hospital 5 47 4 33 89 Kamuli Mission Hospital 8 2 8 4 22 Kitovu Mission Hospital 34 0 56 32 122 Mbarara Regional Referral Hospital 0 0 28 0 28 Total 49 49 138 69 305
During FY 16/17, 98% of all fistula repair surgeries were reported as closed and continent at time of discharge. This very high rate of optimal outcome (closed and continent) has remained consistent over the course of the project and may reflect excellent surgical skills and/or patient selection practices, and is also subject to on-going audit. Outcomes for discharged patients are presented in Figure UGA2. Reported complications were low (<1%). Appendix FF presents data visualizations that illustrate the available country-level data on whether repairs were conducted through routine or concentrated efforts, how many previous repairs clients had undergone, whether repairs were categorized as simple or complex, and discharge outcomes. Etiology data was available for 100% of diagnosed cases. The majority of diagnosed fistula cases were reported to have resulted from obstructed or prolonged labor (86.6%, compared to 95% in FY 15/16), iatrogenic (11.5%, compared to 5.5% in FY 15/16), and other (congenital or cancer, 1%, compared to 0% in FY 15/16). In addition to the surgical repairs reported, 16 women received non-surgical catheter treatment for fistula at Kitovu Hospital during the fiscal year. 50% of these cases were closed and continent at discharge, 19% closed and incontinent and 31% not closed.
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Figure UGA2. Outcome Rates for Surgical Repairs, by Site, FY 16/17
100% Not closed
Closed with remaining incontinence Closed and continent
Benchmark closed and continent (75%)
0% Hoima Jinja Kamuli Kitovu Mbarara FC+/Uganda is providing support to Jinja, Kagando, Kamuli, and Kitovu for the provision of routine POP services. In FY 16/17, a total of 70 surgical POP treatments procedures were carried out at Hoima, Jinja, Kamuli, Kitovu and Mbarara. FC+/Uganda supported two fistula surgeons to attend the UroDak conference in Dakar, Senegal in July 2017. The surgeons attended a workshop on urodynamics and its use in care for fistula and other urological conditions as well as the launch of the West African VVF working group to end fistula. There were two surgeons trained in surgical fistula repair in FY 16/17: one surgeon from Hoima Regional Referral Hospital and one surgeon from Jinja Regional Referral Hospital participated in continuing training, see Table UGA4.
Table UGA4: Surgical Fistula Repair Training, By Quarter, FY 16/17
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 16/17 2016 2017 2017 2017 1st Cont 1st Cont 1st Cont 1st Cont 1st Cont Fistula surgical repair 0 0 0 0 0 1 0 1 0 2 Total 0 0 0 0 0 1 0 1 0 2
As part of fistula treatment and prevention efforts, FC+/Uganda provided training to 606 health care clinicians during FY 16/17, Table UGA5 provides totals for non-surgical trainings of health system personnel by training topic. During the first quarter, FC+/Uganda organized a FP integration training for ten health service clinicians at Jinja Regional Referral Hospital, covering long-acting methods, identifying and recruiting clients needing FP methods and a practicum to strengthen skills. The training was preceded by one-day planning activities at the hospital with the management team and plans were made to begin providing FP services/referrals from all the wards. An additional 40 health care clinicians were trained at Jinja RRH, Lukolo HC III, and Buraru HC III in the second quarter aimed at strengthening the integration of family planning into other services in the maternity ward, pediatric ward and ART clinic to reduce missed opportunities for FP uptake. A training curriculum was also pretested during the training and will be available on line for use. EngenderHealth provided technical and financial support to MOH/RH Division to revise the Basic Skills Curriculum into a Comprehensive FP Clinical Skills Curriculum that addresses all methods including
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LARCs. EngenderHealth spearheaded inclusion of a client centered counselling approach (REDI) in the Comprehensive FP Clinical Skills curriculum. This approach is new to many trainers and providers because Uganda has previously been using the GATHER approach. During the first quarter, 14 health workers from Kalungu HCIII were oriented on client-centered counseling (REDI) counseling and medical eligibility criteria updates and post-partum FP. FC+ staff also focused on how to conduct internal referrals and health education on FP within the facility. FC+/Uganda supported a training for 17 members of the National Training Team in the third quarter. Mentoring and coaching of 20 staff on partograph use and EmONC was carried out during the second quarter at Jinja Regional Referral Hospital, ten staff in Hoima during the third quarter, and 11 staff from Bwera Hospital and 13 staff from Kagando in the fourth quarter. Midwifery tutors and clinical instructors were included in the training to enhance standardization of clinical practices in delivery care between pre- service and service. Follow up of partograph champions trained in Kasese in September 2016 took place and facility assessments indicated 73% of facilities had a significant increase in deliveries monitored using a partograph. As described under Objective 2, FC+/Uganda is working to improve youth access to services. In the second quarter, a five-day training was conducted in Jinja for ten health workers working with health facilities near the locations of youth groups and schools that were mapped out as part of the Aflateen Plus activities. The training was facilitated by FC+/Uganda and a MoH resource person and focused on ensuring that health care workers promote the concept of youth friendly services and act as liaison officers for the SRH youth activities that will be taking place in their communities.
Table UGA5: Non-Surgical Health System Personnel Training, Participants by Topic, By Quarter, FY 16/17
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 16/17 2016 2017 2017 2017 FP integration and infection prevention 10 40 0 0 50 Depression screening and counseling 0 2 0 0 2 FP counseling 14 0 17 0 31 Youth friendly services 0 10 0 0 10 Partograph and EmONC 0 20 10 24 54 FP methods and integration 0 0 35 110 145 Community outreach and advocacy 0 0 272 0 272 Fistula identification and referral 0 0 42 0 42 Total 24 72 376 134 606
During the second quarter, the FC+/Uganda Senior Clinical Associate attended a structured operative obstetrics (SOO) training conducted by Makerere University College of Health Sciences Skills laboratory located at Mulago National Referral Hospital, as part of an American College of Obstetricians and Gynecologists (ACOG) training pilot program. This training focused on strengthening surgical skills of residents at the University and intern doctors in performing cesarean sections. As described in Objective 5, as well as Section II: Objective 1, FC+ global and Uganda staff are supporting ACOG to monitor the implementation of the SOO training pilot. As described in Section II, Objective 4.3, during the first half of FY 16/17, FC+ global staff engaged a midwifery consultant, Pandora Hardtman, to conduct a rapid clinical assessment in DRC, Nigeria, and Uganda of non-surgical catheter treatment for fistula as well as other prevention activities including family planning and maternity care. During a visit to Uganda, she assessed six health facilities and
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interacted with facility staff to better understand strengths and limitation. She also met with Nurse and Midwifery Associations/Unions in order to explore the possibility of expansion of midwifery practice to include non-surgical treatment of fistula. In Uganda, an important focus was upgrading of infection prevention and control practices at supported sites. In addition, the team has reinforced respectful care and privacy in onsite FP mentoring and coaching strategies. Through on site mentoring, health care workers have been educated to use available materials to create safe spaces for one-to-one counseling. The project responded to the stated needs of the project-supported health care workers/facilities by addressing a frequently heard request for postpartum IUD training. At every site assessed in Uganda, there was a provider request (often multiple persons) to be trained on how to provide PPIUD. Providing PPIUD at a site previously incapable of offering this service would make a new method readily available and in theory, a wider method mix would improve overall quality of service. Facilities supported by FC+ and the Gates-funded ExpandFP project supported PPIUD training at Masaka: MRRH, Kiyumba HC IV, Kyanamukaaka HC IV and in Hoima: HRRH, AZUR, Kigorobya HC IV and Kikuube. Moving forward as ExpandFP closes out by December 2018, FC+ will continue to monitor integration of PPIUD at these facilities. FC+ has supported training in FP Integration; FP/IPC Integration; Comprehensive FP Clinical Skills, and NXT Implanon OJT in six supported sites. With the MoH, FC+ has conducted three day updates of HWs on Implanon NXT, SC DMPA (Sayana Press), MEC Wheel, and REDI Counselling Framework for 78 service providers from 66 health facilities within the supported districts. At the request of USAID to build capacity for FP integration, three comprehensive FP clinical skills trainings were completed at Masaka/Kasese/Kalungu, Jinja/Kamuli, and Hoima (see Table UGA5). FC+/Uganda supported FP counseling and service provision at 17 sites in Uganda during FY 16/17. 27,384 counseling sessions took place at supported sites and 36,585 CYP were provided, see Table UGA6 for detail, by site. Method mix contributing to this CYP in Uganda was primarily implants (48%), IUD (21%), tubal ligation (12%), and Depo Provera (8%).
Table UGA6: Family Planning Counseling Sessions and CYP, by Site, By Quarter, FY 16/17
Site Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP23 Azur HCIV 346 771 543 862 356 534 424 414 1,669 2580 Buraru HCIII 370 205 221 137 186 74 294 136 1,071 551 Buseruka 216 79 230 117 232 187 194 164 872 547 HCIII Bwera GH 643 770 634 932 715 1,201 968 2,434 2,960 5,337 Hoima RH 522 501 651 620 885 536 899 821 2,957 2,478 Jinja RRH 700 1,157 642 835 682 1,003 707 973 2,731 3,967 Kagando 444 1,326 782 1,468 544 1,128 819 1,787 2,589 5,710 Kalungu HCIII 98 51 109 94 288 691 623 1,820 1,118 2,656 Kamuli 450 675 352 528 320 480 239 359 1,361 2,042 Karambi HCIII 188 123 327 239 142 246 197 132 854 740 Kigorobya 310 373 913 463 440 541 525 437 2,188 1,813 HCIV Kikuube HCIV 145 140 208 397 178 222 237 200 768 959 Kitovu NA NA 32 0 20 0 16 0 68 0 Kiyumba 185 283 170 326 165 261 149 261 669 1,130 HCIV
23 Due to rounding, totals may differ slightly from the sum of individual quarters.
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Site Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP23 Kyanamukaka 279 515 352 443 221 345 173 265 1,025 1,568 HCIV Masaka RRH NA NA 964 1,009 876 816 907 941 2,747 2,765 Rwesande 231 233 539 587 612 597 355 325 1,737 1,742 HCIV Total 5,127 7,358 7,669 9,053 6,862 8,862 7,726 11,468 27,384 36,585
Supported sites reported an overall cesarean section rate of 26.9% during FY 16/17, based on 39,480 reported deliveries. Information on number of deliveries, by site, is represented in Figure UGA3 and cesarean section rates, by site, are presented in Figure UGA4. Sites reported that 2.1% of all labors were prolonged/obstructed, 18.3% of which received catheterization for fistula prevention, which is a significant increase over the previous fiscal year (3.6%).
Figure UGA3. Number of Obstetric Deliveries, by Site, FY 16/17 (n=39,480)
Azur HCIV 1584 Buraru HCIII 184 Buseruka HCIII 94 Bwera GH 3908 Hoima RH 8022 Jinja 5383 Kagando 2435 Kalungu HCIII 381 Kamuli 2073 Karambi HCIII 927 Kigorobya HCIV 1006 Kikuube HCIV 1047 Kitovu 1749 Kiyumba HCIV 357 Kyanamukaka HCIV 356 Masaka RRH 9167 Rwesande HCIV 807
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Figure UGA4. Cesarean Section Rates, by Site, FY 16/17
0% Vaginal delivery C-Section 100% Azur HCIV 10.6 Buraru HCIII Buseruka HCIII Bwera GH 33.2 Hoima RH 27.1 Jinja 32.5 Kagando 49.7 Kalungu HCIII Kamuli 36.4 Karambi HCIII Kigorobya HCIV Kikuube HCIV Kitovu 48.1 Kiyumba HCIV 3.4 Kyanamukaka HCIV 2.8 Masaka RRH 23.6 Rwesande HCIV 31.7 Uganda total 26.9
Obj. 5: Strengthened evidence base for approaches to improve fistula care and scaled up application of standard monitoring and evaluation (M&E) indicators for prevention and treatment FC+/Uganda has instituted regularly scheduled internal clinical data for decision-making (CDDM) meetings, together with the ExpandFP team. This provides an opportunity for the team to reflect on the project performance, achievements, challenges, and areas needing programmatic attention. Two staff from the Uganda country office also participated in the global EngenderHealth DDM meeting (see Section II, Obj 5). As part of efforts to increase the quality of fistula and family planning data available to stakeholders, data quality assessment (DQA) exercises were conducted in five supported districts of Jinja, Kamuli, Hoima, Kalungu, and Masaka. Assessments included four treatment and ten prevention only sites. The exercises were done with support from biostatisticians at the Ministry of Health and medical records personnel. Data from the hospital registers was compared with the reported data in HMIS reports and DHIS2. Discrepancies in reported data and incomplete data were identified. Immediate feedback on data quality issues was shared with various departments and facility administration immediate action towards improving data quality. As a follow-up action point, it was agreed that the comprehensive results of the DQA would be shared during planned CDDM meetings at supported health facilities. Findings from the exercise particularly revealed data quality gaps related to family planning data. The DQA findings were shared with facility medical records team and those in charge of the FP units at each facility. During the fourth quarter, CDDM activities took place in five supported districts with the objectives of strengthening the evidence base for approaches to improve fistula care and scaling up application of standard monitoring and evaluation indicators for prevention and treatment. FC+/Uganda facilitated data review meetings in each district to promote HMIS data use for informed decision-making aimed at
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improved performance. During the exercise, the CDDM committees in the districts were rejuvenated, facility performance for FY15/16 and FY16/17 were presented and reviewed departmental in-charges built their capacity to analyze and present departmental data. Research on women with incurable fistula (WIF), with FC+ partner TERREWODE, continues to move forward. Data entry has been completed and the data was cleaned during the first quarter of the fiscal year. Most data have been received by FC+, however the team is waiting for a final set of post- intervention data to be able to evaluate intervention effectiveness. Qualitative data analysis has been ongoing and quantitative data analysis will be completed in the first quarter of FY 17/18. It is expected that results will be available in the second quarter of FY 17/18. During FY 16/17, FC+/Uganda developed an individual patient database and began to enter data for supported sites in Jinja, Kamuli, Kitovu and Hoima. This project level database will enable more meaningful analysis of the fistula data captured through the MoH fistula registration forms at supported sites. It is also intended to capture client follow-up information and mortality data. The database is designed as stand-alone, hosted locally at the fistula treatment sites on computers that were procured with support from FC+. Those in charge of records at each facility have been trained on how to use the database. This database will be further harmonized with the client tracker database in the FC+ SST. As described under Objective 1, FC+ continues to collaborate with ACOG on their SOO project. During the second quarter of FY 16/17, FC+/Uganda M&E staff carried out orientations of two project assistants from Mbarara and Makerere University to review the SOO pilot M&E plan, ensure that the project assistants have clear understanding of indicator definitions and data sources, establish project progress and emphasize comprehensive documentation of all FC+/ACOG project activities. FC+/Uganda encouraged the ACOG team to hold internal meetings to review SOO project progress, and to identify and address any programmatic challenges to contribute to better project delivery. The team was also encouraged to follow up and ensure documentation of trained personnel to assess their contribution to all Cesarean Sections conducted at various sites as a means of evaluating project performance. FC+ continues to providing technical assistance for monitoring & evaluation (M&E) in the Phase II pilot. FC+ global contributions to this collaboration are described in Section II. As part of the Aflateen Plus youth strategy activities described in Objectives 2 and 4, a team of four people (two M&E staff, one MoH resource person and the district HMIS resource person) conducted baseline assessments for health facility outcomes at the 12 facilities located near the mapped youth groups in Kamuli and Jinja Districts. FC+/Uganda is also participating the FC+ HMIS process documentation study. Of the four fistula indicators to be included in the Ugandan HMIS, only two were adopted when HMIS tools were revised in 2014. The HMIS process documentation study will find out from key stakeholders in the compilation of data at district, hospital, regional referral hospitals, and at the national level how the fistula indicators are being adopted into the routine data collection system. The exercise includes key informant interviews and document review.
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West Africa/Niger (WAN) EngenderHealth began support for fistula services in the West Africa Region with implementation of a BMGF grant in Niger in 2005. USAID-supported fistula services in the region began in 2007 through the AWARE and FC projects and continue through FC+ in Niger in three treatment and prevention sites and six prevention-only sites as of September 30, 2017. FC+ efforts in Niger are part of a larger West Africa regional focus with the goal of continuing to build Niger as a regional hub for learning and a model for FP/fistula integration activities, education, research, advocacy, and best practices. Emphasis is on collaboration with regional partners to strengthen fistula prevention, treatment, and reintegration efforts throughout West Africa. Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors FC+/WAN continued support in FY 16/17 to the development of regional policy on genital fistula prevention and treatment through partnerships with the West African Health Organization (WAHO), West Africa College of Surgeons (WACS), and UNFPA. In collaboration with the West Africa (WA)/USAID mission and FC+/Global, a communication plan was setup with the WAHO regional office and UNFPA to have a common understanding of the regional strategy harmonization process. As part of the sustainability and legacy “outputs towards impacts”, FC+ has catalyzed launch of a West and Central African Regional Working Group initiative to engage the UN Secretary General’s 2016 call to action to “end fistula within a generation”. The launch of the West and Central African Group for Eradication of Obstetric Fistula (WCAGEOF) was held in Dakar July 14-15, 2017 immediately following the Urology in Dakar (UroDak) meeting. A follow-on meeting is planned for October 2017 with WAHO and UNFPA’s West and Central Africa Region, local and NYC offices participating. Please see Section II, Objective 1 for more detail. The FC+/WAN Country Director attended the Pan-African Conference on Obstetric Fistula in Ouagadougou, Burkina Faso in September 2017, during which he presented on “Community Engagement with Obstetric Fistula: The Experience of Niger.” The conference was organized by the RAMA Foundation around the theme: “Communities mobilized to end fistula,” with participants from African countries including Niger, Benin, Mali, and Burkina Faso. FC+/WAN has been working to strengthen the national Strategy for the Elimination of Female Genital Fistula in Niger (2016-2020). During the first quarter, a workshop was conducted to develop and strengthen the monitoring and evaluation plan for the strategy. The workshop took place in Bangoula, Niger and was attended by 15 fistula and evaluation and research specialists. The workshop covered definitions of concise, realistic and measurable indicators; improvement of data collection, analysis, reporting and dissemination of results system; strengthening of the data quality assurance and supervision mechanism; and establishment of a database to measure the effects and impacts of the implementation of the strategy. In April 2017, a subaward was finalized with le Réseau pour l’Eradication des Fistule (REF). REF’s primary roles are carrying out community awareness activities via radio, coordinating client Nigerien First Lady Dr. Lala Malika Issoufou care including pre-, intra-, and post-operative care greets fistula clients during IDEOF celebrations. Credit: FC+/WAN. and reimbursement of repair and client
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transportation costs.REF, as a national coordinating structure, also has the responsibility to manage routine data collected from clinical partners. FC+/WAN has supported applications from all three supported fistula treatment sites to Direct Relief’s call for donations of fistula repair modules. All applications have been approved but distribution to some sites is delayed due to supply issues. FC+/WAN organized celebrations for the International Day to End Obstetric Fistula in May 2017 at the CNRFO in Niamey. Government Officials, clinical staff, clients and artists commemorated the event, led by the Nigerien First Lady, Dr Malika Issoufou, a dedicated supported of the fight against obstetric fistula in Niger.
Objective 2: Enhanced community understanding and practices to prevent fistula, improve access to fistula treatment, reduce stigma, and support reintegration of women and girls with fistula In order to learn from and share expertise with other organizations working on fistula in Niger, an MoU was signed in October between FC+/WAN and Health and Development International (HDI), an NGO that has collaborated with Government of Niger on community-based prevention of obstetric fistula since 2008. The objective of the MoU is to share best practices as well as lessons learned, and HDI will conduct one day meetings in each integrated health center (CSI) during the first quarter of FY 17/18 provide refresher training to volunteers as well as gather and analyze the community level data that has been collected. FC+/WAN has invested, in years two through four of the project, in the training and support of community volunteers in the health districts of Bouza and Illela in Tahoua region, and Guidan Roumdji, Madarounfa, Dakoro and Mayahi in Maradi region. Dakoro and Mayahi were added in the second quarter of this fiscal year with 180 community volunteers trained in each location at the at Centres de Santé Integre (CSIs) in the third quarter (see Table WAN2). This community awareness approach aims to help reduce fistula incidence and improve referrals for services. Each health center catchment area (five health centers by Health district) has selected target villages (six villages by health center, total of 60 villages for the two health districts), and trained community volunteers from within these communities. Home visits and outreach activities cover topics including: understanding obstetric fistula, key concepts of safe motherhood including facility based delivery, the role of the community in promoting safe motherhood and use of health care, and the importance of male involvement in maternal health. During FY 16/17, a total of 7,704 in-person community Coffee break during community activity in outreach events were carried out, reaching over 200,000 Madarounfa. Credit: FC+/WAN. participants, information is presented, by type, in Table WAN1. These outreach activities include home visits as well as small and large community groups. Through the project’s subaward with REF, messages about fistula prevention and early marriage have been aired on regional radio stations in local languages during the fourth quarter. Estimates of listening audiences were not available at the time of reporting.
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Table WAN1: Community Outreach/Education/Advocacy Events, By Quarter, FY 16/17
Type of Event Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Existing 2,332 67,414 2,196 55,710 2,139 51,146 1,037 27,008 7,704 201,278 community activity Total 2,332 67,414 2,196 55,710 2,139 51,146 1,037 27,008 7,704 201,278
During FY 16/17, a total of 360 community volunteers and educators were trained to work with their communities to provide information on fistula prevention and treatment; see Table WAN2. This concludes the training of community volunteers within the project, with activities in the next fiscal year focused on routine support for outreach activities and efforts to evaluate the outputs, outcomes, and impacts of the project’s community activities. Monthly follow up takes place with the CSIs to monitor implemented activities by community volunteers in their respective villages and identify and address challenges. Quarterly review meetings with the volunteers, regional and health district representatives, and project staff are held during which activities are reviewed, challenges and best practices are explored, and data is validated.
Table WAN2: Community Volunteer/Educator Training, Participants by Topic, FY 16/17
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total 2016 2017 2017 2017 FY 16/17
Community volunteers in Dakoro and Mayahi 0 0 360 0 360 Total 0 0 0 0 10
Obj. 3: Reduced transportation, communications, and financial barriers to accessing preventive care, detection, treatment, and reintegration support Under the REF subaward, FC+/WAN reimburses the roundtrip transportation costs and client repair fees for all clients in need referred to CNRFO, CSME Tahoua, and CSME Maradi for fistula repair.
Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment To improve clinical monitoring within FC+/WAN and at supported sites, a clinical consultant was engaged in the second quarter. The FC+/DRC Clinical Associate provided an orientation on the integration of the project’s SST and medical waste management tools. The SST was subsequently introduced at CNRFO, where the director plans to harmonize the checklist data with that of the national medical record keeping system. In FY 16/17, 190 women with severe incontinence symptoms sought fistula care services at FC+ supported sites, of which 145 were diagnosed with fistula (76%, compared to 82% in FY 15/16). FC+ supported 202 surgical fistula repairs during this period. This represents a 35% decrease in the number of supported repairs, when compared to FY 15/16, primarily due to challenges in providing repairs at CNRFO due to health issues of the responsible surgeon. The number of repairs is higher than the reported number seeking care and diagnosed with fistula as the CNRFO is working to clear a backlog of fistula cases that were identified previously but unable to get repair. Strikes at supported facilities during the first quarter negatively impacted the ability to conduct
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repairs. Additionally, in the fourth quarter, the fistula surgeon at CNRFO was ill and unable to provide services so clients were referred to a concentrated repair effort organized by UNFPA during this period. Some women may be diagnosed with fistula in one quarter and repaired in the next. Because FC+ does not track individual women through our data collection, we are unable to present a definitive percentage of women requiring repair who receive it. We are also unable to report the number of women repaired because women may have multiple repairs over the life of project, or repairs at multiple sites. However, within a given quarter, the number of repairs generally reflects the number of women. Figure WAN1 presents data on women seeking and eligible for fistula treatment, and the number of fistula surgeries supported, by site.
Figure WAN1: Number of Women Seeking and Requiring Fistula Treatment, and Number of Surgical Repairs, by Site, FY 16/17
100
80
60 Seeking Eligible 40 Repairs 20
0 CSME Tahoua CSME Maradi CNRFO
These 202 fistula repair surgeries were conducted at three FC+ supported hospitals: CSME Maradi, CSME Tahoua and Centre National de Référence de la Fistule Obstétricale (CNRFO), see Table WAN3 for detail by quarter. In addition to the surgical repairs supported, 12 women woman received non-surgical catheter treatment (catheterization) for fistula during the fiscal year at CSME Tahoua (10) and CNRFO (2), the outcome of which was 100% closed and continent. 12% (n=25) of all surgeries performed during this fiscal year occurred during concentrated efforts. Etiology data was available for 138 diagnosed fistula cases (95%). The vast majority of fistulas diagnosed were the result of prolonged/obstructed labor (88%), followed by iatrogenic causes (4%). 2% of diagnosed fistula were the result of traumatic causes and the remaining “other” etiology was cancer- related.
Table WAN3: USAID-Supported Surgical Fistula Repairs, by Site, By Quarter, FY 16/17
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 16/17 2016 2017 2017 2017 CSME Tahoua 9 9 28 3 49 CSME Maradi 7 8 0 4 19 CNRFO 31 50 46 7 134 Total 47 67 74 14 202
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Discharged fistula repairs during FY 16/17 were nearly evenly split between simple and not simple cases (44% and 48% respectively with data unavailable for 8% of cases). 84% of all fistula surgery cases discharged in this time period were closed at discharge; with 55% closed and continent and 29% closed and incontinent. 16% were not closed at discharge. Outcomes for discharged patients are presented, by site, in Figure WAN2. Appendix FF presents data visualizations that illustrate the available country-level data on whether repairs were conducted through routine or concentrated efforts, how many previous repairs clients had undergone, whether repairs were categorized as simple or complex, and discharge outcomes. No complications were reported during the fiscal year.
Figure WAN2. Outcome Rates for Surgical Repairs, by Site, FY16/17
100% 90% 80% Not closed 70% 60% Closed with remaining 50% incontinence 40% Closed and continent 30% 20% Benchmark closed and 10% continent (75%) 0% CSME Tahoua CSME Maradi CNRFO
No surgeons were trained during FY 16/17. As part of fistula prevention efforts, FC+ West Africa/Niger provided training to 99 health system personnel during FY 16/17. These included training of 13 health care staff at CSME Tahoua in EmONC and partograph use, 65 health staff trained in infection prevention from CSME Maradi and Tahoua, 15 health agents trained in COPE for maternity care and six doctors trained on fistula diagnostics and referral. Table WAN4 Maternity care training in Maradi. Credit: provides detail on non-surgical trainings for FC+/WAN. health system personnel.
Table WAN4: Non-Surgical Health System Personnel Training, Participants by Topic, By Quarter, FY 16/17
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2016 2017 2017 2017 FY 16/17 EmONC and partograph 13 0 0 0 13 Infection prevention 0 0 0 65 65 Maternity care 0 0 0 15 15
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Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2016 2017 2017 2017 FY 16/17 Fistula diagnosis and referral 0 0 0 6 6 Total 13 0 0 86 99
FC+ supports FP counseling and service provision at two supported sites in Niger. During FY 16/17, 1,199 counseling sessions took place at supported sites and 4,063 CYP were provided; see Table WAN5 for detail, by site. Method mix in Niger during this period was primarily comprised of implants (45%), tubal ligation (31%), and IUCD (13%).
Table WAN5: Family Planning Counseling Sessions and CYP, by Site, By Quarter, FY 16/17
Site Oct-Dec 2016 Jan-Mar 2017 Apr–Jun 2017 Jul-Sep 2017 Total FY 16/17 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP24 CSME 192 296 162 253 62 280 202 274 618 1,103 Tahoua CSME 150 703 93 710 158 764 180 783 581 2,960 Maradi Total 342 998 255 963 220 1,044 382 1,057 1,199 4,063
FC+ supported sites reported an overall cesarean section rate of 55% during the fiscal year out of 4,631 deliveries. 15% of deliveries were reported to be obstructed/prolonged, with 95% of those cases receiving catheterization as a prevention intervention. Information on number of deliveries, by site, is represented in Figure WAN3 and cesarean section rates, by site, are presented in Figure WAN4.
Figure WAN3. Number of Obstetric Figure WAN4. CesareanSection Rates, by Site, FY Deliveries, by Site, FY 16/17 (n=4,631) 16/17 0% 100%
CSME Tahoua 1,582 CSME Tahoua 48.4
CSME Maradi 59.1 CSME Maradi 3,049 Niger Total 55
Vaginal delivery C-Section
Obj. 5: Strengthened evidence base for approaches to improve fistula care and scaled up application of standard monitoring and evaluation (M&E) indicators for prevention and treatment In 2014, with support from EH technical advisors, Tahoua and Maradi Districts in Niger were selected as pilot sites for community engagement activities, focusing on the training of community volunteers to promote utilization of preventive and maternal health services and family planning, and the implementation of Site Walk-Throughs/Visites Guidees (SWT) to strengthen community-facility linkages. SWTs were implemented in August 2016 in four locations within the Integrated Health Centers Gradoume Tajae, Chadakori and Dan Issa. The SWT participants (community leaders, community
24 Due to rounding, totals may differ slightly from the sum of individual quarters.
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volunteers, and facility staff) jointly analyzed problems and proposed locally relevant solutions to improve uptake of maternal, preventive and family planning services. FC+ is in the process of developing a program learning report on the SWTs in Niger to inform programmatic decisions regarding refresher trainings for the community volunteers, identify additional support needs related to implementation of the action plans, and to inform FC+ future implementation of the SWT approach. Data collection, analysis, and documentation will take place during FY 17/18. The FC+/WAN M&E officer meets quarterly with management and health care staff at supported sites, as well as with community volunteers in supported districts to review, validate and analyze routine project data. FC+ West Africa/Niger staff and project partners attended the ISOFS conference in Abuja, Nigeria in October 2016.
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APPENDIX A: FC+ PLANNED AND ACTUAL SUPPORTED SITES, FY 16/17
Country/Site Sector Planned FY 16/17 Actual FY T: Treatment & Prevention 16/17 P: Prevention-only Bangladesh: 10 sites 7T, 3P 7T, 3P Ad-Din Dhaka Private T T Ad-Din Khulna Private T T Kumudini Hospital Private T T LAMB Hospital FBO T T Bangabandhu Sheikh Mujib Medical Government T T University Dr. Muttalib Community Hospital Private T T Mamm's Institute of Fistula & Women's Private T T Health Hope Foundation Hospital, Cox's Bazar Private P P Jhalokathi District Hospital Government P P Hobiganj District Hospital Government P P DRC: 5 sites 5T 5T St. Joseph’s Hospital/Satellite Maternity FBO T T Kinshasa Panzi Hospital FBO T T HEAL Africa FBO T T Imageri Des Grands-Lacs Private T T Maternité Sans Risque Kindu Private T T WA/Niger: 9 sites 3T, 6P 3T, 6P Centre de Santé Mère / Enfant (CSME) Government T T Maradi Centre National de Référence des Government T T Fistules Obstétricales (CNRFO),Niamey Centre de Santé Mère /Enfant (CSME) Government T T Tahoua Madarounfa District Hospital, Maradi Government P P Guidan Roumji District Hospital, Maradi Government P P Bouza District Hospital Government P P Illela District Hospital Government P P Mayahi District Hospital Government P P Dakoro District Hospital Government P P Nigeria: 7441 sites 15T, 770P 14T, 730P General Hospital, Ningi Government T T General Hospital, Ogoja Government T T National Fistula Center, Abakaliki Government T T Laure VVF Center Government T T National Fistula Center, Babbar Ruga, Government T T Katsina Gesse VVF Center, Birnin Kebbi Government T T Sobi Specialist Hospital, Ilorin Government T T Maryam Abatcha Women and Children’s Government T T Hospital, Sokoto Faridat General Hospital, Gusau Government T T University College Hospital, Ibadan Government T T Jahun VVF Center, Jigawa State Government T T (ended in July 2017) Adeoyo General Hospital, Ibadan Government T T
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Country/Site Sector Planned FY 16/17 Actual FY T: Treatment & Prevention 16/17 P: Prevention-only Gambo Sawaba General Hospital, Kofar Government T T Gayan, Zaria, Kaduna State Wesley Guilds Hospital, Osun State Government - T Prevention only sites Government 270P 230P25 Former TSHIP sites Government 500P 500P Pope John Paul II Family Life Centre FBO T - VVF and Maternal Injuries Hospital, Uyo, Akwa Ibom State Evangel VVF Centre, Jos, Plateau State Government T - Uganda: 17 sites 5T, 13P 4T, 13P Kitovu Mission Hospital FBO T T Kamuli Mission Hospital FBO T T Hoima Regional Referral Hospital Government T T Masaka Regional Referral Hospital Government P P Jinja Regional Referral Hospital Government T T Bwera General Hospital Government P P Kiyumba HC IV Government P P Kyanamukaka HC IV Government P P Kalungu HC III Government P P Karambi HC III Government P P Kigorobya HC IV Government P P Azur HC IV FBO P P Buseruka HCIII Government P P Kikuube HCIV Government P P Buraru HCIII Government P P Rwesande HCIV FBO P P Kagando Hospital FBO T - Lukolo HCIII Government P P USAID Supported, Non Fistula Care Plus 17T, 45P IntraHealth (Mali) 4T, 44P JHPIEGO (Guinea) 4T Jinnah Post Graduate Medical Center 1T (Pakistan) Pathfinder (Ethiopia) NA PROSANI (DRC) 1T Vodafone/CCBRT (Tanzania) 7T, 1P TOTAL USAID supported FC+ = 36T, 790P = 824 sites 33T, 752P= 5 Countries 785 sites TOTAL USAID supported, bilateral (non FC+) = 17T, 45P = 5 Countries 62T sites TOTAL USAID supported, All Projects = 50T, 797P 10 countries = 847 sites T: Treatment and Prevention, P: Prevention-only
25 Support to sites in Jigawa State ended during the fiscal year.
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APPENDIX B: FC+ PARTNERSHIPS, BY COUNTRY26
Country Partners Nature of Partnership Bangladesh Government of Bangladesh
Ministry of Health and Family Endorsement and dissemination of National Welfare (MOHFW) Fistula Strategy and National Action Plan, participation in National Task Force on Obstetric Fistula, Vouchers Directorate General of Health National Task Force and Action Plan Services (DGHS) development, Government Medical College and District Hospitals, partograph use, C- Section, strengthening HMIS, surgical training Directorate General of Family FP integration, community outreach Planning (DGFP) Ministry of Social Welfare (MOSW) Reintegration, WDI and Ministry of Women and Children’s Affairs (MCWC)
Quality Improvement Secretariat Establishment of Technical Committee on (QIS), Health Economics Unit, Fistula Ministry of Health Obstetrical and Gynecological Society of Partograph use, C-Section Bangladesh (OGSB) UNFPA National Task Force, strengthening HMIS, policy, Increase treatment capacity, Surgical training Bangladesh Rural Advancement Committee Community outreach and fistula/POP (brac) and NGO Health Delivery Service screening Program (NHSDP) Direct Relief Drugs and disposable surgical supplies Hope Foundation Hospital Strengthening HMIS and FP services Save The Children (MaMoni) BMMMS implementation ICDDRB BMMMS implementation DRC Ministry of Health Fistula prevention and treatment Coordination SMNEA (Health of the Mother, Newborn, Child and Adolescent) Task Force Dissemination of SMNEA standards and guidelines Access to Primary Health Care Project Fistula prevention and treatment, (ASSP) (DFID) Community outreach PROSANI Plus (Projet de Santé Intégré), Fistula prevention and treatment Integrated Health Project (IHP), USAID UNFPA Fistula prevention and treatment Direct Relief Drugs and disposable surgical supplies WA/Niger Ministry of Health Coordination, strategy Centre National de Référence des Fistules Training, treatment and research Obstétricales (CRNFO) Agir pour la Planification Familiale (AgirPF) Fistula prevention, coordination UNFPA Fistula prevention and treatment REF Fistula treatment, community outreach Health and Development International (HDI) Community outreach Community committees Community outreach Nigeria Federal Ministry of Health (Fistula Desk Coordination Office) UNFPA Coordination with ongoing activities
26 This list reflects partnerships in FY 16/17. This list does not include supported sites or other fistula projects supported by USAID bilateral funds.
Annual Report • October 2016 – September 2017 Fistula Care Plus 115
Country Partners Nature of Partnership Médecins Sans Frontières (MSF) Referral and coordination Media, CBOs, Women’s Groups, Ward Community outreach Development Committees, Religious Leaders, Transport Unions. Traditional Rulers Population Council Barriers to treatment National Obstetric Fistula Working Group National fistula prevalence study DOVENET Community outreach Radio Nigeria (FRCN) Public-private partnerships Uni-Gold Medical supplies Direct Relief Drugs and disposable surgical supplies Sun of Hope Foundation Public-private partnerships Islamic Medical Association of Nigeria Public-private partnerships Uganda Ministry of Health(MoH) including all FC+ Fistula prevention and treatment, National supported public facilities technical working groups PPFP integration into National Program Review of National RH Policy guidelines Ministry of Education, Sports, Science and Capacity building for midwifery tutors Technology Possible collaborative partnership to support adolescent/youth reproductive health programming for the youth in school. District Health Offices (Masaka, Kasese, Fistula prevention and treatment interventions Kalungu, Hoima, Jinja, Kamuli) Quality improvement in facilities TERREWODE Social reintegration, particularly with WDI/Persistent fistula-related disorder AMREF Fistula prevention and treatment Population Council Barriers to treatment Direct Relief Drugs and medical supplies UNFPA Fistula prevention and treatment UHMG FP Commodities Village Health Teams, Religious groups, Community outreach and sensitizations Women’s groups Parliament of Uganda –Uganda Women Advocacy on maternal health issues including Parliamentary Association, National fistula (Members of parliament), District and local Community outreaches and mobilization for Political leaders, the media prevention and treatment JPHIEGO Postpartum FP programming including capacity building of health workers, Ministry of Gender, Labour and Social Integrating gender into advocacy for obstetric Development prevention PNFP Hospitals (Kitovu and Kamuli Mission Fistula prevention and treatment Hospitals) Radio stations Public-private partnerships Promoting fistula awareness Private Education Development Network Implementation of youth-focused (PEDN) interventions Uganda Village Project Fistula prevention and treatment Strong Minds Management of stress and depression in fistula clients Clinton Health Access Initiative (CHAI) RH logistics and supply management NXT cascade in Kasese, Kalungu, Jinja and Kamuli USAID Regional Health Integration to Fistula treatment, follow up and reintegration Enhance Services in South Western Uganda (RHITES/SW) FHI360 Communications initiative
Annual Report • October 2016 – September 2017 Fistula Care Plus 116
APPENDIX C: NUMBER OF USAID-SUPPORTED FISTULA REPAIR SURGERIES BY COUNTRY, SITE AND YEAR
Pre- Fistula Care Fistula Care Plus TOTALS FC
FY05- FY 07/08 FY 08/09 FY 09/10 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY14/15 FY 15/16 FY16/17 Pre-FC FC FC+ Grand Total FY07
Country/Site Total Total Total Total Total Total Total Total Total Total Total FY05-FY07 FY08-FY13 FY14-FY18 FY05-FY18
Africa Mercy
Benin NS NS 110 21 20 NS NS NS NS NS NS NS 151 NS 151
Ghana 63 NS NS NS NS NS NS NS NS NS NS 63 NS NS 63
Liberia NS 59 NS NS NS NS NS NS NS NS NS NS 59 NS 59
Togo NS NS NS 97 NS NS NS NS NS NS NS NS 97 NS 97
Total 63 59 110 118 20 NS NS NS NS NS NS 63 307 NS 370
Bangladesh
Ad-Din Dhaka NS NS NS 34 50 53 42 15 22 19 10 NS 179 66 245
Ad-Din Jessore NS NS NS 2 1 25 48 0 21 0 NS NS 76 21 97
Ad-Din Khulna NS NS NS NS NS NS NS NS 37 6 4 NS NS 47 47
BSMMU NS NS NS NS NS NS NS NS 18 30 23 NS NS 71 71
Dr.Muttalib NS NS NS NS NS NS NS NS 30 26 22 NS NS 78 78
Kumudini Hospital 53 57 49 37 25 33 48 26 85 28 33 53 249 172 474
LAMB Hospital 116 52 81 70 74 73 129 67 87 89 83 116 479 326 921
Mamm's Institute NS NS NS NS NS NS NS NS 70 75 68 NS NS 213 213
Memorial Christian 63 13 1 NS NS NS NS NS NS NS NS 63 14 NS 77 Hospital (MCH)
Annual Report • October 2016 – September 2017 Fistula Care Plus 117
Pre- Fistula Care Fistula Care Plus TOTALS FC
FY05- FY 07/08 FY 08/09 FY 09/10 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY14/15 FY 15/16 FY16/17 Pre-FC FC FC+ Grand Total FY07
Country/Site Total Total Total Total Total Total Total Total Total Total Total FY05-FY07 FY08-FY13 FY14-FY18 FY05-FY18
Total 232 122 131 143 150 184 267 108 370 273 243 232 997 994 2223
DRC
HEAL Africa 268 200 214 210 163 288 264 NS 44 183 128 268 1339 355 1,962 Hospital
Imagerie Des NS NS NS NS 38 78 89 NS 40 127 75 NS 205 242 447 Grands-Lacs
Maternité Esengo de NS NS NS NS NS NS 27 NS NS NS NS NS 27 NS 27 Kisenso
Maternite Sans NS NS NS NS 35 151 82 NS 68 226 46 NS 268 340 608 Risque Kindu
Mutombo NS NS NS NS 104 80 119 NS NS NS NS NS 303 NS 303
Panzi Hospital 371 134 268 262 180 500 567 NS 105 223 157 371 1911 485 2,767
St. Joseph NS NS NS NS 45 124 208 NS 128 241 141 NS 377 510 887
DRC Bilaterals
Project AXxes NS 361 442 514 NS NS NS NS NS NS NS NS 1317 NS 1,317
PS Kabongo NS NS NS NS NS 50 NS NS NS NS NS NS 50 NS 50
PS Katako Kombe NS NS NS NS NS 87 NS NS NS NS NS NS 87 NS 87
PS HGR Katana NS NS NS NS NS NS 50 NS NS NS NS NS 50 NS 50
PS Kaziba NS NS NS NS NS 152 135 60 158 240 207 NS 287 665 952
PS Lodja NS NS NS NS NS 82 NS NS NS NS NS NS 82 NS 82
PS Luiza NS NS NS NS NS 28 NS NS NS NS NS NS 28 NS 28
Annual Report • October 2016 – September 2017 Fistula Care Plus 118
Pre- Fistula Care Fistula Care Plus TOTALS FC
FY05- FY 07/08 FY 08/09 FY 09/10 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY14/15 FY 15/16 FY16/17 Pre-FC FC FC+ Grand Total FY07
Country/Site Total Total Total Total Total Total Total Total Total Total Total FY05-FY07 FY08-FY13 FY14-FY18 FY05-FY18
PS Malemba Kulu NS NS NS NS NS 60 NS NS NS NS NS NS 60 NS 60
PS Tshikaji NS NS NS NS NS 49 NS NS NS NS NS NS 49 NS 49
PS Uvira NS NS NS NS NS 13 37 NS NS NS NS NS 50 NS 50
Total 639 695 924 986 565 1742 1,578 60 543 1240 754 639 6490 2597 9726
Ethiopia
Arba Minch Hospital NS NS NS 27 NS NS NS NS NS NS NS NS 27 NA 27
Bahir Dar Fistula 564 596 297 383 307 392 NS NS NS NS NS 564 1975 NA 2,539 Center
Mekelle Center NS NA 166 177 195 198 NS NS NS NS NS NS 736 NA 736
Total 564 596 463 587 502 590 NS NS NS NS NS 564 2,738 NA 3,302
Guinea
Ignace Deen 193 63 49 20 NS NS 0 NS NA NA NA 193 132 NS 325
Jean Paul II NS 36 88 126 144 185 90 NS NA NA NA NS 669 NS 669
Kissidougou 298 130 148 132 193 189 173 NS 15 49 122 298 965 186 1449
Labe NS NS 31 114 122 123 132 NS 5 37 69 NS 522 111 633
Boke NS NS NS NS NS NS NS NS NS 6 24 NS NS 30 30
Kindia NS NS NS NS NS NS NS NS NS NS 27 NS NS 27 27
Mercy Ships training NS NS NS NS NS NS 25 NS NS NS NS NS 25 NS 25 repairs
Total 491 229 316 392 459 497 420 NS 20 92 242 491 2,313 354 3158
Annual Report • October 2016 – September 2017 Fistula Care Plus 119
Pre- Fistula Care Fistula Care Plus TOTALS FC
FY05- FY 07/08 FY 08/09 FY 09/10 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY14/15 FY 15/16 FY16/17 Pre-FC FC FC+ Grand Total FY07
Country/Site Total Total Total Total Total Total Total Total Total Total Total FY05-FY07 FY08-FY13 FY14-FY18 FY05-FY18
Mali
Gao Regional NS NS 46 40 91 53 NS NS NS NS NS NS 230 NA 230 Hospital
Kayes Hospital NS NS NS NS NS NS 70 NS NS NS NS NS 70 NA 70
Mopti NS NS NS NS NS NS 20 NS NS NS NS NS 20 NA 20
Sikasso NS NS NS NS NS NS 140 NS NS NS NS NS 140 NA 140
Mali Bilateral
IntraHealth NS NS NS NS NS NS NS 47 381 244 181 NS NS 853 853
Total NS NS 46 40 91 53 230 47 381 244 181 NS 460 853 1313
Niger
Dosso Regional NS 17 15 22 41 21 13 NS NS NS NS NS 129 NS 129 Hospital
Lamorde Hospital 27 70 84 129 173 110 92 NS NS NS NS 27 658 NS 685 (Niamey)
Maradi Regional Hospital (now CSME NS 123 59 63 67 45 65 0 55 9 19 NS 422 83 505 Maradi)
National Maternity NS NS NS NS NS NS 80 NS NS NS NS NS 80 NS 80 Center, Niamey
National Obstetric Fistula Center, NS NS NS NS NS NS NS 105 144 245 134 NS NS 628 628 Niamey (now CNRFO)
Annual Report • October 2016 – September 2017 Fistula Care Plus 120
Pre- Fistula Care Fistula Care Plus TOTALS FC
FY05- FY 07/08 FY 08/09 FY 09/10 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY14/15 FY 15/16 FY16/17 Pre-FC FC FC+ Grand Total FY07
Country/Site Total Total Total Total Total Total Total Total Total Total Total FY05-FY07 FY08-FY13 FY14-FY18 FY05-FY18
Tahoua (now CSME NS NS NS 6 52 33 44 22 28 54 49 NS 135 153 288 Tahoua)
Tera District Hospital NS 3 NS NS NS NS NS NS NS NS NS NS 3 NS 3
Zinder NS NS NS NS NS NS 79 NS NS NS NS NS 79 NS 79
Total 27 213 158 220 333 209 373 127 227 308 202 27 1,506 864 2,397
Nigeria
National Obstetric Fistula Centre NS NS 189 330 268 277 316 71 283 134 197 NS 1,380 685 2065 Abakaliki
Babbar Ruga 356 536 331 359 330 416 359 160 309 244 357 356 2,331 1070 3757 Hospital (Katsina)
Faridat Yakubu General Hospital 180 150 187 115 114 116 126 21 49 95 77 180 808 242 1230 (Zamfara)
General Hospital Ogoja (Cross River NS NS NS NS NS 114 50 14 17 17 63 NS 164 111 275 State)
UTH Ibadan NS NS NS NS NS NS 37 18 6 6 20 NS 37 50 87
Gesse VVF Center 102 122 151 207 216 215 152 55 140 171 153 102 1,063 519 1684
(Kebbi)
Laure Fistula Center at Murtala Mohammed 339 473 337 265 379 288 313 122 386 270 293 339 2,055 1071 3465 Specialist Hospital (Kano)
Annual Report • October 2016 – September 2017 Fistula Care Plus 121
Pre- Fistula Care Fistula Care Plus TOTALS FC
FY05- FY 07/08 FY 08/09 FY 09/10 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY14/15 FY 15/16 FY16/17 Pre-FC FC FC+ Grand Total FY07
Country/Site Total Total Total Total Total Total Total Total Total Total Total FY05-FY07 FY08-FY13 FY14-FY18 FY05-FY18
Maryam Abacha Women’s and 104 156 152 200 137 138 132 93 183 103 186 104 915 565 1584 Children’s Hospital (Sokoto)
Ningi General NS NS NS NS 63 78 74 NS 131 164 186 NS 215 481 696 Hospital (Bauchi)
Other NS NS NS 136 NS 43 NS NS NS 20 23 NS 179 43 222
Adeoyo GH NS NS NS NS NS NS NS NS 18 18 56 NS NS 92 92
Jahun VVF Center NS NS NS NS NS NS NS NS 79 204 179 NS NS 462 462
Sobi General Hospital (Kwara NS NS NS NS NS 35 21 NS 44 13 50 NS 56 107 163 State)
Family Life VVF NS NS NS NS NS NS NS NS NS 52 NA NS NS 52 52 Center
Hajiya Gambo NS NS NS NS NS NS NS NS NS 72 113 NS NS 185 185 Sawaba VVF Center
Evangel VVF Centre, Jos, Plateau NS NS NS NS NS NS NS NS NS NS NA 0 0 0 0 State
Total 1,081 1,437 1,347 1,612 1,507 1,720 1,580 554 1645 1583 1953 1,081 9,203 5,735 16,019
Rwanda
CHUK 100 36 51 126 109 4 9 NS NS NS NS 100 335 NS 435
Kanombe Hospital NS NS 14 48 38 55 35 NS NS NS NS NS 190 NS 190
Kibogora NS NS NS NS NS 21 0 NS NS NS NS NS 21 NS 21
Annual Report • October 2016 – September 2017 Fistula Care Plus 122
Pre- Fistula Care Fistula Care Plus TOTALS FC
FY05- FY 07/08 FY 08/09 FY 09/10 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY14/15 FY 15/16 FY16/17 Pre-FC FC FC+ Grand Total FY07
Country/Site Total Total Total Total Total Total Total Total Total Total Total FY05-FY07 FY08-FY13 FY14-FY18 FY05-FY18
Ruhengeri 192 47 102 85 131 34 4 NS NS NS NS 192 403 NS 595
Total 292 83 167 259 278 114 48 NS NS NS NS 292 949 NS 1,241
Sierra Leone
Aberdeen 272 363 253 166 211 244 115 NS NS NS NS 272 1,352 NS 1,624
Total 272 363 253 166 211 244 115 NS NS NS NS 272 1,352 NS 1,624
Tanzania
Vodafone/CCBRT NS NS NS NS NS NS NS 705 828 1048 676 NS NS 3,466 3,466
Total NS NS NS NS NS NS NS 705 828 1048 885 NS NS 3,466 3,466
Uganda
Hoima RRH NS NS NS NS NS 184 102 63 49 40 44 NS 286 196 482
Kagando / Bwera 253 118 85 206 363 143 237 NS NS NS NS 253 1152 NS 1405
Kitovu Mission 604 192 183 243 248 190 183 NS 200 204 122 604 1239 526 2369 Hospital / Masaka
Kamuli Mission NS NS NS NS NS NS NS NS NS 63 22 NS NS 85 85 Hospital
Mbarara Hospital NS NS NS NS NS NS NS NS NS NS 28 NS NS 28 28
Jinja RRH NS NS NS NS NS NS NS NS NS 43 89 NS NS 132 132
Total 857 310 268 449 611 517 522 63 249 350 305 857 2,677 967 4,501
Overall Total 4,518 4,107 4,183 4,972 4,727 5,870 5,133 1,664 4,263 5,138 4,765 4,518 28,992 15,830 49,340
EngenderHealth 3,954 3,150 3,278 3,871 4,225 4,759 4,911 852 2,896 3,606 3,492 3,954 24,194 10,846 38,994 Supported
Annual Report • October 2016 – September 2017 Fistula Care Plus 123
Pre- Fistula Care Fistula Care Plus TOTALS FC
FY05- FY 07/08 FY 08/09 FY 09/10 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY14/15 FY 15/16 FY16/17 Pre-FC FC FC+ Grand Total FY07
Country/Site Total Total Total Total Total Total Total Total Total Total Total FY05-FY07 FY08-FY13 FY14-FY18 FY05-FY18
EH Non-USAID NS NS NS NS NS NS NS NS 20 NS NS NS NS 20 20 Supported
EH USAID 3,954 3,150 3,278 3,871 4,225 4,759 4,911 852 2,876 3,606 3,492 3,954 24,194 10,826 38,974 Supported
USAID Bilaterals 564 957 905 1,101 502 1,111 222 812 1,367 1624 1515 564 4,798 5,318 10,680
Total USAID- 4,518 4,107 4,183 4,972 4,727 5,870 5,133 1,664 4,243 5,138 4,765 4,518 28,992 15,810 49,320 Supported
NA= Data not available NS= Site not supported
Annual Report • October 2016 – September 2017 Fistula Care Plus 124
APPENDIX D: FC/ FC+ PEER REVIEWED PUBLICATIONS27
I. Published
Anastasi E, Romanzi L, Ahmed S, Knuttson AT, Ojengbede O, Grant K; Campaign to End Fistula. Ending fistula within a generation: making the dream a reality. Lancet Glob Health. 2017 Aug;5(8):e747-e748. [COMMENTARY – NO ABSTRACT]
Arrowsmith SD, Ruminjo J, Landry EG. Current practices in treatment of female genital fistula: a cross sectional study. BMC Pregnancy and Childbirth. 2010 Nov 10;10:73.
BACKGROUND: Background: Maternal outcomes in most countries of the developed world are good. However, in many developing/resource-poor countries, maternal outcomes are bleaker: Every year, more than 500,000 women die in childbirth, mostly in resource-poor countries. Those who survive often suffer from severe and long-term morbidities. One of the most devastating injuries is obstetric fistula, occurring most often in south Asia and sub- Saharan Africa. Fistula treatment and care are available in many countries across Africa and Asia, but there is a lack of reliable data around clinical factors associated with the success of fistula repair surgery. Most published research has been retrospective. While these studies have provided useful information about the care and treatment of fistula, they are limited by the design. This study was designed to identify practices in care that could lead to the design of prospective and randomized controlled trials. METHODS: Self-administered questionnaires were completed by 40 surgeons known to provide fistula treatment services in Africa and Asia at private and government hospitals. The questionnaire was divided into three parts to address the following issues: prophylactic use of antibiotics before, during, and after fistula surgery; urethral catheter management; and management practices for patients with urinary incontinence following fistula repair. RESULTS: The results provide a glimpse into current practices in fistula treatment and care across a wide swath of geographic, economic, and organizational considerations. There is consensus in treatment in some areas (routine use of prophylactic antibiotics, limited bed rest until the catheter is removed, nonsurgical treatment for postsurgical incontinence), while there are wide variations in practice in other areas (duration of catheter use, surgical treatments for postsurgical incontinence). These findings are based on a small sample and do not allow for recommending changes in clinical care, but they point to issues for possible clinical trial research that would contribute to more efficient and effective fistula care. CONCLUSIONS: The findings from the survey allowed us to consider clinical practices most influential in the cost, efficacy, and safety of fistula treatment. These considerations led us to formulate recommendations for eight randomized controlled trials on the following subjects: 1) Efficacy/safety of short-term catheterization; 2) efficacy of surgical and nonsurgical therapies for urinary incontinence; 3) technical measures during fistula repair to reduce the incidence of post-surgery incontinence; 4) identification of predictive factors for "incurable fistula"; 5) usefulness of urodynamic studies in the management of urinary incontinence; 6) incidence and significance of multi-drug resistant bacteria in the fistula population; 7) primary management of small, new fistulas by catheter drainage; and 8) antibiotic prophylaxis in fistula repair.
Arrowsmith SD, Barone MA, Ruminjo J. Outcomes in obstetric fistula care: a literature review. Current Opinion in Obstetrics and Gynecology. 2013 Oct;25(5):399-403.
PURPOSE OF REVIEW: To highlight the lack of consistency in the terminology and indicators related to obstetric fistula care and to put forward a call for consensus. RECENT FINDINGS: Recent studies show at least some degree of statistical correlation between outcome and the following clinical factors: degree of scarring/fibrosis, fistula location, fistula size, damage to the urethra, presence of circumferential fistula, bladder capacity, and prior attempt at fistula repair. SUMMARY: Consensus about basic definitions of clinical success does not yet exist. Opinions vary widely about the prognostic parameters for success or failure. Commonly agreed upon definitions and outcome measures will help ensure that site reviews are accurate and conducted fairly. To properly compare technical innovations with existing methods, agreement must be reached on definitions of success. Standardized
27 This summarizes all peer-reviewed publications throughout the life of both the FC and FC+ projects, as of March 2017.
Annual Report • October 2016 – September 2017 Fistula Care Plus 125
indicators for mortality and morbidity associated with fistula repair will improve the evidence base and contribute to quality of care.
Barone M, Widmer M, Arrowsmith S, Ruminjo J, Seuc A, Landry E, Hamidou Barry T, Danladi D, Djangnikpo L, Gbawuru-Mansaray T, Harou I, Lewis A, Muleta M, Nembunzu D, Olupot R, Sunday-Adeoye I, Wakasiaka WK, Landoulsi S, Delamou A, Were L, Frajzyngier V, Beattie K, A Gülmezoglu AM. 7 day bladder catheterization is not inferior to 14 day catheterization following repair of female genital fistula: a randomized controlled, non- inferiority trial. Lancet. 2015 Jul 4;386(9988):56-62.
BACKGROUND: Duration of bladder catheterization after female genital fistula repair varies widely. We aimed to establish whether 7 day bladder catheterization was not inferior to 14 days in terms of incidence of fistula repair breakdown among women with simple fistula. METHODS: We conducted a non-inferiority randomized controlled trial at eight hospitals in eight African countries. Women with a simple fistula that was closed after surgery and that remained closed until postoperative day 7 were eligible. Participants were randomized in a 1:1 ratio to 7 or 14-day bladder catheterization. The primary outcome was fistula repair breakdown, based on dye test results, any time after day 7 after catheter removal up to 3 months post-surgery. Secondary outcomes included: repair breakdowns at 7 days after catheter removal or thereafter, urinary retention on day 1, 3 and/or 7 after catheter removal; infections and febrile episodes potentially related to the treatment; catheter blockage; prolonged hospitalization; and residual incontinence at 3 months. The trial is registered with ClinicalTrials.gov, Identifier NCT01428830. FINDINGS: 524 participants were randomized and followed up between January 2012 and August 2013; 261 in the 7-day group and 263 in the 14-day group. The analysis population included 250 participants in the 7-day group and 251 in the 14-day group. There was no significant difference in the rate of fistula repair breakdown between the groups (risk difference 0.8%; 95% CI -2.8-4.5). There were no significant differences in the secondary outcomes between the groups. INTERPRETATION: 7 day bladder catheterization after repair of simple fistula was non-inferior to 14 day catheterization. It is safe and effective for managing women following repair of simple fistula without a significant increased risk of repair breakdown, urinary retention or residual incontinence through 3 months after surgery.
Barone MA, Frajzyngier V, Arrowsmith S, Ruminjo J, Seuc A, Landry E, Beattie K, Barry TH, Lewis A, Muleta M, Nembunzu D, Olupot R, Sunday-Adeoye I, Wakasiaka WK, Widmer M, Gülmezoglu AM. Non-inferiority of short-term urethral catheterization following fistula repair surgery: study protocol for a randomized controlled trial. BMC Womens Health. 2012 Mar 20;12:5.
BACKGROUND: A vaginal fistula is a devastating condition, affecting an estimated 2 million girls and women across Africa and Asia. There are numerous challenges associated with providing fistula repair services in developing countries, including limited availability of operating rooms, equipment, surgeons with specialized skills, and funding from local or international donors to support surgeries and subsequent post-operative care. Finding ways of providing services in a more efficient and cost-effective manner, without compromising surgical outcomes and the overall health of the patient, is paramount. Shortening the duration of urethral catheterization following fistula repair surgery would increase treatment capacity, lower costs of services, and potentially lower risk of healthcare- associated infections among fistula patients. There is a lack of empirical evidence supporting any particular length of time for urethral catheterization following fistula repair surgery. This study will examine whether short-term (7 day) urethral catheterization is not worse by more than a minimal relevant difference to longer-term (14 day) urethral catheterization in terms of incidence of fistula repair breakdown among women with simple fistula presenting at study sites for fistula repair service. METHODS/DESIGN: This study is a facility-based, multicenter, non-inferiority randomized controlled trial (RCT) comparing the new proposed short-term (7 day) urethral catheterization to longer-term (14 day) urethral catheterization in terms of predicting fistula repair breakdown. The primary outcome is fistula repair breakdown up to three months following fistula repair surgery as assessed by a urinary dye test. Secondary outcomes will include repair breakdown one week following catheter removal, intermittent catheterization due to urinary retention and the occurrence of septic or febrile episodes, prolonged hospitalization for medical reasons, catheter blockage, and self-reported residual incontinence. This trial will be conducted among 512 women with simple fistula presenting at 8 study sites for fistula repair surgery over the
Annual Report • October 2016 – September 2017 Fistula Care Plus 126
course of 24 months at each site. DISCUSSION: If no major safety issues are identified, the data from this trial may facilitate adoption of short-term urethral catheterization following repair of simple fistula in sub-Saharan Africa and Asia. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01428830.
Barone MA, Frajzyngier V, Ruminjo J, Asiimwe F, Barry TH, Bello A, Danladi D, Ganda SO, Idris S, Inoussa M, Lynch M, Mussell F, Podder DC. Determinants of postoperative outcomes of female genital fistula repair surgery. Obstetrics and Gynecology. 2012 Sep;120(3):524-31.
OBJECTIVE: To determine predictors of fistula repair outcomes 3 months postsurgery. METHODS: We conducted a multicountry prospective cohort study between 2007 and 2010. Outcomes, measured 3 months postsurgery, included fistula closure and residual incontinence in women with a closed fistula. Potential predictors included patient and fistula characteristics and context of repair. Multivariable generalized estimating equation models were used to generate adjusted risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS: Women who returned for follow-up 3-month postsurgery were included in predictors of closure analyses (n=1,274). Small bladder size (adjusted RR 1.57, 95% CI 1.39-1.79), prior repair (adjusted RR 1.40, 95% CI 1.11-1.76), severe vaginal scarring (adjusted RR 1.56, 95% CI 1.20-2.04), partial urethral involvement (adjusted RR 1.36, 95% CI 1.11-1.66), and complete urethral destruction or circumferential defect (adjusted RR 1.72, 95% CI 1.33-2.23) predicted failed fistula closure. Women with a closed fistula at 3-month follow-up were included in predictors of residual incontinence analyses (n=1,041). Prior repair (adjusted RR 1.37, 95% CI 1.13-1.65), severe vaginal scarring (adjusted RR 1.35, 95% CI 1.10-1.67), partial urethral involvement (adjusted RR 1.78, 95% CI 1.27-2.48), and complete urethral destruction or circumferential defect (adjusted RR 2.06, 95% CI 1.51-2.81) were significantly associated with residual incontinence. CONCLUSION: The prognosis for genital fistula closure is related to preoperative bladder size, previous repair, vaginal scarring, and urethral involvement.
Bedwell C, Levin K, Pett C, Lavender DT. A realist review of the partograph: when and how does it work for labour monitoring? BMC Pregnancy and Childbirth. 2017 Jan 13;17(1):31.
BACKGROUND: The partograph (or partogram) is recommended by the World Health Organisation (WHO), for monitoring labour wellbeing and progress. Concerns about limitations in the way the partograph is used in the clinical context and the potential impact on its effectiveness have led to this realist systematic review of partograph use. METHODS: This review aimed to answer two key questions, 1) What is it about the partograph that works (or does not work); for whom does it work; and in what circumstances? 2) What are the essential inputs required for the partograph to work? A comprehensive search strategy encompassed key databases; including papers of varying methodologies. Papers were selected for inclusion if the focus of the paper was the partograph and related to context, mechanism or outcome. Ninety five papers were included for data synthesis. Two authors completed data extraction and synthesis. RESULTS: The evidence synthesis relates the evidence to identified theories of health worker acceptability, health system support, effective referral systems, human resources and health worker competence, highlighting barriers and facilitators. CONCLUSIONS: This first comprehensive realist synthesis of the partograph, provides the international community of maternity clinicians with a picture of potential issues and solutions related to successful labour recording and management, which is also translatable to other monitoring approaches.
Brazier E, Fiorentino R, Barry MS, Diallo M. The value of building health promotion capacities within communities: Evidence from a maternal health intervention in Guinea. Health Policy and Planning. 2015 Sep;30(7):885-94.
BACKGROUND: This paper presents results from a community-level intervention that promoted use of maternal health services as a means of preventing obstetric fistula. Implemented in the Republic of Guinea, the intervention aimed to build the capacity of community-level committees to heighten awareness about maternal health risks and to promote use of professional maternal health services. METHODS: Data were collected through a population-based survey. A total of 2,335 women of reproductive age were interviewed, including 878 with a live
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birth or stillbirth since the launch of the intervention. An index of community capacity was created to explore the effect of living in a community with strong community-level resources and support for maternal health. Other composite variables were created to measure the content of women’s antenatal counseling and their individual exposure to maternal health promotion activities at the community level. Multivariate logistic regression was used to explore the effect of community capacity and individual exposure variables on women’s use of antenatal care (> 4 visits), institutional delivery, and care for complications. RESULTS: Women living in communities with a high score on the community capacity index were more than twice as likely as women in communities with low score to attend at least four ANC visits, to deliver in a health facility, and to seek care for perceived complications. CONCLUSIONS: Building the capacity of community-level cadres to promote maternity care-seeking by women in their villages is an important complement to facility-level interventions to increase the availability, quality, and utilization of essential health services.
Brazier E, Fiorentino R, Barry S, Kasse Y, Millimono S. Rethinking how to promote maternity care-seeking: factors associated with institutional delivery in Guinea. Health Care for Women International. 2014 Sep;35(7- 9):878-95.
This paper presents findings from a study on women’s delivery care-seeking in two regions of Guinea. We explored exposure to interventions promoting birth preparedness and complication readiness among women with recent live births and stillbirths. Using multivariate regression models, we identified factors associated with women’s knowledge and practices related to birth preparedness, as well as their use of health facilities during childbirth. We found that women’s knowledge about preparations for any birth (normal or complicated) was positively associated with increased preparation for birth, which itself was associated with institutional delivery. Knowledge about obstetric risks and danger signs, was not associated with birth preparation or with institutional delivery. The study findings highlight the importance of focusing on preparation for all births—and not simply obstetric emergencies— in interventions aimed at increasing women’s use of skilled maternity care.
Delamou A, Delvaux T, El Ayadi AM, Tripathi V, Camara BS, Beavogui AH, Romanzi L, Cole B, Bouedouno P, Diallo M, Barry TH, Camara M, Diallo K, Leveque A, De Brouwere V. Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study. Lancet Global Health. 2017; 11:e1152-e1160. (epublication; full publication to follow in late 2017)
Background: Female genital fistula is a devastating maternal complication of delivery in developing countries. We sought to analyse the incidence and proportion of fistula recurrence, residual urinary incontinence, and pregnancy after successful fistula closure in Guinea, and describe the delivery-associated maternal and child health outcomes. Methods: We did a longitudinal study in women discharged with a closed fistula from three repair hospitals supported by EngenderHealth in Guinea. We recruited women retrospectively (via medical record review) and prospectively at hospital discharge. We used Kaplan-Meier methods to analyse the cumulative incidence, incidence proportion, and incidence ratio of fistula recurrence, associated outcomes, and pregnancy after successful fistula closure. The primary outcome was recurrence of fistula following discharge from repair hospital in all eligible women who consented to inclusion and could provide follow-up data. Findings: 481 women eligible for analysis were identified retrospectively (from Jan 1, 2012, to Dec 31, 2014; 348 women) or prospectively (Jan 1 to June 20, 2015; 133 women), and followed up until June 30, 2016. Median follow-up was 28·0 months (IQR 14·6–36·6). 73 recurrent fistulas occurred, corresponding to a cumulative incidence of 71 per 1000 person-years (95% CI 56·5– 89·3) and an incidence proportion of 18·4% (14·8–22·8). In 447 women who were continent at hospital discharge, we recorded 24 cases of post-repair residual urinary incontinence, equivalent to a cumulative incidence of 23·1 per 1000 person-years (14·0–36·2), and corresponding to 10·3% (5·2–19·6). In 305 women at risk of pregnancy, the cumulative incidence of pregnancy was 106·0 per 1000 person-years, corresponding to 28·4% (22·8–35·0) of these women. Of 50 women who had delivered by the time of follow-up, only nine delivered by elective caesarean section. There were 12 stillbirths, seven delivery-related fistula recurrences, and one maternal death. Interpretation: Recurrence of female genital fistula and adverse pregnancy-related maternal and child health
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outcomes were frequent in women after fistula repair in Guinea. Interventions are needed to safeguard the health of women after fistula repair.
Delamou A, Utz B, Delvaux T, Beavogui AH, Shahabuddin A, Koivogui A, Levêque A, Zhang WH, De Brouwere V. Pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa: Scoping Review. Tropical Medicine & International Health. 2016 Nov;21(11):1348-1365.
OBJECTIVE: To synthesise the evidence on pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa and to identify the existing knowledge gaps. METHODS: A scoping review of studies reporting on pregnancy and childbirth in women who underwent repair for obstetric fistula in sub-Saharan Africa was conducted. We searched relevant articles published between 1 January 1970 and 31 March 2016, without methodological or language restrictions, in electronic databases, general Internet sources and grey literature. RESULTS: A total of 16 studies were included in the narrative synthesis. The findings indicate that many women in sub-Saharan Africa still desire to become pregnant after the repair of their obstetric fistula. The overall proportion of pregnancies after repair estimated in 11 studies was 17.4% (ranging from 2.5% to 40%). Among the 459 deliveries for which the mode of delivery was reported, 208 women (45.3%) delivered by elective caesarean section (CS), 176 women (38.4%) by emergency CS and 75 women (16.3%) by vaginal delivery. Recurrence of fistula was a common maternal complication in included studies while abortions/miscarriage, stillbirths and neonatal deaths were frequent foetal consequences. Vaginal delivery and emergency cesarean section were associated with increased risk of stillbirth, recurrence of the fistula or even maternal death. CONCLUSION: Women who get pregnant after repair of obstetric fistula carry a high risk for pregnancy complications. However, the current evidence does not provide precise estimates of the incidence of pregnancy and pregnancy outcomes post-repair. Therefore, studies clearly assessing these outcomes with the appropriate study designs are needed.
Delamou, A., Delvaux, T., Utz, B., Camara, B. S., Beavogui, A. H., Cole, B., Levin, K., Diallo, M., Millimono, S., Barry, T. H., El Ayadi, A. M., Zhang, W.-H. and De Brouwere, V. Factors associated with loss to follow-up in women undergoing repair for obstetric fistula in Guinea. Tropical Medicine & International Health. 2015 Nov;20(11):1454-1461.
Objectives: To analyse the trend of loss to follow-up over time and identify factors associated with women being lost to follow-up after discharge in three fistula repair hospitals in Guinea. Methods: This retrospective cohort study used data extracted from medical records of fistula repairs conducted from 1 January 2007 to 30 September 2013. A woman was considered lost to follow-up if she did not return within 4 months post-discharge. Factors associated with loss to follow-up were identified using a subsample of the data covering the period 2010–2013. Results: Over the study period, the proportion of loss to follow-up was 21.5% (448/2080) and varied across repair hospitals and over time with an increase from 2% in 2009 to 52% in 2013. After adjusting for other variables in a multivariate logistic regression model, women who underwent surgery at Labe hospital and at Kissidougou hospital were more likely to be lost to follow-up than women operated at Jean Paul II hospital (OR: 50.6; 95% CI: 24.9– 102.8) and (OR: 11.5; 95% CI: 6.1–22.0), respectively. Women with their fistula closed at hospital discharge (OR: 3.2; 95% CI: 2.1–4.8) and women admitted for repair in years 2011–2013 showed higher loss to follow-up as compared to 2010. Finally, loss to follow-up increased by 2‰ for each additional kilometre of distance a client lived from the repair hospital (OR: 1.002; 95% CI: 1.001–1.003). Conclusion: Reimbursement of transport was the likely reason for change over time of LTFU. Reducing geographical barriers to care for women with fistula could sustain fistula care positive outcomes.
Delamou, A., Diallo, M., Beavogui, A. H., Delvaux, T., Millimono, S., Kourouma, M., Beattie, K., Barone, M., Barry, T. H., Khogali, M., Edginton, M., Hinderaker, S. G., Ruminjo, J., Zhang, W.-H. and De Brouwere, V. Good clinical outcomes from a 7-year holistic programme of fistula repair in Guinea. Tropical Medicine & International Health. 2015 20: 813–819.
OBJECTIVES: Female genital fistula remains a public health concern in developing countries. From January 2007 to September 2013, the Fistula Care project, managed by EngenderHealth in partnership with the Ministry of Health
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and supported by USAID, integrated fistula repair services in the maternity wards of general hospitals in Guinea. The objective of this article was to present and discuss the clinical outcomes of 7 years of work involving 2116 women repaired in three hospitals across the country. METHODS: This was a retrospective cohort study using data abstracted from medical records for fistula repairs conducted from 2007 to 2013. The study data were reviewed during the period April to August 2014. RESULTS: The majority of the 2116 women who underwent surgical repair had vesicovaginal fistula (n = 2045, 97%) and 3% had rectovaginal fistula or a combination of both. Overall 1748 (83%) had a closed fistula and were continent of urine immediately after surgery. At discharge, 1795 women (85%) had a closed fistula and 1680 (79%) were dry, meaning they no longer leaked urine and/or faeces. One hundred and fifteen (5%) remained with residual incontinence despite fistula closure. Follow-up at 3 months was completed by 1663 (79%) women of whom 1405 (84.5%) had their fistula closed and 80% were continent. Twenty-one per cent were lost to follow-up. CONCLUSION: Routine programmatic repair for obstetric fistula in low resources settings can yield good outcomes. However, more efforts are needed to address loss to follow-up, sustain the results and prevent the occurrence and/or recurrence of fistula.
Delamou, A, Samadari, G, Camara BS, Traore P, Diallo F, Millimono S, Wane D, Toliver M, Laffe K, Verani F. Prevalence and correlates of intimate partner violence among family planning clients in Conakry, Guinea. BMC Research Notes. 2015 8:814
Intimate partner violence (IPV) is a global public health problem that affects women’s physical, mental, sexual and reproductive health. Very little data on IPV experience and FP use is available in resource-poor settings, such as in West Africa. The aim of this study was to describe the prevalence, patterns and correlates of IPV among clients of an adult Family Planning clinic in Conakry, Guinea. The study data was collected for four months (March to June 2014) from women’s family planning charts and from an IPV screening form at the Adult Family Planning and Reproductive Health Clinic of “Association Guinéenne pour le Bien-Etre Familial”, a non-profit organization in Conakry, Guinea. 232 women out of 245 women who attended the clinic for services during the study period were screened for IPV and were included in this study. Of the 232 women screened, 213 (92 %) experienced IPV in one form or another at some point in their lifetime. 169 women reported psychological violence (79.3 %), 145 reported sexual violence (68.1 %) and 103 reported physical violence (48.4 %). Nearly a quarter of women reported joint occurrence of the three forms of violence (24 %).Half of the IPV positive women were current users of family planning (51.2 %) and of these, 77.9 % preferred injectable contraceptives. The odds of experiencing IPV was higher in women with secondary or vocational level of education than those with higher level of education (AOR: 8.4; 95 % CI 1.2–58.5). Women residing in other communes of Conakry (AOR: 5.6; 95 % CI 1.4–22.9) and those preferring injectable FP methods (AOR: 4.5; 95 % CI 1.2–16.8) were more likely to experience lifetime IPV. IPV is prevalent among family planning clients in Conakry, Guinea where nine out of ten women screened in the AGBEF adult clinic reported having experienced one or another type of IPV. A holistic approach that includes promotion of women’s rights and gender equality, existence of laws and policies is needed to prevent and respond to IPV, effective implementation of policies and laws, and access to quality IPV services in Guinea and countries with higher rates of IPV.
El Ayadi A, Nalubwama H, Barageine J, Neilands TB, Obore S, Byamugisha J, Kakaire O, Mwanje H, Korn A, Lester F, Miller S. Development and preliminary validation of a post-fistula repair reintegration instrument among Ugandan women. Reproductive Health. 2017 Sep 2;14(1):109.
BACKGROUND: Obstetric fistula is a debilitating and traumatic birth injury affecting 2-3 million women globally, mostly in sub-Saharan Africa and Asia. Affected women suffer physically, psychologically and socioeconomically. International efforts have increased access to surgical treatment, yet attention to a holistic outcome of post- surgical rehabilitation is nascent. We sought to develop and pilot test a measurement instrument to assess post- surgical family and community reintegration. METHODS: We conducted an exploratory sequential mixed-methods study, beginning with 16 in-depth interviews and four focus group discussions with 17 women who underwent fistula surgery within two previous years to inform measure development. The draft instrument was validated in a longitudinal cohort of 60 women recovering from fistula surgery. Qualitative data were analyzed through thematic analysis. Socio-demographic characteristics were described using one-way frequency tables. We used exploratory
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factor analysis to determine the latent structure of the scale, then tested the fit of a single higher-order latent factor. We evaluated internal consistency and temporal stability reliability through Raykov's ρ and Pearson's correlation coefficient, respectively. We estimated a series of linear regression models to explore associations between the standardized reintegration measure and validated scales representing theoretically related constructs. RESULTS: Themes central to women's experiences following surgery included resuming mobility, increasing social interaction, improved self-esteem, reduction of internalized stigma, resuming work, meeting their own needs and the needs of dependents, meeting other expected and desired roles, and negotiating larger life issues. We expanded the Return to Normal Living Index to reflect these themes. Exploratory factor analysis suggested a four-factor structure, titled 'Mobility and social engagement', 'Meeting family needs', 'Comfort with relationships', and 'General life satisfaction', and goodness of fit statistics supported a higher-order latent variable of 'Reintegration.' Reintegration score correlated significantly with quality of life, depression, self-esteem, stigma, and social support in theoretically expected directions. CONCLUSION: As more women undergo surgical treatment for obstetric fistula, attention to the post-repair period is imperative. This preliminary validation of a reintegration instrument represents a first step toward improving measurement of post-surgical reintegration and has important implications for the evidence base of post-surgical reintegration epidemiology and the development and evaluation of fistula programming.
Frajzyngier V, Ruminjo J, Asiimwe F, Barry TH, Bello A, Danladi D, Ganda SO, Idris S, Inoussa M, Lynch M, Mussell F, Podder DC, Barone MA. Factors influencing choice of surgical route of repair of genitourinary fistula, and the influence of route of repair on surgical outcomes: findings from a prospective cohort study. BJOG. 2012 Oct;119(11):1344-53.
OBJECTIVE: The abdominal route of genitourinary fistula repair may be associated with longer-term hospitalisation, hospital-associated infection and increased resource requirements. We examined: (1) the factors influencing the route of repair; (2) the influence of the route of repair on fistula closure 3 months following surgery; and (3) whether the influence of the route of repair on repair outcome varied by whether or not women met the published indications for abdominal repair. DESIGN: Prospective cohort study. SETTING: Eleven health facilities in sub-Saharan Africa and Asia. POPULATION: The 1274 women with genitourinary fistula presenting for surgical repair services. METHODS: Risk ratios (RRs) and 95% confidence intervals (95% CIs) were generated using log- binomial and Poisson (log-link) regression. Multivariable regression and propensity score matching were employed to adjust for confounding. MAIN OUTCOME MEASURES: Abdominal route of repair and fistula closure at 3 months following fistula repair surgery. RESULTS: Published indications for abdominal route of repair (extensive scarring or tissue loss, genital infibulation, ureteric involvement, trigonal, supratrigonal, vesico-uterine or intracervical location or other abdominal pathology) predicted the abdominal route [adjusted risk ratio (ARR), 15.56; 95% CI, 2.12-114.00]. A vaginal route of repair was associated with increased risk of failed closure (ARR, 1.41; 95% CI, 1.05- 1.88); stratified analyses suggested elevated risk among women meeting indications for the abdominal route. CONCLUSIONS: Additional studies powered to test effect modification hypotheses are warranted to confirm whether the abdominal route of repair is beneficial for certain women.
Frajzyngier V, Ruminjo J, Barone MA. Factors influencing urinary fistula repair outcomes in developing countries: a systematic review. American Journal of Obstetrics & Gynecology. 2012 Oct;207(4):248-58.
We reviewed literature examining predictors of urinary fistula repair outcomes in developing country settings, including fistula and patient characteristics, and perioperative factors. We searched Medline for articles published between January 1970 and December 2010, excluding articles that were (1) case reports, cases series or contained 20 or fewer subjects; (2) focused on fistula in developed countries; and (3) did not include a statistical analysis of the association between facility or individual-level factors and surgical outcomes. Twenty articles were included; 17 were observational studies. Surgical outcomes included fistula closure, residual incontinence after closure, and any incontinence (dry vs wet). Scarring and urethral involvement were associated with poor prognosis across all outcomes. Results from randomized controlled trials examining prophylactic antibiotic use and repair outcomes were inconclusive. Few observational studies examining perioperative interventions accounted for confounding by fistula severity. We conclude that a unified, standardized evidence-base for informing clinical practice is lacking.
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Frajzyngier V, Li G, Larson E, Ruminjo J, Barone MA. Development and comparison of prognostic scoring systems for surgical closure of genitourinary fistula. American Journal of Obstetrics & Gynecology. 2013 Feb;208(2):112.e1-11.
OBJECTIVE: The purpose of this study was to test the diagnostic performance of 5 existing classification systems (developed by Lawson, Tafesse, Goh, Waaldijk, and the World Health Organization) and a prognostic scoring system that was derived empirically from our data to predict fistula closure 3 months after surgery. STUDY DESIGN: Women with genitourinary fistula (n = 1274) who received surgical repair services at 11 health facilities in sub- Saharan Africa and Asia were enrolled in a prospective cohort study. Using one-half of the sample, we created multivariate generalized estimating equation models to obtain weighted prognostic scores for components of each existing classification system and the empirically derived scoring system. With the second one-half, we developed receiver operating characteristic curves using the prognostic scores and calculated areas under the curves (AUCs) and 95% confidence intervals (CIs) for each system. RESULTS: Among existing systems, the scoring systems that represented the World Health Organization, Goh, and Tafesse classifications had the highest predictive accuracy: AUC, 0.63 (95% CI, 0.57-0.68); AUC, 0.62 (95% CI, 0.57-0.68), and AUC, 0.60 (95% CI, 0.55-0.65), respectively. The empirically derived prognostic score achieved similar predictive accuracy (AUC, 0.62; 95% CI, 0.56-0.67); it included significant predictors of closure that are found in the other classification systems, but contained fewer, nonoverlapping components. The differences in AUCs were not statistically significant. CONCLUSION: The prognostic values of existing urinary fistula classification systems and the empirically derived score were poor to fair. Further evaluation of the validity and reliability of existing classification systems to predict fistula closure is warranted; consideration should be given to a prognostic score that is evidence-based, simple, and easy to use.
Landry E, Pett C, Forentino R, Ruminjo J, Mattison C. Assessing the quality of record keeping for cesarean deliveries: results from a multicenter retrospective record review in five low-income countries. BMC Pregnancy and Childbirth. 2014 Apr 12;14:139.
BACKGROUND: Reliable, timely information is the foundation of decision making for functioning health systems; the quality of decision making rests on quality data. Routine monitoring, reporting, and review of cesarean section (CS) indications, decision-to-delivery intervals, and partograph use are important elements of quality improvement for maternity services. METHODS: In 2009 and 2010, a sample of CS delivery records from calendar year 2008 was reviewed at nine facilities in Bangladesh, Guinea, Mali, Niger, and Uganda. Data from patient records and hospital registers were collected on key aspects of care (e.g., timing of key events, indications, partograph use, maternal and fetal outcomes). Qualitative interviews were conducted with key informants at all study sites. RESULTS: A total of 2,941 records were reviewed. Fifty-seven key informant interviews were conducted to learn about record- keeping practices. Patient record-keeping systems were of varying quality across study sites: at five sites, more than 20% of records could not be located. Across all sites, patient files were missing key aspects of CS delivery care: timing of key events (e.g., examination, decision to perform CS), administration of prophylactic antibiotics, maternal complications, and maternal and fetal outcomes. Rates of partograph use were disappointingly low at six sites: 0 to 23.9% of patient files at these sites had a completed partograph on file, and among those found, 2.1% to 65.1% were completed correctly. Information on fetal outcomes was missing in up to 40% of patient files. CONCLUSIONS: Deficits in CS patient record data quality across a broad range of health facilities in low-resource settings in four sub-Saharan Africa countries and Bangladesh indicate an urgent need to improve record keeping.
Landry E, Frajzyngier V, Ruminjo J, Asiimwe F, Barry TH, Bello A, Danladi D, Ganda SO, Idris S, Inoussa M, Kanoma B, Lynch M, Mussell F, Podder DC, Wali A, Mielke E, Barone MA. Profiles and experiences of women undergoing genital fistula repair: findings from five countries. Global Public Health. 2013;8(8):926-42.
This article presents data from 1354 women from five countries who participated in a prospective cohort study conducted between 2007 and 2010. Women undergoing surgery for fistula repair were interviewed at the time of admission, discharge, and at a 3-month follow-up visit. While women's experiences differed across countries, a similar picture emerges across countries: women married young, most were married at the time of admission, had little education, and for many, the fistula occurred after the first pregnancy. Median age at the time of fistula
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occurrence was 20.0 years (interquartile range 17.3-26.8). Half of the women attended some antenatal care (ANC); among those who attended ANC, less than 50% recalled being told about signs of pregnancy complications. At follow-up, most women (even those who were not dry) reported improvements in many aspects of social life, however, reported improvements varied by repair outcome. Prevention and treatment programmes need to recognise the supportive role that husbands, partners, and families play as women prepare for safe delivery. Effective treatment and support programmes are needed for women who remain incontinent after surgery.
Longombe AO, Claude KM, Ruminjo J. Fistula and traumatic genital injury from sexual violence in a conflict setting in Eastern Congo: case studies. Reproductive Health Matters. 2008 May;16(31):132-41.
The Eastern region of the Democratic Republic of Congo (DRC) is currently undergoing a brutal war. Armed groups from the DRC and neighbouring countries are committing atrocities and systematically using sexual violence as a weapon of war to humiliate, intimidate and dominate women, girls, their men and communities. Armed combatants take advantage with impunity, knowing they will not be held to account or pursued by police or judicial authorities. A particularly inhumane public health problem has emerged: traumatic gynaecological fistula and genital injury from brutal sexual violence and gang-rape, along with enormous psychosocial and emotional burdens. Many of the women who survive find themselves pregnant or infected with STIs/HIV with no access to treatment. This report was compiled at the Doctors on Call for Service/Heal Africa Hospital in Goma, Eastern Congo, from the cases of 4,715 women and girls who suffered sexual violence between April 2003 and June 2006, of whom 702 had genital fistula. It presents the personal experiences of seven survivors whose injuries were severe and long-term, with life-changing effects. The paper recommends a coordinated effort amongst key stakeholders to secure peace and stability, an increase in humanitarian assistance and the rebuilding of the infrastructure, human and physical resources, and medical, educational and judicial systems.
Ngongo C, Levin K, Landry E, Sutton I, Ndizeye S. What to measure and why? Experience developing and using novel monitoring indicators in maternal health: the case of obstetric fistula. Journal of Health Informatics in Developing Countries. 2015 9(1): 14-22.
The field of obstetric fistula has historically lacked common definitions for measuring outcomes. This paper recounts the process of developing, refining, and using standardized monitoring indicators and approaches as part of a fistula prevention and repair project working in fourteen countries. The process included the development and refinement of clinical indicators, the introduction of standardizing data collection and reporting at partner health facilities, building capacity to use data for decision making locally, nationally, and within the project, institutionalizing data review meetings and partner health facilities, and supporting the introduction of fistula treatment indicators into national Health Management Information Systems to enable continued measurement and support for fistula treatment services. As monitoring in the field of obstetric fistula continues to become more standardized and routine, the multi-country scope of the project enabled a wide-ranging effort through which indicators for a “new” maternal health content area were developed and applied. This experience provides lessons for other initiatives seeking to strengthen monitoring and reporting related to novel or emerging topics in maternal health services.
Ngongo C, Christie K, Holden J, Ford C, Pett C. Striving for excellence: nurturing midwives' skills in Freetown, Sierra Leone. Midwifery. 2013 Oct;29(10):1230-4.
Midwives provide critical, life-saving care to women and babies. Effective midwives must be clinically competent, with the required knowledge, skills, and attitudes to provide quality care. Their success depends on an environment of supportive supervision, continuing education, enabling policies, and access to equipment and referral facilities. In Freetown, Sierra Leone, the Aberdeen Women's Centre launched a maternity unit with an emphasis on striving for excellence and providing ongoing professional development to its staff midwives. Its success was built upon fostering a sense of responsibility and teamwork, providing necessary resources, conforming to evidence-based standards, and building partnerships. An explicit philosophy of care was crucial for guiding clinical decision making. In its first two years of operation, the Aberdeen Women's Centre assisted 2076
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births with two maternal deaths and 92 perinatal deaths. In-service education and supportive supervision facilitated the midwives' professional growth, leading to capable future leaders who are providing exemplary care to delivering mothers and their newborns in Freetown.
Raassen TJ, Ngongo CJ, Mahendeka MM. Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries. International Urogynecology Journal. 2014 Dec;25(12):1699-706.
INTRODUCTION: Genitourinary fistula poses a public health challenge in areas where women have inadequate access to quality emergency obstetric care. Fistulas typically develop during prolonged, obstructed labor, but clinicians can also inadvertently cause a fistula when performing obstetric or gynecological surgery. METHODS: This retrospective study analyzes 805 iatrogenic fistulas from a series of 5,959 women undergoing genitourinary fistula repair in 11 countries between 1994 and 2012. Injuries fall into three categories: ureteric, vault, and vesico- [utero]/-cervico-vaginal. This analysis considers the frequency and characteristics of each type of fistula and the risk factors associated with iatrogenic fistula development. RESULTS: In this large series, 13.2% of genitourinary fistula repairs were for injuries caused by clinician error. A range of cadres conducted procedures resulting in iatrogenic fistula. Four out of five iatrogenic fistulas developed following surgery for obstetric complications: cesarean section, ruptured uterus repair, or hysterectomy for ruptured uterus. Others developed during gynecological procedures, most commonly hysterectomy. Vesico-[utero]/-cervico-vaginal fistulas were the most common (43.6%), followed by ureteric injuries (33.9%) and vault fistulas (22.5%). One quarter of women with iatrogenic fistulas had previously undergone a laparotomy, nearly always a cesarean section. Among these women, one quarter had undergone more than one previous cesarean section. CONCLUSIONS: Women with previous cesarean sections are at increased risk for iatrogenic injury. Work environments must be adequate to reduce surgical error. Training must emphasize the importance of optimal surgical techniques, obstetric decision-making, and alternative ways to deliver dead babies. Iatrogenic fistulas should be recognized as a distinct genitourinary fistula category.
Ruminjo JK, Frajzyngier V, Bashir Abdullahi M, Asiimwe F, Hamidou Barry T, Bello A, Danladi D, Oumarou Ganda S, Idris S, Inoussa M, Lynch M, Mussell F, Chandra Podder D, Wali A, Barone MA. Clinical procedures and practices used in the perioperative treatment of female genital fistula during a prospective cohort study. BMC Pregnancy Childbirth. 2014 Jul 5;14:220.
BACKGROUND: Treatment and care for female genital fistula have become increasingly available over the last decade in countries across Africa and South Asia. Before the International Federation of Gynaecology and Obstetrics (FIGO) and partners published a global fistula training manual in 2011 there was no internationally recognized, standardized training curriculum, including perioperative care. The community of fistula care practitioners and advocates lacks data about the prevalence of various perioperative clinical procedures and practices and their potential programmatic implications are lacking. METHODS: Data presented here are from a prospective cohort study conducted between September 2007 and September 2010 at 11 fistula repair facilities supported by Fistula Care in five countries. Clinical procedures and practices used in the routine perioperative management of over 1300 women are described. RESULTS: More than two dozen clinical procedures and practices were tabulated. Some of them were commonly used at all sites (e.g., vaginal route of repair, 95.3% of cases); others were rare (e.g., flaps/grafts, 3.4%) or varied widely depending on site (e.g. for women with urinary fistula, the inter-quartile range for median duration of post-repair bladder catheterization was 14 to 29 days). CONCLUSIONS: These findings show a wide range of clinical procedures and practices with different program implications for safety, efficacy, and cost-effectiveness. The variability indicates the need for further research so as to strengthen the evidence base for fistula treatment in developing countries.
Ruminjo R, Landry E, Beattie K, Isah A, Faisel AJ, Millimono S. Mortality risk associated with surgical treatment of female genital fistula. International Journal of Gynecology and Obstetrics. 2014 Apr 18. pii: S0020- 7292(14)00194-5.
OBJECTIVE: Most surgeries proceed without incident, but all major surgeries have inherent risks for adverse events, including death. Some deaths are attributable to the condition requiring surgery, concurrent morbidity, or
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the surgery itself. For fistula treatment, published literature on mortality risk is extremely limited. This article describes the mortality risk associated with surgical treatment of female genital fistula and the contributory and contextual factors. METHODS: Confidential inquiries and clinical audits were conducted at 14 fistula repair sites in seven resource-poor countries. Data collection included interviews with key personnel involved in the clinical management of the deceased and a review of hospital records and client files following an audit protocol. RESULTS: Thirty deaths occurred from 26,060 fistula repair surgeries from 2005 to 2013, 21 attributable to surgery; the case fatality was 0.08 per 100 procedures. The causes of death for nearly half of the cases were various manifestations of sepsis and inflammation. CONCLUSIONS: This case fatality rate for fistula repair surgery is in the same range as comparable gynecologic operations in high-resource settings. Clinical and systemic issues should be addressed to minimize chances of recurrence, improve perioperative care and follow-up, assure prudent referral or deferral of difficult cases, and maintain better records.
Ruminjo J. 2007. Obstetric fistula and the challenge to maternal health care systems. IPPF Medical Bulletin 41(4):3-4. [COMMENTARY – NO ABSTRACT]
Tripathi V. A literature review of quantitative indicators to measure the quality of labor and delivery care. International Journal of Gynecology and Obstetrics. 2016 Feb:132(2): 139-45.
BACKGROUND: Strengthening measurement of the quality of labor and delivery (L&D) care in low-resource countries requires an understanding of existing approaches. OBJECTIVES: To identify quantitative indicators of L&D care quality and assess gaps in indicators. SEARCH STRATEGY: PubMed, CINAHL Plus, and Embase databases were searched for research published in English between January 1, 1990, and October 31, 2013, using structured terms. SELECTION CRITERIA: Studies describing indicators for L&D care quality assessment were included. Those whose abstracts contained inclusion criteria underwent full-text review. DATA COLLECTION AND ANALYSIS: Study characteristics, including indicator selection and data sources, were extracted via a standard spreadsheet. MAIN RESULTS: The structured search identified 1224 studies. After abstract and full-text review, 477 were included in the analysis. Most studies selected indicators by using literature review, clinical guidelines, or expert panels. Few indicators were empirically validated; most studies relied on medical record review to measure indicators. CONCLUSIONS: Many quantitative indicators have been used to measure L&D care quality, but few have been validated beyond expert opinion. There has been limited use of clinical observation in quality assessment of care processes. The findings suggest the need for validated, efficient consensus indicators of the quality of L&D care processes, particularly in low-resource countries.
Tripathi V, Stanton C, Strobino D, Bartlett L. Development and Validation of an Index to Measure the Quality of Facility-Based Labor and Delivery Care Processes in Sub-Saharan Africa. PLoS ONE. 2015. 10(6): e0129491.
BACKGROUND: High quality care is crucial in ensuring that women and newborns receive interventions that may prevent and treat birth-related complications. As facility deliveries increase in developing countries, there are concerns about service quality. Observation is the gold standard for clinical quality assessment, but existing observation-based measures of obstetric quality of care are lengthy and difficult to administer. There is a lack of consensus on quality indicators for routine intrapartum and immediate postpartum care, including essential newborn care. This study identified key dimensions of the quality of the process of intrapartum and immediate postpartum care (QoPIIPC) in facility deliveries and developed a quality assessment measure representing these dimensions. METHODS & FINDINGS: Global maternal and neonatal care experts identified key dimensions of QoPIIPC through a modified Delphi process. Experts also rated indicators of these dimensions from a comprehensive delivery observation checklist used in quality surveys in sub-Saharan African countries. Potential QoPIIPC indices were developed from combinations of highly-rated indicators. Face, content, and criterion validation of these indices was conducted using data from observations of 1,145 deliveries in Kenya, Madagascar, and Tanzania (including Zanzibar). A best-performing index was selected, composed of 20 indicators of intrapartum/immediate postpartum care, including essential newborn care. This index represented most
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dimensions of QoPIIPC and effectively discriminated between poorly and well-performed deliveries. CONCLUSIONS: As facility deliveries increase and the global community pays greater attention to the role of care quality in achieving further maternal and newborn mortality reduction, the QoPIIPC index may be a valuable measure. This index complements and addresses gaps in currently used quality assessment tools. Further evaluation of index usability and reliability is needed. The availability of a streamlined, comprehensive, and validated index may enable ongoing and efficient observation-based assessment of care quality during labor and delivery in sub-Saharan Africa, facilitating targeted quality improvement.
Tunçalp O, Tripathi V, Landry E, Stanton CK, Ahmed S. Measuring the incidence and prevalence of obstetric fistula: approaches, needs, and recommendations. Bulletin of the World Health Organization. 2015 Jan; 93(1):60-62. [COMMENTARY - NO ABSTRACT]
Tunçalp Ö, Isah A, Landry E, Stanton CK. Community-based screening for obstetric fistula in Nigeria: a novel approach. BMC Pregnancy Childbirth. 2014 Jan 24;14:44.
BACKGROUND: Obstetric fistula continues to have devastating effects on the physical, social, and economic lives of thousands of women in many low-resource settings. Governments require credible estimates of the backlog of existing cases requiring care to effectively plan for the treatment of fistula cases. Our study aims to quantify the backlog of obstetric fistula cases within two states via community-based screenings and to assess the questions in the Demographic Health Survey (DHS) fistula module. METHODS: The screening sites, all lower level health facilities, were selected based on their geographic coverage, prior relationships with the communities and availability of fistula surgery facilities in the state. This cross-sectional study included women who presented for fistula screenings at study facilities based on their perceived fistula-like symptoms. Research assistants administered the pre-screening questionnaire. Nurse-midwives then conducted a medical exam. Univariate and bivariate analyses are presented. RESULTS: A total of 268 women attended the screenings. Based on the pre- screening interview, the backlog of fistula cases reported was 75 (28% of women screened). The backlog identified after the medical exam was 26 fistula cases (29.5% of women screened) in Kebbi State sites and 12 cases in Cross River State sites (6.7%). Verification assessment showed that the DHS questionnaire had 92% sensitivity, 83% specificity with 47% positive predictive value and 98% negative predictive value for identifying women afflicted by fistula among women who came for the screenings. CONCLUSIONS: This methodology, involving effective, locally appropriate messaging and community outreach followed up with medical examination by nurse-midwives at lower level facilities, is challenging, but represents a promising approach to identify the backlog of women needing surgery and to link them with surgical facilities.
II. In press/under review/in draft
Tripathi V, Romanzi L. Comment: Integration of pelvic organ prolapse and genital fistula repair in low-resource settings. Being revised for the International Urogynecology Journal.
Introduction: There is a need for expanded access to safe surgical care in low and middle-income countries (LMIC) as illustrated by the report of the 2015 Lancet Commission on Global Surgery. Packages of closely-related surgical procedures may create platforms of capacity that maximize impact in LMIC. Pelvic organ prolapse (POP) and genital fistula care provide an example. While POP affects many more women in LMIC than fistula, donor support for fistula treatment in LMIC has been underway for decades, while treatment for POP is usually limited to hysterectomy-based surgical treatment, occurring with little to no donor support. This capacity building discrepancy has resulted in POP care that is often non-adherent to international standards and in non-integration of POP and fistula services, despite clear areas of similarity and overlap. The objective of this study was to assess the feasibility and potential value of integrating POP services at fistula centers, an example of bundling closely- related surgical services. Methods: Fistula repair sites supported by the Fistula Care Plus project were surveyed on current demand for and capacity to provide POP, as well as perceptions about integrating POP and fistula repair
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services. Results: Respondents from 26 hospitals in sub-Saharan Africa and South Asia completed the survey. Most fistula centers (92%) reported demand for POP services, but many cannot meet this demand. Responses indicated wide variation in POP assessment and grading practices; lower urinary tract symptoms evaluation approaches; and compartment-based POP, urinary, and rectal incontinence surgical skills. Fistula surgeons identified integration synergies but also potential conflicts. Conclusions: Integration of genital fistula and POP services may enhance POP care quality while increasing the sustainability of fistula care.
Mallick L, Tripathi V. Genital Fistula and Gender-based Violence: Cause or consequence? Being revised for Tropical Medicine & International Health.
Objective: Female genital fistula usually results from prolonged/obstructed labor, but can also be traumatic or iatrogenic. As fistula is relatively rare, many studies are limited by small sample sizes, precluding assessment of associations with risk factors and other health concerns. With numerous surveys that include standardized questions on fistula symptoms, the Demographic and Health Surveys (DHS) provide a unique opportunity to evaluate the epidemiology of fistula. This study examined associations between self-reported experience of fistula symptoms and gender-based violence among women interviewed in DHS surveys. Methods: This study used data from twelve DHS surveys with standardized fistula and domestic violence modules. Data from 90,276 women were pooled, weighting each survey equally within the total sample. Multivariable logistic regressions controlled for maternal and demographic factors. Findings: Prevalence of fistula symptoms ranges from 0.4% to 2.0%. Women who have experienced sexual or physical violence, both ever and recently, are more likely to report symptoms of fistula than women who have not experienced such violence. Women whose first experience of sexual violence was committed by a non-partner have more than four times the odds of reporting fistula symptoms compared to women who never experienced sexual violence. These associations largely persist among women who report that violence did not cause fistula symptoms, indicating a need to further investigate temporal relationships between violence and fistula. Conclusion: The increased risk of physical and sexual violence among women with fistula symptoms reported here suggest that fistula programs must incorporate gender-based violence into clinician training and service provision.
Keya KT, Sripad P, Nwala E, Warren C. “Poverty is the big thing”: exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda. Under review at the International Journal of Equity and Health.
Background: Women living with obstetric fistula often live in poverty and in remote areas far from hospitals that offer surgical repair. These women and their families incur a range of costs, some of which include: management of their condition, lost productivity and time, and transport to facilities – all of which prevent them from accessing fistula repair. This study explores, through women, community, and provider lenses, the financial, transport, and opportunity cost barriers and enablers to seeking repair services. Methods: A qualitative approach was applied in Kano and Ebonyi, Nigeria and Hoima and Masaka, Uganda. The study team conducted in-depth interviews (IDIs) with women affected by fistula (n=52) – including those awaiting repair, living with fistula and post-repair, their spouses and other family members (n=17), and health service providers involved in fistula repair and counseling (n=38). Focus group discussions (FGDs) with male and female community stakeholders (n=8) and post-repair clients (n=6) were also conducted. Results: Women’s experiences indicate that costs associated with the obstetric fistula condition reflect a combined set of costs associated with delivery, repair, transport, forgone income, and companion expenses that altogether is often catastrophic. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly across fistula care centers or camps due to funding shortages. In Uganda, most women spent Ugandan Shilling 10,000 to 90,000 (US$3.00-US$25.00) for a single trip to the camp for two people, while Nigerian women (Kano) spent Naira 250 to 2000 (US$0.80-US$6.41) for transportation. Factors influencing the cost of fistula care access include education and vocational skills of women and their family, community-based savings mechanisms, available resources in repair centers, client counselling, and subsidized care and transport. Conclusions: The concentration of women in poverty and the catastrophic costs associated
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with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Findings recommend innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers.
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APPENDIX E: FC/FC+ PUBLICATION READERSHIP METRICS*
PUB TITLE VIEWS JOURNAL YEAR Obstetric fistula and the challenge to maternal health care systems n/a IPPF Medical Bulletin 2007 Fistula and traumatic genital injury from sexual violence in a conflict setting in Eastern Congo: case studies n/a Reproductive Health Matters 2008 Current practices in treatment of female genital fistula: a cross BMC Pregnancy and sectional study 8236 Childbirth 2010 Determinants of postoperative outcomes of female genital fistula repair surgery. n/a Obstetrics and Gynecology 2012 Factors influencing choice of surgical route of repair of genitourinary fistula, and the influence of route of repair on surgical outcomes: findings from a prospective cohort study n/a BJOG 2012 Factors influencing urinary fistula repair outcomes in American Journal of developing countries: a systematic review n/a Obstetrics and Gynecology 2012 Non-inferiority of short-term urethral catheterization following fistula repair surgery: study protocol for a randomized controlled trial 4770 BMC Women's Health 2012 Development and comparison of prognostic scoring systems American Journal of for surgical closure of genitourinary fistula. n/a Obstetrics and Gynecology 2013 Current Opinion in Obstetrics Outcomes in obstetric fistula care: a literature review n/a and Gynecology 2013 Profiles and experiences of women undergoing genital fistula repair: findings from five countries 1150 Global Public Health 2013 Striving for excellence: nurturing midwives' skills in Freetown, Sierra Leone. n/a Midwifery 2013 Assessing the quality of record keeping for cesarean deliveries: results from a multicenter retrospective record BMC Pregnancy and review in five low-income countries. 1961 Childbirth 2014 Clinical Procedures and Practices Used in the Perioperative Treatment of Female Genital Fistula during a Prospective BMC Pregnancy and Cohort Study. 1984 Childbirth 2014 Community-based screening for obstetric fistula in Nigeria: a BMC Pregnancy and novel approach 2999 Childbirth 2014 Iatrogenic genitourinary fistulas: An 18-year retrospective International Journal of review of 801 iatrogenic injuries n/a Urogynecology 2014 Rethinking how to promote careseeking: Factors associated Health Care for Women with institutional delivery in Guinea 1218** International 2014 Measuring the incidence and prevalence of obstetric fistula: Bulletin of the World Health approaches, needs, and recommendations n/a Organization 2014 Mortality risk associated with surgical treatment of female International Journal of genital fistula. 228*** Gynecology and Obstetrics 2014 The value of building health promotion capacities within communities: Evidence from a maternal health intervention in Guinea. n/a Health Policy and Planning 2014 Breakdown of simple female genital fistula repair after 7 day versus 14 day postoperative bladder catheterisation: a randomised, controlled, open-label, non-inferiority trial n/a The Lancet 2015 Development and validation of an index to measure facility- based labor and delivery care processes in sub-Saharan Africa**** 7708 PLOS ONE 2015 Factors associated with loss to follow-up in women undergoing Tropical Medicine and repair for obstetric fistula in Guinea n/a International Health 2015 Good clinical outcomes from a 7-year holistic programme of Tropical Medicine and fistula repair in Guinea. n/a International Health 2015
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PUB TITLE VIEWS JOURNAL YEAR What to measure and why. Experience developing monitoring indicators for an emerging maternal health issue: the case of Journal of Health Informatics obstetric fistula" n/a in Developing Countries 2015 Pregnancy and childbirth after repair of obstetric fistula in sub- Tropical Medicine and Saharan Africa: Scoping Review n/a International Health 2016 A realist review of the partograph: when and how does it work BMC Pregnancy and for labour monitoring? 2749 Childbirth 2017 Development and preliminary validation of a post-fistula repair reintegration instrument among Ugandan women. 532 Reproductive Health 2017 Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study. (epublication; full publication to follow in late 2017) n/a Lancet Global Health 2017 Ending fistula within a generation: making the dream a reality. n/a Lancet Global Health 2017 TOTAL 33,535 * Metrics only available for 10 of the 26 published articles. ** Published through the Maternal and Child Health Integration Program/Maternal and Child Survival Program. *** Due to a change in web platform, updated metrics are no longer available. This number reflects views through late 2014. ****Though metrics are not available, this was one of the top three most downloaded articles in Health Care for Women International in 2014.) Updated 11/01/2017.
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APPENDIX F: FC+ PRESENCE AT 2016 IOFWG AND ISOFS
2016 International Society of Obstetric Fistula Surgeons (ISOFS) & International Obstetric Fistula Working Group (IOFWG) Conferences: Fistula Care Plus (FC+) Presence I. Presentations and Posters at ISOFS Title Country First Author Format 1 Meeting Fistula Clients’ Health Care Needs Through Bangladesh F. Akhtar Presentation Community-based Fistula Diagnosis Events 2 Source of Injury in Iatrogenic Fistula Cases in Bangladesh N. Huda Presentation Bangladesh 3 House-to-house screening for fistula and complete Bangladesh V. Tripathi Presentation perineal tear using the 4-question checklist in Bangladesh 4 Impact de la Fistule Sur La View Sexuelle Des Femmes DRC R. Bukabau Presentation Hôpital Saint Joseph Kinshasa, République Babuya Démocratique Du Congo* 5 Task shifting and competency-based training: a DRC L. Keyser Presentation preliminary model for physiotherapy capacity building in women’s health 6 Iatrogenic fistula – emerging evidence and a call for Global V. Tripathi Presentation action 7 Capacity and demand for pelvic organ prolapse services Global V. Tripathi Presentation at fistula treatment centers 8 Women still at risk during pregnancy and childbirth Guinea A. Delamou Presentation post-repair of obstetric fistula: evidence from a prospective follow-up study in Guinea 9 Recurrence post-repair of female genital fistula in Guinea A. Delamou Presentation Guinea: results from a prospective follow-up study 10 Conservative treatment of obstetric fistula: a quick Nigeria A. Isah Presentation review from supported facilities in Nigeria 11 Mortalities in Fistula Facilities: Engaging Quality Nigeria A. Isah Presentation Assurance and Surgical Safety Culture 12 Record review of fistula cases in Nigeria Nigeria E. Arnoff Presentation 13 Exploring the Awareness of Obstetric Fistula Onset and Nigeria E. Nwala Presentation Availability of Fistula Care in Easter and Northern Nigeria 14 Qualitative assessment of communication needs for Nigeria V. Tripathi Presentation fistula prevention and treatment in Nigeria 15 A 6 Years’ Experience of Managing Obstetric Fistula in Uganda F. Acheng Presentation Hoima Regional Referral Hospital 16 Improving Partograph Use and Documentation Among Uganda A. Masika Presentation Health Workers on Maternity Ward of Bwera District Hospital in Kasese District Uganda* 17 Reducing the Fistula Burden in Kitovu Hospital through Uganda C. Kisekka Presentation Community Mobilization and Treatment
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I. Presentations and Posters at ISOFS Title Country First Author Format 18 The Mainz-Ii Rouch- A Viable Option For The Incurable Uganda F. Kirya Presentation Obstetric Fistula In A Low Income Setting* 19 Adopting the routine treatment model in a public health Uganda I. Asiimwe Presentation facility setting in Uganda (Hoima regional referral hospital) 20 A Church’s Contribution to Ending Obstetric Fistula:The Uganda M. Kahwa Presentation experience of Nyaigana Archdeaconry* 21 Reproductive intentions among women treated for Uganda M. Tumuusime Presentation obstetric fistula – A case study from two treatment sites in Uganda 22 A Retrospective Review Of Obstetric Fistula Repairs At Uganda N. Angella Presentation Jinja Regional Referral Hospital 23 Infertility Among Survivors of Obstetric Fistula, A Uganda N. Florence Presentation Retrospective Analysis of Fistula Survivors at A Fistula Treatment Facility in Rural Uganda* 24 Amidst Underlying Poverty: Exploring Financial, Global E. Nwala Presentation Transportation, and Opportunity Costs Associated with Fistula Management and Repair in Nigeria and Uganda 25 Influence of Psychological, Social, Cultural, and Gender Global P. Sripad Presentation Dynamics on Women’s Decisions to Seek Fistula Repair in Nigeria and Uganda 26 Les defies que recontrent les femmes reparees des FUG- DRC C. Amisi Presentation DB: Cas de Kongolo et Kabalo en RDC* & Poster 27 Les fistules urétéro-vaginales d’origine obstétricale : le DRC D. Nembunzu Poster profil épidémiologique, les circonstances d’accouchement, les éléments diagnostics et thérapeutiques Hôpital Saint Joseph Kinshasa, République Démocratique du Congo* 28 Using results from a site survey to build physiotherapy DRC L. Keyser Poster capacity for women’s health in Democratic Republic of Congo and Nigeria 29 Investigating the use of manual therapy and vaginal DRC L. Keyser Poster dilators for treatment of vaginal stenosis and fibrosis: a case example 30 Randomised trial of 7-day versus 14-day postoperative Guinea A. Delamou Poster bladder catheterisation of simple female genital fistula in Guinea: four years follow-up outcomes in Guinea 31 Surgical Safety Training Program in Fistula Care Nigeria A. Amodu Poster
32 Pregnancy and childbirth after repair of obstetric fistula Regional A. Delamou Poster in sub-Saharan Africa: A scoping review 33 Village Health Teams – a cradle for family planning Uganda M. Tumusiime Poster access –the experience of two communities in rural Uganda Annual Report • October 2016 – September 2017 Fistula Care Plus 142
I. Presentations and Posters at ISOFS Title Country First Author Format 34 Assessing Level of Utilization of Partograph in Uganda F. Acheng Poster Prevention of Obstetric Fistula in Hoima Regional Referral Hospital
* Abstracts written by FC+ partners with technical review and input from FC+ team members.
II. Plenary Presentations at ISOFS by FC+ Team Members Session Title Speaker Conservative Management of Intractable Jessica McKinney Incontinence Fighting for Global Pelvic Floor Care for Patients Lauri Romanzi with Fistula: The Fistula Care Plus Project
III. FC+ Chaired Parallel Panel Sessions at ISOFS Session Title Chair Prevalence/Epidemiology Studies Bethany Cole Untitled [Community outreach, screening, and Lauri Romanzi partnership] Evaluation/Treatment Outcomes/Quality of Care Habib Saduaki Inoperable Fistula Lauri Romanzi Innovations for Fistula Deemed Irreparable Habib Saduaki Untitled [Sexual and reproductive issues among Lauri Romanzi fistula clients, including FGM] Mentoring, Monitoring and Evaluation of Service Adamu Isah Mentoring, Monitoring and Evaluation of Service Bethany Cole
IV. FC+ Sessions at IOFWG Session Description Speakers Fistula Care Plus Updates on 5 Program Objectives: Lauri Romanzi 1) Public Private Partnerships in the Fistula Community of Practice (CoP) Amina Bala 2) The role of CBOs in facilitating UNFPA mandate to end fistula within a Vandana Tripathi generation – How do communities understand the spectrum of risk of Bethany Cole prolonged/obstructed labors specifically and risks of non-SBA delivery in general? 3) Mobile technology and other innovations for fistula screening and referral 4) Global Surgery CoP – Key component towards ending fistula within a generation 5) Standardizing M&E indicators for fistula programs
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APPENDIX G: FC+ CLINICAL MEETING AGENDA AND PARTICIPANT LIST
Ensuring clinical quality across Fistula Care Plus (FC+) services October 29 - November 1, 2016 Nicon Luxury Hotel | Abuja, Nigeria MEETING OBJECTIVES
Discuss clinical issues emerging from FC+ M&E data and DDM analyses. Discuss key Year 4 clinical activity areas, including pelvic organ prolapse (POP) integration, family planning (FP), and fistula etiology classification Review new toolkit of FC+ clinical trackers and checklists for quality assurance and surgical safety; discuss plans for usage in each FC+ country. Discuss other administrative and technical topics relevant to clinical team at start of project year four.
DAY 1: SATURDAY, OCTOBER 29 Time Session Speaker/Facilitator 8:30am Breakfast and sign-in 9:00am Welcome, introductions, and review of agenda and Lauri Romanzi, Project expectations Director 9:30am Setting the stage – four key clinical issues emerging from Lauri Romanzi FC+ M&E/DDM: Vandana Tripathi, Deputy 1. Variation in not-closed rates Director 2. Variation in classification of perineal tears vs. fistula 3. Variation in iatrogenic fistula classification practice 4. Variation in uptake of non-surgical treatment 10:30am Small group discussions of key clinical issues – summary of All participants current responses and actions planned in Year 4 12:00pm Lunch 1:00pm Presentation of country responses to key clinical issues Country rapporteurs 2:00pm POP integration: Update on strategy and progress Renee Fiorentino, Consultant 3:00pm Break 3:15pm FP: Year four initiatives quality, method mix, and adherence Lauri Romanzi to SOPs Bethany Cole, Global Program Manager 4:45pm Preview Day 2 agenda – clinical monitoring and tracking Lauri Romanzi tools
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DAY 2: MONDAY, OCTOBER 31
Time Session Speaker 8:30am Breakfast 9:00 am Review of Day 1 Meeting participant, TBD 9:30am Detailed review of toolkit of clinical trackers and checklists Lauri Romanzi for quality assurance and surgical safety 12:00pm Lunch 1:00pm Country discussion of need for new clinical tools and action All participants plans to introduce relevant elements of clinical toolkit 2:00pm Presentation of country action plans Country rapporteurs 3:00pm Break 3:15pm Electronic medical records and patient databases: Adamu Isah, Nigeria presentation of year four country plans Paul Muwanguzi, Uganda 4:00pm FC+ Year 4 clinical workplans – highlights and common Bethany Cole Themes 4:30pm Review Day 2 & homework (review clinical Lauri Romanzi trackers/checklists) 5:00pm Reception
DAY 3: TUESDAY, NOVEMBER 1 Time Session Speaker 8:30am Breakfast 9:00 am Review of Day 2 Meeting participant, TBD 9:30am Revisions to clinical monitoring and tracking toolkit Lauri Romanzi 10:45am Fistula etiology classification working group: Aims and Lauri Romanzi country-level next steps 12:00pm Lunch 1:00 Open mic: opportunity to discuss clinical issues that have All participants not been raised 2:00pm Administrative issues relevant to country programs Bethany Cole 2:30pm Thanks & closing remarks (break by 3:00pm) Lauri Romanzi
LIST OF PARTICIPANTS (IN ALPHABETICAL ORDER) Country Participants Bangladesh Farhana Akhter, SK Nazmul Huda, Israt Jahan DRC Felicien Banze, Alexandre Delamou, Michel Mpunga Nigeria Olajumoke Adekogba, Abiodun Amodu, Amina Umma Bala, Babafemi Francis Dare, Adamu Isah, Habib Sadauki Uganda Paul Muwanguzi W Africa Niger Issoufou Balarabe, Aboubacar Garba Global Isaac Achwal, Elly Arnoff, Lauren Bellhouse, Bethany Cole, Altiné Diop, Renée Fiorentino, Lauri Romanzi, Vandana Tripathi
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APPENDIX H: CATHETERIZATION FOR FISTULA PREVENTION AND TREATMENT: OPPORTUNITIES FOR PARTNERSHIP
Genital fistula is a devastating injury, most commonly resulting from inadequately managed prolonged/obstructed labor. Around the world, 1-2 million women are living with fistula and need treatment. Tens of thousands of new cases occur each year. With support from USAID, the Fistula Care Plus (FC+) project (www.fistulacare.org) works in priority countries in sub-Saharan Africa and South Asia to strengthen the ability of health systems and communities to address fistula. FC+ currently supports prevention, treatment, and reintegration services in Bangladesh, the Democratic Republic of Congo, Niger, Nigeria, Togo, and Uganda. EngenderHealth also supports fistula treatment in Guinea.
Safe urinary bladder catheterization plays a critical role in fistula care from prevention to treatment: Adequate bladder care, including catheterization if needed, is part of quality labor and delivery care. Catheterization after prolonged or obstructed labor may prevent the formation of obstetric fistula. If fistula has already formed, early catheterization (within 4 weeks of injury) as conservative treatment appears to close up to 25% of fistulas without surgery. Catheterization is an essential part of post-operative care in surgical fistula repair; recent evidence suggests that shortened (7-day) catheterization is non-inferior to longer (14-day) current practices.
Scale-up of safe catheterization, including the adoption of shortened post-repair catheterization, could prevent some fistulas, enable the treatment of many more women, and dramatically reduce the burden repair services place on women by significantly reducing the number of days of catheterization after fistula surgery. Numerous barriers, however, prevent the broader use of catheterization as part of prevention and treatment services in the countries with the greatest fistula burden. These include: Limited availability and poor quality of catheterization supplies Inadequate catheter training, practice, skills, and confidence among clinical cadres providing maternal health services Absence of policies and guidelines to support catheterization for fistula prevention and non-surgical management. Policies that prevent or discourage all relevant cadres from practicing catheterization
FC+ has identified several opportunities for partnership with global manufacturing leaders to address these barriers and realize the potential impact of quality, timely and appropriate catheterization. These include partnership to support: Affordable pricing of high quality urinary bladder catheters, lubricant gel, urine collection bags and related commodities to facilities currently unable to access adequate supplies for obstetric and fistula catheter-based care through existing supply chains. High-quality training and other support so that midwives and other cadres can safely practice catheterization for obstetric and fistula care. Documentation and advocacy to promote evidence-based adoption of policies supporting catheterization for fistula prevention and non-surgical management of fresh fistula.
Partnering with FC+ could also enable:
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Bringing catheter procedures to new facilities and health networks, particularly in rural areas. Increasing the inclusion and prominence of catheterization in national policy and health care training, resulting in increased future demand and formal budget allocation for procurement. Bringing manufacturers to the table at medical events for physicians, health planners, and procurement agents in FC+ countries and at global forums such as the International Confederation of Midwives Triennial Congress in 2017.
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APPENDIX I: CESAREAN SECTION TECHNICAL CONSULTATION EXECUTIVE SUMMARY
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APPENDIX J: CESAREAN SECTION TECHNICAL CONSULTATION MEETING AGENDA
Cesarean Section Safety and Quality in Low Resource Settings | 27-28 July, 2017 Harvard T. H. Chan School of Public Health, Sebastian S. Kresge Building 677 Huntington Avenue, Boston, MA Meeting Location: Building 1, 12th Floor, Room 1208 |
MEETING AGENDA
OBJECTIVES
Convene key technical experts in the maternal/newborn health and safe surgery communities to:
Understand the context of Cesarean section procedures in LMIC settings (facility setting, healthcare worker cadre, indication, outcomes, etc.) Describe important contributors to an unsafe health system environment for Cesarean section Identify knowledge gaps related to Cesarean section safety and quality that require further data or evidence Identify key areas of action to ensure safety and quality of Cesarean sections in LMIC Brainstorm ideas to raise the profile of Cesarean section safety and quality concerns and build commitment to enact a plan of action on this issue
THURSDAY, 27 JULY 2017 Time Session Speaker(s)
8:30am Breakfast and registration 9:00 Welcome to participants Ana Langer Review of meeting objectives and agenda Lauri Romanzi Review of key meeting logistics Mary Nell Wegner 9:30 Participant introductions All 9:45 Fistula Care Plus (FC+) background and program Vandana Tripathi findings Lauri Romanzi Overview of proposed “flashpoints” in C-section safety: concerns & opportunities 10:15 The landscape of C-sections in low-resource settings: Lenka Benova Who, where, why? Francesca Cavallaro 11:00 Tea/coffee break 11:15 Safe surgery: An emerging global movement Lina Roa 11:45 Flashpoint 1: Linkages between safe surgery and maternal Yirgu Gebrehiwot health communities Hannatu Abdullahi Flashpoint 2: Human resources: Workforce density Luis Gadama Flashpoint 3: Human resources: Task shifting 12:30 Lunch 1:30 Flashpoint 4: Clinical decision making and patient selection Fernando Althabe – protocols and practice Kathleen Hill
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Time Session Speaker(s) Flashpoint 5: Informed consent and patient rights Lauri Romanzi Flashpoint 6: Anesthesia care John Varallo Flashpoint 7: Infection prevention and management 2:30 C-section safety and quality: A US perspective Neel Shah 3:00 Tea/coffee break 3:15 The place of C-section in safe surgery plans: Malawi, Luis Gadama Tanzania, and Zambia John Varallo Bellington Vwalika 4:00 C-section safety and quality: The South Asian context Rubina Sohail Manju Chhugani 4:30 Preview Day 2 agenda (break by 5:00pm) Vandana Tripathi 5:30 Cocktail reception – Kresge 110
FRIDAY, 28 JULY 2017 Time Session Facilitator(s)
8:30am Breakfast 9:00 Review of flashpoints and discussion from Day 1 Mary Nell Wegner 9:30 Small groups: Discuss priority actions required to improve Small groups C-section safety and quality 11:00 Report back on small group discussions Small group rapporteurs 11:45 Lunch 12:45 Ranking priority actions to develop a consensus agenda Vandana Tripathi 1:45 What does it take to achieve this agenda: Barriers and Small groups enablers 3:00 Report back on small group discussions Small group rapporteurs 3:45 Acting on the agenda: Immediate next steps Ana Langer 4:15 Close Mary Ellen Stanton
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APPENDIX K: CESAREAN SECTION TECHNICAL CONSULTATION PARTICIPANTS
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APPENDIX L: LANDSCAPE OF CAESAREAN SECTIONS IN SUB-SAHARAN AFRICA AND SOUTH/SOUTHEAST ASIA - DRAFT EXECUTIVE SUMMARY
Draft Executive Summary | July 27, 2017 The landscape of caesarean sections in sub-Saharan Africa and South/Southeast Asia
Part A. Multi-country analysis Data from recent population-representative Demographic and Health Surveys (DHS) conducted in 34 countries in sub-Saharan Africa and 10 in South/Southeast Asia between 2002 and 2016 were analysed. Caesarean section rates were based on most recent live births in the survey recall period and all information about the delivery (location, assistance, and mode) is based on women’s self-report.
1. Where do caesarean sections occur?
- We estimated caesarean section rates for each country, and within countries by area of residence and ownership and level of facility. Ownership or sector was defined as public (all governmental and parastatal facilities) and non-public (all facilities outside of the public sector, including for-profit, non- governmental organisations, faith-based organisations and facilities with unknown ownership/ profit motive). Facility level was defined as hospitals versus lower/unknown/mixed level. In most countries, response options within the non-public sector did not separate hospitals from lower-level facilities (e.g. “private clinic/hospital”); the category “hospital” is therefore composed solely of public sector hospitals in the majority of countries. - Figure 1 shows that the national caesarean section rates ranged widely, from 1.5% in Chad to 33.8% in the Maldives. Caesarean section rates for urban populations were higher than for rural in all countries; the narrowest urban:rural ratio was in Swaziland (1.1) and the widest in Ethiopia (19.2). - The percentage of births occurring in facilities ranged from 12.1% in Ethiopia to 97.2% in the Maldives, with a median across the countries of 66.4%. In none of the sub-Saharan African countries did non- public facilities provide more than half of facility deliveries (highest in Nigeria 37% and Swaziland 43%); some countries had a negligible non-public provision (e.g. <1% in Sao Tome and Principe, 2% in Burkina Faso). On the other hand, four of the ten South/Southeast Asian countries (Bangladesh, India, Indonesia, Pakistan) had a predominantly (>50%) non-public facility delivery provision. In most of the 44 countries, caesarean section rates in non-public facilities were higher than in public facilities (median ratio non-public:public 1.5); Namibia had the highest (3.6) and Vietnam the smallest (0.1) non-public:public caesarean section ratio.
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Figure 1. National (bars), urban (upper error bar) and rural (lower error bar) caesarean section rates 45 40 35 30 25 20 15 10 5
0
DRC
Mali
India
Togo
Chad
Niger
Benin
Nepal
Kenya
Ghana
Gabon
Liberia
Guinea
Nigeria
Zambia
Malawi
Uganda
Gambia
Senegal
Burundi Lesotho
Rwanda
Ethiopia
Namibia
Pakistan
Vietnam
Congo-B
Tanzania
Comoros
Maldives
Indonesia
Sao Sao Tome
Swaziland
Cambodia
Cameroon Zimbabwe
Philippines
Bangladesh
Timor-Leste
Madagascar
Sierra Leone Sierra
Cote Cote d'Ivoire Burkina FasoBurkina Mozambique 2. Who performs caesarean sections?
- We categorised the person with the highest level of medical training from women’s potentially multiple responses about who assisted with their delivery into: doctor (includes the cadre of medical/clinical officer as response options were conflated), non-doctor skilled birth attendant (SBA) such as nurse and midwife (according to WHO and country-level definitions), and all non-SBAs (lower level medical professionals, traditional birth attendants, and relatives). - The percentage of women with a caesarean section who reported that the highest cadre assisting their delivery was not a SBA was minimal (median in 44 countries: 0.4%) and most likely a recall error. However, relatively high levels were seen in Chad and Gambia (4%), and in Senegal (10%). - Countries varied widely in the percentage of caesareans assisted by non-doctor SBA. All countries in South/Southeast Asia had levels ≤5% except for Cambodia (37%) and Timor-Leste (49%). In sub- Saharan Africa, Rwanda had the lowest level (7%), but 28 of the 34 countries in this region had levels above 20% and six above 50% (Burkina Faso and Mali had highest levels at 70%). - We had sufficient sample size to compare percentages of caesareans with non-doctor SBA by facility ownership in 28 of the 44 countries. In sub-Saharan Africa, 18 of the 20 countries with data had a higher percentage of non-doctor SBA caesareans in public compared to non-public facilities (widest difference in Namibia, public: 39%, non-public 3%). In South/Southeast Asia, four countries had higher percentages in public (widest difference in India, public: 7%, non-public 3%), and four countries in non- public facilities (widest difference in Indonesia, public: 10%, non-public 23%).
3. Who delivers by caesarean section?
- We assessed the profiles of women using proxies for nine risk factors for maternal and newborn complications28 which were collected on the DHS: woman’s age 35+ years, woman’s age <16 years, primiparity, grand multiparity (birth order 6+), preceding birth interval <12 months, multiple gestation, received no antenatal care, preceding live birth in recall period resulted in neonatal death, and caesarean section(s) in recall period. Some risk categories are mutually exclusive and some are highly correlated. The maximum possible number of risk factors for a single woman is seven, the maximum seen in data was six. We compared risk profiles between all women with live births, those who delivered in facilities, and those who had a caesarean.
28 These demographic and reproductive risk factors are not in and of themselves indications for caesareans, however they are associated with clinical complications which may in turn be indications for caesarean sections. For example, nulliparous women are at higher risk of prolonged labour, which may in turn cause foetal distress, both of which may indicate need for a caesarean. Annual Report • October 2016 – September 2017 Fistula Care Plus 154
- In the 44 countries, most common risk factors among all women with live births were primiparity (median across countries 22%), grand multiparity (20%), and age 35+ (18%). The median percentage with one or more risk factors was 56%, ranging from 46% (Malawi) to 79% (Ethiopia). - Women delivering by caesarean section were equally or more likely to have had one or more risk factors compared to all women with births (median across countries: 71% and 56%, respectively). - We calculated a ratio comparing the percentage of women with each factor among caesarean births versus among all births. The highest median ratios were seen for three risk factors: caesarean section in recall period (9.2), multiples (2.2), and primiparity (1.5). Conversely, the lowest median ratios (lower than one, meaning they were under-represented in caesarean section births) were among women with no antenatal care (0.2) and grand multiparae (0.5). - Broadly, women with exactly one risk factor were over-represented, and women with two and 3-6 risk factors were under-represented in caesarean sections compared to the underlying population of all births (as can be seen on the example of Ethiopia in Figure 2). This seems to be driven partly by primiparity, a common risk factor. - These results echo other findings that differences in caesarean rates among “NTCS” deliveries (nullipara, term, cephalic, singleton) account for much of the differences in overall caesarean rates between health facilities in high-income countries. Trends among nulliparous women are particularly important given that women with previous caesareans often require a caesarean at the next delivery, especially in contexts where trial of labour after caesarean is rare or unsafe, thereby setting women on a trajectory of repeat caesareans throughout their reproductive life.
Figure 2. Distribution of numbers of risk factors in Ethiopia (DHS 2011)
Part B. Tanzania case study
1. Time trends
- We analysed five rounds of DHS data (1996, 1999, 2005, 2010, and 2016). All analyses were based on the denominator of most recent live births in the 5-year recall period before each survey. - Over the 25-year period covered by the surveys, the overall caesarean section rate increased from 2.3% to 7.0%. The differences between caesarean section rates according to residence were smaller than by wealth quintile (3x higher in urban than rural and 6x higher in richest versus poorest quintile in 2016) as shown in Figure 3. The relative width of these gaps has remained constant.
Figure 3. Caesarean section rates (national, poorest and richest wealth quintile in error bars)
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- The percentage of births that occurred in health facilities increased from 48.8% in 1996 to 67.9% in 2016. The majority of facility births occurred in the public sector, but the share of facility deliveries occurring in the non-public sector increased from 7% to 22% during this time period. - The annual number of caesarean sections performed in Tanzania increased five-fold from 28,500 in 1991-1996 to around 140,000 in 2011-2016 (Figure 3). - The facility caesarean section rate increased from 4.7% to 10.3%. While in 1996, there was no difference in the caesarean section rate between public and non-public facilities, in 2016, non-public facilities had a caesarean section rate 2x higher than public facilities (16.9% versus 8.4%). During this time, the percentage of all caesarean sections in Tanzania performed in public sector facilities declined from 93% to 64%.
2. Characteristics of facilities performing caesareans (Service Provision Assessment 2014/15)
- The majority of caesareans were performed in public hospitals (two thirds) or faith-based organization hospitals (26%). - Over 90% of caesareans was conducted in high- volume facilities (>60 caesareans per month), but 5% was conducted in facilities performing <10 caesareans per month. - Fewer than 50% of facilities performing caesareans had piped water into the facility and a consistent electricity supply, and only 38% had performed all CEmOC signal functions in the past 3 months. - Only 25% of caesareans were done in facilities meeting all three minimum readiness criteria: piped water and consistent electricity, all general anaesthesia equipment, and 24hr rota for caesarean provider and anaesthetist. - The availability of minimum readiness criteria differed by region (Figure 4) and facility type. Figure 4. Percentage of facilities providing caesareans meeting the 3 minimum readiness criteria
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Part C. Bangladesh case study
1. Time trends
- We analysed four rounds of DHS data (1999/00, 2004, 2011, and 2014), examining the most recent live birth in the 3-year recall period of each survey. We found that the overall caesarean section rate increased nearly 10-fold in the 15-year period examined, from 2.9% to 24.4%. There were wide geographic disparities in the rate (by urban/rural residence and region), but the widest disparity was by wealth (in 2014: 7.3% among poorest and 54.1% among richest quintiles), as shown in Figure 5.
Figure 5. Caesarean section rates (national, poorest and richest wealth quintile in error bars)
- Over time, the percentage of all births that occurred in health facilities more than quadrupled from 9.0% (1999/00) to 38.9% (2014).The facility caesarean section rate doubled from 32.5% to 63.1% during this time. The annual numbers of caesarean sections performed in Bangladesh increased from around 100,000 in the recall period of the 1999/00 survey to over 770,000 in the latest survey (Figure 5). - The percentage of facility deliveries occurring in the public sector halved from 64.4% to 33.8% between 1999/00 and 2014. The caesarean section rate in non-public facilities was 1.6x higher than in public facilities in 1999/00 and this ratio rose to nearly 2x higher by 2014. During this time, the share of all caesareans performed by the public sector declined from 53% to 21%.
2. Self-reported clinical information on caesareans (DHS 2014)
- Most caesareans were performed on weekdays (Sunday-Thursday) and between 9-6pm. In public facilities, the proportion of caesareans performed on weekends was lower, and the gap between 9am- 6pm and 6pm-12am was more pronounced than in the non-public sector. - Almost half (45%) of caesareans were reported to be decided on the day of delivery, around one quarter 1-7 days before, and 30% more than seven days before the intervention. On average, women delivering by caesarean stayed in the facility for almost seven days after the birth, with only 3% of women with caesareans staying less than 72 hours (the definition used for too short a stay). - The mean fees paid for a delivery were more than four times as high for caesareans (21,197 taka, USD261 equivalent) than for vaginal deliveries (4800 taka, USD59 equivalent). Caesarean fees were 1.5 times higher in non-public facilities compared with public facilities. - Among all caesareans, the two most commonly reported reasons for the caesarean were “other complications during delivery” (32.7%) and “malpresentation” (32.5%). This highlights the limitations of these data: first, we do not know the reason for one third of caesareans; second, true
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malpresentations are unlikely to account for one third of caesareans (or 8% of all deliveries). Caution is therefore needed in interpreting self-reported reasons for caesareans. - The reported timing of the decision for caesarean was not always consistent with the reported indication. For example, only 44% of caesareans reported to be performed for cord prolapse were decided on the day of the intervention.
This draft Executive Summary was written by Lenka Benova ([email protected]) and Francesca Cavallaro ([email protected]) with guidance from Professor Oona Campbell, and reviewed by Vandana Tripathi ([email protected]). This document is not for circulation. An expanded report on these analyses will be available for circulation in late 2017.
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APPENDIX M: HRH FORUM PROGRAM FLYER
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APPENDIX N: SBA SURVEY ANNOUNCEMENT
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APPENDIX O: ICM 2017 PANEL ADVERTISEMENT
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APPENDIX P: 31ST ANNUAL ICM CONGRESS PANEL
Obstructed labor does not end at delivery: Strengthening postpartum care following prolonged/obstructed labor By Elly Arnoff, Lauri Romanzi, and Vandana Tripathi
On June 20, 2017, at the 31st International Confederation of Midwives (ICM) Triennial Congress in Toronto, Canada, the U.S. Agency for International Development (USAID)– supported Fistula Care Plus (FC+) project at EngenderHealth convened a breakfast panel discussion cosponsored by Bard Medical on postpartum care following prolonged/obstructed labor (P/OL).
The panel was moderated by Dr. Lauri Romanzi, FC+ Director, and involved the following panelists: Dr. Vandana Tripathi, FC+ Deputy Director Dr. Pandora Hardtman, International Midwifery Consultant Dr. Ekpoanwan Esienumoh, Senior Lecturer and Professor of Midwifery at University of Calabar, Nigeria Dr. Jeffrey M. Smith, Vice President, Jhpiego
Dr. Romanzi opened the panel by reminding participants of the many sequalae related to P/OL: Women may experience fistula, sepsis, foot drop, and chronic depression/anxiety, and infants may experience cerebral palsy or even stillbirth, to name a few.
Dr. Tripathi began her presentation by emphasizing that the World Health Organization has called obstructed labor “the most disabling of all maternal conditions,” by contributing to 2.8% of global maternal mortality and complicating 3–6% of deliveries. Despite the gravity of P/OL, substantial gaps and inconsistencies exist in the guidance available to the skilled birth attendants (SBAs) who manage the condition. The research and clinical literature on P/OL provides no clear, consensus definition on the condition, and the terminology associated with it varies, leading to delays in identification of, referral for, and management of P/OL. Additionally, much of the guidance for SBAs does not provide sufficient information on postpartum evaluation and management of P/OL. The majority of the global health focus on the sequelae of P/OL is restricted to identifying and treating obstetric fistula, with no training programs for evaluating and managing other incontinence conditions, mental health sequelae, hypoxic encephalopathy conditions suffered by live born infants, foot drop, diastasis pubis, infertility, or severe vaginal scarring. These sequelae often occur together, and there is
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limited understanding of the extent to which these conditions contribute to stigma, isolation, and an ability to return to a normal life.29
Catheterization is a crucial component of P/OL management and of primary and secondary obstetric fistula prevention.30,31,32 First, catheter insertion during P/OL keeps the bladder empty, so that the passage of the baby is not blocked during labor. Second, short- to medium- term duration of postpartum catheterization may prevent fistula after P/OL, though the evidence base for its efficacy and effectiveness is minimal. Third, a growing body of evidence suggests that catheterization of a bladder that has a fresh fistula may allow the fistula to close spontaneously, without surgical intervention.33
While the literature on fistula contains more guidance on the Foley catheters on display at panel postpartum period, there are still important inconsistencies, such as event. Photo credit: Elly Arnoff. the recommended duration of time for urinary catheterization after P/OL. To understand the range of postpartum practices that SBAs employ, FC+ launched an online global survey targeting SBAs from low- and middle-income countries on intrapartum and postpartum practices related to P/OL and bladder care management. Dr. Tripathi presented the preliminary findings from the survey’s pilot phase, highlighting the considerable variation in responses on how SBAs define P/OL, the criteria they use to assess it, and the amount of time they catheterize after P/OL. Dr. Tripathi concluded by encouraging attendees to take the survey and share it widely with their SBA network, so that the findings represent the reality on the ground and so practitioners can better support SBAs in managing P/OL.
Dr. Hardtman started her presentation with an evocative case study of how midwifery-led prevention and conservative management of obstetric fistula through urinary catheterization has a profound impact for women who experience P/OL and reduces the need for surgical repair of fistula. Not only is urinary catheterization a cost-effective alternative to surgery, but it also capitalizes on nurses’ and midwives’ existing skill set. Dr. Hardtman introduced three important guidelines for the clinical management of obstetric fistula and urinary catheterization: 1) WHO’s Obstetric fistula: Guiding principles for clinical management and programme development (2006); 2) the East, Central, and Southern African Health Community’s The prevention and management of obstetric fistula: A curriculum for nurses and midwives (2012); and 3) the Nigeria Federal Ministry of Health’s Guidelines on urethral catheterization for
29 Drew, L. B., Wilkinson, J. P., Nundwe, W., et al. 2016. Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: a qualitative study. BMC Pregnancy and Childbirth, 16(1), 2. doi: 10.1186/s12884-015- 0755-1. 30 Lewis, G., and De Bernis, L. 2006. Obstetric fistula: Guiding principles for clinical management and programme development. Geneva: World Health Organization (WHO). Accessed at: www.who.int/maternal_child_adolescent/documents/9241593679/en/. 31 Nigeria Federal Ministry of Health. 2016. Guidelines on urethral catheterization for prevention and management of obstetric fistula in Nigeria. Abuja. 32 East, Central and South African Health Community (ECSA-HC) and Fistula Care/EngenderHealth. 2012. The prevention and management of obstetric fistula: A curriculum for nurses and midwives. New York: EngenderHealth/Fistula Care. Accessed at: https://fistulacare.org/wp-fcp/wp- content/uploads/pdf/Training/nursing_curriculum_2012_forweb.pdf. 33 Isah, A., Romanzi, L., and Levin, K. 2016. Conservative treatment of obstetric fistula: A quick review from supported facilities in Nigeria. Presentation at the International Scientific Conference of the International Society of Obstetric Fistula Surgeons, Oct. 24–28, Abuja, Nigeria Annual Report • October 2016 – September 2017 Fistula Care Plus 164
prevention and management of obstetric fistula in Nigeria (2016). While these resources provide concrete guidance to SBAs, the theory-to-practice gap in implementing these practices remains considerable, due to challenges such as the requirement of physician orders before midwives can perform certain interventions and inadequate water and supplies. As a result, these guidelines have not been widely adopted by midwives and nurses. After a discussion of the guidelines, the moderator underscored three distinct points when Dr. Hardtman speaks to the breakfast panel clinicians can utilize urinary catheterization to attendees. Photo credit: Elly Arnoff. address obstetric fistula: 1) intrapartum, if the patient cannot void during labor; 2) immediately following P/OL, as a primary prevention strategy; and 3) during the postpartum period, as conservative treatment of fistula.
Dr. Esienumoh discussed midwifery-managed prevention and conservative management of obstetric fistula efforts in Nigeria. The Nursing and Midwifery Council of Nigeria (NMCN) regulates the practice of midwifery in Nigeria and participates in the formulation of all Federal Ministry of Health (FMOH) guidelines, including the recently released catheterization guidelines. Following the release of the guidelines, NMCN has been working with the FMOH to develop and disseminate related guidelines specifically for nurses and midwives. They are also working on integrating a preservice package into existing curricula for nurses and midwives and updating other training curricula with content from these guidelines. Dr. Esienumoh emphasized that it is critical for nurses and midwives to be at the forefront of developing and implementing such guidelines, and those implementation strategies should be both sustainable and donor-driven.
Dr. Smith discussed the issue of maternal and early newborn sepsis as an additional consequence of P/OL. Dr. Smith stressed the need for a more comprehensive and approach to manage P/OL and its related sequelae and encouraged childbirth clinicians to reflect on whether current approaches contribute to increased infections and complications in labor, citing how increased cesarean section rates also lead to infection or iatrogenic fistulae. Despite substantial progress in reducing maternal mortality over the last two decades, especially in regard to postpartum hemorrhage and pre-eclampsia, there are still considerable gaps in how clinicians address more complex cases. Dr. Smith reviewed the services offered in basic and comprehensive emergency obstetric care facilities and called for innovative approaches to providing intensive obstetric care for complex maternal cases. He stated that P/OL is as severe and urgent an obstetric emergency as eclampsia, hemorrhage, and fetal distress and that it falls upon the maternal health community to make sure that this level of priority includes P/OL in every facility providing childbirth services. Dr. Smith explained that current global guidelines addressing maternal sepsis recommend use of simple antibiotics; however, this requires a series of eight intravenous injections in the first 24 hours after delivery, and doing so is challenging in low-resource settings, where there are considerable shortages of health care workers. Alternative antibiotic regimens that are both effective and simple to implement need to be developed. Dr. Smith concluded by emphasizing the need to think more critically about P/OL and the various dimensions of maternal newborn infection that go along with it.
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While time was limited, panel attendees generated a lively and thoughtful discussion following the formal presentations. One attendee noted that partographs are often completed after deliveries are over, distorting their intended purpose in labor monitoring and identifying prolonged/obstructed labor. Panelists discussed the need for integrated training and support that covers the partograph as part of a continuum of care. (Prior work by EngenderHealth and its partners on the partograph also addresses these challenges34,35. Attendees also discussed the steps involved in building nursing and midwifery capacity to implement the new guidelines and empowering them to optimize their skills and roles in managing P/OL. Dr. Smith pointed out that Derrick Nield from Bard Medical addresses the lessons can be learned from other interventions and audience. Photo credit: Elly Arnoff. services that midwives have integrated into their practice and that all new service provision approaches are opportunities to collect data and document the efficacy of these changes.
Those interested in learning more about intrapartum and postpartum bladder care, management of prolonged/obstructed labor, and urinary catheterization for the prevention of obstetric fistula may consult the following resources:
Bailey, P., Fortney, J., Freedman, L., et al. 2002. Improving emergency obstetric care through criterion-based audit. New York: Averting Maternal Death and Disability (AMDD) Project/Columbia University. Accessed at: www.mailman.columbia.edu/sites/default/files/pdf/criterionbased_auditen.pdf.
Canterbury District Health Board (ed). 2015. Intrapartum and postnatal bladder care. Canterbury, UK: Maternity Guidelines Group. Accessed at: www.cdhb.health.nz/Hospitals-Services/Health-Professionals/maternity-care- guidelines/Documents/GLM0038-Bladder-Care-Intrapartum-and-Postnatal-232105.pdf.
East, Central and South African Health Community (ECSA-HC) and Fistula Care/EngenderHealth. 2012. The prevention and management of obstetric fistula: A curriculum for nurses and midwives. New York: EngenderHealth/Fistula Care. Accessed at: www.engenderhealth.org/files/pubs/fistula-care-digital- archive/3/3.1/Prevention-Management-Nursing-Curriculum-English.pdf.
Graham, W., Wagaarachchi, P., Penney, G., et al. 2000. Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries. Bulletin of the World Health Organization 78(5):614-620. Accessed at: www.who.int/bulletin/archives/78(5)614.pdf.
Hancock, B., & Browning, A. 2009. Practical obstetric fistula surgery. London: Royal Society of Medicine Press. Accessed at: www.glowm.com/resources/glowm/pdf/POFS/POFS_full.pdf.
34 Fistula Care and Maternal Health Task Force. 2012. Revitalizing The partograph: Does the evidence support a global call to action?—Report of an expert meeting. New York, November 15-16, 2011. New York: EngenderHealth/Fistula Care. Accessed at: https://fistulacare.org/wp-fcp/wp-content/uploads/pdf/program- reports/EngenderHealth-Fistula-Care-Partograph-Meeting-Report-9-April-12.pdf. 35 Bedwell, C., Levin, K., Pett, C., et al. 2017. A realist review of the partograph: When and how does it work for labour monitoring? BMC Pregnancy and Childbirth 17(31), 2. doi: 10.1186/s12884-016-1213-4. Annual Report • October 2016 – September 2017 Fistula Care Plus 166
Lewis, G., and De Bernis, L. 2006. Obstetric fistula: Guiding principles for clinical management and programme development. Geneva: World Health Organization. Accessed at: www.who.int/reproductivehealth/publications/maternal_perinatal_health/9241593679/en/
Nigeria Federal Ministry of Health. 2016. Guidelines on urethral catheterization for prevention and management of obstetric fistula in Nigeria. Abuja. Accessed at: https://fistulacare.org/blog/2017/02/nigeria-launches-guidelines/.
World Health Organization (WHO). 2004. Making pregnancy safer: The critical role of the skilled attendant: A joint statement by WHO, ICM and FIGO. Geneva: World Health Organization. Accessed at: http://www.who.int/maternal_child_adolescent/documents/9241591692/en/
WHO. 2008. Education material for teachers of midwifery: Midwifery education modules. –2nd ed. Managing prolonged and obstructed labour. Geneva. Accessed at: www.who.int/maternal_child_adolescent/documents/3_9241546662/en/.
WHO, United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF), and Averting Maternal Death and Disability (AMDD) Project. 2009. Monitoring emergency obstetric care: A handbook. Geneva. Accessed at: http://apps.who.int/iris/bitstream/10665/44121/1/9789241547734_eng.pdf
WHO. 2010. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. Geneva. Accessed at: https://www.k4health.org/sites/default/files/4%20WHO_mgt%20complications%20and%20childbirth%202003_0.p df
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APPENDIX Q: ICM PANEL PRESENTATION: PROLONGED/ OBSTRUCTED LABOR
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APPENDIX R: BRIEFING ON LINKAGES BETWEEN FISTULA AND FGM/C
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APPENDIX S: PRIMARY HEALTH FACILITY SCREENING FISTULA JOB AID
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APPENDIX T: COMMUNITY AGENT FISTULA SCREENING JOB AID
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APPENDIX U: FISTULA SCREENING HOTLINE ALGORITHM
Introduction Hello, welcome to the [fistula screening hotline in Nigeria and fistula treatment hotline in Uganda]. This hotline is meant to help you know if you should seek medical care for something called fistula. Fistula can cause constant leakage of urine and/or feces from your vagina during the day and night. This can be both uncomfortable and embarrassing, but you are not alone - many women like you experience this problem, usually after a difficult childbirth, but sometimes also after an assault or after a surgery or operation. Thankfully, with proper medical care, fistula can be treated. We will ask you some personal questions about you and your health. Please answer the questions using the keypad on your phone to select the option that is correct for you. Please answer honestly so that we can advise you well on the medical care that you should seek. This will take less than 5 minutes of your time – let's begin.
Q Question No. How old were you at your last birthday? For 10-14 years, press 1. 1. For 15-19 year, press 2. For 20-24, press 3. For 25-39, press 4. For over 40 years, press 5. Do you currently experience constant leakage of urine or feces from your vagina during the day and night even when you are not urinating or trying to urinate? 2. If yes, press 1. If no, press 2. Nigeria: Do you live in the state of Ebonyi? If yes, press 1. If no, press 2. 3. Uganda: Do you live in the district of Kalungu? If yes, press 1. If no, press 2. Nigeria: If Q3 is “no,” ask Q4. If Q3 is “yes,” proceed to action messages. Uganda: If Q3 is “no” and Q2 is “yes,” proceed to Q5. If Q3 is “no” and Q2 is “no,” proceed to action messages. If Q3 is “yes,” proceed to action messages. Nigeria: Do you live in the state of Katsina? 4 If yes, press 1. If no, press 2. Nigeria: If Q4 is “no” and Q 2 is “yes,” proceed to Q 5. If Q 4 is “no” and Q 2 is “no,” proceed to action messages. If Q 4 is “yes,” proceed to action messages. Nigeria: Where do you live? Please tell us which state, LGA and village you live in. If you do not know, please say, ‘don’t know.’ 5. Uganda: Where do you live? Please tell us which district and village you live in. If you do not know, please say, ‘don’t know.’
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Action Messages after Screening
Uganda Fistula is curable and you can receive free treatment at the Fistula Center at Kitovu Mission Hospital in Central Region. A village health team volunteer will contact you within four days via the cell phone you Within catchment used to make this call. They will provide you with more information on area fistula as well as a voucher for a free trip for you and a companion of (Q3 is “yes”) your choosing to and from the Fistula Center at Kitovu Mission Hospital -- for diagnosis, where you can get properly diagnosed. After you have Positively screened been diagnosed and return home, a village health team volunteer will (Q2 is “yes”) be in contact with you to arrange another free trip for you and a companion to go to one of the upcoming Fistula camps at Kitovu Mission Hospital and receive treatment. Fistula is curable and you can receive free treatment at the Fistula Community agent Center at Kitovu Mission Hospital in Central Region. The village health facilitated call team volunteer, who helped you make this call, will provide you with -- more information on fistula as well as a voucher for a free trip for you Within catchment and a companion of your choosing to and from the Fistula Center at area Kitovu Mission Hospital for diagnosis, where you can get properly (Q3 is “yes”) diagnosed. After you have been diagnosed and return home, the village -- health team volunteer will be in contact with you to arrange another free Positively screened trip for you and a companion to go to one of the upcoming Fistula (Q2 is “yes”) camps at Kitovu Mission Hospital and receive treatment. Positively screened (Q2 is “yes”) Fistula is curable and you can receive free treatment at one of -- Uganda’s fistula treatment camps throughout the year. Within four Outside catchment days, you will receive a follow up SMS with information on the nearest area fistula treatment center to you. (Q3 is “no”) Your symptoms are likely not caused by a fistula, but it is still important Negatively screened that you talk with a health care worker to determine how best to treat (Q2 is “no”) your current symptoms. Please visit the nearest health facility for advice and treatment. Nigeria Fistula is curable and you can receive free treatment at the National Obstetric Fistula Centre (MCCI) in Abakaliki/National Obstetric Fistula Within catchment Centre at Babbar Ruga in Katsina. A community volunteer from the area organization DOVENET/ FOMWAN will contact you within four days via (Q3 or Q4 is “yes”) the cell phone you used to make this call. They will provide you with -- more information on fistula as well as a voucher for a free trip for you Positively screened and a companion of your choosing to go to the National Fistula Centre (Q2 is “yes”) at Abakaliki/ National Fistula Centre at Babbar Ruga in Katsina, where you can get properly diagnosed and treated for free. Community agent Fistula is curable and you can receive free treatment at the National facilitated call Obstetric Fistula Centre (MCCI) in Abakaliki/ National Obstetric Fistula -- Centre at Babbar Ruga in Katsina. The community volunteer from the Within catchment organization DOVENET/ FOMWAN, who helped you make this call, will area provide you with more information on fistula as well as a voucher for a
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(Q3 or Q4 is “yes”) free trip for you and a companion of your choosing to go to the National -- Fistula Centre at Abakaliki/ National Fistula Centre at Babbar Ruga in Positively screened Katsina, where you can get properly diagnosed and treated for free. (Q2 is “yes”) Positively screened (Q2 is “yes”) Fistula is curable and you can receive treatment at one of Nigeria’s -- treatment facilities. Within four days, you will receive a follow up SMS Outside catchment with information on the nearest fistula treatment center to you. area (Q3 & Q4 are “no”) Your symptoms are likely not caused by a fistula, but it is still important Negatively screened that you talk with a health care worker to determine how best to treat (Q2 is “no”) your current symptoms. Please visit the nearest health facility for advice and treatment.
For women who screen positively (i.e. Q2 is “yes”) both within and outside the catchment areas, proceed for further data collection. Otherwise, call ends. Data Collection We will now ask you some additional questions to better understand your condition and respond in the best possible way. As before, please answer the questions honestly and use the keypad on your phone to select the option that is correct for you. This will take an additional 5 minutes of your time – let's begin. Q No. Question When did the problem of leakage of urine and/or feces start? If it started after you delivered a live or stillborn baby, press 1. 6. If it started after abdominal or pelvic surgery while you were not pregnant, press 2. If it started after a sexual assault, attack, or other injury, press 3. If none of the above, press 4. If answer to Q6 IS 1, go to Q7; if answer to Q5 IS 2, 3 or 4, skip to Q8. Did this delivery (after which leaking started) happen normally, did they pull the baby out, or did they cut you/do an operation? 7. If it was a normal delivery, press 1. If it was an assisted vaginal delivery, press 2. If it was a C-section (delivery through the tummy), press 3. Have you ever sought treatment for this problem? 8. If yes, press 1. If no, press 2. If answer to Q8 is “no”, skip to Q12. From whom did you seek treatment most recently? If it was a health professional (such as doctor, midwife or nurse), press 1. 9. If it was a community or village health worker, press 2. If it was a traditional birth attendant or other provider, press 3. If it was someone else, press 4.
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Did the treatment involve surgery? 10. If yes, press 1 If no, press 2 Who has most recently helped you in seeking treatment? If it was your husband, press 1. If it was your husband’s family (such as mother-in-law), press 2. 11. If it was your own family (such as mother, father, sister), press 3. If it was another person, press 4. If you have not received assistance from others, press 5. End here for callers who answer Q9-11. Why have you not sought treatment? Please select the most significant of the following answer choices. If you did not know that treatment is possible or where to go, press 1. If the cost of travel or treatment was too high, press 2. If the distance of treatment was too far, press 3. 12. If it was because of social barriers, such as a lack of permission, embarrassment, isolation, press 4. If it was because you had Concerns about quality of care at the treatment facility, press 5. If it was another reason, press 6.
Close Out Message after Data Collection If answer to Q2 is “yes” and Q 3 or Q 4 is “yes,” then play the following message: You have now completed the screening process. Thank you for your time. Someone will follow up within four days using this mobile number. If answer to Q 2 is “yes,” Q 3 is “no,” and Q 4 (Nigeria) is “no,” then play the following message: You have now completed the screening process. Thank you for your time. You will receive a follow up SMS to this mobile number within four days. If you would not like to receive a follow up message regarding the nearest fistula treatment facility, please press 1. If you would not like to receive a follow up message regarding the nearest fistula treatment facility, please press 2. Follow Up Voice & SMS Message for Positively Screened Women outside Catchment Area If answer to Q2 is “Yes,” Q3 is “No” and Q4 (Nigeria) is “No” Thank you for calling fistula screening/treatment hotline. Fistula is curable and you can receive free treatment. Please visit [name of referral facility] for diagnosis and treatment.
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APPENDIX V: BARRIER REDUCTION STUDY BRIEF: EBONYI
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APPENDIX W: BARRIER REDUCTION STUDY BRIEF: KATSINA
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APPENDIX X: BARRIER REDUCTION STUDY BRIEF: UGANDA
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APPENDIX Y: FC+ CALL FOR CONCEPT PAPERS ON SECONDARY ANALYSIS OF CLINICAL DATA
Support for Special Studies – Secondary Analysis of Clinical Data Call for Concept Papers | November 2016
Fistula Care Plus (FC+) encourages our clinical staff and partners to conduct country-specific special studies that use existing clinical data to investigate and answer questions of relevance for fistula services and programs. See the attached presentation for an example of such a study (Arnoff et al., 2016). In 2017, FC+ will provide technical assistance to a limited number of such clinical studies. Examples of technical assistance include support in defining research objectives, writing analysis plans, conducting secondary analysis of qualitative or quantitative data, and support in reporting and disseminating findings. This call for papers describes the process for requesting FC+ assistance. We request country staff and partners who have an idea for a special study to submit a short concept paper (maximum of two pages) to the FC+ Deputy Director, Vandana Tripathi, and Program Associate – Evaluation & Research, Elly Arnoff. The concept should include:
Author/Contact Information: Name and title of lead staff or clinical person submitting concept and full phone/email/address information. Study Goal: The question you wish to answer, i.e., WHAT you wish to learn. Data/Sample: A brief description of the clinical data you have access to and the site/population it comes from (health facility, geographic area). Please include the sample size (actual or estimated) and the time period covered by the data. Variables/Methods: Any ideas you have on how the analysis might be conducted (e.g., qualitative, quantitative, retrospective cohort, etc.). Importance of Study: How would conducting a study and answering your question help improve fistula services (e.g., prevention targeting, service coverage/reach, treatment quality, better outcomes)? Current Research Capacity: Availability and skills of author and other staff to support the planned study. (For FC+ staff only): Whether this research is already included in the country workplan and budget, or if it is a new activity. Please submit your concept by November 30, 2016 to [email protected] and [email protected]. Concepts can be submitted in English or French. The FC+ Monitoring, Evaluation, and Research (M&ER) team will review this concept and discuss questions/concerns with the country team. Availability of resources, staff to support study implementation, and relevance to country workplan and local USAID mission priorities will be key questions that guide approval. Because of limited FC+ ME&R staff capacity, we cannot support all study concepts. However, we guarantee that all concepts will receive written feedback on the proposed study (e.g., strengths, weaknesses, feasibility, recommendations for revision). FC+ will respond to all submissions by December 31, 2016. If the overall concept is selected by the M&ER team, a discussion will be scheduled to decide whether the study can be considered a non-human subjects research activity that would not require approval by an
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Institutional Review Board (IRB). If the study is deemed research, IRB review will need to occur before study analysis activities can begin. The FC+ M&ER and country teams will provide support if IRB submission is required. Support to selected studies will begin in January 2017.
Annual Report • October 2016 – September 2017 Fistula Care Plus 200
APPENDIX Z: FC+ ANNUAL PARTOGRAPH MONITORING: FY 14/15
Indicator Indicator
-
A (Mean B
Score) (%
(EITHER (EITHER
ient file? ient Correct Action)
at admission or or admission at
file?
-
throughout labor) throughout
(Quantitative)
at admission or B. or admission at
-
-
throughout labor) throughout labor) throughout labor) throughout
12. Actions Taken? Taken? 12. Actions
6. Partograph from a from a Partograph 6.
11. Cross Action line? Action 11. Cross
B.
A.
7. Contractions (1/2hrly (1/2hrly Contractions 7.
Number records reviewed records Number
referring facility in patient patient in facility referring
10. Maternal Pulse 10. Maternal
9. Maternal Blood Pressure Pressure Blood 9. Maternal
(EITHER A. A. (EITHER
8. Fetal Heart Rate (1/2 hrly hrly (1/2 Rate Heart 8. Fetal
5. Partograph in pat Partograph 5.
Facility name Facility 0: No, 0: No, not 0: No, 0: No, 0: No, 0: No, 0: No, 0: No, Maximum Maximum not in in file; not not not not not appropriat file 1: Yes, in recorded; recorded; recorded; recorded; crossed; e actions = 5 = 100% 1: Yes, file; 1: Yes, 1: Yes, 1: Yes, 1: Yes, 1: not taken; in file N/A: not Recorded Recorded Recorded Recorded crossed 1:Yes, referred; appropriat DK: source e actions cannot be taken determined Bangladesh 175 0.45 n/a 0.41 0.41 0.41 0.38 0.10 0.10 2.05 100.00% LAMB 25 1.00 n/a 0.88 0.88 0.88 0.88 0.04 0.04 4.52 100.00% Ad-din Dhaka 25 1.00 n/a 0.84 0.84 0.84 0.84 0.00 0.00 4.36 n/a Ad-din Jessore 25 0.32 n/a 0.32 0.32 0.32 0.28 0.32 0.32 1.56 100.00% Ad-din Khulna 25 0.32 n/a 0.32 0.32 0.32 0.24 0.32 0.32 1.52 100.00% BSMMU 25 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a Kumudini 25 0.48 n/a 0.48 0.48 0.48 0.44 0.04 0.04 2.36 100.00% Muttalib 25 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a Niger 50 1.00 0.70 0.88 1.00 1.00 1.00 0.00 0.00 4.88 n/a CSME Maradi 25 1.00 0.92 0.76 1.00 1.00 1.00 0.00 0.00 4.76 n/a CSME Tahoua 25 1.00 0.48 1.00 1.00 1.00 1.00 0.00 0.00 5.00 n/a
Annual Report • October 2016 – September 2017 Fistula Care Plus 201
Indicator Indicator
-
A (Mean B
Score) (%
(EITHER (EITHER
ient file? ient Correct Action)
at admission or or admission at
file?
-
throughout labor) throughout
(Quantitative)
at admission or B. or admission at
-
-
throughout labor) throughout labor) throughout labor) throughout
12. Actions Taken? Taken? 12. Actions
6. Partograph from a from a Partograph 6.
11. Cross Action line? Action 11. Cross
B.
A.
7. Contractions (1/2hrly (1/2hrly Contractions 7.
Number records reviewed records Number
referring facility in patient patient in facility referring
10. Maternal Pulse 10. Maternal
9. Maternal Blood Pressure Pressure Blood 9. Maternal
(EITHER A. A. (EITHER
8. Fetal Heart Rate (1/2 hrly hrly (1/2 Rate Heart 8. Fetal
5. Partograph in pat Partograph 5.
Facility name Facility 0: No, 0: No, not 0: No, 0: No, 0: No, 0: No, 0: No, 0: No, Maximum Maximum not in in file; not not not not not appropriat file 1: Yes, in recorded; recorded; recorded; recorded; crossed; e actions = 5 = 100% 1: Yes, file; 1: Yes, 1: Yes, 1: Yes, 1: Yes, 1: not taken; in file N/A: not Recorded Recorded Recorded Recorded crossed 1:Yes, referred; appropriat DK: source e actions cannot be taken determined Nigeria 276 0.17 0.00 0.00 0.01 0.00 0.00 0.00 0.00 0.18 0.00% Takai Clinic, Kano 23 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a Kumbotso, Kano 23 1.00 n/a 0.04 0.13 0.00 0.00 0.04 0.00 1.17 0.00% Maryam Abatcha, Kano 23 1.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 1.00 n/a Ungwa Uku, Kano 23 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a Miga, Jigawa 23 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a Aujara, Jahun, Jigawa 23 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a Dutse, Jigawa 23 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a Gwaram Cottage, Jigawa 23 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a GH Ningi, Bauchi 23 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a Low Cost PHC, Bauchi 23 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a Warji Town Mat, Bauchi 23 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a Gadarmaiwa, Ningi, Bauchi 23 0.00 n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a
Annual Report • October 2016 – September 2017 Fistula Care Plus 202
Indicator Indicator
-
A (Mean B
Score) (%
(EITHER (EITHER
ient file? ient Correct Action)
at admission or or admission at
file?
-
throughout labor) throughout
(Quantitative)
at admission or B. or admission at
-
-
throughout labor) throughout labor) throughout labor) throughout
12. Actions Taken? Taken? 12. Actions
6. Partograph from a from a Partograph 6.
11. Cross Action line? Action 11. Cross
B.
A.
7. Contractions (1/2hrly (1/2hrly Contractions 7.
Number records reviewed records Number
referring facility in patient patient in facility referring
10. Maternal Pulse 10. Maternal
9. Maternal Blood Pressure Pressure Blood 9. Maternal
(EITHER A. A. (EITHER
8. Fetal Heart Rate (1/2 hrly hrly (1/2 Rate Heart 8. Fetal
5. Partograph in pat Partograph 5.
Facility name Facility 0: No, 0: No, not 0: No, 0: No, 0: No, 0: No, 0: No, 0: No, Maximum Maximum not in in file; not not not not not appropriat file 1: Yes, in recorded; recorded; recorded; recorded; crossed; e actions = 5 = 100% 1: Yes, file; 1: Yes, 1: Yes, 1: Yes, 1: Yes, 1: not taken; in file N/A: not Recorded Recorded Recorded Recorded crossed 1:Yes, referred; appropriat DK: source e actions cannot be taken determined Uganda 175 0.86 0.02 0.62 0.62 0.35 0.39 0.07 0.07 0.57 92.31% Karambi HCIII 25 1.00 0.00 0.60 0.60 0.56 0.52 0.00 0.00 3.28 n/a Bwera 25 1.00 0.00 0.56 0.60 0.24 0.40 0.04 0.00 2.80 0.00% Hoima 25 1.00 0.12 0.96 0.96 0.24 0.12 0.08 0.08 3.28 100.00% Kitovu 25 1.00 0.00 0.68 0.68 0.28 0.24 0.12 0.12 2.88 100.00% Masaka RRH 25 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00 n/a Kalungu HCIII 25 0.00 0.00 0.72 0.72 0.44 0.72 0.00 0.00 2.60 n/a Kagando 25 1.00 0.00 0.84 0.76 0.68 0.72 0.28 0.28 4.00 100.00% FC+ TOTAL 676 0.62 0.24 0.48 0.51 0.44 0.44 0.05 0.04 1.92 0.95
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APPENDIX AA: FC+ ANNUAL PARTOGRAPH MONITORING: FY 15/16
-
Indicator A Indicator B
or)
(Mean (% Correct
at admission or
- Score) Action)
at admission or B.
throughout labor)
-
-
Facility nameFacility Numberrecords reviewed 5. Partograph in patient file? 6. Partograph from a referring in patient facility file? 7. Contractions ( 1/2hrly throughout labor) Heart8. Fetal Rate (1/2 hrly throughout lab 9. Maternal Blood Pressure (EITHER A. B. Maternal10. Pulse (EITHER A. throughout labor) Cross11. Action line? Actions12. Taken? (Quantitative) 0: No, not 0: No, not in 0: No, not 0: No, not 0: No, not 0: No, not 0: No, not 0: No, Maximum Maximum = in file file; recorded; recorded; recorded; recorded; crossed; 1: appropriate 1: Yes, in 1: Yes, in 1: Yes, 1: Yes, 1: Yes, 1: Yes, crossed actions not = 5 100% file file; Recorded Recorded Recorded Recorded taken; N/A: not 1:Yes, referred; appropriate DK: source actions cannot be taken determined Bangladesh 136 0.59 n/a 0.56 0.81 0.98 0.98 0.34 0.34 3.92 100.00% LAMB 25 1.00 0.92 1.00 1.00 1.00 1.00 1.00 4.92 100.00% Ad-din Dhaka 25 0.92 0.88 0.92 0.88 0.88 0.00 0.00 4.48 n/a Ad-din Khulna 11 1.00 1.00 1.00 1.00 1.00 1.00 1.00 5.00 100.00% BSMMU 25 0.00 0.00 1.00 1.00 1.00 0.00 0.00 3.00 n/a Kumudini 25 0.60 0.56 0.96 1.00 1.00 0.04 0.04 4.12 100.00% Muttalib 25 0.00 0.00 0.00 1.00 1.00 0.00 0.00 2.00 n/a Niger 50 1.00 0.00 0.50 0.50 1.00 1.00 0.00 0.00 4.00 n/a CSME Maradi 25 1.00 0.40 0.40 1.00 1.00 0.00 0.00 3.80 n/a CSME Tahoua 25 1.00 0.60 0.60 1.00 1.00 0.00 0.00 4.20 n/a Uganda 397 0.51 0.00 0.71 0.68 0.39 0.35 0.12 0.09 2.59 78.43% Karambi HCIII 25 0.00 0.80 0.80 0.28 0.28 0.00 0.00 1.36 n/a
Annual Report • October 2016 – September 2017 Fistula Care Plus 204
-
Indicator A Indicator B
or)
(Mean (% Correct
at admission or
- Score) Action)
at admission or B.
throughout labor)
-
-
Facility nameFacility Numberrecords reviewed 5. Partograph in patient file? 6. Partograph from a referring in patient facility file? 7. Contractions ( 1/2hrly throughout labor) Heart8. Fetal Rate (1/2 hrly throughout lab 9. Maternal Blood Pressure (EITHER A. B. Maternal10. Pulse (EITHER A. throughout labor) Cross11. Action line? Actions12. Taken? (Quantitative) 0: No, not 0: No, not in 0: No, not 0: No, not 0: No, not 0: No, not 0: No, not 0: No, Maximum Maximum = in file file; recorded; recorded; recorded; recorded; crossed; 1: appropriate 1: Yes, in 1: Yes, in 1: Yes, 1: Yes, 1: Yes, 1: Yes, crossed actions not = 5 100% file file; Recorded Recorded Recorded Recorded taken; N/A: not 1:Yes, referred; appropriate DK: source actions cannot be taken determined Bwera 25 0.88 0.48 0.44 0.20 0.20 0.16 0.16 2.20 100.00% Hoima 25 0.64 0.56 0.56 0.08 0.08 0.04 0.04 1.92 100.00% Kiyumba HCIV 25 0.00 0.92 0.96 0.68 0.64 0.32 0.32 3.20 100.00% Jinja 25 0.96 0.28 0.24 0.12 0.12 0.08 0.08 1.72 100.00% Kamuli 25 1.00 0.76 0.60 0.52 0.44 0.08 0.00 3.32 0.00% Kigorobya HCIV 25 0.00 0.96 0.92 0.68 0.64 0.28 0.24 3.20 85.71% Kyanamukaaka 25 0.00 1.00 1.00 0.52 0.56 0.08 0.08 3.08 100.00% HCIV Buraru HCIII 22 0.00 0.88 0.88 0.72 0.16 0.28 0.28 2.64 100.00% Azur HCIV 25 1.00 0.68 0.72 0.04 0.00 0.24 0.12 2.44 50.00% Buseruka HCIII 25 0.00 0.96 0.84 0.56 0.52 0.28 0.20 2.88 71.43% Kikuube HCIV 25 0.48 0.92 0.88 0.64 0.68 0.00 0.00 3.60 n/a Kitovu 25 1.00 0.68 0.68 0.32 0.48 0.00 0.00 3.16 n/a Masaka RRH 25 1.00 0.92 0.88 0.44 0.24 0.04 0.04 3.48 n/a Kalungu HCIII 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a
Annual Report • October 2016 – September 2017 Fistula Care Plus 205
-
Indicator A Indicator B
or)
(Mean (% Correct
at admission or
- Score) Action)
at admission or B.
throughout labor)
-
-
Facility nameFacility Numberrecords reviewed 5. Partograph in patient file? 6. Partograph from a referring in patient facility file? 7. Contractions ( 1/2hrly throughout labor) Heart8. Fetal Rate (1/2 hrly throughout lab 9. Maternal Blood Pressure (EITHER A. B. Maternal10. Pulse (EITHER A. throughout labor) Cross11. Action line? Actions12. Taken? (Quantitative) 0: No, not 0: No, not in 0: No, not 0: No, not 0: No, not 0: No, not 0: No, not 0: No, Maximum Maximum = in file file; recorded; recorded; recorded; recorded; crossed; 1: appropriate 1: Yes, in 1: Yes, in 1: Yes, 1: Yes, 1: Yes, 1: Yes, crossed actions not = 5 100% file file; Recorded Recorded Recorded Recorded taken; N/A: not 1:Yes, referred; appropriate DK: source actions cannot be taken determined Rwesande HCIV 25 0.72 0.56 0.52 0.36 0.36 0.04 0.00 2.52 0.00% Kagando 25 1.00 0.68 0.68 0.44 0.48 0.12 0.04 3.28 33.33% DRC 75 0.74 0.00 0.48 0.35 0.72 0.72 0.01 0.01 3.01 100.00% Heal Africa 25 1 0.44 0.24 0.92 0.92 0.00 0.00 3.52 n/a St. Joseph 25 0.96 0.72 0.72 1.00 1.00 0.04 0.04 4.40 100% Esengo 25 1 0.76 0.44 0.96 0.96 0.00 0.00 4.12 n/a MSRK 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a FC+ TOTAL 658 0.71 0.56 0.59 0.77 0.76 0.12 0.11 3.38 0.94
Annual Report • October 2016 – September 2017 Fistula Care Plus 206
APPENDIX BB: FC+ ANNUAL PARTOGRAPH MONITORING: FY 16/17
Indicator A Indicator B
(Mean Score) (% Correct
-
Action)
bor)
at admission or or admission at
-
at admission or B. or admission at
throughout labor) throughout
-
-
Facility name Facility reviewed records Number in patient Partograph 5. file? from a Partograph 6. patient in facility referring file? 1/2hrly ( Contractions 7. labor) throughout hrly (1/2 Rate Heart 8. Fetal la throughout Pressure Blood 9. Maternal A. (EITHER B. (EITHER Pulse 10. Maternal A. labor) throughout line? Action 11. Cross Taken? 12. Actions (Quantitative) 0: No, not 0: No, not in file; 0: No, not 0: No, not 0: No, not 0: No, not 0: No, not 0: No, Maximum = 5 Maximum = in file 1: Yes, in file; recorded; recorded; recorded; recorded; crossed; 1: appropriate 1: Yes, in N/A: not 1: Yes, 1: Yes, 1: Yes, 1: Yes, crossed actions not 100% file referred; Recorded Recorded Recorded Recorded taken; DK: source 1:Yes, cannot be appropriate determined actions taken Bangladesh 150 0.57 n/a 0.55 0.82 0.99 0.93 0.03 0.03 3.86 100.00% LAMB 25 1.00 n/a 0.96 0.96 1.00 1.00 0.16 0.16 4.92 100.00% Ad-din Dhaka 25 1.00 n/a 1.00 1.00 1.00 1.00 0.00 0.00 5.00 n/a Ad-din Khulna 25 0.64 n/a 0.64 0.92 0.92 0.60 0.00 0.00 3.72 n/a BSMMU 25 0.00 n/a 0.00 1.00 1.00 1.00 0.00 0.00 3.00 n/a Kumudini 25 0.76 n/a 0.72 1.00 1.00 1.00 0.00 0.00 4.48 n/a Muttalib 25 0.00 n/a 0.00 0.04 1.00 1.00 0.00 0.00 2.04 n/a Niger 25 0.84 0.00 0.32 0.72 0.80 0.80 0.00 0.00 3.48 n/a CSME Maradi NA NA NA NA NA NA NA NA NA NA NA CSME Tahoua 25 0.84 0.00 0.32 0.72 0.80 0.80 0.00 0.00 3.48 n/a Uganda 409 0.94 0.01 0.83 0.80 0.55 0.52 0.05 0.02 3.60 45.45% Karambi HCIII 25 1.00 0 0.72 0.68 0.32 0.48 0.00 0.00 2.48 n/a Annual Report • October 2016 – September 2017 Fistula Care Plus 207
Indicator A Indicator B
(Mean Score) (% Correct
-
Action)
bor)
at admission or or admission at
-
at admission or B. or admission at
throughout labor) throughout
-
-
Facility name Facility reviewed records Number in patient Partograph 5. file? from a Partograph 6. patient in facility referring file? 1/2hrly ( Contractions 7. labor) throughout hrly (1/2 Rate Heart 8. Fetal la throughout Pressure Blood 9. Maternal A. (EITHER B. (EITHER Pulse 10. Maternal A. labor) throughout line? Action 11. Cross Taken? 12. Actions (Quantitative) 0: No, not 0: No, not in file; 0: No, not 0: No, not 0: No, not 0: No, not 0: No, not 0: No, Maximum = 5 Maximum = in file 1: Yes, in file; recorded; recorded; recorded; recorded; crossed; 1: appropriate 1: Yes, in N/A: not 1: Yes, 1: Yes, 1: Yes, 1: Yes, crossed actions not 100% file referred; Recorded Recorded Recorded Recorded taken; DK: source 1:Yes, cannot be appropriate determined actions taken Bwera 25 1.00 n/a 0.76 0.76 0.40 0.32 0.12 0.04 3.24 33.33% Hoima 25 0.96 0.08 0.72 0.76 0.32 0.20 0.12 0.04 2.96 33.33% Kiyumba HCIV 25 1.00 0.00 1.00 0.96 0.48 0.60 0.24 0.12 4.04 50.00% Jinja 25 0.96 0.05 0.68 0.64 0.40 0.36 0.04 0.04 3.04 100.00% Kamuli 25 1.00 0.00 0.96 0.96 0.72 0.76 0.08 0.04 4.40 50.00% Kigorobya HCIV 25 1.00 n/a 0.92 0.64 0.68 0.72 0.00 0.00 3.96 n/a Kyanamukaaka HCIV 25 1.00 0.00 0.96 0.96 0.88 0.84 0.04 0.00 4.64 0.00% Buraru HCIII 20 1.00 n/a 1.00 1.00 0.85 0.80 0.00 0.00 4.65 n/a Azur HCIV 25 0.96 n/a 0.76 0.68 0.08 0.04 0.00 0.00 2.52 n/a Buseruka HCIII 16 1 n/a 0.94 0.94 0.88 0.81 0.00 0.00 4.57 n/a Kikuube HCIV 23 1.00 n/a 0.96 0.96 0.61 0.52 0.00 0.00 4.05 n/a Kitovu 25 0.96 0.04 0.72 0.68 0.36 0.28 0.04 0.00 3.00 0.00% Masaka RRH 25 0.64 0.00 0.60 0.60 0.16 0.04 0.00 0.00 2.04 n/a Rwesande HCIV 25 1.00 n/a 0.76 0.72 0.72 0.56 0.00 0.00 3.76 n/a Lukolo HCIII 25 0.52 n/a 1.00 1.00 0.96 0.92 0.08 0.04 4.40 n/a Annual Report • October 2016 – September 2017 Fistula Care Plus 208
Indicator A Indicator B
(Mean Score) (% Correct
-
Action)
bor)
at admission or or admission at
-
at admission or B. or admission at
throughout labor) throughout
-
-
Facility name Facility reviewed records Number in patient Partograph 5. file? from a Partograph 6. patient in facility referring file? 1/2hrly ( Contractions 7. labor) throughout hrly (1/2 Rate Heart 8. Fetal la throughout Pressure Blood 9. Maternal A. (EITHER B. (EITHER Pulse 10. Maternal A. labor) throughout line? Action 11. Cross Taken? 12. Actions (Quantitative) 0: No, not 0: No, not in file; 0: No, not 0: No, not 0: No, not 0: No, not 0: No, not 0: No, Maximum = 5 Maximum = in file 1: Yes, in file; recorded; recorded; recorded; recorded; crossed; 1: appropriate 1: Yes, in N/A: not 1: Yes, 1: Yes, 1: Yes, 1: Yes, crossed actions not 100% file referred; Recorded Recorded Recorded Recorded taken; DK: source 1:Yes, cannot be appropriate determined actions taken Kagando 25 1.00 0.00 0.72 0.72 0.52 0.52 0.12 0.08 3.48 66.67% DRC 124 0.73 0.00 0.46 0.44 0.72 0.66 0.07 0.05 2.85 69.44% Heal Africa 25 0.64 n/a 0.52 0.52 0.68 0.68 0.20 0.08 3.04 0.4 St. Joseph 25 0.8 n/a 0.32 0.36 0.68 0.72 0.04 0.04 2.60 1 IGL 25 0.64 n/a 0.64 0.64 0.76 0.44 0.08 0.08 2.56 1 Esengo 25 1 n/a 0.76 0.44 0.96 0.96 0.00 0.00 4.12 n/a MSRK 24 0.58 n/a 0.08 0.25 0.50 0.50 0.04 0.00 1.91 0 FC+ TOTAL 708 0.77 0.54 0.70 0.76 0.73 0.04 0.03 3.45 0.67
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APPENDIX CC: EH ANNUAL CDDM MEETING AGENDA
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APPENDIX DD: FC+ SUPPORTED TREATMENT SITES MEETING TO DISCUSS DATA
Country/Site Q1 Q2 Q3 Q4 Total Number of Meetings in FY 16/17 Fistula Care Plus Total: 32 treatment sites 94% met at least twice 97% met at least once Bangladesh: 7 treatment sites 100% met at least twice 100% met at least once Ad-Din Dhaka 1 0 0 1 2 Ad-Din Khulna 1 0 0 1 2 Kumudini Hospital 1 0 0 1 2 LAMB Hospital 1 0 0 1 2 Bangabandhu Sheikh Mujib Medical 1 0 0 1 2 University Dr. Muttalib Community Hospital 1 0 0 1 2 Mamm's Institute of Fistula & Women's 1 0 0 1 2 Health DRC: 5 treatment sites 80% met at least twice 100% met at least once St. Joseph’s Hospital/Satellite 1 0 1 1 3 Maternity Kinshasa Panzi Hospital 0 0 1 1 2 HEAL Africa 0 0 0 1 1 IGL 1 0 1 1 3 MSRK 1 0 0 1 2 WA/Niger: 3 treatment sites 100% met at least twice 100% met at least once Centre de Santé Mère / Enfant (CSME) 1 1 1 1 4 Maradi Centre National de Référence des 1 1 1 1 4 Fistules Obstétricales (CNRFO),Niamey Centre de Santé Mère /Enfant (CSME) 1 1 1 1 4 Tahoua Nigeria: 13 treatment sites 92% met at least twice 92% met at least once General Hospital, Ningi 1 1 1 1 4 General Hospital, Ogoja 1 1 1 1 4 National Fistula Center, Abakaliki 1 1 1 1 4 Laure VVF Center 0 1 1 0 2 National Fistula Center, Babbar Ruga, 1 1 1 1 4 Katsina Gesse VVF Center, Birnin Kebbi 1 1 1 1 4 Sobi Specialist Hospital, Ilorin 0 1 1 0 2 Maryam Abatcha Women and 1 1 1 1 4 Children’s Hospital, Sokoto Faridat General Hospital, Gusau 0 1 1 0 2 University College Hospital, Ibadan 0 1 1 0 2 Jahun VVF Center, Jigawa State 0 1 1 0 2 Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 215
Country/Site Q1 Q2 Q3 Q4 Total Number of Meetings in FY 16/17 Adeoyo General Hospital, Ibadan 0 1 1 0 2 Wesley Guilds Hospital NS NS NS 0 New site as of Q4 Uganda: 4 treatment sites 100% met at least twice 100% met at least once Kitovu Mission Hospital 0 0 1 1 2 Hoima Regional Referral Hospital 0 0 1 1 2 Kamuli Mission Hospital 0 0 1 1 2 Jinja Regional Referral Hospital 0 0 1 1 2 NS: not supported during this quarter
Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 216
APPENDIX EE: MEDIA COVERAGE IN FC+ COUNTRIES, FY 16/17
Country Source (type) Title/ Description Date Nigeria Radio Nigeria (Radio) Health Watch radio program Oct 2016 Nigeria Radio Kwara (Radio) Yoruba language radio program Nov 2016
Nigeria Inspiration FM (Radio) “Prolonged obstructed labor, poor nutrition, and inability 2 Feb 2017 to access medical services are contributory to obstetric fistula in women” Nigeria Inspiration FM (Radio) “5,000 fistula cases are repaired every year, about 12,000 3 Feb 2017 new fistula cases occur within the same period” Nigeria Atlantic FM (Radio) “Prolonged obstructed labor can cause an opening in the 3 Feb 2017 birth canal leading to leakage of urine and or faeces” Nigeria Daily Trust (Newspaper) “Recurring fistula challenge demands community 3 Feb 2017 participation” Nigeria Solid FM (Radio) “Prevention of new fistula cases, a major factor for 5 Feb 2017 elimination of the condition” Nigeria Nigeria Daily News “Free at last, fistula patients in Abakaliki communities 6 Feb 2017 (Newspaper) speak out” Nigeria Vanguard (Newspaper) “Free at last, fistula patients in Abakaliki communities 7 Feb 2017 speak out” Nigeria Independent (Newspaper) “Hope at last for VVF ravaged Ebonyi communities” 8 Feb 2017 Nigeria This Day (Newspaper) “Nigeria records 12,000 new cases of obstetric fistula 9 Feb 2017 yearly” Nigeria The Guardian (Newspaper) “Prevention will end fistula scourge, says 10 Feb 2017 EngenderHealth” Nigeria Vanguard (Newspaper) “The anti-VVF fight: How ante-natal exposes danger 11 Feb 2017 signs during pregnancy” Nigeria The Guardian (Newspaper) “Now I can sit anywhere, my life is back” 11 Feb 2017 Nigeria Vanguard (Newspaper) “We have repaired over 3,000 victims of fistula, others, 12 Feb 2017 says Prof. Adeoye” Nigeria Independent (Newspaper) “150,000 Nigerian women are living with obstetric fistula 14 Feb 2017 – Prevention can halt new cases: says EngenderHealth” Nigeria This Day (Newspaper) “Hope for Women with Obstetric Fistula” 16 Feb 2017 Nigeria Vanguard (Newspaper) “Obstetric Fistula: I regained my sex life in Abakaliki” 18 Feb 2017 Nigeria Pioneer (Newspaper) “Ebonyi shines the light on VVF challenges” 20 Feb 2017 Nigeria Vanguard (Newspaper) “200 women benefit from VVF treatment in Cross River 15 Mar2017 State” Bangladesh Medivioce OGSB “It is possible to get 80 percent of fistula in proper 16 May 2017 (Newspaper) treatment“ Bangladesh Daily Ittefaq (Newspaper) “70 thousand women affected by fistula in the country” 16 May 2017 Nigeria Inclusive Press “Root causes of obstetric fistula – Ignorance, poverty and 18 Mar 2017 (Newspaper/Online) medical negligence” Nigeria Radio Nigeria Network “Awareness raising about fistula” in English language 20 May 2017 (Radio) Niger Sahel Dimanche IDEOF coverage (Article in French) “Women’s Dignity” 22 May 2017 Bangladesh Nyadiganta (Newspaper) IDEOF coverage (Article in Bangla) 23 May 2017 Bangladesh The New Nation (Newspaper) “Let us hope for a Fistula Free Society” 23 May 2017 Bangladesh Daily Jugantar (Newspaper) IDEOF coverage (Article in Bangla) 23 May 2017 Bangladesh Daily Manabzameen IDEOF coverage (Article in Bangla) 23 May 2017 (Newspaper) Bangladesh Daily Naya Diganta IDEOF coverage (Article in Bangla) 23 May 2017 (Newspaper)
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Country Source (type) Title/ Description Date Bangladesh Daily New Nation IDEOF coverage (Article in Bangla) 23 May 2017 (Newspaper) Bangladesh Daily Sangbad (Newspaper) IDEOF coverage (Article in Bangla) 23 May 2017 Bangladesh Daily Star (Newspaper) IDEOF coverage (Article in Bangla) 23 May 2017 Bangladesh Medivioce OGSB “World Fistula Day is Today” 23 May 2017 (Newspaper) Nigeria Katsina Radio (Radio) “Awareness raising about fistula” in Hausa language 23 May 2017 Nigeria Vision FM Sokoto (Radio) “Awareness raising about fistula” in Hausa language 23 May 2017 Nigeria Bauchi Radio (Radio) “Awareness raising about fistula” in Hausa language 23 May 2017 Nigeria Radio Nigeria Ibadan (Radio) “Awareness raising about fistula” in Yoruba language 23 May 2017 Nigeria Ebonyi Broadcasting “Awareness raising about fistula” in Igbo language 23 May 2017 Coorporation (Radio) Nigeria Guardian (Newspaper) “Women with fistula should not be stigmatized” 24 May 2017 Nigeria Independent (Newspaper) “Women’s health shouldn’t be controlled by cultural 24 May 2017 beliefs” Nigeria Vanguard (Newspaper) “400,000 Nigerian Women Living with obstetric fistula” 25 May 2017 Nigeria Radio Nigeria Network “Awareness raising about fistula” in Pidgin English 26 May 2017 (Radio) language Bangladesh Medivioce OGSB 4Q Checklist 28 May 2017 (Newspaper) Bangladesh Bangla Tribune (Newspaper) “Safe Motherhood Day Today” 28 May 2017 Bangladesh Medivioce OGSB “Schoolgirls for Fistula Free Bangladesh - Inauguration 28 May 2017 (Newspaper) of the program” Bangladesh Satkhira News (Newspaper) “Happy startup of women's Fistula patient identification 28 May 2017 program nationwide through community clinic” Bangladesh Medivioce OGSB “Obstetrical and Gynaecological Society of Bangladesh 29 May 2017 (Newspaper) Position Paper on Iatrogenic `Fistula in Bangladesh” Bangladesh Medivioce OGSB “ Kathmandu Call for Action 2017: South Asian Group 29 May 2017 (Newspaper) on Fistula and Related Morbidities “For a Fistula-Free South Asia” Nigeria Health Watch (Radio) “Awareness raising about fistula” in English language 29 May 2017 Niger Station Regional de Radio de Fistula Prevention, Treatment and Rehabilitation June 2017 Maradi et Tahoua messages in local languages (Fulfulde, Tamajeck and Hausa) Nigeria This Day (Newspaper) “Giving hope to women with obstetric fistula” 1 Jun 2017 Nigeria Independent (Newspaper) “Without funding Federal Government will be paying lip 1 Jun 2017 service to fistula intervention” Nigeria Daily Trust (Newspaper) “Fistula: the hole afflicting women is treatable” 3 Jun 2017 Nigeria Vanguard (Newspaper) “No longer leaking urine, faeces” 4 Jun 2017 Nigeria Guardian (Newspaper) “Poor funding scant attention escalate Nigeria’s obstetric 4 Jun 2017 fistula burden” Nigeria New Telegraph “VVF: Life of physical, emotional, financial, social 4 Jun 2017 (Newspaper/Online) trauma” Nigeria New Telegraph “Childless VVF survivor goes blind, divorced” 4 Jun 2017 (Newspaper/Online) Nigeria Daily Trust (Newspaper) “Women deemed inoperable inspiring groundbreaking 10 Jun 2017 surgeries” Nigeria Daily Trust (Newspaper) “Health minister back in theatre to repair women with 27 Jul 2017 fistula” Nigeria Najiamamas.blogspot.com.ng “Minister flags off new fistula program at Osun” 27 Jul 2017 (Online) Nigeria Nigeria Health Online “Minister performs fistula surgery in Osun State” 27 Jul 2017 (Online) Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 218
Country Source (type) Title/ Description Date Nigeria The Guardian (Newspaper) “Minister performs fistula surgery in Osun State” 27 Jul 2017 Nigeria This Day (Newspaper) “Nigeria will eradicate fistula in 10 years” 3 Aug 2017 Nigeria The Guardian (Newspaper) “Always visit Health Centre during labour, Emir of 7 Aug 2017 Shonga tells subjects” Nigeria The Guardian (Newspaper) “Emir of Shonga urges subjects to embrace maternal 7 Aug 2017 death prevention care” Nigeria BA News (Newspaper) “Kwara: Plans are underway to increase fistula budget 8 Aug 2017 said commissioner” Nigeria The Guardian (Newspaper) “Free fistula repairs move to Kwara” 8 Aug 2017 Nigeria Nigeria Health Online “Emir of Ilorin vows to lead campaign against fistula” 12 Aug 2017 (Online) Nigeria The Guardian (Newspaper) “Kwara sets aside about 16m for fistula, said 12 Aug 2017 commissioner” Nigeria The Guardian (Newspaper) “Kwara Monarchs to champion advocacy against fistula” 13 Aug 2017 Nigeria Newsbeam Online (Online) “Kwara Monarchs champion advocacy against fistula” 13 Aug 2017 Nigeria Daily Trust (Newspaper) “33 VVF patients undergo surgical interventions in 14 Aug2017 Ilorin” Nigeria Newsbeam Online (Online) “Sobi Hospital records 200 successful VVF operations” 14 Aug 2017 Nigeria This Day (Newspaper) “Kwara carries out 33 VVF successful operations” 17 Aug 2017 Nigeria Vanguard (Newspaper) “Adewole to VVF victims: ‘No more leaking urine’” 20 Aug 2017 Nigeria Nigeria Health Online “Federal Government orders free fistula surgeries in 21 Aug 2017 (Online) tertiary hospitals; Cross River receives EngenderHealth Team” Nigeria The Guardian (Newspaper) “Federal Government mandates free fistula surgery” 22 Aug 2017 Nigeria Daily Trust (Newspaper) “Surgeons create anus for girl born without one” 23 Aug 2017 Nigeria The Guardian (Newspaper) “Lifting fistula burden off sufferers” 27 Aug 2017
In addition to these specific articles, numerous programs were aired repeatedly throughout the year in DRC on radio stations (Radio: Radio Mushauri, Radio KFM, Aki za Binadamu, Radio Muungano, Radio Graben, Radio Semliki, SVEN Radio, Sauti ya Enjili Radio Radio Sango Malamu et Radio Tomisa and Radio Okapi) and television stations (Emmanuel RTV, Hope Channel TV, RTNC, and TVS1).
Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 219
APPENDIX FF: FY 16/17 FC+ COUNTRY REPAIR DATA VISUALIZATIONS
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APPENDIX GG: FC+ CORE INDICATORS: ANNUAL ACHIEVEMENTS
Note: Benchmarks for FY 15/16 are the approved benchmarks based on approved country workplans. Benchmarks for FY 17/18 are drawn from the original project approved FC+ PMP. Blanks indicate indicators/years for which benchmarks have not been finalized.
Goal: To strengthen health system capacity for fistula prevention, detection, treatment, and reintegration in priority countries in Sub-Saharan Africa and South Asia.
Indicator 1: Number of countries supported by Fistula Care Plus (FC+)
Definition: # of countries in which FC+ is supporting fistula repair sites and other activities to strengthen fistula-related policy, community capacity, and services
Additional description/context: FC+ will support countries to strengthen capacity for obstetric fistula prevention, detection, repair, and reintegration of affected women.
Data source and collection: Collected quarterly from project reports by FC+ staff
Benchmark Values36
Year Target Actual Notes
FY2013/14 5 5
FY2014/15 5 6 FC+ has supported activities in Togo through the USAID/WARP mission
FY2015/16 6 6 FC+ has supported activities in Togo through the USAID/WARP mission
FY2016/17 6 5 FC+ supported activities in Togo ended in FY 15/16. Mozambique will be added in FY 17/18.
FY2017/18 6
Indicator 2: Number of sites supported by FC+ for fistula repair and prevention
Definition: # of facilities to which FC+ is providing support for fistula repair services.
Additional description/context: FC+ will support facilities to provide fistula repair services. The majority of these sites will also provide some level of prevention care. Support can include: provider training and clinical mentoring, equipment, and/or other site strengthening activities such as quality improvement (QI) and management capacity building. Support to clients at these sites can include:
36 Benchmarks are aggregated for all indicators unless otherwise stated. Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 223
transport costs to hospitals for surgery, temporary shelter, costs for repair, post-operative hospitalization costs, pre and post operative counseling. and client rehabilitation services during post- operative recovery. Supported sites will provide data to FC+ on clinical indicators including numbers of clients seeking and requiring fistula repair services, the number of repairs performed, and the outcomes for those clients. Supported sites may also be engaged in fistula prevention activities, as defined in indicator 3. However, in reporting, sites will be disaggregated into prevention-only sites and repair/prevention sites. Sites that provide both are reported via indicator 2.
Data source and collection: Collected quarterly from project reports by FC+ project staff and in- country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 26 25
FY2014/15 32 31
FY2015/16 34 37
FY2016/17 36 33
FY2017/18 35
Indicator 3: Number of prevention-only sites supported by FC+
Definition: # of facilities to which FC+ is providing support only for fistula prevention services.
Additional description: FC+ will support facility sites to provide services that prevent fistula. Support can include: include provider training and clinical mentoring, equipment, minor renovation or rehabilitation of facilities, other site strengthening activities such as quality improvement (QI) and management capacity building; and/or community outreach for awareness, screening, detection, and referral activities. FC+ will focus prevention interventions in three areas: a. Emergency obstetric services (EmOC) with immediate interventions to help prevent fistula. We will track three key immediate term interventions which will be a focus of strengthening at selected sites:
Correct use of the partograph to manage labors Availability of C-section services Routine use of catheterization for women who had prolonged/obstructed labor. b. Family Planning (FP) services as a medium term fistula prevention intervention
c. Screening, detection, and referral of women needing fistula treatment to repair sites.
As noted above, facilities will be classified as either prevention-only or repair/prevention sites. Repair sites may also be engaged in any or all of the prevention activities outlined here.
Data source and collection: Collected quarterly from project reports by FC+ staff and in-country partners
Benchmark Values
Year Target Actual Notes
Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 224
FY2013/14 43 16 Delays in funds release and subaward agreements negatively affected prevention-only site support
FY2014/15 39 749 FC+ has temporarily taken on support of a large number of prevention-only sites in Nigeria following the close of the TSHIP project.
FY2015/16 790 789
FY2016/17 791 752 Support to sites in Jigawa State in Nigeria was discontinued during the FY.
FY2017/18 787
Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment and reintegration in the public and private sectors
Indicator 4: Number of countries receiving support from FC+ where governments or supported facilities have revised/adopted/ initiated/implemented policies or guidelines for fistula prevention or treatment
Definition: # of supported countries or facilities (some private sites may develop their own policies/guidelines) that have revised/adopted, initiated, or are continuing to implement policies in support of fistula prevention and treatment services.
Additional description/context: The FC+ Annual Report will include the name of policy/guideline, location, and status (e.g., under development or review, approved, implemented). Fistula-specific polices or guidelines can be part of broader reproductive and/or maternal health documents. For the purposes of FC+, a policy37 is an official statement by a government or health authority that provides an overall direction for a health issue by defining a vision, values, principles, and objectives, and establishing a broad model of action to achieve that vision. Policies may address financing, coordination among agencies and programs, necessary legislation, organization of services, procurement of material resources, required human resources, quality standards, and/or information systems. A guideline is a statement that provides a framework or course of action through which to implement policy objectives, including recommendations and best practices that ensure quality within services to be provided. This indicator includes countries that have fistula policies/guidelines in place at the start of the project.
Data source and collection: Collected annually from project reports and policy/guideline documents by FC+ staff and in-country partners
Benchmark Values
37 Adapted from World Health Organization definitions. Available at: http://www.who.int/mental_health/policy/services/1_MHPolicyPlan_Infosheet.pdf. Accessed January 22, 2014. Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 225
Year Target Actual Notes
FY2013/14 5 5
FY2014/15 5 5
FY2015/16 6 5
FY2016/17 6 5
FY2017/18 5
Indicator 5: Number of countries receiving support from FC+ where governments or supported facilities have addressed WDI, women with TF and/or POP in their fistula and/or broader reproductive/maternal health policies or guidelines
Definition: # of supported countries or facilities (some private sites may develop their own policies/guidelines) that have addressed the needs of WDI, women with TF, and/or women with POP in their relevant policies/guidelines.
Additional description/context: This incorporation can be within fistula-specific documents or broader policies/guidelines on reproductive and/or maternal health services.
Annual report will include the name of policy/guideline, location, and status (e.g., under development or review, approved, implemented). The definitions of policies and guidelines described under indicator 5 will be applied here.
Data source and collection: Collected annually from project reports and policy/guideline documents by FC+ staff and in-country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 0 0 Policy efforts related to WDI/TF/POP to begin in FY14/15
FY2014/15 1 2 Nigeria and Uganda have both held national level meetings drafting policy related to treatment and reintegration of WDI
FY2015/16 2 2 Bangladesh and Niger
FY2016/17 2 4 Bangladesh, Niger, Nigeria, and Uganda
FY2017/18 5
Indicator 6: Number of countries receiving support from FC+ in which governments have budget line item for fistula care
Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 226
Definition: # of supported countries with a specific annual budget allocation to fund fistula prevention, detection, repair, and/or reintegration services.
Additional description/context: This is an annual, rather than aggregated, indicator.
Data source and collection: Collected annually from project reports and key informant interviews by FC+ staff and in-country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 2 2 Budget allocations made in Nigeria and Uganda
FY2014/15 2 2 Budget allocations made in Nigeria and Uganda
FY2015/16 3 2 Bangladesh and Nigeria
FY2016/17 3 3 Bangladesh, Niger, Nigeria
FY2017/18 3
Indicator 7: Number of countries with fistula indicators included in the health management information system (HMIS)
Definition: # of supported countries whose HMIS includes fistula indicators.
Additional description/context: The primary indicator of interest is the number of fistula repairs; however, additional relevant indicators that may be incorporated into HMIS include the number of women identified as needing repair.
Data source and collection: Collected annually from project reports and key informant interviews by FC+ staff and in-country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 4 3 Along with Niger, Nigeria, and Uganda, indicators have also been approved in a 4th country (Bangladesh), but data collection has not yet begun.
FY2014/15 4 3 See FY13/14
FY2015/16 4 4 Bangladesh, Niger, Nigeria, Uganda
FY2016/17 4 4 Bangladesh, Niger, Nigeria, Uganda
FY2017/18 4
Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 227
Indicator 8: Number of public/private partnerships established to address fistula prevention, repair, or reintegration by country
Definition: # of public/private partnerships established to address country-level needs related to fistula prevention, repair, and/or reintegration.
Additional description/context: Partnerships may include the leveraging of private (e.g., corporate) financial resources to fund fistula activities and/or the provision of in-kind support to enable fistula services (e.g., medical equipment, drugs, supplies, human resources).
Data source and collection: Collected semi-annually from project reports by FC+ staff and in-country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 138 3 In addition to the 3 PPPs (Bangladesh, Nigeria, and Uganda), an individual has also donated commodities in Uganda
FY2014/15 2 3 Partnerships for private contribution to fistula activities are active in DRC, Nigeria, and Uganda. Proposals for such partnership are pending in Bangladesh and Niger.
FY2015/16 3 4 Bangladesh, DRC, Nigeria, Uganda
FY2016/17 4 4 Bangladesh, DRC, Nigeria, Uganda
FY2017/18 5
Objective 2: Enhanced community understanding and practices to prevent fistula, improve access to fistula treatment, reduce stigma, and support reintegration of women and girls with fistula
Indicator 9: Number of community volunteers/educators trained in tools and approaches to raise awareness regarding fistulae prevention and repair
Definition: # of community volunteers/educators trained in topics and approaches and approaches, such as social and behavior change communication (SBCC), stigma, gender-based barriers, and male involvement to mobilize communities for fistula prevention, the use of safe motherhood services including family planning and EmOC, and fistula screening/detection/referral for repair.
Additional description/context: Community volunteers/educators are individuals affiliated with or employed by community-based organizations, non-governmental organizations, and/or faith-based organizations. In some countries, they are affiliated with government agencies (e.g., Ethiopia’s Health Development Army); however, while these individuals may liaise with health facilities and providers,
38 This will be achieved in Y2 due to the shortened Y1. Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 228
their role is restricted to health promotion and they are not formally attached to specific health facilities. These are considered to be distinct from the community health workers discussed in Indicator 18 below.
Data source and collection: Collected quarterly from training reports by FC+ staff and in-country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 227 0 Delays in funds release and subaward approvals negatively affected ability to implement community volunteer/educator trainings in FY13/14
FY2014/15 494 776
FY2015/16 607 679
FY2016/17 725 850
FY2017/18 1,423
Indicator 10: Number of community awareness-raising activities/events conducted by program partners
Definition: # events carried out by program partners to provide information about EmOC availability, fistula prevention, screening and detection, repair, and other safe motherhood issues.
Additional description/context: Events may include community gatherings and broadcast messages.
Data source and collection: Collected quarterly from program monitoring reports by FC+ staff and in- country partners.
Benchmark Values
Year Target Actual Notes
FY2013/14 570 12 Delays in funds release and subaward approvals negatively affected ability to implement community outreach and education in FY13/14.
FY2014/15 586 1,990
FY2015/16 1,695 10,393
FY2016/17 6,130 In person:33,425 Home visits in Niger and Aflateen activities in Uganda resulted in Mass media: 659 achievements far above benchmarks.
FY2017/18 10,666
Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 229
Indicator 11: Number of participants reached through community awareness-raising events/activities conducted by program partners
Definition: # of participants reached through community awareness raising events/activities conducted by program partners.
Additional description/context: Participants may include attendees at events in the community, as well as those listening to/watching broadcast messages. Numbers of persons reached will be estimates for some activities; e.g., radio partners will provide estimates of the listenership for broadcast events.39
Data source and collection: Collected quarterly from program monitoring reports by FC+ staff and in- country partners.
Benchmark Values
Year Target Actual Notes
FY2013/14 155,150 10,745 Delays in funds release and subaward approvals negatively affected ability to implement community outreach and education in FY13/14
FY2014/15 232,100 414,067
FY2015/16 In person: In person: 306,750 2,862,124
Mass media: Mass media: 1,550,000 3,676,406
FY2016/17 In person: In person: Mass media reach numbers were not 327,000 557,186 available in all countries.
Mass media: Mass media: 102,150,000 15,289,736
FY2017/18 In person: 676,000
Mass media: 27,339,750
Objective 3: Reduced transportation, communication, and financial barriers to accessing preventive care, detection, treatment, and reintegration support
Indicator 12: Number and type of transportation initiatives introduced, enhanced, and/or tested
39 FC+ has expanded its definition of the reach of community activities to include the audience for radio broadcasts; not all countries have been able to establish baseline estimates of these audiences yet; these benchmarks may thus be revised based on Y1 experience. Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 230
Definition: # of initiatives introduced enhanced, and/or tested to reduce barriers faced by women in traveling to fistula services, particularly repair, in the catchment areas of FC+ sites.
Additional description/context: Initiatives may include vouchers, support from local transportation networks, and other strategies to enable transportation to fistula services.
Data source and collection: Collected semi-annually from program monitoring and evaluation reports by FC+ staff and in-country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 0 0
FY2014/15 2 0 Delays in approvals/conduct of Pop Council study have negatively impacted ability to move forward with designing and piloting initiatives
FY2015/16 2 0 Initiatives planned but not yet implemented, will take place in FY 16/17
FY2016/17 2 2 Nigeria and Uganda
FY2017/18 2
Indicator 13: Number and type of communication technologies introduced, enhanced, and/or tested for improving communication with patients and/or providers
Definition: # of initiatives introduced enhanced, and/or tested to improve communication with providers and/or patients engaged through FC+ sites.
Additional description/context: Initiatives may target health behavior and service utilization messages for women, follow-up support and mentoring for trained providers, and/or monitoring of service provision/uptake by patients and providers.
Data source and collection: Collected semi-annually from program monitoring and evaluation reports by FC+ staff and in-country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 0 0
FY2014/15 1 0 Delays in approval and conduct of Pop Council study have negatively impacted ability to design/test new technologies
FY2015/16 2 0 Initiatives developed but will be implemented in FY 16/17
FY2016/17 2 2 Nigeria and Uganda
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FY2017/18 2
Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment
Indicator 14: Number of women requiring fistula repairs
Definition: # of women diagnosed with obstetric fistula at supported repair sites
Additional description/context: This will be a subset of women seeking treatment at repair sites; women will be screened to determine whether their incontinence is due to obstetric fistula. This indicator encompasses all types of fistula, including urinary and RVF together, and RVF alone.40
Data source and collection: Collected quarterly from hospital registers/ client records/program reports by FC+ staff and partner staff
Benchmark Values
Year Target Actual Notes
FY2013/14 2,131 912
FY2014/15 4,000 3,790
FY2015/16 18,000 4,798
FY2016/17 N/A 4,031
FY2017/18 N/A
Indicator 15a: Number of surgical fistula repairs
Definition: # of fistula repair surgeries performed at supported sites.
Additional description/context: This includes all types of fistula repairs, including urinary alone, urinary and RVF together, and RVF alone. Each time a woman has surgery it will be counted; however, it is unlikely that any woman would get more than one repair surgery per quarter. Therefore the quarterly figure for the number of surgeries should therefore equal the number of women getting fistula repair.
Data source and collection: Collected quarterly from hospital registers/ client records/program reports by FC+ staff and partner staff
40 We have included this indicator in our approved PMP instead of number of women seeking fistula repairs. We know from experience that many women seeking care are often not diagnosed with fistula, but rather have some other condition that results in some incontinence. FC+ will collect information on the number of women seeking care for urinary incontinence as part of our routine clinical monitoring as was done under Fistula Care. If the difference between the number seeking and the number requiring is large then we will know that work needs to be done to improve messages about fistula treatment. We believe for USAID reporting to Congress, the number requiring is more powerful. We are using the term urinary fistula instead of VVF since it more accurately describes the range of typical fistula cases seen at sites. Urinary type fistula includes: vesicovaginal, urethro-vaginal, uretero- vaginal, vesico-uterine. Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 232
Benchmark Values
Year Target Actual Notes
FY2013/14 1,30041 852 Delays in funds release and subaward approvals negatively affected ability to support fistula repairs during FY13/14.
FY2014/15 3.830 2,876 Repairs benchmark increased due to requests from Bangladesh and Nigeria missions
FY2015/16 4,121 3,514
FY2016/17 3,780 3,250
FY2017/18 2,950 Note: Benchmark is for only 9 months of activity, as final quarter will not have active program implementation due to project close-out.
Indicator 15b: Number of conservative fistula treatments (catheterization)
Definition: # of conservative fistula treatments (catheterization) performed at supported sites.
Note: There is no annual benchmark assigned to this indicator.
Additional description/context: This includes the number of catheterizations performed on an existing fistula, as a conservative approach to fistula repair, provided by supported sites.
Data source and collection: Collected quarterly from hospital registers/ client records/program reports by FC+ staff and partner staff.
Benchmark Values
Year Target Actual Notes
FY2013/14 N/A 4
FY2014/15 N/A 304
FY2015/16 N/A 323
FY2016/17 N/A 294
FY2017/18 N/A
41 Release of MCH funds were delayed in Nigeria and Uganda; these two countries account for a large proportion (73%) of the estimated repairs. This benchmark was calculated based on the provision of repairs for two quarters. However, repairs in Uganda were only carried out in the final quarter of the FY.
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Indicator 16: Outcomes of fistula repair (percentage closed and dry)
Definition: Numerator: # of women who received any type of fistula repair surgery (urinary alone, urinary and RVF together, and RVF alone) who when discharged, had a closed fistula and were dry at time of discharge / Denominator: # women who had any type of fistula repair surgery and were discharged X 100
Additional description/context: N/A
Data source and collection: Collected quarterly from hospital registers/ client records/program reports by FC+ staff and partner staff
Benchmark Values
Year Target Actual Notes
FY2013/14 75% 76% Closed and continent data is incomplete for FY13/14 due to new data collection tools. Data presented is what is available for this time period.
FY2014/15 75% 67% 79% of fistulas successfully closed (67% closed and continent, 12% closed and incontinent)
21% not closed
FY2015/16 75% 77% 88% of fistulas successfully closed (77% closed and continent; 11% closed and incontinent)
12% not closed
FY2016/17 75% 78% 89% of fistulas successfully closed (78% closed and continent; 11% closed and incontinent)
11% not closed
FY2017/18 75%
Indicator 17: Complications of fistula repair (percent of repairs with complications)
Definition: Numerator: # of women discharged in a quarter whose fistula repair surgeries resulted in a reportable complication / Denominator: total # of women discharged in a quarter following fistula repair surgeries X 100
Additional description/context: Reportable complications can either be major or minor related to the fistula surgery or to anesthesia. As one woman may have more than one complication, the occurrence types of complications will also be disaggregated. Deaths will be monitored separately and reported to
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USAID annually in a special report. Guidelines regarding complications will be carried over from the Fistula Care Project.
Data source and collection: Collected quarterly from hospital registers/ client records/program reports by FC+ staff and partner staff
Benchmark Values
Year Target Actual Notes
FY2013/14 <20% .4%
FY2014/15 <20% 2.3%
FY2015/16 <20% 2.7%
FY2016/17 <20% 2.1%
FY2017/18 <20%
Indicator 18: Number of health systems personnel trained, by topic, for fistula and/or POP prevention and treatment (disaggregated by training topic, sex and cadre of provider)
Definition: # of persons attending training in support of fistula services
Additional description/context: Type of training will be reported by the primary training category. Training in surgical repair is included in this indicator, and will be disaggregated. Training will be reported for specific topics such as counseling, use of the partograph, quality improvement, data-driven management, etc.
Categories of health system personnel trained may include:
Surgeons and other physicians Nurses and midwives Other non-physician clinicians (e.g., clinical officers) Non-clinician counselors Facility managers Community health workers
For the purposes of FC+, community health workers are individuals formally affiliated with the health system and linked to specific health facilities, generally providing health education and services at the community/household level. This may include both unpaid and paid individuals. This term encompasses cadres known by other titles, depending on the country context (e.g., Ethiopia’s Health Extension Workers).
Data source and collection: Collected quarterly from training reports by FC+ staff and partner staff
Benchmark Values
Year Target Actual Notes
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FY2013/14 526 403 Delays in funds release and subaward approvals negatively affected ability to implement training in FY13/14
Number revised from FY13/14 report to reflect additional data submitted from countries post-reporting
FY2014/15 929 1,065
FY2015/16 1,395 1,414
FY2016/17 1,041 1,391
FY2017/18 838 Note: Benchmark is for only 9 months of activity, as final quarter will not have active program implementation due to project close-out.
Indicator 19: Number of supported facilities that have introduced treatment for POP
Definition: # of facilities to which FC+ is providing support that have introduced POP treatment services.
Additional description/context: Support can include: provider training and clinical mentoring, equipment, minor renovation or rehabilitation of facilities, and/or other site-strengthening activities such as quality improvement (QI) and management capacity building. Supported sites will provide data to FC+ on the number of POP treatment services provided. Some POP facilities may also be providing fistula repair and/or prevention services. In that case, those sites will also be reported in Indicator 2 or 3, as appropriate; this will be disaggregated in the report.
Data source and collection: Collected semi-annually from program reports by FC+ staff and partner staff
Benchmark Values
Year Target Actual Notes
FY2013/14 0 0
FY2014/15 1 0 Sites identified, implementation will begin in FY 15/16
FY2015/16 6 4
FY2016/17 N/A 2
FY2017/18 4
Indicator 20: Number of POP treatment services provided
Definition: # of POP treatment services performed at supported sites.
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Additional description/context: This includes both conservative treatment (e.g., treatment with a pessary) and all types of surgical treatment (e.g., hysterectomy with pelvic support repair, mesh, etc.). Reports will disaggregate by type of treatment.
Data source and collection: Collected quarterly from hospital registers/ client records/program reports by FC+ staff and partner staff
Benchmark Values
Year Target Actual Notes
FY2013/14 0 NA No sites supported yet
FY2014/15 30 NA No sites supported yet
FY2015/16 505 0 Support initiated but actual repairs not yet supported
FY2016/17 N/A 2,022 SJH and Panzi in DRC
FY2017/18 400 Note: Benchmark is for only 9 months of activity, as final quarter will not have active program implementation due to project close-out.
Indicator 21: Couple-years of protection in sites supported by FC+
Definition: The estimated protection provided by family planning services, based upon the volume of all contraceptives distributed to clients during the reporting period
Additional description/context: USAID-endorsed conversion factors for each family planning method will be used to calculate CYP.42 All CYP will be credited to the year in which the method was distributed, rather than annualizing CYP.
Data source and collection: Collected semi-annually from facility FP registers by FC+ staff and in- country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 28,430 40,039
FY2014/15 90,500 107,985
FY2015/16 153,261 195,986
FY2016/17 145,496 263,206
FY2017/18 184,755 Note: Benchmark is for only 9 months of activity, as final quarter will not have
42 Office of Sustainable Development, Bureau for Africa, USAID. Health and Family Planning Indicators: A Tool for Results Frameworks Volume I. Accessed: January 20, 2014. Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 237
active program implementation due to project close-out.
Indicator 22: Number of FP counseling sessions provided to clients
Definition: # of counseling sessions provided to clients at FC+ sites regarding FP methods.
Additional description/context: As a woman may receive more than one FP counseling session in a given quarter, this indicator represents number of service encounters, rather than numbers of individual clients.
Data source and collection: Collected semi-annually from facility FP registers by FC+ staff and in- country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 53,698 38,373
FY2014/15 117,800 149,610
FY2015/16 204,532 366,038
FY2016/17 186,232 423,736
FY2017/18 297,200 Note: Benchmark is for only 9 months of activity, as final quarter will not have active program implementation due to project close-out.
Indicator 23: Completion of partographs and management of labor according to protocol at sites receiving support for strengthening partograph use
Definition: A two part indicator will be used to assess partograph completeness and management of labor according to protocol.
Part 1: Mean partograph completion score for labor records reviewed during the reporting period. Partograph completion scores will be based on five key items that should be present in all records, whether labor was normal or prolonged. 1 point will be assigned for each item, for score range from 0 to 5. These are selected based on USAID/MCHIP/WHO tools and guidelines. They are:
Existence of partograph in labor & delivery file. Fetal heart rate recorded every half hour on partograph. Contractions plotted every half hour on partograph. Maternal pulse recorded at least every half hour on partograph. Blood pressure recorded at least every four hours on partograph. Part 2: % of partographs with action line reached in which the correction actions were taken.
Additional description/context: This information will be collected during medical monitoring supervision visits using FC+ medical monitoring tool. A systematic sample of up to 25 labor & delivery records for the reference period will be reviewed. Instructions for drawing a systematic sample are Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 238
included in the monitoring tool.). Information from partographs will be abstracted using a standardized form. Data will only be collected from sites where FC is working to strengthen the correct use of the partograph.
Data source and collection: Collected annually from medical monitoring reports by FC+ staff and in- country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 0 NA
FY2014/15 50% of sites 18% of sites receiving a mean receiving a mean score of 4 on score of 4 on reviewed reviewed partographs; 60% partographs; of reviewed 78% of reviewed partographs partographs responding responding appropriately appropriately action if action action if action line reached line reached
FY2015/16 60% of sites 24% of sites receiving a mean receiving a mean score of 4 on score of 4 on reviewed reviewed partographs; 60% partographs; of reviewed 75% of reviewed partographs partographs responding responding appropriately appropriately action if action action if action line reached line reached
FY2016/17 65% of sites 38% of sites receiving a mean receiving a mean score of 4 on score of 4 on reviewed reviewed partographs; 65% partographs; of reviewed 67% of reviewed partographs partographs responding responding appropriately appropriately action if action action if action line reached line reached
FY2017/18 70% of sites receiving a mean score of 4 on
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reviewed partographs; 70% of reviewed partographs responding appropriately action if action line reached
Objective 5: Strengthened evidence base for approaches to improve fistula care and scaled up application of standard monitoring and evaluation indicators for prevention and treatment
Indicator 24: Number of evaluation or research studies completed
Definition: # of evaluation or research studies completed that address fistula care services.
Additional description/context: Studies may include evaluation of models of prevention and repair service delivery, quality assessment and improvement research, evaluation of clinical approaches, and assessment of strategies to reduce barriers to fistula treatment. Annual report will list studies by study name, location, and status (i.e., in development/ ongoing/ complete). Completion will be defined as the submission of a final study report to USAID or the submission of a manuscript documenting study findings for publication.
Data source and collection: Collected annually from program research reports by FC+ staff and research partners
Benchmark Values
Year Target Actual Notes
FY2013/14 0 0
FY2014/15 1 1 Population Council literature review completed
FY2015/16 2 2 Uganda formative research completed, Nigeria communications assessment completed
FY2016/17 N/A 3 Nigeria formative research completed, DHS analysis of Cesarean Sections in LMIC, UCSF/Makarere study
FY2017/18 4
Indicator 25: % of supported sites reviewing fistula monitoring data bi-annually to improve fistula services
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Definition: Numerator: # of sites in which fistula monitoring data are reviewed at the facility to assess program progress / Denominator: # of supported sites X 100
Additional description/context: This indicates the proportion of supported FC+ sites with a functioning process for reviewing fistula monitoring data in order to improve services. A functioning review process is defined as a team of staff from the site who meet at least twice a year43, with or without outside assistance (e.g., supervisory teams, FC+ staff) to review and discuss the data and make program decisions to improve fistula services based on these data.
Data source and collection: Collected semi-annually from program monitoring reports by FC+ staff and in-country partners
Benchmark Values
Year Target Actual Notes
FY2013/14 40% NA
FY2014/15 45% 55%
FY2015/16 50% 68%
FY2016/17 70% 94%
FY2017/18 75%
43 The ideal is for these data to be reviewed on a monthly or quarterly basis, depending on service volume at a particular facility. However, experience from the original FC project indicates that this is very difficult, given shortages in human and other resources. FC+ will advocate with partner facilities to strengthen data monitoring and review systems, but has noted that in the approved PMP that bi-annual review is the minimum achievable floor for this indicator. Semi-Annual Report • October 2016 – March 2017 Fistula Care Plus 241