Elective Report Joanna Smith

Vesico-vaginal fistula repair at , Masaka

During my elective period, I spent eight weeks at Kitovu Hospital, Masaka in Central . It is a two hundred bed hospital with a further twenty-eight beds in a dedicated obstetric fistula repair unit. The aim of my elective was to gain an in-depth understanding of obstetric fistulae (vesico-vaginal fistula or VVF), a devastating medical condition that affects large numbers of women in developing countries. I also intended to gain experience in Obstetrics and Gynaecology and to consider whether this is a career to which I would be suited and to gain an insight into the realities of working as a doctor in a developing country.

Obstetric fistula in Uganda

An obstetric fistula is an abnormal opening that forms during labour between the vagina and the bladder or less commonly between the bladder and the rectum. Obstetric fistulae occur most commonly as a result of prolonged and obstructed childbirth. Obstructed labour occurs as a result of cephalo-pelvic disproportion and malpresentation and leads to a fistula when these complications are not recognised and managed by healthcare professionals in the appropriate setting.i It has been estimated that 90% of obstetric fistulae are preventable.ii

Before my placement at Kitovu Hospital, I had never encountered a patient with VVF, largely because it is a problem that is rarely encountered in western medicine; it is a disease of the poor. In Uganda it has been estimated that 2,000 new cases of obstetric fistulae are recorded every year and 2.6% of women of reproductive age have experienced symptoms of an obstetric fistula. This equates to a prevalence of approximately 142,000 women.iii

Obstetric fistulae remain a problem in Uganda for a number of reasons. Firstly maternal healthcare services including family planning, skilled care at birth, basic and comprehensive emergency obstetric care, and affordable treatment of fistula are either difficult to access, too expensive or in many rural areas are non-existent. The majority of women seen at Kitovu hospital are from the local Buganda tribe. Bugandan culture dictates that women should deliver vaginally and if any intervention is required during childbirth, then the mother is deemed a failure; a woman’s status in society depends on her childbearing ability. Only 47% of all Ugandan women attend four antenatal appointments and only 40% of women deliver in a healthcare facility.iv As a result women who are likely to have difficulties during delivery are not identified and when women find themselves in obstructed labour they are often miles away from emergency obstetric services. This increases the likelihood of both stillbirth and obstetric fistula.

Many Ugandan healthcare workers do not have the skills to manage fistulae effectively and the equipment necessary for the procedure is lacking or unreliable. Women cannot afford to pay for surgery and therefore there is little incentive for African physicians to become skilled in fistula repair as it is not a lucrative market.

The impact of obstetric fistulas is devastating. As a result of fistulae, women are left incontinent of urine, faeces or in some situations, both. In turn, this leads to social stigmatization, isolation, marital breakdown and a poor, humiliating quality of life for many women.

Elective Report Joanna Smith

Kitovu Hospital, Masaka

Kitovu Hospital is located in the hills above Masaka in central Uganda. From its position on the hill it overlooks and beyond, Lake Victoria. The hospital began in 1951 as a small first-aid post, run by the Medical Missionaries of Mary, an order of sisters from Ireland. In 2001, the Irish sisters handed the hospital over to a Ugandan order of nuns. In 2005 St. Anne’s fistula unit was set up at the hospital. Until this time, Uganda lacked the specialist services required to deal with the large burden of obstetric fistulas. Kitovu became one of the key sites in the country for fistula repair in a programme funded by USAID, through Engender Health and UNFPA. The fistula programme is run by Dr Maura Lynch.

St. Anne’s unit is opened four times a year for a “fistula camp.” Each camp lasts between two and three weeks and is visited by specialist surgeons from the UK. During each fistula camp, vesico-vaginal fistula repair is provided free of charge to Ugandan women of all ages. They include young teenagers who have developed fistulae often as a result of early childbirth and grandmothers who have lived stigmatised with fistulae for many years. The camps are advertised by word of mouth and also on local radio. Women travel for many miles to Kitovu: by foot, in mini-buses, by ferry across Lake Victoria and on the back on motorbikes.

The programme at Kitovu encourages visiting trainees to come and participate in fistula camps including doctors, anaesthetists, theatre staff and nurses. There is a strong emphasis on the idea that the effective treatment of obstetric fistulas can only be achieved with a cohesive multi-disciplinary team, focusing not only on the surgical procedure, but also on good pre- and post-operative care. Trainees have come from a variety of African countries including Angola, Niger, Zambia and Ethiopia. Under the supervision of the specialist surgeons, they are taught the steps of assessing and repairing vesico-vaginal fistulae in order to enable them to provide this service in their own hospitals.

Fistula camp, April 2012

My visit to Kitovu Hospital coincided with a fistula camp. The camp lasted three weeks and during that time, three consultants visited from the UK, including Dr John Kelly, a retired obstetrician from Birmingham who dedicates much of his time to fistula work in developing countries. In the week leading up to the camp, the hospital began to buzz with activity. The fistula unit which had stood closed was opened and cleaned and a tent was erected at the rear of the hospital complex which would serve as living quarters for women and their children waiting for their turn for theatre. Long before the camp was due to start, women, bearing baskets of food, cooking utensils and bedding began to arrive at Kitovu. On arrival women were asked to fill in a registration questionnaire. They were asked questions about their age, how far they had travelled and how many children both live and stillborn they had. Each woman was then assessed by a consultant, who determined the size and exact positioning of the fistula and what surgery was indicated.

During the course of the camp 73 women underwent surgery. The eldest woman was aged 70 and the youngest 18. There is a dedicated theatre for fistula repair at Kitovu which is set up with two operating tables, so that two women can be operated on Elective Report Joanna Smith

simultaneously. During this particular fistula camp, there were no visiting trainees and so I was lucky enough to assist at a number of fistula repairs and to get first-hand experience of surgery. This enabled me develop an understanding of the anatomy of a fistula and the surgery required to repair them.

It was a privilege to watch women, who timidly entered the operating theatre, leaking urine and who were barely able to make eye contact, leave the hospital smiling, with their dignity and quality of life restored. On the first day seven women underwent fistula repair. As the camp went on, the number of women operated on each day increased, as did the complexities of each case. Repairs of small and simple vesico-vaginal fistulae were usually straightforward however some procedures were more complex including the repair of a number of recto-vaginal fistulae, prolapse repairs and also repair of a third degree perineal tear with re-modelling of the anal sphincter.

Following surgery women stay on the fistula unit for 2 weeks with a catheter in place, to reduce the risk of infection and to encourage healing. A visiting counsellor also spends time with the women and advice is given about the importance of antenatal care in future pregnancies and about the need for a caesarean section for future deliveries.

Reflection

During my elective placement, I was able to follow women with obstetric fistulae through the process of pre-operative assessment, surgery and recovery. It was interesting and deeply moving to hear how they had come to attend the fistula camp. It was also frustrating to see that although only a simple procedure is required to repair obstetric fistulae, many women suffer in silence for years before accessing the services that they need. It is evident that the issue of reducing the incidence of obstetric fistulae in Uganda is complex. Multiple factors contribute to the high prevalence of the condition. It is clear that whilst women are judged by their potential to bear children both at a young age and by traditional methods without skilled birth attendants, obstetric fistula will continue to be a burden on maternal health in Uganda. The problem is exacerbated by poor healthcare facilities, under-developed infrastructure and poverty, which all act as barriers to women accessing the services that they need.

The fistula programme at Kitovu is a good example of a positive way that doctors from developed countries can contribute to the improvement of healthcare services in poorer nations such as Uganda. They can spend a short period of time sharing valuable and relevant skills and knowledge with local healthcare professionals who disseminate what they have learnt to other health facilities in the country. It is easy to measure how many women benefit directly from attending the fistula camp at Kitovu by the number of successful fistula repairs, however the wider impact on women’s health, dignity and quality of life in Uganda must also be significant.

i Cook R.J, Dickens B.M & Syed, S. Obstetric Fistula: The challenge to human rights. International Journal of Obstetrics and Gynaecology, 2004; 87(1):72-77 ii World Health Organisation. 10 Facts on Obstetric Fistula. 2010. iii Creanga A, Iliyasu Z & Arinaitwe, L. An Evaluation of the United Nation Population Fund/Uganda’s Obstetric Fistula Program. The United Nation Population Fund, 2008. iv Uganda Bureau of Statistics. Uganda Demographic and Health Survey, 2007.