Fistula Care Plus Associate Cooperative Agreement AID-OAA-A14-00013 Annual Report October 1, 2017 to September 30, 2018
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, 2018
EngenderHealth 505 9th St. NW, Suite 601 Washington, DC 20004 Telephone: (202) 902 2000 Fax: (202) 783 0281 E-mail: [email protected]
Copyright 2018. EngenderHealth/Fistula Care Plus. All rights reserved.
Fistula Care Plus (FC+) c/o EngenderHealth 505 9th St. NW, Suite 601 Washington, DC 20004 Telephone: (202) 902 2000 Fax: (202) 783 0281 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 ...... 5 TABLES ...... 7 FIGURES ...... 8 EXECUTIVE SUMMARY ...... 9 INTRODUCTION ...... 11 SECTION I: MANAGEMENT ACTIVITIES ...... 12 OVERVIEW...... 12 STAFFING AND RECRUITMENT ...... 12 PROJECT MANAGEMENT ...... 12 PARTNERSHIP: GLOBAL AND COUNTRY-LEVEL ...... 13 LEVERAGING FC+ FOR ADDITIONAL FISTULA PROGRAMMING ...... 16 INTERNATIONAL CLINICAL SUPPORT AND TECHNICAL ASSISTANCE (TA) TRAVEL ...... 16 MEETINGS ...... 18 FUNDING ...... 22 SECTION II: GLOBAL ACCOMPLISHMENTS ...... 24 FISTULA CARE PLUS ACHIEVEMENTS ...... 24 OBJECTIVE 1: STRENGTHENED ENABLING ENVIRONMENT TO INSTITUTIONALIZE FISTULA PREVENTION, TREATMENT, AND REINTEGRATION IN THE PUBLIC AND PRIVATE SECTORS ...... 25 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 ...... 33 OBJECTIVE 3: REDUCED TRANSPORTATION, COMMUNICATIONS, AND FINANCIAL BARRIERS TO ACCESSING PREVENTIVE CARE, DETECTION, TREATMENT, AND REINTEGRATION SUPPORT ...... 35 OBJECTIVE 4: STRENGTHENED PROVIDER AND HEALTH FACILITY CAPACITY TO PROVIDE AND SUSTAIN QUALITY SERVICES FOR FISTULA PREVENTION, DETECTION, AND TREATMENT...... 38 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...... 49 SECTION III: COUNTRY REPORTS ...... 57 BANGLADESH ...... 57 DEMOCRATIC REPUBLIC OF CONGO ...... 68 MOZAMBIQUE ...... 77 NIGERIA...... 81 UGANDA ...... 97 WEST AFRICA/NIGER (WAN) ...... 116 APPENDIX A: FC+ PLANNED AND ACTUAL SUPPORTED SITES, FY 17/18...... 123 APPENDIX B: FC+ PARTNERSHIPS, BY COUNTRY, FY 17/18 ...... 125 APPENDIX C: FC+ PARTNERSHIPS WITH FAITH-BASED ORGANIZATIONS (FBOS) ..... 128
APPENDIX D: NUMBER OF USAID-SUPPORTED FISTULA REPAIR SURGERIES BY COUNTRY, SITE AND YEAR ...... 132 APPENDIX E: FC/ FC+ PEER REVIEWED PUBLICATIONS ...... 139 APPENDIX F: FC/FC+ PUBLICATION READERSHIP METRICS* ...... 153 APPENDIX G: HUMAN RESOURCES FOR HEALTH CESAREAN SECTION SESSION INVITATION ...... 155 APPENDIX H: HRH FORUM PRESENTATIONS ...... 156 APPENDIX I: CESAREAN SECTION TECHNICAL CONSULTATION DISSEMINATION PRESENTATION ...... 160 APPENDIX J: FCOP WEBINAR ANNOUNCEMENT ...... 165 APPENDIX K: IHI POSTER QOC IN TANZANIA...... 168 APPENDIX L: IHI POSTER CESAREAN SECTION CONSULTATION...... 169 APPENDIX M: IHI POSTER SST IMPLEMENTATION ...... 170 APPENDIX N: 58TH ANNUAL CONFERENCE OF WEST AFRICAN COLLEGES OF SURGEONS (WACS) PROGRAM ...... 171 APPENDIX O: WACS LIST OF FC+ AND CONSULTANT PARTICIPANTS ...... 173 APPENDIX P: WEST AFRICA REGIONAL MEETING FOR FISTULA ELIMINATION AGENDA ...... 174 APPENDIX Q: WEST AFRICA REGIONAL MEETING FOR FISTULA ELIMINATION PARTICIPANTS LIST ...... 177 APPENDIX R: WEST AFRICA REGIONAL MEETING FOR FISTULA ELIMINATION - FC+/DRC PRESENTATION ...... 181 APPENDIX S: WEST AFRICA REGIONAL MEETING FOR FISTULA ELIMINATION – FC+/NIGERIA PRESENTATION ...... 184 APPENDIX T: BANJUL CALL TO ACTION FOR A FISTULA FREE ECOWAS REGION ..... 187 APPENDIX U: COSECSA/GIEESC EH/FC+ SPONSORED EVENT ...... 188 APPENDIX V: PARTICIPANT LIST FOR FC+ DINNER SIDE EVENT ...... 192 APPENDIX W: SURVEY FOR COSECSA/GIEESC FC+ EVENT ...... 193 APPENDIX X: WHO GIEESC BIENNIAL MEETING AGENDA ...... 194 APPENDIX Z: FC+ BARRIER REDUCTION INTERVENTION STUDY DISSEMINATION PRESENTATION – UGANDA ...... 201 APPENDIX AA: HSR SESSION APPLICATION ...... 206 APPENDIX BB: FIGO SESSION SUMMARY ...... 208 APPENDIX CC: ACOG ETOO PRESENTATION ...... 210 APPENDIX DD: BANGLADESH MATERNAL MORBIDITY VERIFICATION STUDY DISSEMINATION PRESENTATION ...... 213
APPENDIX EE: FC+ SUPPORTED TREATMENT SITES MEETING TO DISCUSS DATA ... 222 APPENDIX FF: AFLATEEN PRESENTATION FOR USAID/WASHINGTON BROWN BAG . 224 APPENDIX GG: SDI PARTNERS MEETING AGENDA ...... 229 APPENDIX HH: FC+ SDI PARTNER MEETING PRESENTATION ...... 231 APPENDIX II: FCOP SBA SURVEY WEBINAR PRESENTATION...... 233 APPENDIX JJ: 2017 GLOBAL SURVEY OF INTRAPARTUM AND POSTPARTUM CLINICAL PRACTICES ...... 238 APPENDIX KK: C-SECTION PRESENTATION FOR USAID BROWN BAG ...... 239 APPENDIX LL: ETOO USAID PRESENTATION ...... 245 APPENDIX MM: FC+ FIGO 2018 PLANNED PRESENCE ...... 248 APPENDIX NN: USAID BRIEFING ON FC+/POPULATION COUNCIL BARRIER INTERVENTION STUDY ...... 251 APPENDIX OO: WIF TERREWODE STUDY PRELIMINARY FINDINGS SUMMARY ...... 257 APPENDIX PP: INVITATION TO HEALTH SYSTEMS RESEARCH CONFERENCE PANEL ON CESAREAN SECTION SAFETY IN LOW-RESOURCE SETTINGS ...... 262 APPENDIX QQ: BARRIER INTERVENTION STUDY KNOWLEDGE PRODUCTS PIPELINE ...... 263 APPENDIX RR: FY 17/18 FC+ COUNTRY REPAIR DATA VISUALIZATIONS...... 265 APPENDIX SS: FC+ ANNUAL PARTOGRAPH MONITORING: FY 14/15 ...... 269 APPENDIX TT: FC+ ANNUAL PARTOGRAPH MONITORING: FY 15/16 ...... 272 APPENDIX UU: FC+ ANNUAL PARTOGRAPH MONITORING: FY 16/17 ...... 275 APPENDIX VV: FC+ ANNUAL PARTOGRAPH MONITORING: FY 17/18 ...... 278 APPENDIX WW: FC+ PLANNED PRESENCE AT ISOFS 2018 ...... 281 APPENDIX XX: PARLIAMENTARY PRESENTATION ON UGANDA COSTING STUDY ..... 285 APPENDIX YY: FC+ CORE INDICATORS: ANNUAL ACHIEVEMENTS ...... 289
ACRONYMS AND ABBREVIATIONS
ACOG ...... American College of Obstetricians and Gynecologists ANC ...... Antenatal Care BMGF ...... Bill and Melinda Gates Foundation BMMMS ...... Bangladesh Maternal Mortality Survey BSMMU ...... Bangabandhu Sheikh Mujib Medical University C-Section ...... Cesarean Section CBO ...... Community Based Organization COSECSA ...... College of Surgeons of East, Central and Southern Africa 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 ECSACOG ...... East, Central and Southern Association College of Obstetricians and Gynecologists EmOC ...... Emergency Obstetric Care EmONC ...... Emergency Obstetric and Neonatal Care ETOO ...... Essential Training in Operative Obstetrics 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 GIEESC ...... Global Initiative for Emergency and Essential Surgical Care GOB ...... Government of Bangladesh HC ...... Health Center HGR ...... General Reference Hospital HMIS ...... Health Management Information System HRH ...... Human Resources for Health HSD ...... Health Services Delivery IGL ...... Imagerie des Grand Lacs IHI ...... Institute for Healthcare Improvement IMAN ...... Islamic Medical Association of Nigeria IOFWG ...... International Obstetric Fistula Working Group IRB ...... Institutional Review Board ISOFS ...... International Society of Obstetric Fistula Surgeons IUCD ...... Intrauterine contraceptive device IVR ...... Interactive voice response LGA ...... Local Government Area
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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 NCE ...... No cost extension NFTWG ...... National Fistula Technical Working Group NOFIC ...... National Obstetric Fistula Center NSOAP ...... National Surgical, Obstetric, and Anesthesia Plans OBGYN ...... Obstetricians and gynecologists OF ...... Obstetric fistula OGSB ...... Obstetrical and Gynaecological Society of Bangladesh PGSSC ...... Harvard Program on Global Surgery and Social Change 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 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 WACS ...... West and Central Africa College of Surgeons WDI ...... Women Deemed Incurable
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TABLES
Title Page Table 1: Active Subawards as of September 30, 2018 14 Table 2: International Technical Assistance Travel, FY 17/18 17 Table 3: Meetings and Presentations, FY 17/18 18 Table 4: Select Fistula Care Plus Achievements and Benchmarks, FY 17/18 24 Table 5: Total Number of Clinical Training Participants, by Country, by Topic, FY 17/18 25 Table 6: FC+ Twitter Account Metrics, FY 17/18 33 Table 7: Community Outreach/Education Events, by Country, FY 17/18 35 Table 8: Community Volunteer/Educator Training, Participants by Country, FY 17/18 35 Table 9: Fistula Treatment Barriers Reduction Intervention, Outputs by Site, Jun 17 – Apr 2018 37 Table 10: Number of USAID-Supported Surgical Fistula Repairs, by Country, FY 17/18 43 Table 11: Training in Surgical Fistula Repair, Participants by Quarter, FY 17/18 46 Table 12: Training for Health System Personnel (excluding fistula/POP surgery), FY 17/18 46 Table 13: Number Seeking, Requiring, and Receiving POP Treatment, by Country, FY 17/18 48 Table 14: Peer-Reviewed Articles Published, FY 17/18 53 Table 15: FC+ Blog Posts, FY 17/18 54 Table BGD1: Community Outreach/Education/Advocacy Events, FY 17/18 62 Table BGD2: Community Volunteer/Educator Training, Participants, By Quarter, FY 17/18 62 Table BGD3: USAID-Supported Surgical Fistula Repairs, by Site, FY 17/18 63 Table BGD4: Surgical Fistula Repair Training, Participants by Trainee Institution, FY 17/18 65 Table BGD5: Non-Surgical Health System Personnel Training, Participants by Topic, FY 17/18 65 Table BGD6: Family Planning Counseling Sessions and CYP, by Site, FY 17/18 66 Table DRC1: Community Outreach/Education/Advocacy Events, FY 17/18 71 Table DRC2: USAID-Supported Surgical Fistula Repairs, by Site, FY 17/18 73 Table DRC3: Surgical Fistula Repair Training, by Trainee Institution, FY 17/18 74 Table DRC4: Non-Surgical Health System Personnel Training, Participants by Topic, FY 17/18 75 Table DRC5: Family Planning Counseling Sessions and CYP, by Site, FY 17/18 75 Table MOZ1: Community Outreach/Education/Advocacy Events, FY 17/18 78 Table MOZ2: USAID-Supported Surgical Fistula Repairs, by Site, By Quarter, FY 17/18 79 Table MOZ3: Non-Surgical Health System Personnel Training, Participants by Topic, FY 17/18 80 Table NGA1: Community Outreach/Education/Advocacy Events, FY 17/18 86 Table NGA2: Community Volunteer/Educator Training, Participants by Topic, FY 17/18 87 Table NGA3: USAID-Supported Surgical Fistula Repairs, by Site, FY 17/18 91 Table NGA4: Surgical Fistula Repair Training, Participants by State, FY 17/18 93 Table NGA5: Non-Surgical Health System Personnel Training, Participants by Topic, FY 17/18 93 Table NGA6: Family Planning Counseling Sessions and CYP, by Site, FY 17/18 94 Table UGA1: Community Outreach/Education/Advocacy Events, FY 17/18 103 Table UGA2: Community Volunteer/Educator Training, FY 17/18 104 Table UGA3: USAID-Supported Surgical Fistula Repairs, by Site, FY 17/18 108 Table UGA4: Surgical Fistula Repair Training, By Quarter, FY 17/18 109 Table UGA5: Non-Surgical Health System Personnel Training, Participants by Topic, FY 17/18 111 Table UGA6: Family Planning Counseling Sessions and CYP, by Site, FY 17/18 112 Table WAN1: Community Outreach/Education/Advocacy Events, FY 17/18 118 Table WAN2: Community Volunteer/Educator Training, Participants by Topic, FY 17/18 119 Table WAN3: USAID-Supported Surgical Fistula Repairs, by Site, FY 17/18 120 Table WAN4: Non-Surgical Health System Personnel Training, by Topic, FY 17/18 121 Table WAN5: Family Planning Counseling Sessions and CYP, by Site, FY 17/18 121
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FIGURES
Title Page Figure 1: Fistula Care Plus Project Framework 11 Figure 2: Fistula Care Plus Website Views, by Month 33 Figure 3: Cesarean Section Rates, by Country, FY 17/18 40 Figure 4: Number of Women Seeking and Requiring Fistula Treatment, and Number of 42 Surgical Repairs, By Country, FY 17/18 Figure 5: USAID-Supported Surgical Fistula Repairs, by Quarter, FY 17/18 43 Figure 6: Outcome Rates for Fistula Surgical Repairs, by Country, FY 17/18 45 Figure 7: Family Planning Counseling Sessions, by Country, FY 17/18 47 Figure 8: Family Planning CYP, Short-Term vs. Long-Term/Permanent Methods, by 48 Country, FY 17/18 Figure BGD1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 63 Surgical Repairs, by Site, FY 17/18 Figure BGD2: Outcome Rates for Surgical Repairs, by Site, FY 17/18 64 Figure BGD3: Number of Obstetric Deliveries, by Site, FY 17/18 66 Figure BGD4: Cesarean Section Rates, by Site, FY 17/18 66 Figure DRC1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 72 Surgical Repairs, by Site, FY 17/18 Figure DRC2: Outcome Rates for Surgical Repairs, by Site, FY 17/18 73 Figure DRC3: Number of Obstetric Deliveries, by Site, FY 17/18 76 Figure DRC4: Cesarean Section Rates, by Site, FY 17/18 76 Figure MOZ1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 79 Surgical Repairs, by Site, FY 17/18 Figure MOZ2: Outcome Rates for Surgical Repairs, By Site, FY 17/18 80 Figure NGA1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 90 Surgical Repairs, by Site, FY 17/18 Figure NGA2: Outcome Rates for Surgical Repairs, by Site, FY 17/18 92 Figure UGA1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 108 Surgical Repairs, by Site, FY 17/18 Figure UGA2: Outcome Rates for Surgical Repairs, by Site, FY 17/18 109 Figure UGA3: Number of Obstetric Deliveries, by Site, FY 17/18 113 Figure UGA4: Cesarean Section Rates, by Site, FY 17/18 113 Figure WAN1: Number of Women Seeking and Requiring Fistula Treatment, and Number of 120 Surgical Repairs, by Site, FY 17/18 Figure WAN2: Outcome Rates for Surgical Repairs, by Site, FY 17/18 121 Figure WAN3: Number of Obstetric Deliveries, by Site, FY 17/18 122 Figure WAN4: Cesarean Section Rates, by Site, FY 17/18 122
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EXECUTIVE SUMMARY
The annual report presents key accomplishments and activities for the fifth fiscal year (October 1, 2017 to September 30, 2018) of Fistula Care Plus (FC+). EngenderHealth manages the project in collaboration with international and national partners. During FY 17/18, USAID supported fistula treatment and prevention services through the FC+ project in six countries—Bangladesh, the Democratic Republic of the Congo (DRC), Mozambique, Niger, Nigeria, and Uganda. USAID also supports fistula activities in DRC, Ethiopia, Guinea, Mali, Pakistan, and Rwanda through bilateral funding. EngenderHealth 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, 2017 to September 30, 2018 period included: Objective 1: Strengthened enabling environment Publication of WHO recommendation on shorter-duration bladder catheterization following surgical repair of fistula, based on Fistula Care project randomized controlled trial results Progress on fistula strategy development in Bangladesh, DRC, Nigeria, Uganda, and West Africa Cesarean section technical consultation report publication and action agenda dissemination Support to and participation in meetings of regional colleges of surgeons in East, Southern and Central Africa (COSECSA) and West and Central Africa (WACS) Support to the formation and launch of the ECSA College of Obstetrics and Gynecology (ECSACOG) that will strengthen regional standards for OBGYN education and credentialing Safe surgery advocacy and National Surgical, Obstetric and Anesthesia Plans (NSOAP) advancement, including presentation and participation at WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) and World Health Assembly meetings International Day to End Obstetric Fistula events held globally on May 23, 2018 South Asian Group on Fistula and Related Morbidities advocacy coalition dedicated to accelerating the 2016 UN Secretary General’s call to action to “End fistula within a generation”, embodied in the March 2017 Kathmandu Call for Action 2017 West and Central Africa Task Force for the Elimination of Fistula advocacy coalition dedicated to accelerating the 2016 UN Secretary General’s call to action to “End fistula within a generation”, embodied in the 2018 Banjul Call to action for a Fistula Free ECOWAS Region Collaborations between Department of Urology at University of Kinshasa (DRC) and Wake Forest Institute for Regenerative Medicine (USA) to explore a way forward to provide regenerative medicine therapies for Congolese women suffering complex fistula and/or complex co-morbidities, such as women with “closed/incontinent” fistula treatment outcomes and WDI. Support for ongoing collaboration between the American College of Obstetrics and Gynecology, the Uganda academic OBGYN education sector, and the Uganda Ministry of Health
Objective 2: Enhanced community understanding and practices 749 community volunteers/educators trained in tools and approaches to raise awareness regarding fistula prevention and repair Community stakeholders, including religious leaders, village committees in Uganda and Nigeria; schoolgirls in Bangladesh; and community volunteers in Niger, trained and supported for outreach and awareness-raising activities 17,678 in-person community awareness-raising activities/events conducted by program partners, reaching 681,597 participants Mass media awareness-raising efforts reached an estimated 20.9 million people
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Objective 3: Reduced transportation, communications, and financial barriers Findings of Uganda formative research for the Fistula Treatment Barrier Reduction Intervention presented to national, state, and local stakeholders Implementation of the Intervention in Nigeria and Uganda Midline process evaluation of Intervention with Population Council, with implementation of appropriate course corrections Endline data collection for the Intervention in Nigeria and Uganda Publication of technical briefs, manuscript, and other dissemination events related to formative research and resulting Intervention
Objective 4: Strengthened provider and health facility capacity 37 sites supported by FC+ for fistula treatment and prevention activities; 12 sites supported through other USAID bilateral funding 3,104 surgical fistula repairs and 162 non-surgical repairs supported through FC+; 1,071 surgical repairs and two non-surgical repairs supported by other bilateral USAID programs; this has brought the total USAID-supported surgical fistula repairs since 2005 to 53,495 and the total EngenderHealth- supported surgical fistula repairs to 42,320 210 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; 217 sites supported through other USAID bilateral support 456,930 family planning (FP) counseling sessions provided at supported sites (233,840 at FC+ supported sites, and 223,090 through former TSHIP sites), with FP services resulting in 315,229 Couple Years of Protection (197,273 through FC+ sites and 117,956 through former TSHIP sites) 23 surgeons trained in fistula repair 1,289 health system personnel trained in non-surgical fistula repair and prevention topics
Objective 5: Strengthened evidence base Two Fistula Community of Practice webinars held: 1) Cesarean section safety and quality in low resource settings: Highlights from a global technical consultation; 2) Global survey of skilled birth attendants on intra- and post-partum bladder care and management of prolonged/obstructed labor Convening of a satellite session on cesarean section safety and quality at the 2017 Fourth Global Forum on Human Resources for Health and presentation of three posters disseminating research and program evidence at the 2018 First Africa Forum on Quality and Safety in Healthcare Acceptance of 15 oral presentations and one panels at the 2018 FIGO World Congress and one satellite panel at the Health Systems Research Symposium FC+ and American College of Obstetrics and Gynecology (ACOG) collaboration on monitoring and evaluation of ACOG’s Essential Training in Operative Obstetrics (ETOO) program. Publication of five peer-review articles on fistula, pelvic organ prolapse (POP), and cesarean section services in low-resource settings Publication of 11 blog posts highlighting FC+ and partner programmatic experience Completion of knowledge generation activities in Uganda: 1) Study with TERREWODE to evaluate effectiveness of intervention for women with fistula deemed incurable and 2) documentation of Aflateen PLUS intervention to build reproductive health and other life skills among adolescents and youth HMIS process documentation data collection completed in four countries (Bangladesh, Nigeria, Uganda, and Guinea)
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INTRODUCTION
This annual report provides a summary of accomplishments for the fifth fiscal year (October 1, 2017 – September 30, 2018) 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 YY) 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. During FY 17/18, FC+ supported fistula prevention and treatment activities with USAID funding at a total of 247 sites in Bangladesh, the Democratic Republic of the Congo (DRC), Mozambique, Niger, Nigeria, and Uganda: 37 treatment and prevention sites and 210 prevention-only sites. The number of supported sites varied over the course of FY 17/18, more than in prior fiscal years, due to country program initiation and closure. FC+ support to Mozambique initiated in FY 17/18, through collaboration with Focus Fistula. FC+ support to Nigeria ended at the end of FY 17/18, including the support provided for temporary data collection on FP services at an additional 500 former TSHIP sites. See Appendix A for a full list of FC+ planned and actual supported sites for the fiscal year. In addition to the support provided via FC+, USAID provides bilateral support to fistula work carried out at 229 sites (12 treatment, 217 prevention-only) in six countries: DRC (through ProSani); Ethiopia (through Pathfinder); Guinea (through Jhpiego); Mali (through IntraHealth); Pakistan (through the Jinnah Post Graduate Medical Center); and Rwanda (through MCSP). In FY 17/18, EngenderHealth continued fistula-related activities in Guinea through the Jhpiego-led Health Services Delivery (HSD) project, along with support from the Fistula Foundation that complements HSD activities in Guinea for training providers, strengthening referral networks, and care for women with fistula in Guinea.
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 monitoring reintegration in the public fistula treatment, reduce accessing preventive care, fistula prevention, detection, and evaluation (M&E) indicators and private sectors stigma, and support detection, treatment, and and treatment for prevention and treatment reintegration of women and reintegration support girls with fistula
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SECTION I: MANAGEMENT ACTIVITIES Overview During FY 17/18, the global FC+ team’s management activities included onboarding of a sixth project country (Mozambique), recruitment and orientation of outstanding staff positions, finalization and implementation of project subawards, workplan and budget development, and application for a project No-Cost Extension (NCE). FC+’s project offices in Niger and Nigeria were closed out during the fiscal year, with activities continuing on Niger through implementation of the project subaward with REF with management from the FC+ core team. Support for project activities in Nigeria concluded during the fourth quarter of the fiscal year. Management activities provided the oversight and operational framework that enabled the achievements described in Sections II and III. Staffing and Recruitment Jarryd Botha joined FC+ as Financial Management and Administrative Specialist in February 2018. Lauren Bellhouse left the project as full-time staff in January 2018, continuing as a part-time consultant. Bethany Cole left the project in June 2018 and Elly Arnoff left the project in August 2018. During FY 17/18, the FC+/Global team was comprised of the following staff: Lauri Romanzi: Project Director Vandana Tripathi: Deputy Director Bethany Cole: Global Projects Manager (through June 2018) Jarryd Botha: Financial Management and Administrative Specialist (as of February 2018) Isaac Achwal: Senior Clinical Advisor and Regional Strategy Specialist (as of June 2018) Lauren Bellhouse: Senior Program Associate (through January 2018) Elly Arnoff: Program Associate – Evaluation and Research (through August 2018) Altiné Diop: Program Associate Karen Levin: Senior Program Associate, Monitoring and Evaluation (50% LOE) Caitlin Donaghy: Program Assistant (45% LOE February – August 2018) SK Nazmul Huda: Global Activities Manager (as of June 2018)
Project Management FC+ leadership oversaw project management through participation in meetings with USAID/W; finalization of FY 17/18 workplans and budgets; preparation of an NCE application to USAID for FY 18/19 and subsequent drafting of FY18/19 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. USAID/W granted approval of a one- year NCE in May 2018. FC+ leadership oversaw closure of project offices in Niger and Nigeria during the third and fourth quarters of the fiscal year. 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. During FY 17/18, FC+ was able to gather data from five bilateral projects: ProSani in DRC, Pathfinder in Ethiopia, Jhpiego in Guinea, IntraHealth in Mali, and the Maternal Child Survival Program (MCSP) in Rwanda. The USAID-funded Vodafone project in Tanzania ended its fistula-related activities in September 2017, and the ProSani project in DRC ended in June 2018. MCSP in Rwanda is ending in early 2019 and has concluded active implementation. Throughout FY 17/18, FC+ continued to hold coordinated country program reviews (CPR) involving monthly teleconferences between Clinical, Program Management, M&E, and Finance staff from global
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and country offices to streamline and harmonize staff and programmatic functions in relation to objectives, indicators, and program innovations. The FC+/Global Projects Manager worked with the FP compliance point persons in each office to update and harmonize the FP compliance plans. They are stored centrally on EngenderHealth’s intranet. 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 March 2018, FC+ leadership participated in a USAID Management Review of the project, an annual discussion of FC+ progress to date. FC+ staff also participated in an internal EngenderHealth portfolio review. FC+, at the request of the USAID Mission in Maputo, Mozambique, has partnered with Maputo-based NGO Focus Fistula through the leadership of Dr. Igor Vaz. A subaward with Focus Fistula was initiated on February 1, 2018, and covers activity through November 30, 2018. The goal of this sub-award is to strengthen the clinical capacity of selected ministry and private facilities and staff to provide accessible, quality obstetric, iatrogenic and traumatic fistula surgical and non-surgical treatment services in Mozambique. During the subaward, Focus Fistula will record and share clinical training methods, including the production and dissemination of a surgical training video recorded at the UroMap conference in Mozambique. The subaward will also include efforts to engage in task-shifting amongst nurses and midwives, and will focus on creating and improving upon existing clinical data systems to support quality assurance.
Partnership: Global and Country-Level During the fifth project year of FC+, engagement with collaborative partners to avoid end-of-project gaps in fistula services was a priority for the project’s sustainability and legacy platform, as is documentation of project achievements and challenges. In FY 16/17, 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. FC+ will re-engage with Fistula Foundation in FY 18/19 to determine whether sustainable Fistula Foundation support of selected facilities is possible. FC+ actively continues to contribute to the global safe surgery community of practice through our webinars (see Section II, Objective 5), technical consultation activities, and collaboration with the WHO Global Initiative for Essential and Emergency Surgical Care (GIEESC). FC+ has participated in and provided technical support to organizations and institutions involved in regional surgical safety efforts, particularly the College of Surgeons of East, Southern and Central Africa (COSECSA); the East, Central, Southern Africa (ECSA) College of Obstetrics and Gynecology; and the West African College of Surgeons (WACS); see Section II, Objective 1 for details. During FY 17/18, FC+ worked with global partners to strengthen and disseminate the evidence base for improved fistula care. FC+ has continued collaboration with the Population Council to implement and
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evaluate interventions in response to the completed research study that identified 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 1 as well as Section III: Uganda). FC+ continues to collaborate with global maternal health stakeholders, including Jhpiego and the Maternal and Child Survival Program (MCSP) for the dissemination of the safer cesarean section action agenda and the M&E Technical Working Group of the WHO Quality, Equity, and Dignity Network. See Section II, Objective 1 for details. FC+ also works with a variety of faith-based organizations (FBOs) in several countries, to advance objectives across the project results framework. These FBO partnerships are summarized in Appendix C. FC+ participated in the annual meeting of Christian Connections for International Health, held in Baltimore, Maryland in July 2018. During FY 17/18, FC+ global and country staff continued to finalize, implement, and monitor in-country partnerships and subawards for facilities that receive FC+ support. As of September 30, 2018, there are 13 active subawards and one professional services agreement 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, 2018
Institution Start End Date Number Amount Description Date
Global
Population 1-Oct-14 31-Dec-18 SUBA094 $986,086 To build institutional knowledge about interventions to Council reduce financial barriers, particularly related to transportation, for women seeking fistula repair services, with a focus on Nigeria and Uganda.
Bangladesh
Ad-Din 1-Oct-16 30-Sep-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- 30-Sep-18 SABD011 $138,471 To enable LAMB Hospital to further strengthen and Hospital 16 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 30-Sep-18 SABD010 $69,280 To provide support to build the capacity of Kumudini Hospital Hospital to improve the quality and availability of fistula treatment services, and prevent fistula through strengthening maternal health services and increasing access to FP.
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Institution Start End Date Number Amount Description Date
BSMMU 1-Oct-16 30-Sep-18 SABD012 $104,582 To develop and strengthen 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-Sep-14 31-Oct-18 SACD002 $895,989 To improve access to quality fistula services through Hospital improved fistula service delivery, training of providers, and strengthening quality assurance mechanisms.
HEAL Africa 1-Sep - 31-Oct-18 SACD001 $695,255 To strengthen the capacity of HEAL Africa and its staff 14 to provide accessible, quality obstetric fistula repairs and prevention services.
Panzi Hospital 1-Sep-14 31-Oct-18 SACD003 $986,196 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 FP.
Beniker 21-May- 31-Oct-18 PSCD001 $157,578 To improve access to quality fistula services through Hospital1 18 improved fistula service delivery, training of providers and strengthening quality assurance mechanisms.
Mozambique
Focus Fistula 1-Feb-18 30-Nov-18 SAMZ001 $468,864 To strengthen the clinical capacity of selected ministry and private facilities and staff to provide accessible, quality obstetric, iatrogenic and traumatic fistula surgical and non-surgical treatment services, using a strategic platform that advocates for and facilitates the UN Secretary General’s 2016 call to action: “eradicate fistula within a generation.”
Niger
Réseau pour 1-Apr-17 30-Sep-18 SANE002 $68,047 To strengthen the enabling environment in Niger to l’Eradication institutionalize fistula prevention, treatment, and des fistules reintegration in the public and private sectors. REF will (REF) enhance community understanding and practices to prevent fistula, improve access to fistula treatment, reduce stigma, and support reintegration of women and girls with fistula
Uganda
Kitovu 1-Mar-17 31-Oct-18 SAUG004 $237,629 To enhance community understanding and practices Hospital 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 whose fistula is the result of sexual violence. To reduce transportation, communication and financial
1 Funding support to Beniker is provided via a Professional Services Agreement (PSA), not a subaward.
Annual Report • October 2017 – September 2018 Fistula Care Plus 15
Institution Start End Date Number Amount Description Date
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 31-Oct-18 SAUG005 $80,344 To provide repairs to 100 women with fistula, enhance Mission community understanding and practices to prevent Hospital fistula, reduce barriers to accessing preventive care, treatment, and reintegration support, and strengthen facility level capacity for fistula management.
Kisiizi Hospital 1-Jan-18 30-Nov-18 SAUG006 $98,942 To build the capacity of the Church of Uganda’s Kisiizi Mission Hospital to repair female genital fistula, plan and implement follow up of repaired women, community education, client mobilization activities, and improve the quality and availability of fistula treatment and prevention services.
In addition to work with project partners, FC+ staff participated in several meetings and coordination processes led by USAID and its flagship projects. These included meetings of the USAID PRH Gender Cooperating Agencies (CAs), the PRH Service Delivery Improvement (SDI) CAs, the Interagency Working Group for Reproductive Health in Conflict (IAWG): Maternal and Newborn Health subworking group, the USAID Health Research Information Tracking (HRIT) webinar, a workshop for validation of PRH indicators, and several brown bag lunches and research briefings. See Table 3 for details of meetings in which FC+ participated during FY 17/18. Leveraging FC+ for Additional Fistula Programming EngenderHealth continues to support fistula services in Guinea, an FC Project country. 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 and the Fistula Foundation. 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.
International Clinical Support and Technical Assistance (TA) Travel FC+ global staff and consultants have carried out international clinical support and TA visits to six countries during FY 17/18 (see Table 2). This travel included:
Management visits, partner meetings (Bangladesh, DRC, Niger, Nigeria, Mozambique, Uganda); Training and support for fistula and POP surgery (DRC); Strengthening FP service provision (Nigeria); Clinical monitoring, site and needs assessments (DRC, Mozambique); Research (Uganda, Niger, Nigeria);
Annual Report • October 2017 – September 2018 Fistula Care Plus 16
Table 2: International Technical Assistance Travel, FY 17/18
Traveler Dates/Location Purpose Lauri Romanzi Oct 6-17, 2017 To conduct follow up clinical monitoring and clinician training of East DRC and West DRC fistula surgeons at Saint Joseph in Kinshasa Elly Arnoff Oct 20-Nov 2, 2017 To conduct midpoint monitoring of the barrier intervention in Kalungu and present a summary of findings from the baseline data collection to Uganda staff at USAID and to national and district-level stakeholders.
Pandora Hartman Nov 4-14, 2017 To provide strategic and technical input on development of FP and (consultant) Nigeria fistula focused health training strategies in Nigeria Isaac Achwal Nov 19 – Dec 7, 2017 To conduct clinical monitoring at five supported treatment sites and DRC needs assessment at Beniker and Lubumbashi. Lauri Romanzi Dec 4-15, 2017 To provide program management review of new partner Focus Fistula, Bethany Cole Mozambique attend GIEESC meeting, and regional working group exploratory meeting Altine Diop Jan 29-Feb 7, 2018 Niger: to conduct a management review in preparation for project Niger and Nigeria closeout, review of REF subaward spending and assist in data collection for Niger community engagement program learning documentation. Nigeria: to participate in one day meeting on strategy for delaying early marriage in Niger and Nigeria Bethany Cole Feb 5-18, 2018 To conduct a management review in preparation for project closeout, nd Bangladesh site visits, meetings with USAID and partners, present at 2 HOPE Maternal Health and Fistula conference, and attend partner’s meeting Jarryd Botha May 6-14, 2018 Subaward start up and support. Mozambique Elly Arnoff Jun 19-28, 2018 Program monitoring and preparation for endline data collection for the Nigeria Barrier Intervention study. Jarryd Botha Jul 9-16, 2018 Financial review and subaward compliance check. DRC Jarryd Botha Jul 28 – Aug 10, 2018 Project office close out and compliance review Nigeria SK Nazmul Huda Aug 13-22, 2018 Conduct a situation analysis regarding fistula programming in Mozambique, review FC+ project implementation by Focus Fistula Jarryd Botha Mozambique (FF), workplan development with FF leadership, FF needs assessment and action planning. Subaward operational support and financial training.
Isaac Achwal Aug 21-31, 2018 To conduct needs assessments at Maputo Central, Nampula Central and Xai Central Hospitals Mozambique Lauri Romanzi Sep 10-14, 2018 Close out activity for FC+/Nigeria office, handover of FC+ legacy and Jarryd Botha Nigeria transition to USAID/Nigeria Jarryd Botha Sep 24-28, 2018 EngenderHealth strategic planning and FC+ management meetings SK Nazmul Huda Washington DC
Annual Report • October 2017 – September 2018 Fistula Care Plus 17
Meetings FC+/Global staff convened, attended, and presented at numerous meetings in FY 17/18, as summarized in Table 3.
Table 3: Meetings and Presentations, FY 17/18
Meeting Dates/Location Convened Attending FC+ Inputs / Presentations by FC+? Exploring Oct 26, 2017 No Bethany Cole Participation Partnership Webinar Governance in Global Health Rwandan Society Oct 27-29, 2017 No Lauri Romanzi EngenderHealth/FC+ support of Obstetricians Kigali, Rwanda Isaac Achwal featured in ECSACOG charter and Gynecologists Rose Mukisa presidential plenary address Annual General Paul Kaduyu Meeting Felicien Banze Participation Vouchers for Oct 18, 2017 No Lauren Bellhouse Participation Family Planning Webinar Services Gender Analysis Nov 7, 2017 No Lauren Bellhouse Participation for Maternal Washington DC Health Programming Fourth Global Nov 13-17, 2017 No Vandana Tripathi Panel on cesarean section safety and Forum on Human quality in low resource settings. See Resources for Appendix H for more detail. Health (HRH) Safe Motherhood Dec 8, 2017 No Elly Arnoff Participation Initiative 30th Washington DC Lauren Bellhouse Anniversary Altine Diop Vandana Tripathi WHO Global Dec 6-9, 2017 No Lauri Romanzi, Hosted side event “East and Initiative for Maputo, Bethany Cole, Southern Africa Conversation on the Emergency and Mozambique Justus Barageine, Eradication of Obstetric Fistula”. Essential Surgical Fred Kirya, Care (GIEESC) Michel Mpunga, Participation Biennial Obonyo John Conference and Hyacinth, College of Josaphat Surgeons of East, Byamugisha, Central and Bellington Vwalika , Southern Africa SK Nazmul Huda, (COSESCA) Farhana Akhter, Annual Meeting Suzy Elneil, Serigne Magueye Gueye Interagency Dec 12, 2017 No Lauren Bellhouse Participation Working Group for Washington, DC Reproductive Health in Conflict (IAWG): Maternal and Newborn Health subworking group Community Care Dec 13, 2016 No Lauren Bellhouse Participation Management Webinar Indicators Cesarean section Jan 11, 2018 Yes Vandana Tripathi FC+ organized each meeting, to consultation Boston, MA Lauri Romanzi present a summary of the CS dissemination consultation key discussion points
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Meeting Dates/Location Convened Attending FC+ Inputs / Presentations by FC+? meetings with and action agenda; at each meeting, Harvard Program partnership and follow-up on Global Surgery opportunities were discussed. See and Social Appendix I for summary presentation. Change (PGSSC), Maternal Health Task Force (MHTF), Harvard Women & Health Initiative (W&HI), and Ariadne Labs USAID Population Jan 17, 2018 No Bethany Cole Participation and Reproductive Washington DC Health Partners’ Meeting Population and Jan 18, 2018 No Karen Levin Participation Reproductive Washington DC Health Indicator Validation Workshop QED Networking January 18, 2018 No Vandana Tripathi Participation M&E Technical Geneva (teleconference) Working Group Meeting Gender Based Jan 31, 2018 No Bethany Cole Participation Violence Quality Webinar Assurance Tool Addressing Feb 27, 2018 No Vandana Tripathi Participation Critical Health Webinar Karen Levin System Barriers to Improve RMNCAH Services Institute for Feb 19-21, 2018 No Vandana Tripathi Three poster presentations on Healthcare Durban, South maternal health Quality of Care Improvement (IHI) Africa measurement, Cesarean Section First Africa Forum safety/quality consultation, and on Quality and Surgical Safety Toolkit (SST) (see Safety in Appendices K, L, and M). Healthcare 58th Annual Feb 26 – Mar 2, No Altine Diop Presentations on the surgical safety Conference of the 2018 SK Nazmul Huda toolkit (SST) from the experiences of West African Banjul, The Iyeme Efem DRC and Nigeria. (see Appendices N College of Gambia Oladosu Ojengbede and O) Surgeons (WACS) Amodu Abiodun Felicien Banza Participation Serine Magueye Gueye Dolores Nembunzu USAID Office of Feb 27, 2018 No Elly Arnoff Presentations on FC+’s gender action Population & Washington DC plan and the barrier intervention Reproductive study. Health (PRH) Gender Participation Cooperating Agencies' (CAs) meeting USAID FC+ Mar 5, 2018 No Lauri Romanzi Annual discussion of FC+ progress Management Washington DC Vandana Tripathi Review Bethany Cole
Annual Report • October 2017 – September 2018 Fistula Care Plus 19
Meeting Dates/Location Convened Attending FC+ Inputs / Presentations by FC+? West and Central Mar 5-7, 2018 Yes Altine Diop Significant financial and Africa Task Force Banjul, The Felicien Banze administrative sponsorship for the Elimination Gambia Iyeme Efem Multiple presentations (see of Fistula SK Nazmul Huda Appendices P, Q, R, S, and T)
Participation Telling the Mar 7, 2018 No Vandana Tripathi Participation Implementation Webinar Story: WHO programme reporting standards (PRS) for sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) Plan Mar 13, 2018 No Elly Arnoff Participation International’s New York, NY Bethany Cole Financial Education and Life Skills for Girls: Challenges and Opportunities Consortium of Mar 15, 2018 No Lauri Romanzi Participation Universities for New York, NY Global Health (CUGH) Safe Surgery Event East, Central and Mar 19-21, 2018 No Isaac Achwal Participation Southern Africa Dar Es Salaam, Health Community Tanzania (ECSA-HC) Health Ministers’ Conference USAID Health Mar 21, 2018 No Elly Arnoff Participation Research Webinar Information Tracking (HRIT) Webinar National Surgical, March 21-22, No Lauri Romanzi Presentation on obstetrics portion of Obstetric and 2018 NSOAP platform Anesthesia Plans Boston, MA (NSOAP) Participation Planning in the Eastern Mediterranean and African Region DHIS2 Mar 22-23, 2018 No Karen Levin Participation Symposium Washington DC A Global Survey Apr 10, 2018 Yes Vandana Tripathi FC+ organized webinar through the of Skilled Birth New York, NY Karen Levin FCoP, presenters included Vandana Attendants on Webinar Elly Arnoff Tripathi (Deputy Director) and Elly Intra- and Post- Lauri Romanzi Arnoff (Program Associate for Partum Bladder Evaluation and Research). See Care and Appendix II. Management of
Annual Report • October 2017 – September 2018 Fistula Care Plus 20
Meeting Dates/Location Convened Attending FC+ Inputs / Presentations by FC+? Prolonged/Obstru Webinar available at: cted Labor https://fistulacare.org/resources/webi nars/ Youth Apr 23, 2018 No Elly Arnoff USAID Brown Bag presentation given Engagement in Washington DC Vandana Tripathi by Elly Arnoff, see Appendix FF. Uganda: Implementation of Aflateen PLUS Activity WHO Emergency Apr 24, 2018 No Lauri Romanzi Presentation on “Investing the “O” in and Essential Geneva, “SOA”: MNCH & SRH lessons Surgical Care Switzerland learned to catalyze safe surgery Program: Empowering Participation maternal/ reproductive health and safe surgery USAID PRH SDI Apr 25, 2018 No Vandana Tripathi FC+ and the Advancing Partners and Partners Meeting Washington DC Elly Arnoff Communities (APC) Project implemented by JSI made presentation on the topic of capacity building, see Appendix HH. Cesarean section May 15, 2018 No Lauri Romanzi USAID Brown Bag presentation on safety and quality Washington DC Vandana Tripathi proceedings from FC+/MHTF in low-resource consultation on cesarean section settings. safety. See Appendix KK. Adaptive May 23, 2018 No Bethany Cole Participation Management Washington DC Deep Dive: Global (via webinar) Digital Health World Health May 21-26, 2018 No Lauri Romanzi Dr. Romanzi was a panelist in the Organization’s Geneva, SK Nazmul Huda Safe Surgery for Women side event 71st World Health Switzerland and the Global Surgical Obstetric Assembly Anesthesia Care Technical Meeting. Obstetric fistula May 25, 2018 No Vandana Tripathi Participation repair in Rwanda. Washington DC
Why Jun 7, 2018 No Karen Levin Participation Interoperability Washington DC Matters to You: (via webinar) Global Digital Health Network 11th ECSA Best Jun 26-28, 2018 No Isaac Achwal Participation Practices Forum Arusha,Tanzania and Directors Joint Consultative Committee Meeting Christian July 13, 2018 No Karen Levin Participation Connections for Baltimore, MD International Health Annual Meeting International Aug 26-30, 2018 No Lauri Romanzi Co-chair of the IUGA-ICS Continence Philadelphia, PA Terminology Working Group for Society (ICS) Pelvic Floor Fistula Annual General Meeting
Annual Report • October 2017 – September 2018 Fistula Care Plus 21
Meeting Dates/Location Convened Attending FC+ Inputs / Presentations by FC+? MSH Global Sep 11, 2018 No Vandana Tripathi Participation Impact Event: Webinar Rethinking Maternal and Newborn Health Services Maternal Health Sep 17, 2018 No Vandana Tripathi Participation Task Force Global Boston, MA Maternal Health Symposium Wilson Center Sep 18, 2018 No Vandana Tripathi Participation Maternal Health Washington DC Initiative/Maternal and Child Survival Program (MSCP) event: Aligning the Stars for Quality RMNCH Care! What Does it Take Barriers to Sep 18, 2018 No Vandana Tripathi Brown Bag presentation at USAID/W treatment and Washington DC on presentation of findings and care for women outputs to date of FC+/Population living with genital Council partnership on fistula fistula in Nigeria treatment barriers. See Appendix NN and Uganda: A for presentation. research to action partnership United Nations Sep 24, 2018 No Lauri Romanzi Inputs to roundtable strategy General Assembly New York, NY side event: Cervical Cancer United Nations Sep 24, 2018 No Lauri Romanzi Participation General Assembly New York, NY side event: Access Challenge Forum on Maternal Health United Nations Sep 25, 2018 No Lauri Romanzi Participation General Assembly New York, NY side event: ICM Roundtable EngenderHealth Sep 26-28, 2018 No Lauri Romanzi Participation Planning and Washington DC Vandana Tripathi Strategy Meeting Jarryd Botha SK Nazmul Huda Altine Diop
Funding The FC+ project was awarded on December 12, 2013 with a ceiling of $82,766,762 ($74,490,086 federal share + $8,276,676 cost share). In FY 17/18, an additional $3.97 million has been added to bring the total life of project obligation to $44.625 million (about 53.9% of total ceiling). The project was awarded a No Cost Extension (NCE) for FY 18/19, to end on September 30, 2019. At this time, FY18 funding has not yet been shared with the project.
Annual Report • October 2017 – September 2018 Fistula Care Plus 22
Total expenses through September 30, 2018 were reported at $40.599 million (about 49% of total ceiling). Projected expenditures and subaward commitments for the NCE FY 18/19 as of September 30, 2019 are projected to be $5.39 million.
Annual Report • October 2017 – September 2018 Fistula Care Plus 23
SECTION II: GLOBAL ACCOMPLISHMENTS Fistula Care Plus Achievements In the fifth 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 17/18. Full reporting on FC+ benchmarks for core indicators, updated annually, can be found in Appendix YY. Appendix D provides information on all USAID-supported fistula repair surgeries from 2005-present.
Table 4: Select Fistula Care Plus Achievements and Benchmarks, FY 17/18
FY13/14 FY14/15 FY15/16 FY16/17 FY17/18 FY17/18 Actual Actual Actual Actual Benchmark2 Actual
Number of countries supported by FC+ 5 6 6 5 6 6
Number of sites supported by FC+ for 25 31 37 33 36 37 fistula repair and prevention
Number of prevention-only sites 16 249 289 252 287 210 supported by FC+ 500 former 500 former 500 former 500 former 500 former TSHIP TSHIP TSHIP TSHIP TSHIP
Number of participants in community 114 776 679 850 1,423 749 volunteer/educator training in tools and approaches to raise awareness regarding fistula prevention and repair
Number of community awareness- 12 1,990 10,352 33,425 10,666 17,678 raising activities/events conducted by (in person) (in person) (in person) program partners 41 659 53 (mass media) (mass media) (mass media)
Number of participants reached 10,745 414,067 2,862,124 557,186 676,000 681,597 through community awareness-raising (in person) (in person) (in person) (in person) events/activities conducted by 3,676,406 15,289,736 27,339,750 20,919,065 program partners (mass media) (mass media) (mass media) (mass media)
Number of surgical fistula repairs 873 2,876 3,514 3,250 2,950 3,104
Number of participants in health 161 1,065 1,414 1,391 838 1,289 systems personnel training, by topic, for fistula and/or POP prevention and treatment (disaggregated by training topic, sex and cadre of provider)3
Number of FP counseling sessions 38,373 149,610 167,424 (FC+) 205,048(FC+) 297,200 233,840(FC+) provided 198,614 218,688 223,090 (Former TSHIP) (Former TSHIP) (Former TSHIP)
Number of CYP provided 40,039 107,986 106,645 (FC+) 170,019(FC+) 188,625 197,273(FC+) 89,341 93,187 117,956 (Former TSHIP) (Former TSHIP) (Former TSHIP)
2 FY 17/18 benchmark represents nine planned months of active program implementation, through June 2018. Actual achievement covers the full 12 months of the fiscal year, as the project received a no-cost extension. 3 Does not include training of surgeons to provide fistula repair.
Annual Report • October 2017 – September 2018 Fistula Care Plus 24
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 185 clinicians,4 focusing on fistula identification and referral, and IntraHealth trained 215 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, FY 17/18
WA/ Bangladesh DRC Mozambique Nigeria Uganda Niger First Training in Surgical Fistula 1 1 0 0 9 1 12 Repair Continuing Training in Surgical 6 0 0 0 4 2 12 Fistula Repair Surgical Fistula TOT 0 0 0 0 0 0 0 First Training in Surgical POP 0 0 0 0 0 0 0 Repair Continuing Training in Surgical 0 0 0 0 0 0 0 POP Repair ANC 0 0 0 0 0 0 0 Catheterization for fistula 0 0 0 0 68 0 68 prevention Community, outreach and 0 0 0 0 0 0 0 advocacy Data management 0 15 0 0 21 0 36 EmONC 0 7 0 20 0 0 27 EmONC and labor monitoring 0 0 0 0 0 10 10 FP counseling 0 0 0 0 0 30 30 FP methods 0 31 0 0 0 29 60 FP and fistula counseling 0 0 0 0 18 30 48 Fistula counseling 0 0 0 0 0 0 0 Gender 0 0 0 0 0 0 0 Infection Prevention 0 232 0 0 0 0 232 Non-surgical POP treatment 0 24 0 0 0 0 24 Pre- and Post-Operative Care 419 84 168 0 32 4 707 Quality Assurance 0 0 0 15 0 0 15 Other 0 32 0 0 0 0 32 TOTAL 426 426 168 35 152 1055 1,3126
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 FY 17/18, FC+ continued to develop Public Private Partnerships (PPPs) with a focus on ensuring the sustainability of these efforts beyond the project.
4 Data available through June 2018 5,5 One surgeon participated in both first and continuing training and is only counted once in the fiscal year total.
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FC+ collaborates with LABORIE Inc., a urodynamics and pelvic floor therapy company with emerging interest in supply chain strengthening in sub-Saharan Africa. Since executing an MoU with FC+ to strengthen the role of academia in the sustainability platform of the project, LABORIE has supported several international events. Laborie most recently co-sponsored the participation of four urogynecological surgeons from Nigeria to attend the Bristol Certificate in Urodynamics course held in Istanbul, Turkey in February 2018. Those attending have plans to implement step down training in- country to share knowledge and skills acquired during the course. Implementation of urodynamics is mandatory for quality of care minimums to address the needs of women who remain incontinent after surgery to close the fistula. With support from the USAID Mission in the DRC, FC+ launched procurement of a Laborie urodynamics unit and one year of disposable supplies for St. Joseph Hospital in Kinshasa, with delivery, installation, and Laborie-supported multi-disciplinary team training anticipated in the second quarter of FY 18/19. The project’s PPP efforts include improving anesthesia quality of care in coordination with Gradian Health Systems. After conducting an anesthesia machine needs assessment survey at all supported repair sites in a previous fiscal year, Saint Joseph Hospital in Kinshasa, DRC was chosen as the first site to receive the Universal Anesthesia Machine (UAM). Installation and support to staff is ongoing. Gradian has provided training to 12 technicians at SJH and staff report improved quality of care for patient safety, with consistent operation even with power failures. Over 63 operations have been performed thus far using the machine. It has also provided economic benefit as it more efficiently utilizes oxygen cylinders. Through referral from USAID’s Susan Rae Ross, FC+ continued to work towards a PPP memorandum of understanding (MOU) with Bard Medical, a renowned multi-national distributor of high quality bladder catheters, to promote task shifting of catheter treatment of fistula to National Midwifery Societies in LMIC generally, piloting the concept in FC+ supported countries. Discussions stalled with the FY 17/18 closeout of FC+ Nigeria, as original plans were to engage the Nigerian Council of Nurses and Midwives and Nigerian FMOH in this collaboration. FC+ engaged in a competitive bid process to establish pessary supply chain in DRC with Bioteque, a medical device distributor. DRC was selected as it is the sole country of activity where supported facilities met a minimum acceptable standard of care that allowed a full programmatic integration of POP care within supported fistula centers. In FY 18/19, FC+ seeks to engage a sustainability platform for continued DRC pessary supply post-project. However, initial feedback indicates that community expectations and barriers to care for extended outpatient pessary management have resulted in a rejection of pessary management that may preclude DRC pessary supply chain sustainability. In October 2017, FC+ sponsored Wake Forest University and University of Kinshasa participation in the first “OBSTRACT” regenerative medicine conference in London. Due to visa challenges, Prof Matthieu Loposso of the Urology Department at the University of Kinshasa was unable to attend. Prof Koudy Williams of Wake Forest did attend OBSTRACT, and email communications ensued between the two colleagues thereafter. Dr. Williams gave presentations on non-cellular advances in autologous tissue reengineering that may have near-future applicability to complex wound healing in low- and middle- income settings, for fistula and other conditions. FC+ was able to successfully facilitate further collaboration in August 2018, leveraging Professor Loposso’s attendance at the 2018 ICS meeting in Philadelphia, Pennsylvania to support his introduction to the Wake Forest team and a visit to the Wake Forest Institute for Regenerative Medicine (WFIRM) in North Carolina in September 2018. Professor Loposso was hosted by the WFIRM Urology team to explore a way forward to provide regenerative medicine therapies for Congolese women suffering complex fistula and/or complex co-morbidities, such as women with “closed/incontinent” fistula treatment outcomes and WDI.
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Throughout 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. In April 2018, the FC+ Project Director presented at and participated as a moderator at a meeting on “Empowering maternal/reproductive health and safe surgery: Breaking down siloes for greater impact,” hosted by the GIEESC in Geneva, Switzerland. The meeting was an opportunity for key international stakeholders to strategize for integration of obstetrics/MNCH within the National Surgery Obstetrics Anesthesia Plan (NSOAP) framework, focusing on service integration and integrated funding. The group identified opportunities for future engagement of the NSOAP community and recommended the need for workforce density maps for SOA and for SOA task- shifting and HCW density, at the national level, for optimal NSOAP implementation monitoring and evaluation In May 2018, the FC+ Project Director participated as a panelist at the 71st WHO World Health Assembly in Geneva. The panel was entitled “A Conversation with Obstetric and Anesthesia Champions” and can be viewed at: https://vimeo.com/273593206. She also participated as a panelist at the Global Surgical Obstetric and Anesthesia Care Technical Meeting, held as a side event of the Assembly. Her input advocated for cesarean section safety in low- and middle-income countries, eradication of end-stage prolonged/obstructed labor, gender equity in health care, and ending fistula through optimized, affordable, and accessible maternity care. In January 2018, the World Health Organization (WHO) released its recommendations on the length of bladder catheterization following surgical repair of a simple obstetric urinary fistula (http://www.who.int/reproductivehealth/publications/simple-obstetric-urinary-fistula/en/). This recommendation, of a seven-day inpatient catheterization regimen, draws on the FC Project’s randomized controlled trial on this topic, and follows sustained advocacy and support by FC+ and USAID. The recommendation has the potential to dramatically shorten hospital stays for women after fistula repair, increasing the number of women who can be served by fistula treatment centers and reducing the burden on women undergoing surgical repair. The primary target audience for the guideline is health-care professionals, particularly fistula surgeons and nurses providing postoperative care to women after surgery for obstetric urinary fistula. The guideline will also be useful to national and local policy-makers, and staff of nongovernmental and other organizations involved in fistula care services. In June 2018, a commentary on the WHO catheterization recommendation was published in the British Journal of Obstetrics and Gynaecology (BJOG). Authored by UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) staff, the commentary can be accessed at: https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/1471-0528.15276. Across FC+ countries, catheterization guidelines have been adapted and adopted in Bangladesh, Nigeria, and Uganda. During FY 17/18, FC+ continued advocacy and participation in the development of a costed fistula strategy in Uganda, the National Fistula Strategy in Bangladesh, the next iteration of the National Fistula Strategy in Nigeria, and establishment of a national strategic plan for fistula in DRC. A meeting held in Banjul, with participation from all ECOWAS countries, resulted in a West Africa regional strategy. FC+ is working with project partner Direct Relief to streamline enrollment, MOUs, and materials receipt so that all eligible FC+ supported sites may benefit from sustainable 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
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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 the fourth quarter of FY 17/18, nine supported sites have received fistula modules from Direct Relief: five in DRC, three in Uganda, and one in Niger. Nigeria applications were approved but identification of an in-country expeditor and the FY 17/18 closeout of FC+ Nigeria precluded successful engagement. As part of global advocacy efforts to encourage international support for fistula prevention and treatment, the FC+ Project Director and Sarah Craven, Director of the Washington office of UNFPA, met with New York State Congresswoman Carolyn Maloney in August 2018 to discuss and comment on current fistula legislation she is drafting. FC+ country and global 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, and project efforts building sustainability described in Objectives 1 and 4.
Sub-Objective 1.2: Improve data available on OF to facilitate planning FC+ has carried out multiple activities during FY 17/18 to promote improved availability of fistula data for programmatic implementation. In collaboration with USAID/W, the FC+-managed Fistula Community of Practice (FCoP) facilitates 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 leverages 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+ continues to organize the FCoP webinar series, open to all interested individuals and organizations. In November 2017, the FCoP held its fourth webinar, entitled “Cesarean section safety and quality in low- resource settings: Highlights from a global technical consultation.” In April 2018, the FCoP held its fifth webinar entitled “A Global Survey of Skilled Birth Attendants on Intra- and Postpartum Bladder Care and Management of Prolonged/Obstructed Labor”. More detail on these webinars is included under Objective 5.3. As part of dissemination efforts from the cesarean section safety and quality technical consultation that FC+ co-sponsored in FY 16/17, the FC+ Project Director and Deputy Director organized stakeholder meetings with the Harvard Program on Global Surgery and Social Change (PGSSC), the Maternal Health Task Force (MHTF), the Harvard Women & Health Initiative (W&HI), and Ariadne Labs in January 2018. FC+ shared the final report from this consultation at these meetings (https://fistulacare.org/resources/program-reports/cesarean-section-technical-consultation/) and discussed potential collaborations to advance the consultation action agenda. During the meeting with PGSSC, perspectives from the technical consultation were shared, with a particular focus on the context of national surgery obstetric and anesthesia plans. A collaboration is now ongoing to implement a costing study of the full morbidity and mortality impacts resulting from prolonged/obstructed labor (P/OL), building on work that FC+ has frequently cited in demonstrating the impact of P/OL and the need for safer cesarean section environments (http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0034595). The FC+ Project Director attended a second meeting at PGSSC in March 2018, the National Surgical, Obstetric and Anesthesia Plans (NSOAP) Planning in the Eastern Mediterranean and African Region (https://www.pgssc.org/dubai-nsoap-workshop). The Project Director gave a presentation on the
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obstetrics portion of the NSOAP platform and held discussions with other participants to continue the collaborative momentum between the groups. A policy brief on the learnings and outcomes of this workshop was published in May 2018, and is available from PGSCC’s website: https://docs.wixstatic.com/ugd/d9a674_a8367aa7b82642ac81f67fb435660801.pdf. Ariadne Labs is a joint center between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, whose aim is to improve global health care through simple, scalable solutions to breakdowns in the health care system. In the January 2018 meeting with Ariadne Labs, discussions focused on the value of a checklist/job aid similar to the Better Birth Checklist that focuses on surgical obstetrics. This meeting also included discussion of advocating for fistula to be a sentinel indicator of maternal health system strengthening gaps. FC+ will continue to look for opportunities for achievable collaboration with Ariadne Labs during FY 18/19. The dissemination meetings with W&HI resulted in agreement to co-author a commentary on the cesarean section technical consultation and discussion of the possibility of a technical event at the Harvard School of Public Health to discuss iatrogenic fistula as a health systems failure case study. This commentary was reviewed and approved by USAID in the second quarter of FY 17/18. It was rejected by the two initial general global health journals to which it was submitted, and journals more focused on surgical care are now under consideration. Additional dissemination activities continued through global technical forums and are described under Objective 5. 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 taken place nationally and regionally throughout fiscal year. National and regional working groups have met with FC+ support and participation in FY 17/18 in Bangladesh, DRC, Nigeria, Uganda, and West Africa to revise and update national strategies for the elimination of fistula, as noted in sub-objective 1.1 above. Globally, FC+ has continued advocacy efforts within the global safe surgery community to capitalize on potential within this community to accelerate the achievement of the UNSG’s 2016 call to action to “end fistula within a generation” through surgical systems strengthening within the maternal health community. FC+ is working to strengthen regional institutions through support for working groups and colleges of surgeons, promoting a sustainable legacy for safe surgery and fistula elimination efforts. During FY 17/18, these efforts were focused on the East, West, Central and Southern regions of Africa. College of Surgeons of East, Southern and Central Africa Meeting The FC+ Project Director and Global Projects Manager joined staff from FC+ field offices and supported facilities to participate in the College of Surgeons of East, Southern and Central Africa (COSECSA) meeting held in Maputo, Mozambique in December 2017. The 18th COSECSA conference focused on Surgical Education and Modern Advances in Surgery. The obstetrics component of the platform within the region involves a heavy focus on task-shifting SRH and MNCH surgical interventions to minimally educated, specifically trained surgical healthcare workers (HCW). Much of the discussion related to SRH and MNCH also reflected variable levels of concern related to quality of care accountability systems, not limited to, but particularly highlighted within, these task-shifted MNCH and SRH HCW cadres. The West African College of Surgeons incoming president, Professor Serigne M. Gueye, urologic surgeon, fistula expert and FC+ international consultant, gave the annual address to COSECSA. The president of the newly formed ECSA College of Obstetrics and Gynecology also addressed the plenary. The foundation of the ESCACOG was specifically supported in 2015 and
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2016 by the FC+ project. Post-launch support for ECSACOG continues, with a focus on monitoring ECSACOG executive team’s work towards drafting and submission of necessary strategy documents to the ECSA-HC, and for multidisciplinary collaborations with other Colleges of the ECSA-HC. FC+ and partners hosted a multi-disciplinary evening side event during COSECSA. A full list of participants can be found in Appendix V. A total of 22 organizations from the public and academic sectors were represented at the event, including UNFPA, WHO, EH, Fistula Foundation, American College of Obstetricians and Gynecologists (ACOG) Global Women’s Health, Royal College of Obstetrics and Gynaecology (RCOG) Global Health, Harvard Program for Surgery and Social Change, West African College of Surgeons (WACS), College of Surgeons of East, Southern and Central Africa (COSECSA), East, Southern and Central African College of Obstetrics and Gynaecology (ECSACOG), among others. A participant survey was distributed at the event to better understand current thinking around the role of the academic sector in safe surgery and the best way to catalyze partnership between the safe surgery and safe motherhood communities. The event invitation and survey can be found in Appendices U and W. Highlights from the survey results included identified gaps in cross regional learning, sustained funding sources, committed surgeons ready to train young doctors, multisector collaboration, integration and holistic management of cases, and data for tracking. Additional organizations were identified for inclusion in future discussions and suggestions were made to increase involvement of professional societies and ministries as well as the private sector, sharing ideas and working on a single platform, focus on training and supplies, understanding fistula burden and research, gathering accurate and reliable metrics, developing national fistula/safe surgery plans, and communication/advocacy within the surgical community. WHO Global Initiative for Emergency and Essential Surgical Care Biennial Meeting Concurrently with the COSECSA annual general meeting, the WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC http://www.who.int/surgery/globalinitiative/en/) convened its 2017 Biennial Meeting in Maputo, Mozambique, held for the first time ever outside of Geneva. The meeting included member state updates as well as discussions for future actions. East, Central, and Southern Africa Health Community Conference The FC+/Global Senior Clinical Associate participated in the East, Central, and Southern Africa Health Community (ECSA-HC) 65th Health Ministers’ Conference in Dar es Salaam, Tanzania in March 2018. During the meeting, health ministers from member countries passed multiple resolutions of which one focused on the recommitment of the community to the ECSA College of Health Sciences and its training of medical specialists in the region. A summary of highlights from the meeting can be found at: http://ecsahc.org/65th-hmc-highlights/. West Africa College of Surgeons Annual Conference In addition to the East and Southern Africa activities described above, regional efforts took place in West and Central Africa during FY 17/18. These included a meeting of the West African College of Surgeons (WACS) and a meeting of the West and Central African Task Force for the Elimination of Fistula. At the end of February 2018, FC+ supported the participation of five FC+ staff (from U.S., Bangladesh, Nigeria, and DRC), two surgeons from supported facilities in DRC and Nigeria, and a consultant from Senegal at the 58th Annual Conference of the West Africa College of Surgeons, held in Banjul, the
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Gambia. The conference included scientific sessions, admission of new fellows to the college, and faculty board and accreditation meetings. FC+ presented on experiences implementing the SST in DRC and Nigeria, see Appendices R and S for presentations and Appendices N and O for the conference agenda and FC+ participant list. West and Central Africa Task Force for the Elimination of Fistula Meeting Immediately following the WACS conference, in March 2017, EngenderHealth/FC+ supported a meeting of the West and Central Africa Task Force for the Elimination of Fistula, held in Banjul, The Gambia. Four FC+ representatives (from Bangladesh, DRC, Nigeria, and USA) participated in this high-level meeting of the Task Force, focused on the development of a regional strategy following preparatory work after UroDak, held in July 2017 in Dakar, Senegal. Objectives of the meeting included:
Presentation of the regional landscape of obstetric fistula and to discuss the main challenges in ending fistula in the region; Review, update and harmonize country strategies to intensify efforts to end fistula; Present and discuss the Regional Strategic Plan/ Proposal on ending fistula; Develop detailed costing of regional proposal and roadmap; Design a resource mobilization and funding plan; and Establish a more effective coordination system and a monitoring and evaluation mechanism with key indicators for monitoring progress toward elimination at the regional and country levels.
The meeting was opened by Her Excellency the First Lady of Republic of the Gambia who referenced the Conference of First Ladies held in Niamey, Niger in 2016 during which a commitment was made to work towards the elimination of fistula. UNFPA presented on the regional landscape of fistula management and the challenges faced in efforts to eliminate fistula both globally and within the region. Dr. Serigne The U.S. Ambassador to the Gambia, the First Lady of the Magueye Gueye, Professor, Gambia and representatives of WAHO and UNFPA at the West and Central Africa Task Force for the Elimination of Fistula. Surgeon and Vice President of Credit: SM Gueye. WACS presented on the development of a strategy for fistula elimination in Sub-Saharan Africa, situating fistula within the broader emphasis on safe motherhood, the importance of gathering better fistula prevalence data and the issue of management of cases where fistula are deemed not curable. The FC+/Bangladesh Country Project Manager presented on his country’s experience with developing and implementing a call to action and importance of both community and policy involvement. The FC+ core team Program Associate took part in the francophone roundtable discussion to streamline and finalize the call to Action for fistula elimination in the region. The second half of the meeting focused specifically on the fistula elimination strategies of ten countries (The Gambia, Benin, Burkina Faso, Cameroon, Guinea, Ghana, Ivory Coast, Niger, Senegal, and Nigeria). The presentations showed that most content was composed of the same elements, with some
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differences concerning treatment protocols. However, the prevention and reintegration / rehabilitation pillars differed greatly from one country to another, hence the need for a regional strategy that would include all elements and support a common approach. The FC+/DRC Senior Technical Advisor presented on naming and the differentiation between elimination and eradication. The FC+/Nigeria Country Program Manager took part in a roundtable discussion to present on the Nigerian experience. The Task Force agreed to finalize the Banjul Call to Action for a Fistula Free ECOWAS Region (see Appendix T), which WAHO will use to advocate for fistula elimination within the health ministries in West and Central Africa region. They also plan to create a regional fund to support cross-border fistula activities, and harmonize country strategies and mobilize internal resources of governments and international organizations with donors and international NGOs. The full meeting agenda and participant list can be found in Appendices P and Q. Maternal Health and Fistula Conference, HOPE Foundation The FC+ Global Project Manager presented on including safe surgery as part of fistula elimination strategy at the Maternal Health and Fistula Conference, organized by HOPE Foundation and the Fistula Foundation in February 2018 in Cox’s Bazaar, Bangladesh. International Society of Obstetric Fistula Surgeons (ISOFS) Biannual Conference FC+ has been playing a significant role in providing financial and logistical support to the organizers of the biannual International Society of Obstetric Fistula Surgeons (ISOFS) conference, to be held next in December 2018 in Kathmandu, Nepal. In June 2018, the FC+ Acting Global Field Manager traveled to Kathmandu with Professor Sayeba Akhtar, Asian Representative of ISOFS, to facilitate planning of the upcoming meeting, as well as to network with the leadership of the South Asian Association for Regional Cooperation and to learn more about pelvic therapy programs in Nepal. UNFPA Nepal is also mobilizing support for the conference. In September 2018, an additional trip was made to provide technical assistance to the local organizing committee and to negotiate the engagement strategy for FC+ with the ISOFS leadership and local organizing committee. The FC+ global team has also been coordinating abstract development for the ISOFS meeting (see Objective 5). International Day to End Obstetric Fistula (IDEOF) FC+ country and global staff supported events commemorating the International Day to End Obstetric Fistula throughout the world on May 23, 2018. Country-specific events are described in Section III of this report. At the global level, FC+ participated in a UNFPA event held at United Nations headquarters, cosponsored with Health Hands of Joy. FC+ also participated in the Johnson and Johnson/UNFPA social media #CallYourMidwife campaign. The FC+ Project Director participated on the panel entitled “Ending Obstetric Fistula: Policies and Interventions to Improve Maternal Health and Increase Access to Safe Childbirth” hosted by Congresswoman Carolyn B. Maloney. She highlighted the critical need to strengthen both prevention and treatment efforts in order to truly end fistula for all women everywhere. FC+ External Relations As part of a coordinated external relations strategy, the FC+ blog and Twitter account have been updated regularly throughout FY 17/18. During this fiscal year, the blog has featured 11 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 24,907 page views during the fiscal year (see Figure 2 for views by month). The FC+ Twitter account metrics are presented in Table 6.
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Table 6. FC+ Twitter Account Metrics, FY 17/18
Metric FY 17/18 Total since April 2015 Twitter Followers 745 745 Impressions (number of times tweets appear on feeds) 796,298 1.2 million Link clicks 116 519 Retweets 185 1317 Favorites/Likes 275 1279 Mentions 277 972 Total Engagements (number of times someone interacts 875 4,811 with a tweet)
Figure 2. Fistula Care Plus Website Views by Month
9831 10632 8439 6675 6764 6026 6145 6111 6470 5437 5562 4921
Oct-Dec Jan-Mar Apr-Jun Jul- Sep Oct-Dec Jan-Mar Apr-Jun Jul- Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep 15 16 16 16 16 17 17 17 17 18 18 18
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. Throughout FY 17/18, 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. Two illustrative examples of global support to implementation of the Gender Action Plan come from Nigeria and Uganda.
In Nigeria, after refining the community communications and engagement strategy based on an assessment conducted in early 2016, support for implementation included community mobilization efforts with community structures to conduct community-based SBCC activities by reaching households with
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messages about the dangers of prolonged/obstructed labor and encouraging skilled birth attendance at health facilities. Part of this strategy is strengthening Men as Partners (MAP) groups to encourage male involvement to address harmful gender norms that prevent women’s access to maternal health services. Family support is crucial to recovery and reintegration after fistula repair, including the ability to use voluntary FP and maternal health services that can prevent fistula recurrence. MAPs were trained on interpersonal communication skills and approaches for raising community awareness about fistula prevention and treatment. In Sokoto and Zamfara states, MAPs conducted peer education sessions for other men to discuss issues around male involvement in maternal health and encouraged men to share decision making power with their wives.
In Uganda, partner facilities focused on addressing gender-related issues in fistula prevention and treatment. To increase male involvement in caretaking, a traditional role for women, men were mobilized to accompany their wives who were fistula clients to concentrated repair efforts. While there, the men were given the same amenities, such as meals and a return transport refund. Spouses attending concentrated fistula repair efforts, such as at Kamuli Mission Hospital, were organized and involved in sensitization meetings. These meetings were an avenue to discuss gender issues that increase women’s vulnerability to maternal morbidities such as fistula and related factors such as poverty, gender-based violence, and alcohol and substance abuse. Participants also discussed topics such as voluntary FP, healthy pregnancy, and the impact of delays in care seeking on women’s health. A primary focus of conversations was the importance of respectful communication within couples. At the end of the meetings, men were encouraged to commit to providing more financial support to their spouses, help with domestic work as clients recover from fistula surgery, and abstain from sex until their spouses fully recovers. Participating men also committed to serving as community role models and sharing information regarding fistula prevention. As only a small proportion of spouses have accompanied women to fistula treatment, these meetings have also been opportunities to discuss barriers to increasing male engagement in health care. 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, Mozambique, Niger, Nigeria, and Uganda in FY 17/18. A total of 17,731 community outreach/education/advocacy events were carried out, reaching over an estimated 21.6 million people. Of these events, 17,678 were in-person community activities that reached an estimated 681,597 people. 53 mass media activities were supported, estimated to reach over 20.9 million people. Additional detail by country can be found in Table 7 below, as well as in Section III. Additionally, a total of 749 community volunteers and educators were trained in Bangladesh, Niger, Nigeria, and Uganda during FY 17/18. Participants included 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. In the final half of the project, efforts have shifted focus from training towards increased outreach activity in communities and with media, community structures, and religious institutions.
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Table 7: Community Outreach/ Education Events, by Country, FY 17/18
Country Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Bangladesh -in person 27 1,428 18 963 16 888 9 1,143 70 4,422 -mass media 0 0 2 42 1 17 0 0 3 59 DRC -in person 5 138 5 402 2 117 5 307 17 964 -mass media NA NA NA NA NA NA 4 2.2 mil 4 2.2 mil Mozambique -in person NS NS 1 37 1 95 1 68 3 200 WA/Niger -in person 1,407 34,990 1,305 31,721 914 21,335 0 0 3,626 87,686 Nigeria -in person 253 76,184 193 89,492 102 46,100 0 0 548 211,776 Uganda -in person 1,403 134,686 10,465 118,501 322 25,692 7 97,670 13,414 376,549 -mass media 2 4,171,617 30 3,500,000 7 8,771,617 1,224 2,275,772 46 18,719,006 Total 3,097 4,419,043 12,019 3,740,798 1,365 8,865,861 1,250 4,574,960 17,731 21,600,662 -in person 3,095 247,426 11,987 240,756 1,357 94,227 1,239 99,188 17,678 681,597 -mass media 2 4,171,617 32 3,500,042 8 8,771,634 11 4,475,772 53 20,919,065
Table 8: Community Volunteer/Educator Training, Participants by Country, FY 17/18
Country Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total 2017 2018 2018 2018 FY 17/18 Bangladesh 0 0 0 98 98 DRC 0 0 0 0 0 Mozambique NS 0 0 0 0 WA/Niger 0 360 0 0 360 Nigeria 145 117 0 0 262 Uganda 29 0 0 0 29 Total 174 477 0 98 749
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.
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 have included testing innovative incentives and enablers to help women overcome these obstacles.
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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. In 2016, 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. In FY 16/17, FC+ launched the Fistula Treatment Barrier Reduction Intervention to strengthen community-based screening and referral to the treatment facility in two sites within Nigeria (Ikwo and Katsina LGAs) and one in Uganda (Kalungu District). The Population Council is conducting implementation research to evaluate the effects of this Intervention. The Intervention utilized a consistent fistula screening algorithm across multiple communication and referral channels, including community agents, 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. In each of the three sites, FC+ supported activities that sought to strengthen community-based screening and referral to the treatment facility. In FY 16/17, FC+ trained community agents (CBO volunteers in Nigeria and VHTs in Uganda) and health workers (doctors, midwives, nurses, and community health care workers) at primary health facilities to identify potential fistula clients and refer these women for treatment. 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-day trainings on identifying fistula patients, promoting healthy pregnancies, and community engagement activities; and a total of 82 volunteers were trained across Ikwo and Katsina LGAs in Nigeria and 275 volunteers were trained across Kalungu District in Uganda. By July 2017, the barrier intervention was fully launched in all three intervention sites (Ebonyi and Katsina States in Nigeria and Kalungu District in Uganda). FC+ also collaborated with Viamo (formerly VOTO Mobile) to design a free interactive voice response (IVR) fistula screening hotline that collected data on positively screened callers. The fistula hotline was widely advertised through graphic flyers disseminated by the community agents and PHC workers at community venues. Community agents followed-up with women who called into the hotline and facilitated their free transport to the fistula treatment facility using a transportation voucher designed for the intervention. Community agents also used 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 used a paper-based job aid to screen patients at primary health facilities. Community agents and primary health workers followed up with positively screened women and facilitated their free transport to the fistula treatment facility using the transportation voucher. All three screening channels – community agents, health workers, and the hotline - collected the same data, and used the same fistula symptom-screening question. At the intervention’s midline, the Population Council and FC+/Global M&E/R staff conducted a mid- course visit to disseminate to local and national stakeholders findings from the intervention’s baseline
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data and conduct qualitative data collection with the aim of identifying challenges experienced by the intervention’s facilitators and recommending mid-course corrections to improve the intervention’s effectiveness. The visit to Nigeria occurred in the fourth quarter of FY 16/17 and to Uganda in the first quarter of FY 17/18, see Appendices Y and Z for presentations. The Population Council conducted 39 interviews in Nigeria and 16 interviews in Uganda with purposively selected key informants, including the intervention’s implementers, facilitators, and beneficiaries. The Population Council conducted a rapid analysis of the qualitative data and shared with FC+ findings around the challenges encountered. The Population Council and FC+ teams jointly developed recommendations for mid-course changes based on these findings. The key recommendation developed was to reinforce facilitator’s roles and responsibilities within these newly established screening and referral mechanisms and to strengthen linkages between the community agents and PHC providers working within the same catchment area. In the second quarter of FY 17/18, both FC+/Nigeria and FC+/Uganda conducted activities to address the recommendations identified from the midline findings. In Nigeria, FC+ conducted a one-day refresher training for the intervention’s facilitators – NOFIC staff, PHC workers, CBO staff, community volunteers, and drivers – to update them on findings from mid-line assessment, and reinforce roles and responsibilities of each facilitator. In Iwko, 72 participants attended and in Katsina, 56 participants attended. In Uganda, FC+ conducted supervision support visits to 18 participating PHCs. The meetings at the PHCs included the previously trained PHC workers, the District VHT Coordinator, and VHTs working in that catchment area, and focused on reinforcing roles and responsibilities and strengthening communication linkages between the PHC workers and the VHTs. FC+ has concluded the implementation of the Intervention in both Nigeria and Uganda. Table 9 summarizes the program monitoring data collected through April 2018 across the three sites. Endline program monitoring data are being cleaned and analyzed in Katsina, Nigeria, and full Intervention outputs will be included in the first FY 18/19 report.
Table 9: Fistula Treatment Barriers Reduction Intervention, Outputs by Site, June 2017- April 2018
Intervention output Ebonyi, Nigeria Katsina, Nigeria Kalungu, Nigeria Total
# of fistula hotline calls 301 144 120 565 # of women screened 228 101 88 417 positively
# trips provided to 177 Data being 37 214 + Katsina data fistula facility finalized
# of women referred 156 Data being 51 207 + Katsina data through intervention finalized
Population Council completed endline data collection in Uganda and Ebonyi State in Nigeria in September 2018, while in Katsina State, Nigeria data collection among post-repair clients and a facility assessment of the National Obstetric Fistula Center (Babba Ruga) will be completed in the first quarter of FY 18/19. Thirty-three data collectors were trained in the three sites (9 in Uganda, 12 in Ebonyi, 12 in Katsina). A pre-test finalized changes on the instruments as well as enabling data collectors to refine their skills, and clarify any digital data collection tool incongruencies in Uganda. Endline data collection included quantitative and qualitative methods.
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Quantitative data collected include 122 health facility assessments (51 in Uganda, 40 in Ebonyi, 31 in Katsina), 300 primary health care provider (PHC) surveys (107 in Uganda, 100 in Ebonyi, 93 in Katsina), and 148 post-repair women’s exit interviews (46 in Uganda, 51 in Ebonyi, 52 in Katsina). Qualitative data collected include 24 focus group discussions (FGDs) in communities (8 in Uganda, 8 in Ebonyi, 8 in Katsina) and 38 in-depth interviews (IDIs) with key stakeholders involved implementing the barrier reduction intervention and its sustainability (18 in Uganda, 11 in Ebonyi, 9 in Katsina). Notable challenges during data collection in all three sites—in part due to the lag between suspension of intervention activities and the beginning of endline data collection—involved capturing a sufficient sample of post-repair clients for interview as they exited the fistula centers in Nigeria or camps in Uganda (many had already gone home and were hard to reach). To overcome this challenge, the research team in Nigeria worked through NOFIC, DOVENET, and FOMWAN to identify and follow up with clients and invite them to PHC facilities closer to their homes for interviews. The Katsina fistula center assessment was also delayed to the end of October because the focal person (in-charge) was away on holiday. Population Council will submit the final research report to FC+ within 60 days after the end of the subaward (i.e., February 28, 2019). At this time, all technical briefs and reports developed to date through this partnership are available at: https://www.popcouncil.org/research/fistula-care-plus. Additional information on knowledge products resulting from the FC+/Population Council research-to-action partnership is provided in Section II, Objective 5.
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 17/18, FC+ supported training for 10 health personnel in Uganda in use of the partograph. 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.
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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 through FY 17/18 can be found in Appendices SS through VV. A total of 674 records from FY 17/18 were reviewed at a total of 27 facilities in three countries (Bangladesh, DRC, and Uganda), see Appendix VV for detailed scored by site. Reviews were not carried out in Nigeria or Mozambique where partograph support has not been implemented, or in Niger due to closure of the office. Record review indicated wide variety in rates and quality of partograph completion between sites, and between countries. Uganda has shown continual improvement over the life of the project, likely due to strong partograph training and a focus on ongoing mentoring, with 99% of patient files reviewed this year containing partographs (compared to 94% in FY 16/17 and 51% in FY 15/16). DRC also showed improvement, with 81% of files containing a partograph compared to 73% in FY 16/17 and 74% in FY 15/16. In Bangladesh, rates of completion have remained steady at 54% this fiscal year compared to 57% in FY 16/17 and 59% 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 and fetal heart rate were monitored in 56% of records, with the other components recorded in 78-81% of records, which reflects a slight decrease from the previous year. In DRC, contractions and fetal heart rate monitoring were found in 55- 56% of records, an increase over the previous year’s 46% and 44% respectively. Maternal blood pressure and pulse were recorded more frequently than the previous year as well (84% for both compared to 72% and 66% in FY 16/17). Finally, in Uganda, contractions and fetal heart rate were present in about 80% of the records (similar to FY 16/17), while maternal blood pressure and pulse were present in 66% and 60% respectively, an increase over 50-55% of records in FY 16/17 and 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 17/18 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. DRC also shows a steady improvement, which is positive reinforcement of efforts to strengthen partograph use through trainings. FC+ will continue to utilize these findings in programmatic activities for FY 18/19. During FY 17/18, FC+ supported sites reported a total of 72,305 deliveries in four program countries (Bangladesh, DRC, Niger, and Uganda). Data was not available from Mozambique or Nigeria, where the project has not worked directly to support facility 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
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average cesarean section rates in these countries. The total cesarean section rate across all FC+ supported sites was 37% (Figure 3). Cesarean section rates at supported sites vary widely at the country level (27% in Uganda, 34% in DRC, 60% in Niger, and 61% in Bangladesh) and at the facility level, due to the varied patient profiles and clinical mandates of different facilities. Across supported sites, 2.8% of all deliveries were reported as prolonged/obstructed labors, with 26.1% of those prolonged/obstructed labors receiving catheterization for fistula prevention. The reported numbers range widely by country and by site, with a high of 18% 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 (96%), while rates in other countries were much lower (2% in DRC, 1% in Uganda). Site-level data can be found in Section III, by country.
Figure 3: Cesarean Section Rates, by Country, FY 17/18 (n=72,305 deliveries)
Bangladesh 39.5 60.5
DRC 65.9 34.1
Vaginal delivery Niger 40.1 59.9 C-Section
Uganda 72.8 27.2
FC+ Total 63 37
Sub-Objective 4.2 Increase capacity for treatment
Royal College of Obstetricians and Gynecologists (RCOG) Global Health Division During FY 16/17, FC+ and RCOG Global Health agreed to create a competency-based educational manual, anchored in RCOG teaching product protocols, to support accredited multi-disciplinary sub- specialty fellowship programs for urogynaecology/female pelvic medicine emerging under the leadership of senior academic fistula surgeons in Africa and South Asia. The manual will guide and document achievement and assessment of skills for patient evaluation of incontinence/bladder & colorectal dysfunction, pelvic organ prolapse and genital tract fistula, as well as capture skills for surgical and non- surgical treatment in each of these three areas. Communications and content production occurred throughout FY 16/17 and FY 17/18. The production and distribution of the manual is supported by an MoU between EngenderHealth and RCOG that allows flexible engagement of supporting partners at various points, which may include senior members of ISOFS for review and drafting of the manual’s introduction, and UNFPA for printing and distribution. In April 2018, a meeting was held to review all content, refine content flow and identify content gaps, as well as to discuss location and date options for introduction of a zero draft of the education and training manual for the evaluation of surgical and non- surgical management of fistula, prolapse and incontinence within the growing female pelvic medicine and reconstructive surgery (FPMRS) community of practice in South Asia and Africa. FC+ continues to work with RCOG global health team to complete this output by June 2019.
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Surgical Safety Toolkit In response to gaps in clinical records, challenges understanding M&E data trends, and in response to specific clinical staff requests at supported facilities, FC+ introduced the Surgical Safety Toolkit (SST) in FY 16/17. The SST includes a set of clinical trackers and quality assurance checklists. The SST is designed to support the provision of surgical care at a minimum acceptable standard, as outlined by global actors such as the World Health Organization and the Lancet Commission on Global Surgery. The SST contributes to 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. In December 2017, FC+ engaged consultant Renée Fiorentino to assist with documenting implementation of the SST. FC+ is implementing a “PDSA-style” (plan-do-study-act7) process based on uptake and qualitative user feedback. A framework organized around process, data completion and data use was developed to guide the documentation of SST implementation, and ongoing support is being provided to clinical staff to respond to this framework. The framework supported progress in the streamlining of the SST data gathering processes within each country team and submission for cross- country review. In FY 18/19, FC+ will begin project-wide data analysis to provide meaningful end of project messages. Preliminary learning from SST implementation was summarized in a poster represented by the FC+ Deputy Director at the IHI 2018 Africa Forum in Durban, South Africa in February 2018, including three categories of facilities revealed by SST checklist gap analysis: 1) strong clinical data systems and strong staff engagement; 2) weak clinical data systems and strong staff engagement; and 3) weak clinical data systems and weak staff engagement. This grouping has guided FC+ support efforts including systems analysis and coaching of facility staff by FC+ clinical officers. The anesthesia portion of the intra-op checklist and the post-op daily rounds checklist have both emerged as particularly important in sentinel event analysis and associated systems strengthening. FC+ clinical staff in DRC, Nigeria, and Bangladesh have all presented these preliminary learnings at conferences during FY 17/18. SST adoption and use in Bangladesh has been the most robust of supported countries, and an abstract on these achievements was accepted for the FIGO conference to be held in October 2018. The SST, already available on the project website in English and French, and will be translated into Portugese for use in Mozambique. The SST checklists and client tracker are being used as the basis for a chart abstraction tool being proposed for use at Soroti Hospital (Uganda) where senior surgeon Fred Kirya has been treating severe, intractable urinary incontinence after fistula repair, and women whose fistula cannot be closed due to lack of adequate residual bladder wall surface area with diversion techniques.
7 https://innovations.ahrq.gov/qualitytools/plan-do-study-act-pdsa-cycle
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Appropriate approaches for documenting the process and outcomes of SST implementation are being considered, particularly with the data obtained in Bangladesh and possibly DRC. Documentation would include comparisons between specified M&E data trends, such as “not closed” rates in facilities, and client-level data to begin to understand trends in demographic and/or medical/surgical histories among women whose surgeries failed. Documentation would also seek to better describe trends in FP engagements both for counseling/service provision and method mix. Clinical services at supported treatment and prevention sites During FY 17/18, a total of 5,806 women with severe incontinence symptoms sought fistula care services at FC+ supported sites, compared with 5,637 women in FY 16/17. Of these women, 3,862 were diagnosed with fistula (67% of those seeking, compared with 72% in FY 16/17). Of those diagnosed, 3,500 were medically eligible for surgical repair. FC+ supported the provision of 3,104 surgical fistula repairs in FY 17/18 (89% of those eligible, compared with 83% and 3,250 repairs in FY 16/17). 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 17/18
2500
2000 Seeking 1500 Eligible 1000 Repairs 500
0 Bangladesh DRC Mozambique Niger Nigeria Uganda Including projects receiving bilateral funding, a total of 4,175 surgical repairs were supported by USAID in ten countries (Bangladesh, DRC, Ethiopia, Guinea, Mali, Mozambique, Niger, Nigeria, Rwanda, and Uganda) during FY 17/18, of which 3,104 (74%) were supported through FC+ (see Figure 5 and Table 10 for detail). The remaining 1,071 surgical repairs were supported by USAID bilateral projects. FC+ site level repair data is presented in Section III, by country.
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Figure 5: USAID-Supported Surgical Fistula Repairs, by Quarter, FY 17/18 (n=4,175)
1400 1308 1202 1200 FC+ 1000 967 916 796 698 800 703 689 Bilateral 600 392 406 400 Total USAID 200 264 9 supported 0 Q1 Q2 Q3 Q4
Table 10: Number of USAID-Supported Surgical Fistula Repairs, by Country, FY 17/18
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sept Total 2017 2018 2018 2018 FY 17/18 Bangladesh 86 57 48 76 267 DRC 62 217 186 95 560 Mozambique NS 15 40 47 102 WA/Niger 10 61 79 0 150 Nigeria 458 485 252 365 1,560 Uganda 87 81 191 106 465 Total FC+ 703 916 796 689 3,104 DRC: ProSani (bilateral) 0 44 0 0 44 Mali: IntraHealth (bilateral) 30 86 65 9 190 Rwanda: MCSP 64 4 181 0 249 Ethiopia: Pathfinder 99 141 126 NA 366 Guinea: Jhpiego HSD project 71 117 34 NA 222 Total USAID bilateral 264 392 406 9 1,071 Total All USAID-supported 967 1,308 1,202 698 4,175
In addition to the surgical repairs described above, FC+ supported non-surgical treatment of fistula using catheterization for a total of 162 women during FY 17/18. The vast majority of these treatments were performed in Nigeria (132, 81%), followed by Uganda (19, 12%). ProSani also supported non-surgical treatment for two women in DRC during the fiscal year. It is important to note that much prevention and early treatment of fistula using catheterization is likely to occur outside of fistula treatment centers in maternity service sites that are not part of the FC+ project and do not report through our routine monitoring systems. During FY 17/18, FC+ was able to collect etiology data for 87% (n=3,343) of all diagnosed cases, a small increase compared to 85% of diagnosed cases in FY 16/17. Data reported during this period indicate that for cases with available data, the etiology of the diagnosed fistula was: obstructed/prolonged labor 81% (n=2,719, compared to79% in FY 16/17); iatrogenic 16% (n=529, compared to 17% in FY 16/17); traumatic <1% (n=27, compared to 2% in FY 16/17); and other causes (primarily cancer or congenital) 2% (n=68, compared to the same 2% in FY 16/17). 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 fiscal year, all 37 supported sites reported this data, though it was incomplete at some sites; as noted
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above, reporting that 16% 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 (43%) and DRC (20%) (see Section III, by country). These two countries have consistently reported the highest iatrogenic rates throughout the life of the project. Increasing discussion with country and site teams is required to ensure that 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 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, which is in process with a second draft under working group review for consensus definitions of all terminology related to genital tract fistulae, including but not limited to etiology. FC+ has inserted the working definitions as used by the project in the client tracker of the SST, into the zero-draft of the IUGA-ICS Joint Report. The Joint Report will include a section on definition of “Women Deemed Incurable”. The working group co- chairs, including the FC+ Project Director, have taken steps to facilitate ICS support for an advisory committee of senior fistula surgeons in Africa and South Asia to review the WDI portion of the document to set the stage for buy-in from the community of healthcare workers to be served by the Joint Report. During the ICS Annual General Meeting, held in Philadelphia in August 2018, the fistula terminology working group met and reviewed the latest version of the document. The FC+ Project Director also provided a Pelvic Floor Fistula (PFF) Terminology update to the general ICS membership. The FC+ Project Director is engaged in a monthly review and editing process with the ICS working group appointed to the PFF document that will be ongoing, to be completed by the 2019 ICS annual general meeting and submitted for peer-review publication thereafter. FC+ emphasizes the importance of routine, high quality service provision and encourages and supports 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 concentrated repair 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. Concentrated repair efforts are also utilized as a strategic approach to address the overwhelming backlog of clients. During FY 17/18, provision of repairs at supported sites was nearly evenly split between routine services (51%) and concentrated repair efforts (49%). This is a decrease in the percentage of routine service repairs compared to previous years (64% in FY 16/17 and 53% in FY 17/18), possibly attributable to more complex case load and the need for outreach repair services to reach women in more and more remote areas. During FY 17/18, 88.4% of all discharged FC+ repair cases were closed at the time of discharge, compared to a similar 88.6% in FY 16/17. 79.9% of all cases were closed and continent (i.e., dry in the case of fistula resulting in leakage of urine) at discharge, 8.5% were closed with remaining incontinence, and 11.6% were not closed (compared to 77.7%, 10.9% and 11.4% respectively in FY 16/17), 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
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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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. Of the 2,903 discharged cases during the fiscal year, data on level of fistula complexity were available for 2,622 cases (90% of cases, compared to 79% in FY 16/17). Of these, 34% were classified as simple fistula and 66% were not simple (compared to 41% and 59% respectively in FY 16/17). During the reporting period, simple fistula made up approximately a quarter of reported cases in Niger (25%) and Nigeria (23%), and approximately half of the reported cases in Uganda (45%), Bangladesh (50%), and DRC (54%). Mozambique reported the highest percentage of simple fistula cases, at 57%.
Figure 6. Outcome Rates for Fistula Surgical Repairs, by Country, FY 17/18
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%)
Reported complication rates for surgically repaired fistula cases at supported sites were generally low (1.5% project-wide), with countries reporting rates ranging from <1% in Niger and Nigeria to 5% in Bangladesh, 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 17/18, FC+ trained 23 surgeons in three countries (Bangladesh, Nigeria, and Uganda) in fistula surgical repair, based on the FIGO training curriculum. 12 surgeons participated in first training in fistula surgical repair and 12 took part in continuing training (see Table 11, one surgeon participated in both first and continuing training during the fiscal year). More detailed training information can be found in Section III, by country. To date, FC+ has supported fistula surgical repair training for a total of 69 surgeons. The bilateral project managed by IntraHealth in Mali also reported training 19 surgeons during the reporting period. Such training is an important part of building low- and middle-income countries’ ability to independently provide fistula care through local human resources, reducing dependency on external volunteers and consultants.
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Table 11: Training in Surgical Repair, Participants by Quarter, FY 17/18
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total 2017 2018 2018 2018 FY 17/18 First Training in Surgical Fistula Repair 1 1 10 0 12 Continuing Training in Surgical Fistula Repair 5 4 5 2 129 Total 6 5 15 2 2310
A total of 1,289 health system personnel in six countries (Bangladesh, DRC, Mozambique, Niger, Nigeria, and Uganda) participated in FC+ supported training in non-surgical topics during FY 17/18, including catheterization for fistula prevention, EmONC and labor monitoring, FP counseling and methods, non-surgical POP treatment, pre- and post-operative care, and facilitative supervision (see Table 12, and country descriptions in Section III). These trainings contribute to fistula and POP prevention, identification, referral, treatment, and post-repair services as well as clinical data management.
Table 12: Training for Health System Personnel (excluding fistula/POP surgery), Participants by Quarter, FY 17/18
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total 2017 2018 2018 2018 FY 17/18 ANC 0 0 0 0 0 Catheterization for fistula prevention 68 0 0 0 68 Community, outreach and advocacy 0 0 0 0 0 Data management 0 21 6 9 36 EmONC 0 20 7 0 27 EmONC and labor monitoring 0 0 10 0 10 FP counseling 15 15 0 0 30 FP methods 29 0 31 0 60 FP and fistula counseling 0 0 18 30 48 Fistula counseling 0 0 0 0 0 Gender 0 0 0 0 0 Infection Prevention 0 0 0 232 232 Labor monitoring 0 0 0 0 0 Non-surgical POP treatment 24 0 0 0 24 Pre- and Post-Operative Care 0 189 291 227 707 Quality Assurance 15 0 0 0 15 Other 0 0 0 32 32 Total 151 245 363 530 1,289
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 to include the February 2018 update to the WHO FP Handbook11. During the first half of FY 16/17, FC+ conducted a rapid clinical assessment of 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. Implementation of the recommendations from these assessments is ongoing. An illustrative example from Uganda is enhancing sustainability of quality of care and infection prevention and control (IPC) measures at Jinja Regional Referral and Kamuli Mission Hospitals. By
9 One surgeon from Uganda received continuing training in each quarter and is counted only once in the fiscal year total. 10 One surgeon from Uganda received initial training in the first quarter and continuing training in the second and fourth quarters, and is only counted once in the fiscal year total. 11 https://www.fphandbook.org/
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engaging IPC committee members to discuss moving beyond a traditional quality improvement (QI) framework to one of quality assurance (QA) strategies, the focus is on operationalizing and adhering to QI and infection control recommended guidelines and practices, and strengthening internal supports for supervision and assessment. In Uganda, FC+ has also worked with the Ministry of Health to update FP training materials to include content on long-acting methods and informed, voluntary, client-centered counselling applying the EngenderHealth REDI Counseling Framework. Between October 2017 and May 2018, FC+ implemented a health worker training strategy including classroom and practical sessions, and regular onsite follow-up, mentoring, and coaching. FC+ has also supported client education sessions at partner facilities to build awareness of and demand for the full range of available methods. Trained health workers report substantial increases in knowledge and confidence, reduction in bias against certain methods, and increased skills for and appreciation of the value of relationship building and high-quality counseling. In Uganda, FC+ works with faith-based health facilities as well as government partners. To further increase the availability of all FP methods and support full, informed choice, FC+ has integrated fertility awareness methods (FAM) into FP trainings and worked closely with the Uganda Catholic Medical Bureau (UCMB) in review of training materials and guidelines. Kamuli Mission Hospital, has been supported to establish a natural FP/FAM Clinic and two service providers were trained in other methods so that they can provide a total package of information in agreement with the hospital management. A key challenge has been availability of moon beads, especially in public facilities; however, recently the beads have been included as part of National Medical Store procurements. During FY 17/18, a total of 456,930 counseling sessions were provided at supported sites, and FP services resulted in a total of 315,229 Couple Years of Protection (CYP), increases compared to 423,736 counseling sessions and 263,206 CYP in FY 16/17. The method mix contributing to this total CYP includes implants (63%), injectables (12%), IUCD (11%), tubal ligation (6%), 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 17/18 (n=456,930)
Bangladesh 34,153 Number of Counseling Sessions DRC 2,684
Niger 925
Nigeria 172,568
Nigeria former TSHIP 223,090
Uganda 23,510
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Figure 8. Family Planning CYP, Short-Term vs. Long-Term/Permanent Methods, by Country, FY 17/18 (n=315,229)
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 17/18, FC+ has worked to develop program plans for the establishment and support of treatment for WDI and women suffering from POP. FC+ has been working to establish functioning supply chains for pessaries in supported countries. A pessary supply chain was established with Bioteque, a FC+ PPP partner, 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. Though the project planned to work with the Mission to secure sustainable supply chain for ring-plate pessaries post-project, facility-based feedback indicates that barriers to reliable access to outpatient pessary management and patient preference for surgery may preclude post-project sustainability of pessary supply. Throughout FY 17/18, 20 FC+ supported sites (four in DRC, two in Niger, eight in Nigeria, and six in Uganda) provided routine data on non-surgical and surgical POP treatment. During the reporting period, these sites reported that 2,061 women sought treatment for possible POP symptoms with 1,250 women diagnosed with and eligible for treatment for POP (61% of those seeking). A total of 1,142 women received POP treatment during this period (91% of those eligible). Supported sites reported providing 1,865 non-surgical POP treatments and 1,021 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 three pessaries reported (at Jinja and Kitovu in Uganda). 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, FY 17/18
Country #Seeking #Eligible % of Seeking #Receiving % of Eligible DRC 1,407 905 64% 846 93% WA/Niger 59 50 85% 39 78% Nigeria 434 140 32% 102 73% Uganda 161 155 96% 155 100% Total 2,061 1,250 61% 1,142 91%
Twenty (1.9%) 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
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the time of discharge. The project is not currently able to gather longer term follow up data to monitor repair breakdown after discharge.
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 as well as the use of HMIS fistula data by health workers/managers at facility, regional and national levels. Key professional respondents 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. In FY 17/18, FC+ completed data collection in Bangladesh, Nigeria, Uganda, and Guinea, with a total of 35 professional respondent interviews. Analysis of these data could not be completed as anticipated in FY 17/18 due to the departure of the FC+ Program Associate – Research & Evaluation. FC+ will seek to complete this analysis in FY 18/19 through short-term technical assistance and/or consultant support. 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 continued to be active in the global DHIS2 community during FY 17/18, attending the annual DHIS2 Symposium in March 2018 in Washington DC to share FC+/EngenderHealth experience and learn about the latest developments in the field as well as participating in several webinars. FC+ conducts internal DDM exercises after the close of each quarter to discuss program data and identify issues in need of follow-up. FC+ has continuously updated the indicators and visualizations reviewed during global DDMs to reflect emerging project priorities (e.g., fistula etiology trends) or learning from other projects and partners (e.g., approaches recommended at the Institute for Healthcare Improvement First Africa Forum on Quality and Safety). This practice has been carried out in Bangladesh, DRC, Niger, 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+ has been orienting Focus Fistula staff in Mozambique to project approaches to data collection and use.
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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 once during the fiscal year to review their data, similar to FY 16/17; 56% (compared to 94% in FY 16/17) met at least twice (See Appendix EE for country and site details). This decline is attributed to close out in Nigeria and Niger that curtailed activities. In addition to facilitating such reviews, FC+ has also trained 36 health personnel throughout the fiscal year in data management and DDM.
Sub-Objective 5.3 Use research findings to improve practice
In November 2017, FC+ held its fourth webinar on the topic of cesarean section safety and quality in low- resource settings: Highlights from a Global Technical Consultation. Presenters in the webinar included: Vandana Tripathi, FC+ Deputy Director; Lenka Benova, London School of Medicine and Tropical Hygiene; Dr. John Varallo, JHPIEGO/MCSP; and Mary Nell Wegner, MHTF. The discussion covered an overview of global cesarean section trends, issues of surgical safety and quality, and the consensus agenda developed at the consultation to address challenges through action across the maternal, newborn, and safe surgery communities. Implementation of this agenda is essential for realizing the potential impacts of universal access to essential obstetric surgery. Forty-nine people joined the webinar broadcast and the archive recording is available at the FC+ website and on YouTube (https://www.youtube.com/watch?v=l_cFxssLv3E). More information about the technical consultation can be found at https://fistulacare.org/resources/program-reports/cesarean-section-technical-consultation/. In April 2018, FC+ organized the fifth webinar of the FCoP to share research results entitled, “A Global Survey of Skilled Birth Attendants on Intra- and Postpartum Bladder Care and Management of Prolonged/Obstructed Labor”. Presenters in the webinar included: Vandana Tripathi, FC+ Deputy Director; Elly Arnoff, FC+ Program Associate for Evaluation and Research; and Sheena Currie, Senior Maternal Health Advisor, JHPIEGO. FC+ shared findings from a key informant survey of skilled-birth attendants (SBAs) in low- and middle-income countries (LMICs) that examined SBAs’ training, knowledge, practices, and facility environment as they relate to intrapartum and postpartum bladder care and management of prolonged/obstructed labor. The program and research implications of survey findings were discussed, particularly in reference to midwifery training and practice. 45 people joined the webinar broadcast and the archive recording is available at the FC+ website and on YouTube (https://youtu.be/0wI53f-rOfM). The report of survey findings can be found at: https://fistulacare.org/wp- fcp/wp-content/uploads/2018/07/Report_Survey-of-Intrapartum-and-Postpartum-Clinical- Practices_Final_7.18.pdf. 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 in the fourth quarter of FY 16/17, as described in detail in Objective 3.
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To date, numerous knowledge products, including research Capacity building: reports, technical briefs, and manuscripts have been developed Nigeria FP data and disseminated through this partnership, and additional publications are planned for FY 17/18 (see Appendix QQ). All FC+/Nigeria identified a lack of publications developed to date through this partnership are appropriate FP data in the national Health available at https://www.popcouncil.org/research/fistula-care- Management Information System plus. Additional information on this research is provided in (HMIS), which negatively affects facility and district ability to use data for decision Section II, Objective 5. FC+ and Population Council have also making. FC+/Nigeria’s strategy to build continued to share the findings of the partnership through in- capacity of supported sites to report country, global, and USAID technical forums. In October timely, complete, and accurate FP data 2017, FC+ presented baseline findings and intervention into the HMIS included: progress updates to representatives from USAID/Uganda, the Ugandan FMOH, and local stakeholders. FC+ and Population • Review of FP indicators, available data sources, and data reporting flow Council presented on the process and findings of the treatment from local to national levels barriers research to the USAID PRH and MCH teams on • Identification of key personnel September 18. A presentation on the treatment barriers index responsible for reporting at all levels was accepted for presentation at the October 2018 Health • Planning meetings and trainings with Systems Research Symposium, and FC+ was invited to local/state FP/M&E stakeholders • Data validation meetings for local present on the collaboration at the Service Communication M&E/FP staff before HMIS entry Community of Practice, also convening in October 2018. FC+ • Data review meetings for comparison will also submit an abstract on the collaboration to the 2019 of facility-based and HMIS data Women Deliver conference. • Monthly mentoring visits to facilities with identified gaps As described under Objective 1, the FC project RCT on the • Biannual data quality audits non-inferiority of shortened duration of catheterization after surgical repair was the basis for newly issued WHO In just over one year: • 100% monthly reporting rate recommendations supporting the practice of short direction achieved catheterization and an accompanying commentary • Monthly summaries of data available disseminating this new information. at the facility level and in HMIS • Data completeness significantly Conference presentations and publications continue to foster improved evidence-based change in research and FC+ program • Understanding of FP indicators and practices. Throughout the fiscal year, FC+ convened and quality of documentation presented at multiple meetings and conferences to disseminate significantly improved findings from research and program evaluations; see Table 3 for details. Percent of Supported Sites Reporting FP HMIS Data In November 2017, FC+ hosted a brown bag lunch session at 100 the Fourth Global Forum on Human Resources for Health 95 (HRH) on “Strengthening the Surgical, Obstetric, and 90 Anesthesia Workforce to Ensure the Safety and Quality of 85 Cesarean Section Services in Low-resource Settings” (see 80 Appendix G for invitation and Appendix H for presentations). FC+ participated in several USAID-organized briefings in Jun-17 Oct-16 Oct-17 Feb-17 Apr-17 Dec-16 Dec-17 Aug-17 order to disseminate findings and share updates on activities with USAID/Washington staff. In April 2018, at USAID/Washington’s invitation, FC+ presented at a brown bag lunch on the Aflateen PLUS Activity focusing on youth
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engagement in Uganda, see Appendix FF for presentation. Detail on Aflateen and FC+ youth engagement work is provided in Section II, Objective 5.4, and Section III, Uganda, Objective 2. In May 2018, FC+ presented on the proceedings of the FC+/MHTF-convened consultation on cesarean section safety, see Appendix KK for presentation. In September 2018, FC+ presented at a briefing for USAID PRH/MCH teams on the FC+/Population Council research-to-action partnership to address barriers to fistula treatment. Appendix NN includes the slides from this presentation. The FC+ Deputy Director attended the First Africa Forum on Quality and Safety in Healthcare, convened in Durban, South Africa by the Institute for Health Improvement (IHI) in February 2018. Three FC+ posters were presented at the meeting on quality of care measurement in maternal health, the cesarean section technical consultation, and the SST (abstracts can be found in Appendices K, L, and M). Data analysis and visualization methods showcased by others at the conference were subsequently incorporated into the FC+ DDM process. FC+ submitted a satellite session application to the 5th Global Symposium on Health Systems Research (HSR) to be held in October 2018 in Liverpool, England. This application was accepted, the session will include presentations on the global context of cesarean section, pressures affecting cesarean care, and recommendations of the technical consultation. The FC+ Deputy Director has worked during the reporting period to prepare this panel presentation, see invitation in Appendix PP. FC+ submitted, and subsequently had accepted, a panel session request for the 22nd FIGO World Congress of Gynecology and Obstetrics meeting to be held in October 2018 in Rio De Janeiro, Brazil. The session will include an overview of the provision of cesarean sections in low-resource settings, the role of a safe surgery eco-system in prevention of obstetric and iatrogenic fistula, clinical decision making for operative delivery, and workforce challenges (see Appendix BB for session summary). In addition, 15 FC+ abstracts for oral presentations were accepted for the upcoming Congress, see Appendix MM for details. One of these abstracts, “Improving contraceptive method mix through rights based multidimensional approaches in Fistula Care Plus supported sites in Uganda” was selected as a FIGO Ipas Best Paper award winner. FC+ supported submission of abstracts to the 2018 International Conference on Family Planning (ICFP), to be held in Kigali, Rwanda in November 2018. Three posters and one oral presentation were selected including FC+ work in Uganda in the areas of use of data for decision-making, the role of trained religious leaders in promoting FP to improve maternal health, and FP integration. As noted in Objective 1.3, FC+ Global has been coordinating project staff and partner abstract development and submission for presentation at the 2018 ISOFS meeting. A total of 38 abstracts have been developed and reviewed, and are being finalized for submission (see Appendix WW). 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 17/18, five articles related to FC+ supported activity were accepted or published in peer-reviewed journals (see Table 14). The Mallick and Tripathi article on fistula and gender based violence has been highlighted in an MHTF blog (https://www.mhtf.org/2016/05/24/building-awareness-of-the-link-between-fistula-and-gender-based- violence/) and was selected for inclusion in the Baylor fistula research summary circulated periodically to the global fistula community. 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. FC+ has drafted a commentary on the cesarean section technical consultation. However, this commentary has been rejected by the first two global health journals to which it was submitted; FC+ is revising the
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commentary for submission to a more surgery-focused journal, and to incorporate new policy papers officially released at the 2018 FIGO World Congress.
Table 14: Peer-Reviewed Articles Published, FY 17/18
Authors Title Journal Mallick, L. and Tripathi, V. The association between female Tropical Medicine and International genital fistula symptoms and gender- Health. 15 December based violence: A multicountry 2017. doi:10.1111/tmi.13008 secondary analysis of household https://onlinelibrary.wiley.com/doi/full/1 survey data 0.1111/tmi.13008 Tripathi, V., Elneil, S., and Demand and capacity to integrate International Urogynecology Journal. 6 Romanzi, L. pelvic organ prolapse and genital February 2018. doi: 10.1007/s00192- fistula services in low-resource 018-3561-2. [Epub ahead of print] settings. https://www.ncbi.nlm.nih.gov/pubmed/ 29411073 Keya, KT; Sripad, P; Nwala, E; "Poverty is the big thing": exploring International Journal for Equity in and Warren, CE. financial, transportation, and Health. 2018 Jun 1;17(1):70. opportunity costs associated with https://www.ncbi.nlm.nih.gov/pubmed/ fistula management and repair in 29859118 Nigeria and Uganda. Cavallaro, F; Pembe, A; Caesarean section provision and BMJ Open 2018 Oct 4;8(9):e024216. Campbell, O; Hanson, C.; readiness in Tanzania: analysis of https://bmjopen.bmj.com/content/bmjo Tripathi, V.; Wong, L; crosssectional surveys of women and pen/8/9/e024216.full.pdf Radovich, E; and Benova, L. health facilities over time. El Ayadi, AM; Barageine, J; Trajectories of Women's Physical and Tropical Medicine and International Korn, A; Kakaire, O; Turan, J; Psychosocial Health Following Health. 2018 Oct 29. doi: Obore, S; Byamugisha, J; Obstetric Fistula Repair in Uganda: A 10.1111/tmi.13178. [Epub ahead of Lester, F; Nalubwama, H; Longitudinal Study. print] Mwanje, H; Tripathi, V; and https://www.ncbi.nlm.nih.gov/pubmed/ Miller, S. 30372572
Appendix E provides a list of FC/FC+ peer-reviewed journal publications and Appendix F provides metrics for readership of articles published by FC/FC+. While metrics are only available for some FC/FC+ articles, these have been viewed nearly 43,700 times. 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. This report, The Landscape of Cesarean Section in Sub- Saharan Africa and South and Southeast Asia (https://fistulacare.org/wp-fcp/wp- content/uploads/2015/10/LSHTM-report_Nov-8_final_for-web.pdf) was approved by USAID and published in November 2017, and assesses the landscape of cesarean sections in low and middle income countries using recent, comparable, nationally representative DHS survey data from 44 countries. Bangladesh and Tanzania are presented as case studies, accompanied by an in-depth review of time trends in the level and provision of caesarean sections. The full meeting report of the cesarean section safety and quality in low-resource settings technical consultation has been disseminated and is available on the FC+ website (https://fistulacare.org/wp- fcp/wp-content/uploads/2018/04/Report-of-Cesarean-Section-Technical-Consultation_July-2017.pdf ), the MHTF website, and the London School of Hygiene and Tropical Medicine Research Online repository. Collaboration with the London School also resulted in development and publishing of a manuscript on Cesarean section provision and readiness in Tanzania, see Table 14.
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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 17/18, the project shared 11 posts on the FC+ blog (https://fistulacare.org/blog), see Table 15. FC+ also provided input into a MHTF blog post on measurement of untreated fistula, available at: https://www.mhtf.org/2018/05/24/measuring-the-numbers-of-untreated-obstetric-fistula-the-example-of- ethiopia/.
Table 15: FC+ Blog Posts in FY 17/18
Blog Title Date First Ladies Move to Eliminate Obstetric Fistula and Protect Child Rights in West Africa October 5, 2017 Upcoming FCoP Webinar on Cesarean Section Safety and Quality in Low-Resource October 23, 2017 Settings Surgery: A Cure for Fistula, But Also a Cause December 27, 2017 Remembering a life of service: Sister Maura Lynch, MMM January 9, 2018 WHO Releases new Guidelines on Short-Duration Catheterization Following Simple January 25, 2018 Fistula Surgery Leading Experts Discuss Fistula, Safe Surgery and the Way Forward February 9, 2018 Press 1 for Yes, 2 for No: How digital health platforms connect women to maternal March 2, 2018 health services Leaving No One Behind on International Day to End Obstetric Fistula May 23, 2018 Measuring the Numbers of Untreated Obstetric Fistula: The Example of Ethiopia May 24, 2018 Improving rights-based family planning June 29, 2018 The Hidden Costs of Fistula Repair Surgery September 14, 2018
Sub-Objective 5.4 Contribute to the evidence for improved programming and care During FY 17/18, FC+ and ACOG continued collaboration on ACOG Global Program’s cesarean section/EmONC training in Uganda, Essential Training in Operative Obstetrics (ETOO), formerly 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 is in place between FC+ and ACOG. In the second quarter, the FC+ Deputy Director reviewed ETOO program data to develop an M&E summary for discussion at a March 2018 ACOG meeting in Kampala, see Appendix CC. In April 2018, the FC+ Deputy Director met with ACOG Global representatives to review data from the Uganda ETOO project. After a discussion of monitoring and evaluation processes and future plans, the FC+ Deputy Director updated a summary presentation on ETOO outputs and outcomes to date, for use at upcoming meetings to be held in Uganda, see Appendix LL. An abstract prepared from this data has been accepted for presentation at FIGO 2018 and the ETOO collaboration will also be showcased at the FC+ satellite event at the Health Systems Research Symposium. Further collaboration will focus on improving engagement with trainees post-training to expand data collection on service outcomes and potentially participating in ACOG-led expansion of the ETOO model in Uganda. As described under Objective 2, FC+ and TERREWODE applied 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). Data analysis was completed in the fourth quarter of FY 17/18, documenting substantial improvements in QoL among WDI. These findings have been
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summarized in a preliminary report, and will be further documented in a technical brief (Appendix OO). Study findings, including recommendations regarding optimal tools for QoL assessment and for fistula services supporting WDI, will be shared with partners in Uganda and globally. To understand the range of postpartum practices that SBAs employ, in FY 16/17, FC+ launched an online global survey targeting SBAs from LMIC on intrapartum and postpartum practices related to P/OL and bladder care management. Preliminary findings were shared on the FC+ blog: https://fistulacare.org/blog/2017/07/icm-postpartum-care-panel/. During the first half of FY 17/18, the survey analysis was completed. The final report of this analysis was completed and submitted to USAID/Washington in the third quarter of this fiscal year. The report is available on the FC+ website at: https://fistulacare.org/wp-fcp/wp-content/uploads/2018/07/Report_Survey-of-Intrapartum-and- Postpartum-Clinical-Practices_Final_7.18.pdf. Also in the third quarter, FC+ organized a webinar for the FCoP to present these findings, further details are provided under Objective 5.3 (see Appendix II for webinar presentation). An abstract on these findings has also been developed for the 2018 ISOFS meeting to be held in Kathmandu. In FY 17/18, the FC+ core team supported the Uganda team to complete a process documentation of a youth engagement strategy centered on the Aflateen PLUS curriculum, developed by EngenderHealth in collaboration with Private Development Education Network (PEDN). This initiative aimed to empower in and out of school youth to engage in behaviors that increase their ability to make responsible financial, social, and reproductive health decisions, including messages on voluntary FP and where to access services. Trained facilitators collaborated with health workers to conduct youth outreach events using sports, edutainment and drama, incorporating services such as HIV/AIDS testing, and provision of condoms and other FP methods. During a typical implementation quarter (January-March 2018), 674 in- school participants accessed health information and 274 were referred to school nurses by teachers, and 230 out-of-school participants accessed health information and 222 received health services. Out-of- school participants also reached over 5,360 individuals with health information and referred 1,716 to health facilities. During the process documentation, teachers reported highly valuing the financial education component (e.g. savings tools, planning and budgeting, financial enterprises) of the curriculum; peer educators appreciated the increase in their capacity to make health referrals, and health workers reported increased skills in communicating with and serving adolescents and youth. All cadres of facilitators appreciated the learner-centered/empowerment training approach, which was novel relative to other, more didactic training approaches they had been exposed to. In considering tangible changes in health knowledge and behaviors, respondents noted a decline in pregnancy-related school drop-outs, increased confidence among youth to seek out information on FP and to request condoms, and an increased ‘savings’ culture and use of savings to address financial challenges such as transportation costs and school fees. Respondents also described supply-side barriers that made it challenging for youth and community members to follow up on referrals (e.g., inadequate supplies at health facilities). These findings have been shared through a briefing to USAID in April 2018, and an abstract summarizing the process dissemination will be submitted for the 2019 Women Deliver conference. FC+ has provided technical review and commentary to clinical research initiatives planned by partners, which advance project evidence interests. During FY 17/18, these include a survey led by Harvard’s PGSSC to estimate burden of disease associated with obstructed labor as well as a study to document impacts of urinary diversions for women with incurable fistula in Uganda, led by Dr. Fred Kirya at Makarere University. FC+ is providing technical support to these research activities, which are led by other institutions. These are not FC+ research activities, should this level of engagement change, FC+ will submit concept and protocol materials to AORs for review/approval in accordance with PMP and USAID
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policy. The Harvard survey was launched in September 2018, and circulated to fistula surgeons and clinicians attending P/OL cases around the world, including at FC+ supported sites. Survey results will be available in the first quarter of FY 18/19. Following the ISOFS conference in Abuja, the FC+ Project Director issued a call for concepts for the analysis of existing clinical data at supported sites. 13 concepts were received 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 were 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. During the first and second quarters of FY 17/18, FC+ global research staff worked with Panzi clinical researchers to seek in-country ethical review and approval by amending an existing protocol for conducing secondary analysis using fistula patient data from the Panzi Hospital database. During this period, FC+ global research staff also developed data extraction tools that are being reviewed by the Panzi clinical research team for the prioritized studies on barriers to fistula care and fistula recurrence. Due to the departure of the FC+ Program Associate – Evaluation and Research, the FC+ team no longer has capacity to complete providing technical support to this analysis. It is hoped that, with the support received to date, the Panzi team is able to complete the analysis independently.
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SECTION III: COUNTRY REPORTS
Please note: reports are provided only for objectives that were actively addressed in FY 17/18. 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+, with seven hospitals providing fistula treatment and eight hospitals providing prevention only services during FY 17/18. FC+ is also working with 200 community clinics on implementation of the FC+ 4Q Checklist (a job aid for fistula screening). 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. All currently supported fistula treatment sites in Bangladesh provide referrals to fistula clients for social and medical services and five sites provide reintegration services. In FY 17/18, the Bangladesh Country Project Manager (CPM) has taken on additional duties within the project, now also serving as the FC+ Acting Global Field Manager.
Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors FC+/Bangladesh works nationally and regionally to strengthen the enabling environment for fistula prevention, treatment, and reintegration. Safe Surgical Practice Strengthening the enabling environment for safe surgical practices is a priority within FC+ activities. Representatives from FC+ Bangladesh participated in the 7th WHO Global Initiative Session for Emergency and Essential Surgical Care, which took place in conjunction with the 18th Annual College of Surgeons of East, Central and Southern Africa (COSECSA) in December 2017 in Maputo, Mozambique. The conference focused on safe surgical practice to prevent iatrogenic fistula and other morbidities and complications arising from surgical procedures. The FC+/Bangladesh Clinical Associate attended workshops on surgical equity and surgical anesthesia at the Challenges of Our Era Summit in Milan, Italy in March 2018. Speakers discussed the role of science, technology, and innovation in improving health. In March 2018, FC+/Bangladesh supported a workshop hosted by Mamm’s Institute of Fistula and Women’s Health (MIFWH) on safe surgery practices. The workshop covered a multitude of issues related to the provision of safe surgery and a panel discussion addressed the specific roles of different actors in the operating theater including anesthesiologists, obstetricians and gynecologists, urologists, and surgeons. Workshop participants included the President and members of the Obstetrical and Gynecological Society of Bangladesh (OGSB), the Chief of the University Fistula Center of Bangabandhu Sheikh Mujib Medical University (BSMMU), the President of the Urological Association of Bangladesh, the Director of Primary Health Care, DGHS and the Asian representative to ISOFS. In May 2018, the FC+/Bangladesh CPM participated in the WHO 71st World Health Assembly in Geneva, Switzerland. Discussions held at the Assembly have led to a collaboration between FC+/Bangladesh and Harvard’s Program in Global Surgery and Social Change (PGSSC), WHO, and the Bangladesh MOH to convene a South Asian regional National Surgical, Obstetric, and Anesthesia Plan (NSOAP) Conference in Dhaka.
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In July 2018, FC+/Bangladesh convened a workshop on Safer Surgery at BSMMU. Participants in the workshop included Dr. Kanak Kanti Barua, Vice Chancellor of BSMMU, Prof. Shahidullah Shikdar, Pro- Vice Chancellor (Education) BSMMU, Joseph Monehin: Deputy Director of OPHNE, USAID, Dhaka, and Animesh Biswas of UNFPA, as well as nursing students from BSMMU. The workshop was an opportunity to emphasize some of the concepts Safer Surgery Workshop at BSMMU in carried from the World Health Assembly, including July 2018. Credit: Dr. Farhana Delwar promotion of safer surgery practices to combat maternal morbidity, including female genital fistula. Enabling Environment within Bangladesh FC+ collaborates in Bangladesh with UNFPA and the National Fistula Task Force (NFTF) to strengthen the enabling environment and support institutionalization of fistula services in both the public and private sectors. During the first quarter, the NFTF met to disseminate the National Fistula Strategy, as part of the process of finalization and ratification. The FC+/Bangladesh Country Director then met the Line Director, Maternal, Neonatal, Child and Adolescent Health and the Director of Primary Health Care at the Directorate General of Health Services (DGHS) and two key leaders of the Ministry of Health and Family Welfare (MOHFW) to review and successfully finalize the draft national fistula strategy. A consultative workshop was held in February 2018 at Kumudini Hospital on the development of catheterization guidelines for the prevention and treatment of female genital fistula, building off the recommendations from the 2013 FC Catheterization for Fistula Prevention Meeting Report (https://fistulacare.org/wp-fcp/wp-content/uploads/pdf/program-reports/Catheterization-Fistula- Prevention-Meeting-Report-Nigeria-8-21-13FINAL.pdf ). The workshop participants included 15 nurses from different government district hospitals, the Urban Primary Health Care Project (UPHCP), and private hospitals as well as officials from UNFPA and Dhaka Medical College Hospital. In February 2018, FC+/Bangladesh held a seminar to present findings from a population-based survey on caesarean section and experiences at LAMB Hospital. Prof. John Richards of Simon Fraser University, Vancouver and Dr. Beatrice Ambuen Berger presented the key paper at the seminar. Trends in cesarean section rates, long-term consequences, and potential responses from the Obstetrical and Gynecological Society of Bangladesh (OGSB) were discussed. Dr. Joseph Monehin, Deputy Director, OPHNE, USAID Bangladesh; Dr. Sanjib Ahmed, Clinical Services Technical Specialist, USAID; Dr. Sathya Doraiswamy, Chief of Health, UNFPA; and Professor Samina Chowdhury, President Elect, OGSB provided input on these issues from both national and global perspectives. FC+/Bangladesh has also continued close collaboration with the OGSB in this fiscal year. During the first quarter, FC+ provided financial support to a conference organized by OGSB in collaboration with the University Fistula Center of BSMMU. During the conference, the Kathmandu Call for Action 2017 For a Fistula-Free South Asia, the WHO Safe Surgery Checklist, the FC+ Surgical Safety Toolkit (SST), and the FC+ 4Q Checklist (see Objective 2) were highlighted and OGSB position papers, brochures, and leaflets on female genital fistula were distributed to OGSB members. The University Fistula Center of BSMMU has published a year planner for promoting referral and fistula case identification by health providers, which was also distributed at the conference. In March 2018, FC+/Bangladesh organized a meeting with project partners BSMMU, Ad-Din Hospital, and Kumudini Hospital. The meeting included a detailed programmatic and financial review of project
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activities, as well as discussion about safe surgery practices and the issue of iatrogenic fistula in Bangladesh, where FC+ supported sites consistently report a high proportion of repaired fistula cases as iatrogenic in origin (See Objective 4 below). Strategies to strengthen follow-up of fistula patients were brainstormed, and updates provided on the use of the 4Q Checklist for primary diagnosis and advocacy efforts to include fistula indicators in government registers. FC+/Bangladesh participated in the Maternal Health and Fistula Conference, organized by HOPE Foundation and the Fistula Foundation in February 2018 in Cox’s Bazaar. The FC+ Global Project Manager and FC+ Bangladesh Country Project Manager/Acting Global Field Manager presented papers in the conference. FC+ had a stall at the conference displaying project activities and distributing SBCC materials. In May 2018, the FC+/Bangladesh CPM joined Dr. Munira Ferdausi, professor of Obstetrics and Gynecology at Shahid Shurawardy Medical College, on a talk show recorded for Bangladesh Television (BTV). The discussion focused on the trend of rising cesarean section rates within Bangladesh and globally and its global health implications. The broadcast date for the program has not yet been determined. In August 2018, FC+/Bangladesh convened a meeting with UNFPA and BSMMU to discuss rehabilitation of fistula clients in southwestern districts of Bangladesh. In the fourth quarter, FC+/Bangladesh held two meetings to review progress of implementation, discuss issues, and identify priorities for the rest of the project with program personnel, finance and administrative staff from partner organizations and facilities. As part of ongoing efforts to engage and motivate journalists to cover the topic of fistula, in February 2018 FC+/Bangladesh organized a Media Leaders Workshop on Fistula Communication for representatives of the electronic and print media in Cox’s Bazaar. Participants learned about fistula prevention and treatment and possibilities for utilizing the media to spread awareness. There was a particular focus on community radio stations, and those attending developed an action plan for how to increase fistula coverage in the media. Two similar workshops were held in Dhaka in the fourth quarter, in collaboration with the University Fistula Centre (UFC) of BSMMU, with a total of 80 electronic and print media leaders attending. Regional and International Activities In addition to nationally focused efforts, FC+/Bangladesh has been working on the regional and international stage to advocate for better coordination of fistula efforts. During the HOPE conference, FC+/Bangladesh facilitated a side event of a meeting of the South Asian Group of Fistula and Related Morbidities. At the side event, those responsible for fistula programming as well as surgeons and stakeholders discussed the experiences and challenges in their respective countries with regard to fistula. The focus of the meeting was regional coordination among countries for prevention and treatment of female genital fistula, collaboration in training, and facilitating technical exchange of key issues. In his role as Acting Global Field Manager, the FC+/Bangladesh CPM participated in the regional meeting on fistula in the ECOWAS region where he presented on the Asian Experience in fistula programming and helped lead the development of the Banjul Call to Action for a Fistula Free ECOWAS Region (see Appendix T). This regional meeting immediately followed the meeting of the West Africa College of Surgeons in March 2018. He also participated in the West African Implementing Partners Meeting of West Africa, held in Accra, Ghana in May 2018 during which the group finalized the Banjul Call to Action. The West Africa Health Organization (WAHO) will use this to advocate for fistula
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elimination efforts within the region, including a regional fund to support cross-border fistula activities and harmonization of national strategies and donor resource allotments. The FC+/Bangladesh CPM and Acting Global Field Manager has been playing a significant role in providing FC+ support to the organizers of the biannual International Society of Obstetric Fistula Surgeons (ISOFS) conference, to be held in December 2018 in Kathmandu, Nepal. UNFPA Nepal is also mobilizing support for the conference.
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 A functional referral network between facilities and the community is critical to strengthening efforts towards fistula prevention, treatment, and reintegration for reducing stigma and enhancing community support. In line with government priorities, FC+ has been examining opportunities for scaling up use of the 4Q Checklist for fistula identification through community clinics. This checklist, developed earlier in the project with brac, former project partner, innovates fistula case finding through the use of a four question job aid used by 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. Converting the checklist to use at community clinics will require adaptation of training and monitoring strategies. Part of FC+/Bangladesh’s strategy to identify and assist women with fistula is providing support for community fistula diagnosis events (CFDEs). These events help facilitate identification of women residing outside of the immediate environs of supported facilities, using a community clinic-based identification and referral system. During FY 17/18, six CFDEs were held throughout the country identifying 67 fistula cases for referral.
During the first quarter, one CFDE was held in collaboration with Ad- Din Hospital, in conjunction with community awareness outreach activity in Jessore and Khulna. Staff from Satkhira Medical College Hospital and BIRDEM Hospital in Dhaka participated. Twenty women with fistula were identified and referred for treatment. Two CFDEs were held during the second quarter in Jessore and Khulna, during which 13 women with fistula were identified and referred. In the third quarter, two CFDEs took place, with 16 fistula cases and ten 3rd/4th degree perineal tears identified in Jessore, and 14 fistula cases and nine 3rd/4th degree perineal tears identified in Khulna. In addition, Community-Based Skilled Birth Attendants (CSBA) trained previously in the project by Kumudini Hospital have begun referring women for screening. In the fourth quarter, one CFDE was held in Gaibandha district where four fistula cases, six 3rd/4th degree perineal tear cases, and ten prolapse cases were identified. During the first quarter FC+/Bangladesh carried out a visit to Bandarban to orient providers at USAID- funded NGO Health Service Delivery Project (NHSDP) clinics and representatives of RHstep and Green Hill (local NGOs) to the checklist. A wrap up visit was held in Faridpur during the first quarter, carrying out the final steps of a similar effort in Faridpur that took place during the previous fiscal year.
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FC+/Bangladesh has focused some of its fistula prevention efforts on reaching schoolgirls with messages about the prevention and treatment of fistula, under an initiative called the “Schoolgirls for a Fistula Free Bangladesh.” During the aforementioned visit to Bandarban, FC+/Bangladesh met with high school teachers and female students and worked together to organize a program working towards a fistula free generation. Schoolgirls for Fistula Free Bangladesh event in Satkhira, May 2018. Credit: NN Biswas. In March 2018, in collaboration with Kumudini Hospital and BSMMU, FC+/Bangladesh organized schoolgirls’ programs in Satkhira and Bandardban for adolescent girls, as well as local and national level government health officials, and NGO representatives. In May 2018, a program was organized at United Academy in Satkhira for 193 students in ninth and tenth grades. Kumudini also organized programs for 288 schoolgirls from Tangail and Dhaka in September 2018. The events were also attended by local government representatives and medical staff. In July 2018, LAMB organized a program for 260 female students in Rangpur which was also attended by representatives from local government and USAID. During FY 17/18, a total of 70 in-person community outreach events were carried out for community members, health clinicians, and local officials, as well as three mass media events. An estimated 4,481 participants were reached through these community outreach, education, and advocacy events, information is presented, by type, in Table BGD1. During the first quarter, outreach activities included orientation programs for community health workers and volunteers organized by Ad-din and LAMB Hospitals, orientation for inpatient and outpatient Obstetrics and Gynecology department staff at Kumudini Hospital. During the second quarter of the fiscal year, Lamb Hospital conducted ten community orientation education programs in the Rangpur, Dinajpur and Nilphamari Districts. These sessions involved 487 community members and health center staff. These programs focused on awareness building for fistula case identification, referrals, prevention, and rehabilitation, as well as FP and maternal health. Kumudini Hospital also organized one community orientation event where FP, safe delivery, and male partner involvement were discussed. In March 2018, a community fistula awareness meeting was held with micro-credit beneficiary groups, fistula patients post-repair, and health workers and nurses from the regions of Ad-din Jessore and Khulna, during which discussions took place on the prevention, treatment, and rehabilitation of female genital fistula at the community level. During the third quarter, Kumudini Hospital conducted 12 community education programs in Tangail, with 398 women participating from the community, and health centers at the local and national level. These programs focused on building awareness on fistula case identification, referrals, prevention, and rehabilitation. Lamb Hospital organized one community orientation event in Nilphamari District for 80 participants where FP, safe delivery, and male partner involvement were discussed.
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Table BGD1: Community Outreach/Education/Advocacy Events, By Quarter, FY 17/18
Type of Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 Event # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Existing 20 1,172 13 805 14 671 7 1,063 54 3,711 community activity Health 0 0 1 74 0 0 0 0 1 74 facility Health 4 228 0 0 0 0 0 0 4 228 clinicians Policy 0 0 3 32 1 24 0 0 4 56 makers Maternal 3 28 1 52 1 193 2 80 7 353 health/ fistula- focused Radio/TV 0 0 2 42 1 17 0 0 3 59 Total 27 1,428 20 1,005 17 905 9 1,143 73 4,481
-in person 27 1,428 18 963 16 888 9 1,143 70 4,422 -mass 0 0 2 42 1 17 0 0 3 59 media
During the fourth quarter of the fiscal year, Lamb Hospital organized three trainings for Community Fistula Advocates (CFA), see Table BGD2. These trainings of 98 CFAs covered orientations to FP, fistula, ANC, gender, male involvement, maternal health and stigma.
Table BGD2: Community Volunteer/Educator Training, Participants, By Quarter, FY 17/18
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total FY 17/18 2017 2018 2018 2018 Community Fistula 0 0 0 98 98 Advocates Total 0 0 0 98 98
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). In FY 18/19, learning from analysis of SST will be summarized, particularly to understand FP service needs and outputs among fistula clients. During FY 17/18, 464 women with severe incontinence symptoms sought fistula care services at FC+ supported sites, of which 323 were diagnosed with fistula (70%, compared to 60% in FY 16/17). FC+ supported 267 surgical fistula repairs during this fiscal year (89% of the 300 women who were diagnosed with fistula and medically eligible for surgery, compared to 243 repairs in FY 16/17). 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 the reporting period, FC+ supported surgical repairs for 96 3rd and 4th degree perineal tears (compared to 93 in FY 16/17). 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
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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 presents data on women seeking and eligible for fistula treatment, and the number of fistula surgeries supported, by site. This fiscal year showed a significant increase in the number of fistula diagnoses among women seeking care, a 15% increase compared to the previous fiscal year. This was attributed to concerted community engagement efforts, including patient follow up and counseling carried out by community health workers and the mobilization of patients through the CFDEs carried out during all four quarters (see Objective 2 for details).
Figure BGD1: Number of Women Seeking and Requiring Fistula Treatment, and Number of Surgical Repairs, by Site, FY 17/18
120 110 100 90 80 70 Seeking 60 50 Eligible 40 30 Repairs 20 10 0 Ad-Din Ad-Din BSMMU Dr. Muttalib Kumudini LAMB Mamm's Dhaka Khulna Institute
These 267 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).12 Some supported sites in Bangladesh hold concentrated fistula repair efforts during which more complicated cases are repaired by bringing in an expert surgeon. Ad-Din Khulna Hospital held concentrated efforts in the first and third quarters, and LAMB held concentrated efforts in the first, second, and fourth quarters. 63 women received fistula surgery (24% of all surgeries performed during the fiscal year) and 26 3rd/4th degree perineal tear repairs were performed during these efforts.
Table BGD3: USAID-Supported Surgical Fistula Repairs, by Site, By Quarter, FY 17/18
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 17/18 2017 2018 2018 2018 Ad-Din Dhaka 2 4 2 7 15 Ad-Din Khulna 14 0 12 0 26 BSMMU 8 8 0 9 25 Dr. Muttalib 3 6 1 2 12 Kumudini 15 7 6 6 34 LAMB 25 13 17 12 67 Mamm’s Institute 19 19 10 40 88 Total 86 57 48 76 267
12 Ad-Din Jessore screened and referred women for repairs, but did not conduct any fistula surgical repairs.
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Etiology data was available for all 323 diagnosed fistula cases. Just over half of fistulas diagnosed were the result of prolonged/obstructed labor (50.2%, compared to 53% in FY 16/17), followed closely by iatrogenic causes (42.7%, compared to 39.4% in FY 16/17). 1.2% of diagnosed fistula were the result of trauma (compared to 2.9% in FY 16/17) and the remaining “other” etiology (6%) was primarily congenital. The proportion of fistula deemed iatrogenic continues to be very high in Bangladesh, consistently higher than other countries where FC+ supports fistula repair. The proportion was high at all supported sites, with variation: from a low of 36% at LAMB to highs of 67% at Dr. Muttalib, 50% at Ad- Din Dhaka and Ad-Din Khulna, and 47% at Kumudini. Discharged fistula repairs in FY 17/18 were nearly evenly classified as simple cases (49.6%) or not simple (50.4%). 89.2% of all fistula surgery cases discharged in this time period were closed at discharge; with 82.5% closed and continent and 6.7% closed and incontinent. 10.8% were not closed at discharge. This is an improvement over the closure rates reported for FY 16/17 which were 77.7%, 8.3%,and 13.6% respectively. Outcomes for discharged patients are presented, by site, in Figure BGD2. Reported complications were low at supported sites (5.4% overall) with BSMMU reporting 29% complications (n=three post-operative, two major surgical, and one anesthesia related complication), Mamm’s and BSMMU 5%, Ad-Din Khulna 4%, and all other sites reporting <3%.
Figure BGD2. Outcome Rates for Surgical Repairs, by Site, FY 17/18
100% 90% 80% 70% Not closed 60% 50% 40% Closed with remaining 30% incontinence 20% Closed and continent 10% 0% Benchmark closed and continent (75%)
During FY 17/18, FC+ Bangladesh supported surgical training for seven surgeons, with one receiving first training and the other six participating in continuing training. During the first quarter, in conjunction with a concentrated fistula repair effort held by Ad-din Hospital in Khulna, surgeons from Bangabandhu Sheikh Mujib Medical University, Shaheed Suhrawardy Medical College and Hospital, Sylhet M A G Osmani Medical College Hospital, and Ad-Din Akij Medical College Hospital participated in continuing training, see Table BGD4 for details. In the second quarter, Professor Sayeba Akhter of LAMB Hospital provided training to three surgeons from LAMB; one first training and two continuing trainings.
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Table BGD4: Surgical Fistula Repair Training, Participants by Trainee Institution, FY 17/18
Institution Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total Total # 2017 2018 2018 2018 FY 17/18 surgeons trained 1st Cont 1st Cont 1st Cont 1st Cont 1st Cont Total BSMMU 0 1 0 0 0 0 0 0 0 1 1 Shaheed 0 1 0 0 0 0 0 0 0 1 1 Suhrawady Medical College Sylhet Medical 0 1 0 0 0 0 0 0 0 1 1 College Ad-Din Akiij 0 1 0 0 0 0 0 0 0 1 1 LAMB 0 0 1 2 0 0 0 0 1 2 3 Total 0 4 1 2 0 0 0 0 1 6 7
As part of fistula prevention efforts, FC+/Bangladesh provided training to 419 health system personnel during FY 17/18. These trainings included community health workers, surgeons, and physicians and covered multiple topics, with the primary focus of training, in the first half of the year, on ensuring surgical safety. Table BGD5 provides detail on non-surgical trainings for health system personnel. A training of trainers on the prevention and care of female genital fistula was held in the third quarter for health service clinicians, organized by the office of the Civil Surgeon in Rangpur. There were 18 participants including Upazila Health and Family Planning Officers, Medical Officers, Senior Staff Nurses and Public Health Nurses. A Training of Trainers on fistula prevention and similar training was held in Bhola district treatment, in Rangpur, April 2018. Credit: NN during the fourth quarter for 27 participants. Biswas. Also in the third quarter, FC+/Bangladesh carried out three trainings to orient a total of 166 Community Health Care Providers (CHCPs) on fistula prevention and treatment, with health care clinicians from multiple Upazilas in Rangpur and Satkhira districts in attendance. Topics covered a wide range of material including identification of fistula clients using the 4Q checklist, rehabilitation and reintegration, FP, male involvement, gender, and stigma. LAMB also trained 18 CHWs on fistula identification, referral, and treatment as well as ANC and FP. During the fourth quarter, training events included 20 paramedics, doctors, and nurses in Bhola district and 69 Community Health Care Providers (CHCPs) from community clinics in Charfashion and Lalohon upazilas on fistula prevention, identification, referral and treatment. The CHCP training also included orientation to the 4Q checklist.
Table BGD5: Non-Surgical Health System Personnel Training, Participants by Topic, FY 17/18
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2017 2018 2018 2018 FY 17/18 Pre- and post-operative care 0 101 18 0 119 TOT on fistula prevention and treatment 0 0 18 0 18 Fistula prevention and treatment 0 0 166 116 282 orientation Total 0 101 202 116 419
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FC+ supports FP counseling and service provision at most supported sites in Bangladesh. During FY 17/18, 34,153 counseling sessions took place at supported sites and 19,407 CYP were provided; see Table BGD6 for detail, by site. Method mix in Bangladesh during this period was primarily comprised of tubal ligation (62% of CYP), oral contraceptives (12%), implants (9%), Depo (7%) and IUCD (Copper T- 7%).
Table BGD6: Family Planning Counseling Sessions and CYP, by Site, By Quarter, FY 17/18
Site Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP13 Ad-Din 3,700 2,037 3,700 1,909 3,400 2,092 2,519 2,197 13,319 8,235 Dhaka Ad-Din 131 246 825 632 2,515 457 1,129 758 4,600 2,093 Khulna BSMMU 966 599 2,340 1,071 3,565 244 2,075 664 8,946 2,578 Kumudini 322 747 1,060 859 1,030 775 610 1,700 3,022 4,081 LAMB 990 529 1,044 645 1,132 530 1,100 717 4,266 2,420 Total 6,109 4,158 8,969 5,115 11,642 4,099 7,433 6,035 34,153 19,407
FC+ supported sites reported 16,759 total obstetric deliveries with an overall cesarean section rate of 61% 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 the fragmented nature of record keeping systems 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, Deliveries, by Site, FY 17/18 (n=16,759) FY 17/18 0% 100%
Ad-din Dhaka 6,646 Ad-din Dhaka 70 Ad-Din Khulna 71.6 Ad-Din Khulna 2,454 BSSMU 79.9 BSMMU 2251 Kumudini 53.3
Kumudini 1,159 LAMB 19.8 Bangladesh Total 60.5 LAMB 2,832 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 FC+ was a key implementation partner of the Bangladesh Maternal Morbidity Verification Study (MMVS), helping design the morbidity assessment survey module and carrying out a series of
13 Due to rounding, totals may differ slightly from the sum of individual quarters.
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community-based Fistula and Prolapse Diagnosis Event (CFPDE) during FY 16/17. Data collected supported development of a national estimate of the current fistula burden in Bangladesh. A dissemination meeting took place in January 2018, in Dhaka, to share the results from the MMVS, see Appendix DD for dissemination slide presentation. Participants in the meeting included the MMVS research teams, government health officials, representatives of USAID, UNFPA, and other NGOs. After presenting the findings, there was discussion about next steps and coordinating efforts to curb the burden of genital fistula and other morbidities in Bangladesh. FC+/Bangladesh conducted Data Quality Assessment (DQA) visits at all supported fistula treatment sites throughout the entire fiscal year. These visits included cross checking reported data with site files and registers to check consistency as well as collecting, reviewing and discussing the data for the SST with site staff. Internal data for decision making (DDM) reports are prepared for all supported sites using the most recent available data for review meetings. FC+/Bangladesh and supported site staff submitted abstracts that were accepted at the FIGO World Congress to be held in October 2018 (see Appendix MM).
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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 four hospitals as of September 30, 2018: HEAL Africa, Panzi Hospital, Saint Joseph Hospital (SJH) and Beniker Hospital. Support has ended to two previously supported sites, MSRK and IGL. USAID has also provided bilateral support to the Projet de Santé Integré (ProSani) for fistula repair at Kaziba General Reference Hospital in DRC. ProSani ended during this fiscal year and will be followed by a comprehensive integrated health project that has not yet begun. 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 life of the project, 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 particular instability this fiscal year in the Kinshasa area as violence erupted in conjunction with the organization of national elections, as well as an Ebola outbreak in the north. 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 Task Force (SMNE Task Force) along with experts from the MOH and professionals working in the field of maternal, neonatal, and child health (MNCH) and fistula. The Task Force has provided a platform for reflection, designing standards and guidelines, and monitoring activities and progress. FC+/DRC has been working with UNFPA to spearhead efforts to create a National Multidisciplinary Working Group for the Elimination of Obstetric Fistula within the Task Force. During the second quarter, FC+/DRC provided technical and financial support to the MOH as it held a workshop to review and build consensus on the National Strategy for the Elimination of Obstetric Fistula. FC+/DRC sponsored the participation of staff from Panzi, HEAL Africa, Beniker Clinic, and Kyeshero Hospital at the workshop. During the workshop, terms of reference for the Task Force were also adopted and the terms of the National Multidisciplinary Working Group were established. The Working Group agreed to take on the responsibility of implementing the adopted national strategy. In the second half of the fiscal year the National Strategy was finalized, published, and printed. However, its official presentation and rollout has been delayed due to emergency health priorities that emerged in the Eastern region of the country. In June and July 2018, FC+/DRC supported briefings on the norms and guidelines of Maternal, Newborn, Child and Adolescent Health (SRMNEA). The briefings occurred in two phases, the first for supported sites in the eastern part of the country (HEAL Africa, HGR Panzi and clinicians from surrounding structures) and the second for SJH, six other faith-based and public sector facilities. The workshops were led by experts from the National Program for Reproductive Health (PNSR). At the conclusion of the briefing, 500 kits of the SRMNEA standards and guidelines were distributed to the facilities and the Provincial Divisions of Health in South Kivu, North Kivu and Kinshasa. In November 2017, the Eighth Congress of the Congolese Society of Gynecology and Obstetrics (SCOGO) was held at Panzi. The theme of the congress was “Maternal Morbidity and Mortality” and Panzi’s fistula program organized a three-day workshop to develop a five-year strategic and operational plan for addressing fistula.
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On May 23, 2018, FC+/DRC and UNFPA provided technical and financial support to the Ministry of Public Health to organize celebrations for the International Day to End Obstetric Fistula (IDEOF) at Saint Joseph Hospital. The ceremony was attended by nearly 200 people, including many representatives from the Ministry of Health, representatives from the Army and National Police, WHO, UNAIDS and private sector participants including Vodacom Foundation. IDEOF celebrations also took place in Goma, by HEAL Celebration on International Day to End Africa, and Bukavu, by Panzi, where attendees Obstetric Fistula. Credit: D. Nembunzu included local government and MoH officials, NGO missions, WHO, UNICEF, UNFPA, as well as women and girls who have experienced fistula. In addition to national efforts, FC+/DRC has been working to strengthen the enabling environment for fistula services regionally throughout West and Central Africa. A representative from FC+ DRC and from Panzi participated in a meeting in Kigali, Rwanda, held in September 2017, to establish the Regional College of Gynecology and Obstetrics for Eastern, Central and Southern Africa (ECSACOG). The FC+/DRC Senior Program Manager participated in the biennial meeting of the WHO Global Initiative for Emergency and Critical Surgical Care (GIEESC) held December 2017 in Maputo, Mozambique. The meeting was held in conjunction with the 18th Annual Meeting of the College of Surgeons of East, Central and South Africa (COSECSA). FC+ hosted a dinner during the meeting to discuss the elimination of obstetric fistula and explore the possibility of collaboration between different surgical communities and fistula surgeons to accelerate achievement of the UN Secretary General’s 2016 call to action to end fistula. In March 2018, the FC+ Technical Advisor in DRC participated in an international workshop co- organized by FC+/WA, WAHO, USAID/WA and UNFPA in Banjul, The Gambia, of the Western and Central African Working Group for the Elimination of Obstetric Fistula. During the workshop, participants reviewed the indirect and direct causes of fistula and discussed how best to address the causes of fistula through appropriate policies, legislation, and strategies. In particular, traumatic and iatrogenic fistula and their particular challenges were discussed. Participants provided feedback on the recent Western and Central Africa College of Surgeons (WACS) workshop and weighed in on the role of WACS in regional capacity building. The workshop was an opportunity to introduce the Western and Central African Working Group for the Elimination of Obstetric Fistula (WCAGEOF). A round table discussion included donors’ and implementing partners’ responses to addressing fistula, and participants worked together to harmonize national strategies and ensure a committed, coordinated regional response by developing a regional strategy for the elimination of obstetric fistula in Western and Central Africa by 2030. As part of efforts to strengthen sustainable implementation of tools for surgical safety, the FC+/DRC Technical Advisor and the Project Manager at SJH attended the 58th Annual Scientific Conference of the College of Surgeons of West Africa (WACS) and presented an abstract on the introduction of the Surgical Safety Toolkit (SST) in DRC.
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Throughout FY 17/18, supported sites have directly leveraged funds from their own partners to complement the activities they are able to do with FC+ funds. Panzi continues its partnership with the radio station Sven to support awareness raising in the community and outreach efforts. In Kinshasa, partner repair site SJH received drugs, supplies, and direct technical and logistical support for a fistula concentrated repair effort from the Belgian NGO "Doctors Without Vacation" as well as food, clothing, and hospital gowns donated by private individuals. SJH also collaborates with the NGO "Florilèges" to broadcast information on television channels after conducting an awareness campaign among the military forces. The Minister of Gender and Family has initiated a private fundraising campaign to help pay for fistula repair at SJH and to support reintegration Alma Golden, USAID Senior of healed fistula patients who remain in Kinshasa. The Belgian Deputy Assistant Administrator, NGO Fistul-Aid donated funds for feeding women receiving visits with clinicians and fistula surgeries and UNFPA has provided equipment and surgical patients at SJH. Credit: FC+/DRC. supplies, as well as “dignity kits” for women post-surgery. In July 2018, Alma Golden, USAID’s Bureau for Global Health Senior Deputy Assistance Administrator visited SJH, selected as an example of USAID-funded work in Kinshasa. She was able to meeting clinicians and fistula patients and expressed particular support for increased surgical capacity and social reintegration activities for fistula clients post-surgery. 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 FY 17/18, in addition to the IDEOF celebrations described in Objective 1, all four supported fistula treatment sites conducted awareness raising campaigns in their communities to improve knowledge about fistula, access to treatment, male involvement, FP, and the fight against stigma. FC+ supported sites in DRC carried out 17 in-person community outreach efforts reaching 964 people, see Table DRC1. Estimates for several mass media efforts were unavailable, but four mass media outreach efforts reached an estimated 2.2 million people. HEAL Africa’s community outreach activities during the fiscal year included a dialogue during the first quarter with religious leaders and students in Goma to discuss maternal and girls’ health including the use of FP and the role of male partners in supportive care and prevention of maternal morbidities. HEAL Africa also carried out community outreach activity in the village of Rubare, outside of Goma as well as in Masisi territory. The efforts brought together people from the local NGOs, local governance, churches, and schools, and focused on the prevention of fistula and prolapse, as well as gender and behavior change in health. Throughout FY 17/18, HEAL Africa also carried out outreach activities in the city of Goma with religious and school officials focused on the themes of “the health of the mother and the girl” and “the prevention of fistula, everyone’s business.” They also organized a four-day awareness raising effort in the village of Alimongo, outside of Goma, that reached community members, local officials, church and school officials, and local NGOs with messages regarding fistula and prolapse prevention, gender, health, and behavior change. Panzi Hospital carried out community outreach efforts during the year that included organizing a community meeting in Bagira, creating a network with Muslim leaders, and hosting a meeting on “using
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data to improve performance” during the first quarter. During the second quarter, two outreach efforts were organized in the health zone of Walungu, one focused on students at the Institute Kidodobo and the other at Kidodobo Church. In the third quarter, events were held at the Kashofu Institute and Kashofu Parish during which messages were shared related to FP, fistula, gender, maternal health, reintegration and stigma. In the fourth quarter, a community meeting at the Nyawera Mosque reached 136 Muslim women. As noted in Objective 1, Panzi also continues to work in partnership with Radio Sven to broadcast community awareness raising messaging related to gender norms and roles. Radio Sven has an estimated listening audience of over 300,000 people. During the second quarter, SJH held a community meeting for 98 people at the CETA (Centre d’Entrainement des Troupes Aéroportées – Airborne Troup Training Center) military camp, which provided an opportunity to reach military wives with messages related to free access to fistula treatment, FP availability, and safe pregnancy and childbirth. SJH also produced a series of radio and television broadcast for channel RTNC3 and Radio Venus. Beniker organized two community outreach efforts in the third and fourth quarters in Kinsevere, located on the periphery of Lubumbashi, with messages related to fistula treatment and prevention. Beniker also produced two mass media programs on FP during the fourth quarter.
There were no community volunteer/educator trainings in DRC during FY 17/18.
Table DRC1: Community Outreach/Education/Advocacy Events, By Quarter, FY 17/18
Type of Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 Event # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Existing 2 30 1 98 0 0 0 0 3 128 community activity Health facility 0 0 0 0 0 0 0 0 0 0 Health 0 0 0 0 0 0 0 0 0 0 clinicians Policy makers 0 0 0 0 0 0 0 0 0 0 Maternal 3 108 4 304 2 117 5 307 14 836 health/ fistula- focused Radio/TV NA NA NA NA NA NA 4 2,2 mil 4 2.2 mil Total 5 138 5 402 2 117 9 2,200,307 21 2,200,964
-in person 5 138 5 402 2 117 5 307 17 964 -mass media NA NA NA NA NA NA 4 2.2 mil 4 2.2 mil
Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment FC+/DRC held a partners’ meeting in Lubumbashi in August 2018 to review activities carried out during FY 17/18 and plan activities for FY 18/19. FC+/DRC carried out clinical monitoring visits at IGL and MSRK in the first quarter. Conclusions from these visits led to the close out of support to these two sites during the second quarter of the fiscal year. A follow up assessment visit took place at Beniker Polyclinic in Lubumbashi, where an assessment during
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the previous fiscal year indicated readiness for the site to begin receiving project support for fistula treatment services, pending mission approval. Support to Beniker began in May 2018. During the third quarter, FC+ donated a UAM Anesthesia Machine to SJH to help strengthen their capacity to provide safe, high quality surgical services. Anesthestists have been oriented to the new machine and it is functional and in use at the facility. FC+/DRC also worked with staff at SJH to support the formation of a COPE (client-oriented, provider-efficient services) committee as a subcommittee of their current hospital scientific committee. Partograph and waste management monitoring was carried out at all supported sites in the third quarter. The SST is utilized at all FC+ supported sites in DRC. During the fiscal year, SJH developed a data collection sheet for clients seeking prolapse services as well as adapting and adopting an operative protocol. A protocol on the management of anuria postoperatively for fistula surgery was developed with the assistance of all sites. The final model, after review and input from the FC + Project Director, has been shared with all sites for their final assessment before implementation. During FY 17/18, 868 women with severe incontinence symptoms arrived seeking fistula care at FC+ supported sites, of which 672 were diagnosed with fistula (77%, compared with 75% diagnosed in FY 16/17). Of these diagnosed cases, 562 were medically eligible for surgical repair (84%). FC+ supported 560 fistula repair surgeries during this period (99.6% of those eligible, compared with 547 repairs in FY 16/17). 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: Number of Women Seeking and Eligible for Fistula Treatment, and Number of Surgical Repairs, by Site, FY 17/18
400
300
Seeking 200 Eligible Repairs 100
0 HEAL Africa Beniker Panzi SJH These 560 fistula repair surgeries were conducted at four FC+ supported hospitals: Beniker, HEAL Africa, Panzi, and SJH, see Table DRC2 for detail by quarter. 26% of these repairs were provided via routine service provision, with 74% of repairs carried out via outreach efforts (compared to 38% and 62%
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respectively in FY 16/17). Supported sites are traveling farther and farther to reach women who have not been able to easily access facility-based services. In addition to the surgical repairs reported here, three women received non-surgical catheter treatment for fistula at HEAL Africa: two were closed and continent at discharge and one was not closed. In addition to these FC+ supported repairs, Hôpital General de Référence (HGR) Kaziba provided 44 surgical repairs and two non-surgical catheter treatments through the ProSani project, bilaterally funded by USAID. Information on the etiology of diagnosed fistula was available for 623 (93%) of diagnosed cases. 71% were identified as being caused by obstructed or prolonged labor; 19% identified as iatrogenic in nature; <1% identified as having a traumatic etiology; and 1.9% due to cervical cancer. It was noted that Panzi and Beniker had a significantly lower percentages of cases with iatrogenic etiology (9% and 0% compared to 25% at HEAL and 39% at SJH).
Table DRC2: USAID-Supported Surgical Fistula Repairs, by Site, By Quarter, FY 17/18
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2017 2018 2018 2018 FY 17/18 Beniker NS NS 50 30 80 HEAL Africa 9 108 19 11 147 Panzi 6 81 98 15 200 SJH 47 28 19 39 133 FC+ Total 62 217 186 95 560 HGR Kaziba (ProSani) 0 44 0 0 44 USAID-supported Total 62 261 186 95 604
A total of 501 fistula cases were discharged during FY 17/18. Of these, 54% (n=271) were classified as simple fistula and 46% (n=229) as not simple, with data unavailable for one case. There is a small increase in the percentage of cases deemed not simple when compared to the previous fiscal year (46% compared to 41%). 93.6% of all discharged fistula surgery cases were closed at time of discharge: 91.8% were closed and continent and 1.8% were closed and incontinent (compared to 91.6% and 3.5% in FY 16/17). Outcomes for discharged patients are presented, by site, in Figure DRC2. Reported complications were low at supported sites (2.2% overall) with a range of 6.6% at HEAL, related to anesthesia, to 3% or less at the other supported sites.
Figure DRC2. Outcome Rates for Surgical Repairs, by Site, FY 17/18
100% 90% Not closed 80% Closed with remaining 70% incontinence 60% Closed and continent 50% 40% Benchmark closed and continent (75%) 30% 20% 10% 0% HEAL PANZI SJH Beniker
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During FY 17/18, all four supported sites reported providing POP treatment to 846 women. The sites reported 848 surgical POP treatments and 1,834 non-surgical treatments. SJH has developed a client card and a protocol for surgical practice for the care of women with POP. In the third quarter of the fiscal year, one surgeon from SJH participated in his first training for surgical fistula repair, see Table DRC3.
Table DRC3: Surgical Fistula Repair Training, Participants by Trainee Institution, FY 17/18
Institution Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2017 2018 2018 2018 FY 17/18 1st Cont 1st Cont 1st Cont 1st Cont 1st Cont SJH 0 0 0 0 1 0 0 0 1 0 Total 0 0 0 0 1 0 0 0 1 0
As part of fistula prevention and treatment efforts, FC+/DRC provided training on a variety of topics to 425 health care clinicians and facility staff during FY 17/18; see Table DRC4. During the first quarter, Panzi, with FIGO funding, organized a medical and surgical coaching visit from Dr Fekade Ayenachew of the Hamlin Addis Ababa Fistula Hospital. Dr. Fekade is a FIGO expert surgeon who visited on behalf of FIGO’s Fistula Surgery Training Initiative as part of efforts to accredit the hospital as an International Fistula Training Center. Recommendations included organizing a workshop to develop a five-year strategic plan and restructuring of the hospital’s organization chart that was completed at the end of the visit. During November 2017, a team comprised of one doctor, one physiotherapist, and two nurses from HEAL Africa visited Panzi Hospital to exchange experiences and joined 20 Panzi staff members for training on non- surgical management of prolapse and fistula with pessary placement, urodynamics, and physiotherapy. During the Family planning training with participants second quarter, 49 staff members at Panzi, including acting as live anatomical models. Credit: nurses, midwives, doctors, surgeons and a data clerk, M. Mpunga. participated in a refresher training that covered multiple topics including fistula pre- and post-operative treatment, emergency obstetric care, counselling, FP and data management all aimed at ensuring the continued quality of fistula service provision. In the third quarter, 31 health clinicians participated in FP training at Beniker that covered methods and counseling. Seven clinicians at HEAL participated in training related to safe motherhood and the new SRMNEA guidelines. In addition, six clinicians participated in a workshop on science writing, see Objective 5 for detail. Panzi organized three trainings in the fourth quarter of the fiscal year. Topics covered included a course on physiotherapy for 32 non-physician clinicians, doctors and administrative staff; a course on workplace communication and waste management in response to the recent Ebola outbreak for 232 people including non-physician clinicians, doctors, administrative and facility support staff; and a training on ANC, fistula
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counseling, prolapse and postoperative care for fistula patients for 35 doctors, clinicians and administrative staff.
Table DRC4: Non-Surgical Health System Personnel Training, Participants by Topic, By Quarter, FY 17/18
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2017 2018 2018 2018 FY 17/18 Pre- and post-operative care, FP and 0 49 0 35 84 fistula service quality assurance Pelvic Organ Prolapse (POP) 24 0 0 0 24 management FP methods and counseling 0 0 31 0 31 Science writing workshop 0 0 6 0 6 EmONC 0 0 7 0 7 Data for decision making 0 0 0 9 9 Physiotherapy 0 0 0 32 32 Infection prevention 0 0 0 232 232 Total 24 49 44 308 425
FC+ supported the participation of Dr. Angel Mukuliboy of SJH and Dr. Esther Kitambala of HEAL at the 5th Urological Meeting organized by the Institute for Training and Research in Urology and Family Health, held in Dakar, Senegal in April 2018. In FY 17/18, FC+/DRC continued support to ensure that FP services are provided and integrated with fistula service provision at supported sites. FP activities have been integrated into three supported sites, including SJH which is a Catholic facility. FP service provision at Beniker is under development. During the fiscal year, 2,684 counseling sessions took place at supported sites and 4,675 CYP were provided (see Table DRC5 for detail, by site).
Table DRC5: Family Planning Counseling Sessions and CYP, by Site, By Quarter, FY 17/18
Site Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP14 HEAL 36 241 39 435 41 420 38 428 154 1,524 Africa Panzi 322 545 342 589 211 522 322 639 1,197 2,296 SJH 717 291 330 384 202 103 84 76 1,333 855 Total 1,075 1,077 711 1,408 454 1,046 444 1,144 2,684 4,675
FC+/DRC supported sites reported an overall cesarean section rate of 34% in the FY 17/18, with a total of 7,557 deliveries. Information on number of deliveries, by site, is presented in Figure DRC3 and cesarean section rates, by site, are presented in Figure DRC4. Less than 1% of reported deliveries were prolonged/obstructed labor and of those, 2% received catheterization for fistula prevention.
14 Due to rounding, totals may differ slightly from the sum of individual quarters.
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Figure DRC3. Number of Obstetric Figure DRC4. Cesarean Section Rates, by Site, Deliveries, by Site, FY 17/1815 (n=7,557) FY 17/18
0% 100% HEAL Africa 1,763 HEAL Africa 62.7 37.3
Panzi 3,130 Panzi 68.3 31.7 SJH 2,663 SJH 65.2 34.8 Beniker 1
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 During the fourth quarter, FC+/DRC supported a data for decision making training at Beniker Hospital for nine clinical staff, see Table DRC4 for detail. In the third quarter, orientations to clinical and management tools were provided to staff as part of on-boarding Beniker as a supported site. FC+ consultant Dr. Alex Delamou conducted a scientific report writing workshop (see Table DRC4) during the third quarter which brought together 12 participants from FC+, HEAL, Panzi, and SJH. The workshop focused on working with supported site staff on being able to analyze and publish their data on "Frequency and Management of Non-Obstetric Fistula in the Democratic Republic of Congo," a study that was approved by USAID in FY 16/17 In the fourth quarter, Dr. Denis Mukwege from Panzi Hospital Article writing workshop in Goma. published an article in the International Journal of Gynaecology Credit: M. Mpunga. and Obstetrics entitled Panzi score as a parsimonious indicator of urogenital fistula severity derived from Goh and Waaldjik classifications (https://www.ncbi.nlm.nih.gov/pubmed/29705989). FC+/DRC and supported site staff submitted abstracts that were accepted at the FIGO World Congress to be held in October 2018 (see Appendix MM).
15 Beniker serves very few maternity cases – maternity services are new to the facility in an attempt to provide more comprehensive services.
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Mozambique FC+ activity in Mozambique began in December 2017 and is supported through a subaward with the Mozambique-based organization Focus Fistula. The goal of this sub-award is to strengthen the clinical capacity of selected ministry and private facilities and staff to provide accessible, quality obstetric, iatrogenic and traumatic fistula surgical and non-surgical treatment services in Mozambique. The current period of the agreement is February 1, 2018 – November 30, 2018. During this first three quarters, efforts were primarily focused on orientation and startup of activities. Activities included recruitment and orientation of staff, preliminary set-up of the subaward. Translation and preparation of key documents from English to Portuguese were completed in the second quarter in order to begin the orientation process for Focus Fistula staff. In addition, documents on procurement processes, timesheet completion, staff financial responsibilities and travel request forms have been prepared. Staff have received orientation on financial procedures such as how to procure multiple bids for a purchase and how to complete purchase orders. In addition, ethical documents such as photo consent forms and voluntary and informed consent forms have been translated to use with fistula clients in Mozambique. Staff will continue to be oriented on pertinent financial materials as onboarding occurs. Supported repairs began in April 2018, with a total of three sites providing repairs as of September 30, 2018: Hospital Central Maputo, Clinica Cruz Azul, and Nampula Central Hospital. Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors Focus Fistula is in discussions with the Ministério da Saúde (MISAU – Ministry of Health) in Mozambique and UNFPA to develop a national strategy for the prevention, treatment, and reintegration of women with fistula. Through negotiations, MISAU has agreed that Focus Fistula will be able to work with public health units, provincial health directorates, and medical and paramedical staff, as well as have access to housing, infection prevention and waste management resources. MISAU and Focus Fistula will also work together on the transport of patients to and from treatment facilities. UNFPA will provide disposable supplies to concentrated fistula repair efforts and seek out consultation from Focus Fistula on the national fistula program. Discussions have also been initiated with the Foundation for Community Development (FCD) and Cabora Bassa Hydroelectric (HCB) regarding the possibility of financial support for fistula activity in Mozambique. Focus Fistula has received disposable materials from Direct Relief during the fiscal year, including materials and medicines. The delivery was greatly delayed by customs inspection but arrived at the end of November 2017 and has since been utilized in repair efforts. Fistula patients awaiting surgery. Credit: P. Celestino. 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 FY 17/18, awareness raising campaigns were conducted at three supported fistula treatment sites in conjunction with concentrated repair efforts to improve knowledge about fistula, access to treatment, male involvement, FP, and the fight against stigma. Community outreach focused on reaching school-age
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youth with messages about avoiding early marriage, use of FP, and safe motherhood practices, as well as outreach to families of patients and local government officials. FC+ supported sites in Mozambique carried out three in-person community outreach efforts reaching 200 people, see Table MOZ1.
Table MOZ1: Community Outreach/Education/Advocacy Events, By Quarter, FY 17/1816
Type of Event Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Maternal NS NS 1 37 1 95 1 68 3 200 health/ fistula- focused Total -in person NS NS 1 37 1 95 1 68 3 200
Focus Fistula is in negotiations with TV SUCESSO to enter into a collaboration to raise fistula awareness through social behavior change and communication. They are also negotiating with Escola Superior de Communicão e Arte (ECA), a multimedia group, to provide videos and other media communications materials to be used during surgical repair efforts.
Objective 3: Reduced transportation, communications, and financial barriers to accessing preventive care, detection, treatment, and reintegration support
Focus Fistula provides support for transport through provision of fuel for ambulances and other patient transport vehicles, as well ensuring fistula patients receive adequate food during repair efforts. Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment During the fourth quarter, the FC+ Sr. Clinical Associate joined Focus Fistula staff to carry out baseline site assessments for Maputo and Nampula Central Hospitals as well as Xai Xai Provincial Hospital. In September 2018, a site assessment was carried out at Inhambane Provincial Hospital. Challenges were discussed with hospital leadership and items were identified for future action, including improving pre-operative preparation of patients, Health clinician training in Nampula. lengthening hospital stay post-surgery, improving Credit: S. Costa. patient follow up mechanisms, ensuring FP counseling and services for patients, and formalizing patient tracking systems. During FY 17/18, 192 women with severe incontinence symptoms arrived seeking fistula care at FC+ supported sites, of which 173 were diagnosed with fistula (90%). Of these diagnosed cases, 156 were
16 Data in this table present revisions to data reported in the FY 17/18 semi-annual report. Refinement of data collection and reporting systems indicated that data reported in the semi-annual report was misclassified.
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medically eligible for surgical repair (90%). FC+ supported 102 fistula repair surgeries during this period (65% of those eligible). 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 MOZ1 presents data on women seeking and requiring fistula treatment, and the number of fistula surgeries supported, by site.
Figure MOZ1: Number of Women Seeking and Eligible for Fistula Treatment, and Number of Surgical Repairs, by Site, FY 17/18
120
100
80 Seeking 60 Eligible 40 Repairs
20
0 Cruz Azul HC Maputo Nampula These 102 fistula repair surgeries were conducted at three FC+ supported hospitals: Hospital Central Maputo, Clinica Cruz Azul, and Nampula Central Hospital, see Table MOZ2 for detail by quarter. 70% of these repairs were provided via concentrated repair efforts with 30% carried out via routine service provision. Information on the etiology of diagnosed fistula was available for 100% of diagnosed cases. Of those cases, 88% were identified as being caused by obstructed or prolonged labor; 9% identified as iatrogenic in nature; and 2% identified as having a traumatic etiology.
Table MOZ2: USAID-Supported Surgical Fistula Repairs, by Site, By Quarter, FY 17/18
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2017 2018 2018 2018 FY 17/18 Hospital Central Maputo NS 6 24 0 30 Clinica Cruz Azul NS 9 16 0 25 Nampula Central Hospital NS 0 0 47 47 Total NS 1517 40 47 102
A total of 92 fistula cases were discharged during FY 17/18. Of these, 56.5% (n=52) were classified as simple fistula and 43.5% (n=40) as not simple. 100% of all discharged fistula surgery cases were closed at time of discharge: 95.7% were closed and continent and 4.3% were closed and incontinent. Outcomes for
17 Data for the January-March quarter was submitted as one data set, even though repairs were conducted at two sites. We only have site-specific detail for the number of repairs supported, all other data is combined for both sites for this quarter.
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discharged patients are presented, by site, in Figure MOZ2. Reported complications were low at supported sites, 2.2% overall.
Figure MOZ2. Outcome Rates for Surgical Repairs, by Site, FY 17/18
100% Not closed 80% Closed with remaining incontinence 60% Closed and continent
40% Benchmark closed and continent (75%) 20%
0% Cruz Azul Maputo Nampula
During each concentrated repair effort, Focus Fistula provides orientations and basic training to local clinicians that covers information on fistula physiopathology, treatment, prevention and pre- and post- operative care. At the Central Hospital of Maputo and Cruz Azul, the concept of preventive catheterization was introduced for patients with prolonged delivery as a standard. As part of fistula prevention and treatment efforts, FC+ supported training of 168 health care clinicians and facility staff in Mozambique during FY 17/18; see Table MOZ3.
Table MOZ3: Non-Surgical Health System Personnel Training, Participants by Topic, By Quarter, FY 17/18
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2017 2018 2018 2018 FY 17/18 Pre- and Post-Operative Care NS 35 57 76 168 Total NS 35 57 76 168
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+ is working together with Focus Fistula to ensure that M&E systems are adequate and functional for project reporting and for tracking patients and providing quality services.
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Nigeria USAID-supported fistula services in Nigeria began in 2007 through the previous FC project and continued under FC+ through the end of FY 17/18 in 14 treatment and prevention sites and 682 prevention-only sites, including 500 sites inherited from the former TSHIP project. During FY 17/18, FC+ worked in 13 states in Nigeria: Bauchi, Cross River, Ebonyi, Kaduna, Kano, Katsina, Kebbi, Kwara, Osun, Oyo, Sokoto, Yobe, and Zamfara. FC+ supported efforts in Nigeria concluded in September 2018, as the Mission is not participating in the global project’s No-Cost Extension into FY 18/19. FC+ fistula prevention and treatment efforts in Nigeria 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. The third and fourth quarters of FY 17/18 focused on winding down activity in Nigeria and closure of the FC+/Nigeria office.
Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors In FY 17/18, 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 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. Advocacy Visits During the first quarter, advocacy visits in Cross River State resulted in pledged support from the governor’s wife for feeding and rehabilitation of fistula clients and promised support from the House of Assembly to include fistula as a line item in the state budget. FC+/Nigeria will work with the State Ministry of Health (SMoH) to draft a fistula policy for the state. The team also met with the Commissioners of Health in the states of Sokoto, Kebbi, and Oyo to discuss setting up fistula desks with budget lines in each of the states as part of steps to ensure continuity and sustainability of fistula treatment. In Ebonyi State, meetings also took place with the Commissioner of Health and the Senior Special Advisor to the Governor on Health to continue lobbying for the establishment of a functional fistula desk within the state to ensure for sustainability of fistula efforts. During the third quarter, the team met with representatives of the Kwara State Ministry of Health to advocate for continued state government support for the fistula program. The state has a budget line item for fistula activity. The FC+/Nigeria Country Program Manager met with the Yobe State Honorable Commissioner of Health and the Permanent Secretary of the Yobe State Ministry of Health. The team from Yobe State came to seek the collaboration and support of FC+ in providing fistula services at the Maryam Abatcha Women and Children’s Hospital in Yobe State. The State requested that FC+ support the provision of consumables for fistula repairs, refurbishment of the hospital, and the supply of equipment and instruments. The strong commitment of the State to take ownership of the program led to FC+’s decision to pursue this collaboration. During the second quarter, FC+/Nigeria met with Chief Medical Directors of the teaching hospitals in Kano and Cross River States to discuss the planned commencement of fistula services in these hospitals. FC+/Nigeria completed an assessment of infrastructure at Calabar Teaching Hospital in Cross River State and subsequently provided support for refurbishment of the space allocated for fistula clients.
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Meetings were also held with supported site NOFIC Abakaliki to ensure continued fistula services at the end of FC+. The center will continue to support fistula activities despite a paucity of funds and the end of FC+ support to the center. In the fourth quarter, advocacy efforts focused on key project partners as the project approached its end. Meetings were held with UNFPA and the FMOH to discuss the close-out schedule and how to ensure fistula service provision continued at formerly supported sites. Safe Surgery
Throughout FY 17/18, FC+/Nigeria has helped facilitate communications between the Nigerian FMOH and Harvard’s Program for Global Surgery and Social Change (PGSSC) team related to the evolving National Surgery, Obstetric and Anesthesia Plan (NSOAP) in Nigeria. Nigeria has completed initial NSOAP baselining and is due to commence in one state from each of the six geopolitical zones. NSOAP policy fills surgical obstetric intervention gaps within EmONC services, and fundamentally underpins FC+’s objectives to strengthen the enabling environment, provide high quality clinical services, and monitor outputs and impact.
National Working Groups and Stakeholder Activity FC+/Nigeria was a member of the technical working group launched by the Federal Ministry of Women Affairs and Social Development to support implementation of the National Strategy to End Child Marriage in Nigeria. During the first half of FY 17/18, FC+/Nigeria supported and participated in working group meetings where implementation of the National Strategy was discussed, a draft costed work plan was finalized and activities towards implementation were prioritized. To support this government priority to end child marriage in Nigeria, FC+/Nigeria initiated a cross border collaboration and sharing of ideas between Nigeria and Niger. This collaboration facilitated the sharing of experiences between the two countries, given religious and cultural similarities between Niger and the northwestern states of Nigeria. An initial meeting was held in Katsina State in February 2018 with participants from the FMWA and its counterpart in Niger, FC+/Nigeria, and FC+/WA/Niger. Participants reviewed both countries’ strategies towards elimination of child marriage and documented similarities and differences. A larger meeting was under consideration that would include state ministries, religious leaders, and other stakeholders from both countries, but with the closure of offices in both Niger and Nigeria, these plans are canceled. During the first quarter, a two-day national stakeholders meeting was convened by the FMOH, in collaboration with FC+/Nigeria and UNFPA. These meetings ensure regular interaction between providers and stakeholders to share ideas and experiences, towards the goal of elimination of fistula in Nigeria. Presentations at the meeting provided state-level updates, documentation and exchange of information on Federal and State government plans to end obstetric fistula by 2030, consultation with states on development of the National Strategic Framework (NSF) for the Elimination of Fistula, and discussion of steps to facilitate moving forward with fistula programs at the state level including establishment of fistula desks and budget lines. This stakeholder meeting also provided an opportunity to present several major accomplishments and collaborative efforts of the FMOH towards elimination of fistula. This includes national training on management of obstetric fistula for doctors and nurses; development of the NSF and standards of practice on the clinical management of obstetric fistula; establishment of three National Obstetric Fistula Centers with plans to expand to an additional three; approval of waiver of surgical and laboratory fees for all
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fistula patients in Federal Medical Centers and Federal Teaching Hospitals; and the implementation of the National Guidelines on Urethral Catheterization for conservative treatment of obstetric fistula. Also in collaboration with the FMoH, and the Centre for Population and Reproductive Health (CPRH) at the University College Hospital in Ibadan, Oyo State, FC+/Nigeria organized a technical committee workshop to develop a standardized classification system for genital fistula in Nigeria and to develop the final draft of management guidelines and protocols for Persistent Fistula-related Disorder (PFD), formerly referred to as Women Deemed Incurable (WDI). The initial workshop was held in Ibadan in May 2018 and a follow up workshop was held in Abuja in June 2018. At the end of the workshops, the committee was able to develop a concise but comprehensive fistula classification system that will be pretested and recommended for adoption by health workers involved in fistula care in Nigeria. A final draft of the PFD guidelines is under revision and will be sent to the FMoH for adoption when finalized. In January 2018, 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 2018 PNM focused specifically on surgeons and nurses from supported sites, and the development of sustainability plans for fistula interventions beyond the project’s lifespan. The meeting included presentations and discussions on interventions, progress to date, and challenges affecting fistula service provision in Nigeria. The group was able to agree on feasible and sustainable action plans for better coordination of fistula activities at various centers, in line with the NSF. FC+/Nigeria continued discussions initiated at the end of FY 16/17 with Christopher Blind Mission (CBM) International to identify areas of possible collaboration. CBM has been funding ECWA Evangel Hospital in Jos since 2008 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, with particular emphasis on women with disabilities. CBM has received funding from the Australian government to cost share activities with an implementing partner on comprehensive fistula intervention in Nigeria, and had approached EngenderHealth for a potential partnership. With the closure of the FC+/Nigeria office, CBM will need to continue discussions with the USAID independently. 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. During the first quarter, a media round table had participants from print and electronic media in 11 states across Nigeria. Media engaged in discussion of issues related to fistula, strengthening fistula reporting, and identifying new areas of media advocacy and future programs by Fistula Ambassadors. A similar roundtable was held in the second quarter for participants from ten states. Meetings and Conferences FC+/Nigeria 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 the first quarter, FC+/Nigeria supported, attended, and presented at the Institute’s 8th International Conference on Social Work. The conference theme was “Managing Rehabilitation and Reintegration within the Context of Social Work” which fit well with the project’s efforts towards rehabilitation and reintegration in the context of fistula management in Nigeria. The conference provided a platform for fistula service
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providers to learn more about the psychosocial needs of women living with fistula and how those needs can best be addressed as part of fistula management. ISOWN also presented an award to FC+ for the impact its program has had in Nigeria. In November 2017, FC+/Nigeria sponsored the attendance of 21 fistula service providers from supported sites to attend the 51st conference of the Society of Obstetrics and Gynecology of Nigeria (SOGON) held in Sokoto State with the theme “Maternal and Newborn Health in a Challenging Economy.” The project sponsored a plenary panel discussion on “Unlocking of Potentials for Obstetric Fistula Elimination in Nigeria,” led by Professor Oladosu Ojengbede of UCH Ibadan. FC+/Nigeria was able to display and distribute resource materials including the national catheterization guideline’s flow chart for conservative treatment of fistula, fistula prevention posters for antenatal clinics and maternities, information on iatrogenic fistula, and the barrier study intervention methodology and findings. FC+/Nigeria staff also participated in a meeting, during the first quarter, of the National Council on Health, the highest health policy making body in Nigeria, with the theme of “Economic Recovery and Growth Plan (ERGP) and the Health Sector: Matters Arising.” FC+/Nigeria also supported the participation of a Nigerian fistula surgeon at the West Africa College of Surgeons 58th Annual Conference and Scientific Meeting held in the Gambia in February 2018. FC+/Nigeria staff attended, along with FC+/Global, FC+/DRC, and FC+/Bangladesh staff. During the conference, the FC+/Nigeria team presented on “Implementation of Surgical Safety Toolkits in Fistula and Genital Prolapse Surgery.” In May 2018, FC+/Nigeria participated in the 58th annual Nigerian Medical Association (NMA) conference, sponsoring a plenary session that covered issues related to iatrogenic fistula and building technical capacity of health clinicians. International Day to End Obstetric Fistula Celebrations Celebration of the International Day to End Obstetric Fistula took place on May 23, 2018. The theme of 2018 IDEOF was “Leaving no one behind: let us commit to ending fistula now!” FC+/Nigeria, in collaboration with several SMoHs, fistula and FP service providers, and community partners organized several activities to commemorate the day. These included a street rally, FP outreach activities, and radio and television programs. Posters, handbills, and other SBCC materials on fistula and FP were IDEOF Street Rally celebration. distributed. Credit: FC+/Nigeria.
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, reviewed and approved by USAID/Nigeria. Community mobilization efforts supported 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 included 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.
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Part of this strategy is strengthening Men as Partners (MAP) groups to encourage male involvement to address harmful gender norms that prevent women’s access to maternal health services. Family support is crucial to recovery and reintegration after fistula repair, including the ability to use voluntary FP and maternal health services that can prevent fistula recurrence. MAPs were trained on interpersonal communication skills and approaches for raising community awareness about fistula prevention and treatment. In Sokoto and Zamfara states, MAPs conducted peer education sessions for other men to discuss issues around male involvement in maternal health and encouraged men to share decision making power with their wives.
In states where FC+/Nigeria did not directly support community mobilization, FC+ prioritized strategic engagement of and advocacy to community leaders via local mass media to reach wider, grass roots audiences. FC+/Nigeria supported a total of 548 in-person community outreach events, reaching an estimated 211,776 people during FY 17/18, see Table NGA1. Events included home visits, community dialogues, church outreaches, and town hall meetings. These activities raised community awareness about fistula Peer education on Men as Partners (MAP) in maternal health. Credit: prevention, particularly increasing utilization of skilled FC+/Nigeria. birth attendants, antenatal care and FP services. They also focused on identifying and mobilizing women with fistula symptoms for treatment, discouraging stigmatization against women with fistula, and providing reintegration support for repaired clients. Through supported CBOs, FC+/Nigeria conducted advocacy visits to relevant stakeholders, policy makers at state and local government area (LGA) levels, traditional rulers and community leaders. These visits provided an opportunity to sensitize community leaders about fistula prevention and treatment and other interventions. The CBOs continued to strengthen collaboration with fistula centers for improved client mobilization and referrals. Health facility staff were also involved in community awareness raising events, training and review meetings with community advocates. Communities regularly donated use of training halls to CBOs for use in training of community volunteers. FC+/Nigeria also worked with “fistula champions” – women who had their fistula successfully treated – who conduct peer education sessions and providing empathetic support to women who arrive at facilities seeking care. As part of on-going efforts to identify and engage religious leaders to be Religious Leaders Advocacy Champions (RLACs) throughout the country, in the first half of the fiscal year FC+/Nigeria provided orientations on fistula related issues and programming to 55 religious and traditional leaders across 50 communities in Kwara State. These traditional and religious leaders play a significant role in the dissemination of health information in communities, especially on public health interventions, by providing accurate information on health services while discouraging harmful traditional and religious practices and beliefs leading to maternal morbidities and mortality. They also support reconciliations and reintegration of women with fistula who have been estranged from their families and/or communities. FC+/Nigeria worked in partnership with the Institute of Social Work of Nigeria (ISOWN) to mainstream the social aspect of fistula care rehabilitation and reintegration into broader daily social work practice in four supported states through capacity building of social workers. During the second quarter, FC+/Nigeria organized a workshop for ISOWN members from Bauchi, Kebbi, Osun, and Oyo States. Those trained then provided step down trainings to ISOWN members across the local government areas in their
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respective states. These members are integrating fistula messages in their activities to raise community awareness about fistula treatment and prevention, referrals to treatment sites, and support psychosocial counseling and reintegration of women living with fistula who have been abandoned by their families or those who have been repaired and need support for community reintegration or reunification with their families. During concentrated fistula repair efforts organized in Osun, Oyo and Bauchi states, ISOWN facilitated mobilization of clients, conducted psychosocial counseling for clients pre- and post-surgery, and planned A religious leader in Sokoto working skills acquisition and reintegration interventions for clients. with the family of a fistula patient. In the fourth quarter, despite close-out of FC+/Nigeria Credit: FC+/Nigeria. support, ISOWN continued to mobilize clients and conduct rehabilitation and reintegration activities using their own funding in Osun and Oyo States. Outreach efforts during the reporting period also targeted students with a symposium at the School of Health Technology in Ebonyi. These students graduate on to Community Health Extension Worker (CHEW) posts at lower level health facilities such as PHCs. The symposium included student presentations as well as a presentation from NOFIC Abakaliki about fistula identification and treatment. Students were encouraged to become fistula advocates and help prevent fistula from occurring through early detection of prolonged obstructed labor and implementation of early catheterization. During the first and second quarters, FC+/Nigeria conducted community educational entertainment activities including screenings of the film DRY and community drama performances. DRY screenings took place in Ebonyi and Zamfara State. Community dramas were conducted primarily in village squares in the northern states. In addition to print and electronic media efforts described in Objective 1, FC+/Nigeria continued to work with partners to utilize radio communications to spread messages about prevention of prolonged obstructed labor and fistula, as well as create awareness about services available at treatment sites. During the first quarter, three Health Watch radio programs aired on Radio Nigeria, the largest radio network in Africa. Radio Nigeria has an estimated media coverage of 14 million listeners. The 30-minute programs, which air in Sokoto, Kebbi, Oyo, Ebonyi, Kwara, and Cross River States, address topics including legislators at the battle front of fistula elimination, prolonged/obstructed labor and its consequent morbidities, and success stories of fistula clients. A live radio show on fistula prevention and treatment, with call-in participation, aired on Ebonyi Broadcasting Corporation Abakaliki and a television program with a pre-recorded panel discussion on fistula aired on Cross River State Broadcasting Corporation Calabar.
Table NGA1: Community Outreach/Education/Advocacy Events, By Quarter, FY 17/18
Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Existing 253 76,184 193 89,492 102 46,100 0 0 548 211,776 community events Total 253 76,184 193 89,492 102 46,100 0 0 548 211,776
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Given low use of preventive maternal health services, including FP, in many of the FC+ focal states in Nigeria, efforts continued to cultivate champions for social change, with a focus on existing community development structures such as CBOs, Ward Development Councils (WDCs), and other influential social leaders. During FY 17/18, FC+/Nigeria conducted training of 262 community volunteers and educators not formally affiliated with a health facility, see Table NGA2. FC+/Nigeria supported CBO training of community volunteers from newly engaged LGAs on approaches and tools for community awareness raising activities about fistula treatment and prevention. The trained volunteers were supported to lead community-level activities in their various communities including home visit/pregnancy monitoring and community dialogues with ongoing supportive supervision support from the CBOs. This support for home visits, initiated with community volunteers in FY 16/17, resulted in nearly 14,000 household visits, reaching over 47,000 household Home visit by community volunteers. Credit: members in FY 17/18. During these visits, 1,553 FC+/Nigeria. women were referred for ANC and 269 for delivery at health facilities.
Table NGA2: Community Volunteer/Educator Training, Participants, By Quarter, FY 17/18
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total FY 17/18 2017 2018 2018 2018 Community volunteers 145 117 0 0 262 Total 145 117 0 0 262
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 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. The intervention was implemented at two sites in Nigeria, at the request of USAID/Nigeria. In Nigeria, the Fistula Treatment Barrier Reduction Intervention took place in the catchment areas of two fistula treatment facilities - NOFIC Abakaliki and NOFIC Babbar Ruga, in Ebonyi and Katsina States. Within each of the catchment areas, fistula awareness and case identification were promoted through three channels: outreach by community based agents, mass media (radio), and primary health care worker screening and referral. Through each of these channels, women who screened positive as suspected fistula cases based on the presence of fistula symptoms received referral to a fistula treatment center, including a voucher to support transportation costs. These were paired with mass media and an interactive voice response (IVR)-based fistula screening hotline available through mobile phone. In the intervention areas, women could make an IVR phone call that screened them with standard questions regarding the presence of fistula symptoms. Suspected cases received referral to a fistula treatment center for clinical examination and repair.
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FC+ trained 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 were selected and trained by the project partners DOVENET in Ikwo LGA of Ebonyi State and FOMWAN in Katsina LGA of Katsina State. During the first quarter of the fiscal year, FC+ and Population Council conducted monitoring visits as part of a mid-term evaluation of the implementation of the Fistula Treatment Barriers Intervention; The visits allowed for dissemination and solicitation of feedback on baseline findings from national and local stakeholders, and the opportunity to conduct purposively selected key informant interviews with implementers and beneficiaries of the barrier reduction intervention. Key informants included fistula patients, community agents, primary health center (PHC) providers, transportation agents, CBO staff, National Obstetric Fistula Center (NOFIC) staff, and FC+ Nigeria staff. Actions identified for mid-course corrections based on the data collection have already begun to be implemented, including the refresher training described in Objective 3. Other recommended actions include:
Focus on community agents to fill the gap for the hotline challenges related to network connectivity and language difficulty; Review and increase stipends of community agents and transport reimbursements to reach women, who are harder to reach in rural areas; Enhance promotional materials for FC+ barrier intervention, including the re-printing of the IEC flyer advertising the fistula hotline to be an enlarged poster that can displayed more easily.
During the second quarter of FY 17/18, based on these recommendations, refresher orientations were provided for all actors in the intervention study, including PHC providers, community agents, fistula service providers, and transportation agents. A one-day orientation was conducted in both Ebonyi and Katsina States to reinforce roles and responsibilities of the intervention’s community-based screening and referral mechanisms and strengthen communication, coordination, and collaboration between the intervention’s facilitators. In Ebonyi, 72 participants attended and in Katsina, 56 participants attended. Community agents were also linked with PHC providers working in the same ward to facilitate screening and referral of suspected cases of fistula. The refresher training also included an opportunity for facilitators to discuss challenges, such as management of co-morbidities and long wait times. FC+/Nigeria concluded intervention implementation in the third quarter of FY 17/18. Population Council completed endline data collection in Ebonyi in FY 17/18 and will complete data collection in Katsina in the first quarter of FY 18/19. Population Council will submit the final research report to FC+ within 60 days after the end of the subaward (i.e., February 28, 2019). At this time, all technical briefs and reports developed to date through this partnership are available at: https://www.popcouncil.org/research/fistula- care-plus. Additional information on this research is provided in Section II, Objective 3 and 5.
Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment In 2016 FC+ developed a Surgical Safety Toolkit (SST) to address gaps in safe surgery and quality assurance in facilities. The FC+ SST was introduced to standardize project systems-based review of surgical activities and ultimately to improve clinical outcomes. Experience in Nigeria and DRC has demonstrated the investment required to standardize patient-level information systems to optimize the safety and quality of elective fistula and prolapse surgery.
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FC+/Nigeria provided support to the State Ministry of Health (SMOH) to provide routine supportive supervision and mentoring visits as part of efforts to expand access to and use of modern contraceptives across the FP supported sites in the states. During this fiscal year, supportive supervision visits were carried out with relevant partners representing the SMOH and LGAs in selected health facilities in Sokoto, Ebonyi and Zamfara States. These activities promote efficient, effective, and equitable service provision while ensuring the availability of all needed equipment and instruments, consumables, IEC materials, and monthly service statistics tracking. They also provide an opportunity to monitor compliance and adherence to USAID FP legislative and policy requirements. During FY 17/18, FC+ provided support to 14 fistula treatment facilities in 13 states in Nigeria, of which ten conduct regular routine fistula repairs. Conscious efforts were 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. In particular, the FC+/Nigeria clinical team continued to provide support to facilities in their efforts to improve anesthesia safety in response to needs identified earlier in the project, as well as supporting the implementation of the SST. FC+/Nigeria commenced support of fistula treatment interventions in Yobe State in FY 17/18. The high projected burden of obstetric fistula in the Northeastern region of Nigeria, compounded by a population underserved due to the Boko Haram insurgency, helped identify Yobe State as a strategic location for support. Following a site assessment, a concentrated fistula repair effort was conducted at the Women and Children Hospital, in Damaturu, Yobe State. FC+/Nigeria support enabled introduction of fistula management guidelines and protocols, the SST, and other quality improvement approaches including monitoring and evaluation. FC+/Nigeria also supported an expert fistula surgeon and two nurses to visit the site and mentor site staff. During FY 17/18, 2,782 women with severe incontinence symptoms arrived seeking fistula care at FC+ supported sites, of which 2,028 were diagnosed with fistula (73%, compared to 78% in FY 16/17). FC+ supported 1,560 fistula repair surgeries during this period (83% of the 1,878 women who were diagnosed and eligible for surgery, compared to 1,953 surgeries in FY 16/17). 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, 132 women received catheter treatment for fistula at eight supported sites, the majority of which took place at Laure VVF Center, NOFIC Babbar Ruga, Maryam Abatcha Sokoto and Gesse VVF Center. 84% of catheter-treated cases were closed and continent at discharge, 4% were closed and incontinent, and 12% were not closed.
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Figure NGA1: Number of Women Seeking and Eligible for Fistula Treatment, and Number of Surgical Repairs, FY 17/18
0 100 200 300 400 500 600 700 800 Adeoyo Faridat GH Ningi Seeking GH Ogoja Eligible Gesse Repairs Hajiya Gambo Sawaba Laure Maryam Abatcha Yobe Maryam Abatcha Sokoto NOFIC Abakaliki NOFIC Babbar Ruga Sobi Specialist Wesley Guilds
Data on the etiology of fistula was available for 1,561 diagnosed cases (77%, compared to the same percentage in FY 16/17). Of those cases where etiology was identified, the majority (85%) were due to prolonged/obstructed labor. 12% were diagnosed as iatrogenic fistula, <1% as traumatic and 2% attributed to cancer and congenital fistula. These percentages were very similar to those reported in FY 16/17. 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 national fistula registers and the SST have already greatly improved the availability of fistula etiology data (77% in FY 16/17 and FY 17/18, compared to 56% in FY 15/16). The 1,560 fistula repair surgeries supported during FY 17/18 were conducted at 13 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. Over the life of FC+, 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 emphasized the importance of routine, high quality service provision, and scaled down its support for the pooled effort approach as the project continued. FC+ encouraged and supported 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 was 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 were utilized as a strategic approach to address the overwhelming backlog of clients and provide repair for particularly complex cases. During FY 17/18, FC+/Nigeria organized a total of 19 concentrated fistula repair efforts across project sites, repairing a total of 453 fistula clients. Pooled
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repairs accounted for 36% of all surgical fistula repairs during this fiscal year (compared to 29% in FY 16/17 and 47% in FY 15/16). Some sites (Sobi, Wesley Guilds, and Ogoja) provided repairs solely through concentrated efforts during the fiscal year, while others (Laure, NOFIC Abakaliki, NOFIC Babbar Ruga, Faridat) provided the vast majority of their repairs through routine services. Concentrated efforts during this period in Kano, Kebbi and Sokoto were cost-shared with UNFPA.
Table NGA3: USAID-Supported Surgical Fistula Repairs, By Quarter, FY 17/18
Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 2017 2018 2018 2018 17/18 Adeoyo GH 22 36 3 39 100 Faridat GH 46 23 25 6 100 GH Ningi 17 53 22 64 156 GH Ogoja 20 13 0 0 33 Gesse VVF Center 19 53 35 7 114 Hajiya Gambo Sawaba 30 28 0 0 58 Laure VVF Center 87 71 25 68 251 Maryam Abatcha Yobe 27 0 13 0 40 Maryam Abatcha Sokoto 33 51 54 59 197 NOFIC Abakaliki 61 45 29 53 188 NOFIC Babbar Ruga 81 90 46 62 279 Sobi Specialist Hospital 15 0 0 7 22 Wesley Guilds 0 22 0 0 22 Total 458 485 252 365 1,560
Data on the classification of simple/not simple repairs discharged 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, has allowed for more complete data on the clinical profile of all fistula patients. This data is recorded by the surgeon during surgery, rather than at discharge, so the denominator is the number of surgeries during the period. For FY 17/18, 23% of repairs were identified as simple fistula and 77% as not simple. Of all fistula repair surgeries discharged during FY 17/18, 84% were closed at discharge: 71.4% were closed and continent and 12.4% were closed and incontinent (compared to 71.5% and 13.7% respectively in FY 16/17). FC+ worked to implement the client tracker component of the SST adequately in order to better understand the not closed rates in each facility. See Figure NGA2 for surgical outcomes, by site. It is hoped that the ongoing efforts to ratify a national policy on women with PFD (persistent fistula- related disorder) will help to ensure that those women who remain not closed receive appropriate treatment and support (see Objective 1). Outcomes for discharged patients are presented, by site, in Figure NGA2. Clinical and program staff 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. Reported complications were low at supported sites (<1% overall) with sites reporting very low rates ranging from .4 to 2.2%.
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Figure NGA2. Outcome Rates for Surgical Repairs, by Site, FY 17/18
100% Not closed
Closed with remaining incontinence Closed and continent
0% Benchmark closed and continent (75%)
During the third quarter, 13 surgeons participated in training for surgical fistula repair: nine participated in their first FC+ sponsored training and four receiving continuing training, see Table NGA4 for detail. A quick assessment of provider technical capacity across supported sites was conducted as part of project wind-down activities. As a result, FC+/Nigeria decided to conduct a final project training of surgical teams to include well- selected participants from almost all supported states. This activity aimed to bridge identified Surgeons participating in surgical training. knowledge and skill gaps, and boost their capacity Credit: FC+/Nigeria. for repair of greater numbers and higher complexity fistula, improve quality, and ensure surgical safety through a facility-based, hands-on training approach. These surgical team trainings were conducted concurrently with concentrated fistula repair efforts in Kebbi and Sokoto States. As noted in Objective 1, in November 2017, FC+/Nigeria sponsored the attendance of 21 fistula clinicians from supported sites to attend the 51st SOGON conference and in May 2018, FC+ participated in the 58th annual Nigerian Medical Association (NMA) conference.
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Table NGA4: Surgical Fistula Repair Training, Participants by State, FY 17/18
State Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total # 2017 2018 2018 2018 surgeons trained 1st Cont 1st Cont 1st Cont 1st Cont Total Cross River 0 0 0 0 3 0 0 0 3 Katsina 0 0 0 0 1 0 0 0 1 Bauchi 0 0 0 0 1 0 0 0 1 Kebbi 0 0 0 0 0 1 0 0 1 Zamfara 0 0 0 0 0 1 0 0 1 Oyo 0 0 0 0 1 0 0 0 1 Sokoto 0 0 0 0 1 1 0 0 2 Osun 0 0 0 0 2 0 0 0 2 Kwara 0 0 0 0 0 1 0 0 1 Total 0 0 0 0 9 4 0 0 13
As part of efforts by FC+/Nigeria to strengthen healthcare capacity to provide and sustain a high quality of services, the project collaborated with the Nursing and Midwifery Council of Nigeria (NMCN) to develop the Nursing and Midwifery Led Prevention and Conservative Management of Fistula through Early Catheterization pre-service, educator-focused curriculum update. FC+/Nigeria provided training to 139 health care clinicians during the fiscal year, see Table NGA5. Trainings covered topics including catheterization for fistula prevention, the use of data for decision making, FP and fistula counseling, and pre- and post-operative care. FC+/Nigeria, in collaboration with the NMCN, conducted a two-day Training of Trainers (ToT) orientation workshop for 68 pre-service educators from selected accredited nursing and midwifery training institutions in the North West and South East zones of Nigeria. The purpose of the training is to increase the knowledge of participants on use of the guidelines for the prevention of fistula through the use of catheterization and, with the inclusion of this guideline in the training curriculum of NMCN, these participants will then be able to train aspiring nurses and midwives on the use of the guidelines. Dr. Pandora Hardtman, CNM, FC+ consultant, led the sessions, supported by FC+/Nigeria staff. In conjunction with the surgeon training carried out in the third quarter, 32 health clinicians including ward nurses, perioperative nurses, and anesthetists were trained in pre- and post-operative fistula care. Also during the third quarter, 18 nurses and midwives participated in training focused on FP methods and counseling and fistula counseling.
Table NGA5: Non-Surgical Health System Personnel Training, Participants by Topic, By Quarter, FY 17/18
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2017 2018 2018 2018 FY 17/18 Catheterization for fistula prevention 68 0 0 0 68 Data management/ DDM 0 21 0 0 21 FP and fistula counseling, FP method 0 0 18 0 18 provision Pre- and post-operative care 0 0 32 0 32 Total 68 21 50 0 139
During FY 17/18, 395,658 FP counseling sessions took place at supported sites in 12 States, and 253,245 CYP were provided, see Table NGA6 for detail, by state.
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Table NGA6: Family Planning Counseling Sessions and CYP, By State, By Quarter, FY 17/18
Site Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP18 Bauchi Former 29,874 17,625 31,343 17,863 29,654 14,935 28,585 15,641 119,456 66,063 TSHIP Bauchi 51 53 50 64 44 52 40 28 185 557 Cross 484 982 1,153 2,208 1,719 2,892 2,092 3,276 5,448 9,358 River Ebonyi 28,373 23,581 20,487 13,160 11,526 5,502 10,374 5,240 70,760 47,483 Kaduna 788 1,795 702 1,840 455 1,032 752 1,826 2,697 6,491 Kano 5,690 5,948 6,432 5,855 4,880 4,396 6,440 5,405 23,442 21,603 Katsina 134 288 108 126 54 67 99 149 395 629 Kebbi 1,809 1,383 1,574 1,060 1,480 1,075 1,408 815 6,271 4,332 Kwara 3,145 2,176 3,554 3,211 3,295 2,550 4,012 2,457 14,006 10,394 Osun NS NS 887 1,601 1,688 2,184 1,560 1,237 4,135 5,022 Oyo 7,403 6,158 5,909 3,643 5,291 4,389 6,781 6,976 25,384 21,165 Sokoto 1,597 2,337 1,658 1,195 1,656 1,024 1,788 1,101 6,699 5,658 Sokoto Former 29,244 14,807 29,523 13,243 27,175 11,981 27,692 11,862 113,634 51,893 TSHIP Zamfara 680 703 765 739 827 756 874 756 3,146 2,954 Total 109,272 77,835 104,145 65,806 89,744 52,834 92,497 56,770 395,658 253,245 NS: Not Supported
FC+/Nigeria collaborated with State Ministries of Health (SMOH) to expand access to and use of modern contraceptives across supported states. The project, through the implementation of several interventions aimed at improving contraceptive availability, accessibility, and quality of FP counseling and services, also conducted routine supportive supervision and mentorship visits. Routine mentoring visits help ensure that FP services at sites are continuously improving. Issues identified during visits result in action plans which are followed up on in subsequent visits. During the first quarter, FC+/Nigeria conducted routine visits to supported FP sites across Ebonyi, Kwara, Kano, Katsina and Zamfara states. The facilities visited during this review period included General Hospitals, Primary Health Centers, and fistula treatment and prevention sites across the states. During the visits, FP advisors also implemented data reviews, monitoring of infection prevention and control processes, and compliance Supportive supervision visit with nurses and monitoring and adherence with USG FP legislative and midwives. Credit: FC+/Nigeria. policy requirements. FC+/Nigeria conducted partograph orientations during the first quarter of FY 17/18 for nurses, nurse midwives, and doctors working in the maternity units in Wesley Guild Hospital, Obafemi Awolowo Maternity Teaching Hospital, Adeoyo Maternity Teaching Hospital, and Sobi Specialist Hospital to strengthen prevention of obstetric fistula through use of appropriate labor management tools. Each center
18 Due to rounding, totals may differ slightly from the sum of individual quarters.
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was also provided with printed copies of the FC+/Nigeria-developed labor chart containing the WHO modified partograph for use in the labor rooms.
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 focused 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. This was realized through partnership and collaboration with existing government structures in supported states, and included meetings, technical assistance, joint site visits, training, and human resource and financial support. The goal is for there to be an effectively functioning system, without donor support. To strengthen data quality, FC+/Nigeria worked with supported sites to encourage each fistula center to conduct at least one data for decision making (DDM) meeting every quarter. This meeting ensures that all the service providers participate in data review on a regular basis, strengthening both the quality of the data and ensuring the involvement of those providing the services in the data review process. In the reporting period, FC+/Nigeria has also carried out supportive technical visits to nearly 350 supported FP provision sites throughout the country. During these visits, FC+/Nigeria and facility staff went through site data together and reviewed both the quality and completeness of the data. Such efforts have yielded steady improvements in the number of sites that are submitting a full complement of data to the national HMIS each month, reaching full achievement of 100% of supported sites during this fiscal year. As noted in Table NGA4, during the second quarter of the fiscal year, FC+/Nigeria M&E staff conducted a three-day refresher’ training on the use of data for decision making for 21 health care staff from 11 supported treatment facilities. Following the refresher, staff from seven of those facilities successfully organized DDM meetings at their facility. During the second quarter, FC+/Nigeria M&E staff conducted data quality assessments (DQAs) in Kano and Katsina States, as part of efforts to strengthen existing systems and ensure quality data. Facilities were selected using a stratified random sampling technique and were assessed for data availability, data consistency, and data validity for selected indicators. Findings showed improvement from previous DQAs, but identified remaining challenges attributed to staff shortages, lack of designated M&E staff, and poor computer literacy skills. In the third quarter, the FC+/Nigeria M&E team conducted mentoring visits at selected fistula centers and FP sites. During the visits, post-training follow up was conducted in the newer FP sites in Osun and Oyo States. Data validation exercises were also conducted and facility service providers were mentored on the proper use of HMIS tools in data documentation and reporting. The team also worked closely with the LGA M&E officers to ensure that facility data is correctly transcribed into the National DHIS instance, providing quality data for informed decision making and strengthening the state level M&E system. As noted in Objective 3, during the first quarter of the fiscal year, FC+ and Population Council conducted monitoring visits as part of a mid-term evaluation of the implementation of the Fistula Treatment Barriers Intervention; Population Council subsequently conducted endline data collection related to the Intervention in Ebonyi and will complete these activities in Katsina in FY 18/19.
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FC+/Nigeria staff submitted abstracts that were accepted at the FIGO World Congress to be held in October 2018 (see Appendix MM).
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Uganda USAID-supported fistula services in Uganda began in 2004 through the previous FC project and continue through FC+ in six treatment and prevention sites and 14 prevention-only sites as of September 30, 2018. At the request of the USAID/Uganda mission, Kisiizi Hospital was added as a supported fistula treatment facility in the second quarter of FY 17/18, Kagadi Hospital received support as an outreach fistula treatment site for Hoima Regional Referral Hospital. 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. FC+/Uganda shared office space with a project funded through the Bill and Melinda Gates Foundation (BMGF) until the closing of that project in late 2017.
Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors National Engagement 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. In partnership with USAID’s Advocacy for Better Health project, FC+/Uganda worked to cost out fistula repair services in Uganda through an integrated approach to service provision and through a concentrate repair approach. Funding gaps in fistula management were identified and strategies developed to communicate those identified issues to those who could address them. In September 2018, the findings were presented to Members of Parliament at a meeting to build a case for a stand-alone budget line for fistula within the national health care budget (see Appendix XX for the presentation slide set). Twenty- two MPs attended the meeting and pledged to put forward a motion in Parliament. FC+/Uganda has provided support to the National Ugandan Fistula Technical Working Group (FTWG) over the life of the project. 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. At the end of FY 16/17, with financial support from FC+, the FTWG engaged a consultant, the expert surgeon Dr. Fred Kirya of Soroti Regional Referral Hospital, to lead a team to develop a new costed fistula strategy for Uganda. In the second quarter of FY 17/18, Dr. Kirya presented the draft strategy to FTWG members and solicited feedback. In the fourth quarter, the strategy was presented again to the FTWG and approved. It will be presented at the next meeting of the senior management committee and health policy advisory committee who will give input on operational policy direction. A second meeting of the FTWG was held in September 2018, supported by FC+/Uganda. Discussions during the meeting included rising rates of iatrogenic fistula and action to be taken as well as the high cost of fistula repair that had been set within a new women’s hospital. Members of the working group requested that the government revisit the cost as it is a deterrent to care seeking. Final versions of fistula campaign materials developed by FHI360 and FC+ were presented for feedback. These materials will be forwarded to the community health department where other Implementing Partners can access and print them for their own use.
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At the request of the Commissioner of Curative Services in the MOH, FC+/Uganda donated a computer, printer and supplies to the fistula desk within the Ministry. A fistula focal person stationed at the fistula desk within the office of the Commissioner Curative Services at the Ministry of Health is responsible for the day-to-day communication between relevant implementing partners and the Ministry. However, this desk has limitations and relies mainly on support from partners for its operations. The donation will help ensure that communications continue to be provided effectively. During FY 17/18, the FC+/Uganda Medical Program Associate participated in the development of the Comprehensive Family Planning National Training Manual and obtained official MoH approval to operationalize its use as a national document. She also participated in the review and finalization of the national Adolescent Health Policy document. She also participated in meetings with the MoH and key FP advocacy partners to discuss Uganda’s FP2020 commitments. The FC+/Uganda Medical Program Associate attended a one-day meeting during the third quarter that brought together religious leaders, MOH representatives, and key stakeholders with the purpose of encouraging the Uganda Catholic Medical Bureau and Uganda Protects Medical Bureau leadership to introduce new modern and effective fertility awareness methods in health facilities and communities throughout the country. The methods discussed included the Standard Days method with cycle-beads, the two-day method, and lactational amenorrhea. A key challenge has been availability of moon beads, especially in public facilities; however, recently the beads have been included as part of National Medical Store procurements. In September 2018, FC+/Uganda participated in the validation assessment of the Minimum SRHR and Related Social Services Package for Hard-to-Reach and Vulnerable Populations in Uganda, which includes women with obstetric fistula. This validation followed a qualitative study supported by UNFPA to investigate perceptions and the defining characteristics of hard to reach and vulnerable populations in Uganda, their SRHR health needs, and service access barriers. The package is expected to standardize care and will be forwarded to MOH for discussion before publication. FC+ continued its collaboration with the American College of Obstetricians and Gynecologists (ACOG) in FY 17/18 to strengthen Maternal and Child Health (MCH) care services in Uganda. The Essential Training for Operative Obstetrics (ETOO) course equips trainees with management, technical and surgical skills, needed to perform safe lifesaving operative obstetrical procedures including caesarean section. The course is designed to be participant-centered, problem-based and clinically relevant. It was introduced within the context of a shortage of trained personnel in many African countries, which leaves many women without the care that they need, contributing to high maternal mortality and morbidity. Structured training of surgical skills reinforces good surgical techniques and helps reduce significant human resource gaps that are prevalent in many low resource settings. The FC+ global team provided technical assistance for monitoring and evaluation of the ETOO initiative (see Section II, Objective 5.4), which is implemented by ACOG and the teaching institutions of Makarere University Kampala, Mbarara University of Science and Technology, and Busitema University in Mbale. During the second quarter of FY 17/18, a two-day meeting was conducted to provide an interim progress report to stakeholders and to plan for next steps. Course implementation has been successful thus far with all planned supervised training taking place and initiation of the monitoring and evaluation plan as well as process documentation. The meeting also involved selection of a new title for the program, with participants unanimously choosing “Essential Training in Operative Obstetrics” as the new name. See Objectives 4 and 5 as well as Section II, Objective 1 for additional information on this partnership.
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In September 2018, FC+/Uganda supported the ETOO launch at Makerere University School of Health Sciences with an event including a maternal health panel discussion with the theme ‘Safe Surgery: Saving Mothers & Babies at Birth.’ FC+/Uganda also facilitated a meeting between ACOG and USAID Regional Health Integration to Enhance Services in East Central Uganda (USAID RHITES EC) in an initial step towards seeking support for the ETOO training program from the USAID mission in Uganda. Regional Initiatives As described in Section II, Objective 1, FC+ is also participating in regional initiatives to foster and promote collaboration. Following the launch in Kigali, Rwanda of the East Central and South African College of Health Obstetrics and Gynecology (ECSACOG), whose founding was supported by FC+, a meeting was scheduled between the American College of Obstetrics and Gynecology (ACOG) Global Health collaboration team and ECSACOG. FC+/Uganda supported the attendance of the chairperson of the examinations and credentials committee at that meeting, held in Addis Ababa, Ethiopia in October 2017. The purpose of the meeting was to kick start the formation of an ACOG-ECSACOG collaboration. During the meeting, ACOG delegates expressed interest in supporting the new college to improve the quality of training and services across the Eastern, Central, and Southern African sub regions. Dr. Annettee Nakimuli and Dr. Dereje Negussei from ECSACOG and Dr. Herbert Peterson and Carla Eckhardt from ACOG were assigned the task of developing a draft proposal document for the collaboration. FC+/Uganda also supported five participants, including two ECSACOG executives, two fistula surgeons from FC+ supported facilities and one Ministry of Health (MoH) official, to attend the 7th WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) Biennial Meeting and a meeting of the College of Surgeons of East Central and South Africa (COSECSA), both held in Maputo, Mozambique in December 2017. The GIEESC meeting brought together global public health leaders, policymakers, champions of global surgery, and others to discuss the developments and efforts to bring about safe, affordable, and timely surgical care and anesthesia administration. The ECSACOG executives participated in COSECSA examination proceedings to learn and extrapolate the processes to be implemented in ECSACOG. FC+ also hosted a dinner meeting for 24 participants with the theme: “Safe surgery will end fistula”. Participants included delegates representing the ECSA region, UNFPA, WHO GIEESC, ACOG, COSECSA, RCOG Global Health, Fistula Foundation, West Africa College of Surgeons, Harvard Program for Surgery and Social Change, and ISOFS. Region-specific ideas on sustainable approaches to fistula elimination were discussed. ECSACOG executives also met with ACOG representatives to discuss possible collaboration. ACOG committed to offer consultancy support to ECSACOG in setting up its structures when training begins. The possibility of signing a Memorandum of Understanding (MOU) between the two bodies was further discussed. The fistula surgeons and MoH official attended a meeting where the possibility, merits and process of forming an East African group for elimination of obstetric fistula were discussed. FC+/Uganda participated in the East African Community (EAC) Regional Share Fair in June 2018, held in Entebbe, Uganda, that brought together participants from Burundi, Kenya, Rwanda, South Sudan, Tanzania and Uganda to share experiences in developing systematic knowledge management processes that would contribute to addressing health program challenges faced within RMNCAH/HIV integration programs. As part of the exhibition portion of the fair, FC+/Uganda shared some of the knowledge products developed through the project including the fistula communication campaign messages developed in partnership with FHI 360 and the Aflateen PLUS youth integrated MCH/ HIV activities.
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In August 2018, FC+/Uganda participated in a country validation meeting of EAC member states to draft a regional advocacy and communication strategy for RMNCAH and HIV/AIDS. The outputs of the meeting would feed into the fourth EAC Joint Technical Working Group (JTWG) on RMNCAH and HIV/AIDS and the 17th EAC Sectoral Council of Ministers of Health for consideration and approval. The strategy is intended to increase awareness to influence behavior, social attitudes, and mobilize support to achieve Social Development Goal (SDG) 3 and other health related SDGs. Meeting and Conference Participation During the second quarter of FY 17/18, FC+/Uganda staff participated in an EngenderHealth Regional Strategy meeting and a Clinical Support Team meeting held in Dar es Salaam, Tanzania. In April 2018, FC+/Uganda supported the participation of two expert Ugandan surgeons, Dr. Fred Kirya and Dr. Justus Barageine, at the 2018 Uro’Dak 2018 conference in Somone, Senegal. The team attended a urodynamic workshop with hands on sessions at Hospital General de Grand-Yoff during which urodynamic techniques were explained and their importance among patients with obstetric fistula and other urological conditions highlighted. They participated in theoretical and practical sessions on ultrasound guided biopsy. The surgeons attended a scientific conference on topical issues in urology including fistula, cancer, infections, trauma and sexual medicine at which they each chaired sessions. They also participated in scientific meetings for the Pan Africa Urological Association (PAUSA) and the Africa Society for Sexual Medicine (ASSF), the latter selecting Dr. Kirya to be on the sexual medicine research committee while Dr. Barageine was selected as an executive member. Three FC+/Uganda staff participated in International Nurses’ Day celebrations held in May 2018 in the Kitgum district in Northern Uganda, under the theme ‘Nurses: A voice to lead – Health is a human right’. The event was organized by the Uganda Nurses and Midwives Union (UNMU), a professional body ensuring the highest standards of practice for the nursing and midwifery professions. UNMU held their Annual General Meeting and Annual Scientific Conference during which two presentations were made highlighting FC+ work in Hoima, Masaka and Kalungu districts. “Feasibility of Task Sharing in Primary Screening of Obstetric Fistula Clients by Midwives – Lessons Learnt from a Fistula Treatment Site, Uganda” was presented by the FC+/Uganda Program Associate for Community Engagement and “Assessment of Health Worker Knowledge and Practices in Fistula Management in Kalungu and Masaka” was presented by the FC+/Uganda Program Associate for Monitoring and Evaluation. The conference was officiated by His Excellence Yoweri Kaguta Museveni, the President of Uganda, and included participants from the nurses’ professional bodies of South Sudan and Kenya. FC+ participated in IDEOF celebrations held in Kibuku District at the Kavule Primary School on May 23, 2018. Speakers included a Member of Parliament from the Kibuku District and the State Minister of Health who both highlighted the importance of antenatal care in fistula prevention, and encouraged people to access FP services. In August 2018, FC+/Uganda participated in the first Ugandan National Reproductive Maternal Newborn Child and Adolescent Health (RMNCAH) Symposium held in Kampala. FC+/Uganda made two presentations during the symposium: “Increasing opportunities for obstetric fistula case detection and treatment by using multifactorial approaches – a case of Kalungu District” and “Performance of the Fistula Care Plus project: 2018”.
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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 13,414 in-person community outreach/education/advocacy events reaching an estimated 376,549 participants during FY 17/18, see Table UGA1. The majority of these activities were part of the project’s youth initiative, described VHT Fistula Champion below, but also include community outreach activities with messaging related to fistula, male involvement, birth spacing, birth John Bwanbali, a 35 year-old VHT preparedness, and the use of ANC and maternity services. Mass formerly attached to Karambi Health media efforts during this period reached an estimated 18.7 million Center III in Kasese District, people through radio programs. participated in FC+ VHT trainings and meetings promoting maternal In addition to youth-focused activities described below, in-person health and fistula prevention and community outreach has primarily worked with village health treatment. He relocated to Kagadi teams (VHTs) and local religious leaders to increase awareness and District in search of new health-seeking behaviors among more rural communities, while opportunities. Utilizing the skills he mass media has utilized radio programs as a means of connecting gained during his earlier VHT with broader audiences, particularly in harder to reach areas. To trainings, in his new region he took strengthen the link between community members and health care the initiative to initiate community institutions, a follow up meeting was held for Primary Health Care sensitization and identification of workers (PHCWs) and VHTs in Kalungu District in the second women with symptoms of urinary quarter, where data on their accomplishments was reviewed, trends incontinence following childbirth. and challenges discussed, and messaging was reinforced. In particular, the discussions have looked at FP activity at the facilities At a concentrated repair effort at and ANC and maternity data including home-based versus facility Kagadi Hospital, John identified five birth rates. In the third quarter, similar meetings with VHTs and women within the same village PHCWs were held in facilities in Jinja, Kasese, and Hoima suffering with symptoms, all of Districts. whom had had home births. Radio announcements about the repair FC+/Uganda continued its work throughout FY 17/18 with effort never reached the area due to religious institutions in Masaka and Hoima, utilizing the its remote location and poor community structures as a forum to share messaging around the reception. John used personal prevention and treatment of fistula through Catholic, Protestant, contacts and resources to facilitate and Muslim religious leaders. In the third quarter, two meetings their journey to Kagadi for repair. were conducted in Hoima and Masaka with leaders who had previously participated in training, to follow up on their current activities and how the trainings could be improved in the future. During the fiscal year, leaders from the three religious communities reported conducting over 4,400 sessions on male involvement, birth spacing, birth preparation, and use of ANC and maternity services that reached over 550,000 people. During FY 17/18, FC+/Uganda supported five community dialogue meetings for 96 community members in Jinja and Kamuli Districts to engage the communities in generating responses and actions to address identified problems and gaps relating to sexual health, relationships, and reproductive intentions in a participatory manner. Discussions were held on ways in which youth can be meaningfully involved in reducing sexual health risks and highlighted socio-economic issues affecting the youth in their communities. The meetings involved opinion leaders, community leaders, and youth community members and peer educators.
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During the first quarter, as part of the concentrated fistula repair efforts taking place at Kamuli Mission Hospital, 61 spouses and family members of women with obstetric fistula were strategically organized and involved in sensitization meetings. This was an opportunity for men to discuss gender-related issues that can impact development and management of obstetric morbidities including fistula. The meetings helped engage spouses and families to understand and commit to the need for more financial support to their spouses, to help with domestic work as their wives recovered from fistula surgery and to abstain from sex until the fistula clients have fully recovered. Participants also committed to acting as role models in their communities and sharing information regarding fistula prevention. During the second quarter, Jinja Hospital also focused on addressing gender-related issues in fistula prevention and treatment. To increase male involvement in caretaking, a traditional role for women, men were mobilized to accompany their wives who were fistula clients to the concentrated repair effort scheduled at the hospital. While there, the men were given the same amenities, such as meals and a return transport refund. Together with their spouses, the men were sensitized on the importance of involvement in maternal health and reproductive health care services, and issues related to FP. Participants discussed implications to the reproductive life of a woman and the quality of the family, birth preparedness, the three delays, and how these could be overcome to promote the “healthy mother and healthy baby” concept. Even with this concerted effort, only 12.8% of women had a male caretaker accompany them to the facility. A total of 39 women and five men participated in the meetings. Similar efforts were planned for the Hoima and Kisiizi concentrated repair efforts in the third quarter, but despite outreach efforts the turn-out of men supporting or escorting women to the hospital was very poor. In the fourth quarter, at the Kagadi concentrated repair effort, 132 people (38 men, 94 women) took part in facilitated discussions on gender relations, the interaction between gender relations and fistula, poverty, gender-based violence, substance abuse, and inter-couple communication. Radio announcements are one of the main approaches to mobilize clients for concentrated repair efforts in Uganda. During the fiscal year, radio outreach programs were aired in conjunction with all concentrated fistula repairs efforts. Stations participating in airing the programs included CBS, Sun Radio, Voice of Kigezi, Radio Rukungiri, Baaba FM, Kiboga, Radio West, and Radio Maria. In total, mass media efforts are estimated to have reached over 18.7 million listeners during the fiscal year, see Table UGA1. In addition to announcements for mobilization, a talk show was conducted on CBS Radio in January 2018 during which the resident fistula surgeon at Kitovu Mission Hospital participated. She provided information on what obstetric fistula is, its causes and how it can be prevented, as well as the treatment available. She participated in a similar show on Radio Akaboozi in Luganda in May 2018. Also in May 2018, the FC+/Uganda Senior Clinical Associate participated in a talk show about obstetric fistula on Radio One, one of the most popular English language broadcasters with countrywide coverage.
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Table UGA1: Community Outreach/Education/Advocacy Events, By Quarter, FY 17/18
Type of Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 Event # # Reached # # # # # # # # Events Events Reached Events Reached Events Reached Events Reached Existing 81 2,458 9,471 116,641 0 0 864 95,307 10,416 214,406 community activity Maternal 1,320 131,641 930 930 302 24,895 359 2,231 2,911 159,697 health/ fistula- focused Health 1 526 64 930 20 797 0 0 85 2,253 providers Health facility 1 61 0 0 0 0 1 132 2 193 Radio/TV 2 4,171,617 30 3,500,000 7 8,771,617 7 2,275,772 46 18,719,006 Total 1,405 4,306,303 10,495 3,618,501 329 8,797,309 1,231 2,373,442 13,460 19,095,555
-in person 1,403 134,686 10465 118,501 322 25,692 7 97,670 13,414 376,549 -mass media 2 4,171,617 30 3,500,000 7 8,771,617 1,224 2,275,772 46 18,719,006
FC+/Uganda supported a meeting during the first quarter to review draft Social and Behavior Change Communication (SBCC) materials developed by the Communication for Health Community (CHC)/ Obulamu project, under FHI360, for use in national efforts to prevent and treat fistula in Uganda. The meeting included officials from the MoH, representatives from fistula treatment sites, fistula surgeons, former fistula patients, and other partners that contribute to fistula care in Uganda. Feedback and technical input on the campaign materials were provided and the materials were finalized by September 2018. FC+ and Obulamu conducted a dissemination meeting in September to launch the campaign which includes SBCC Poster developed by Obulamu and FC+ collaboration to materials such as posters and audio and visual clips develop and disseminate fistula-related SBCC materials. for radio and television. Recognizing that lifelong habits are often formed during early years of a person’s life, FC+/Uganda prioritized adolescents and youth in its community engagement efforts. Reaching young people with reproductive health and FP information in a manner that is relevant to their needs and empowers young people with knowledge and skills to make responsible choices is one way in which FC+/Uganda addresses fistula prevention. In partnership with the Private Education Development Network (PEDN) and Aflatoun International, EngenderHealth adapted the evidence-based Aflateen curriculum, integrating sexual health, FP, and fistula prevention content with the existing social and financial education modules. By connecting the Aflateen learner-centered, social and financial approach with EngenderHealth’s gender-transformative 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. The curriculum was rolled out to ten in-school and ten out-of-school youth groups distributed equally across the Districts of Jinja and Kamuli and this dual in- and out-of- school strategy aims to offer-friendly environments, where young people have genuine opportunities to engage in dialogue and personal exploration in order to foster sense of efficacy.
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In FY 16/17, FC+ conducted a needs assessment and mapping of schools and out-of-school youth groups in Kamuli and Jinja districts; supported training of teachers and peer-educators to roll out the Aflateen PLUS curriculum with youth groups and of school nurses and community health workers to provide adolescent/youth friendly SRH services; provided continuous supportive supervision to teachers, peer- educators, nurses, and community health workers; and supported additional community mobilization activities implemented by trained peer-educators. Throughout, FC+/Uganda has monitored the activity, The chairperson of the Luzinga Senior including participation of youth in the clubs, whether Secondary School Aflateen PLUS youth group they pass on information to their communities, and providing an update on activities. youth receiving health services. Credit: A. Kyajumbuka. In FY 17/18, 1,526 in-school youth and 785 out-school youth participated in club meetings. During this time, in- and out-school youth club members disseminated information to a total of 16,287 community members, and a total of 2,984 youth club members received health services from either the school nurse or a health facility. Support is also being provided via distribution of social enterprise materials including brooms, garden racks, wheelbarrows, gloves, brushes and soap. To assist with financial literacy and self- efficacy, and to promote a culture of savings among the club members, materials such as saving ledger cards, saving boxes, chains and padlocks were distributed to ten in-school youth clubs. A facilitation skills training was conducted during the first quarter for 29 out-of-school youth peer educators in Jinja District, see Table UGA2. The purpose of the trainings was to enhance participant facilitation skills and capacity to deliver information to fellow Aflateen PLUS club members. Participants also received refresher training on the Aflateen PLUS curriculum with special emphasis on SRH and reproductive empowerment content.
Table UGA2: Community Volunteer/Educator Training, Participants by Topic, By Quarter, FY 17/18
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total FY 17/18 2017 2018 2018 2018 Aflateen volunteers 29 0 0 0 29 Total 29 0 0 0 29
Obj. 3: Reduced transportation, communications, and financial barriers to accessing preventive care, detection, treatment, and reintegration support As described in Section II, Objective 3, FC+/Uganda continued working with the Population Council during FY 17/18 to implement and evaluate an intervention package designed using the results of the formative research on barriers to fistula treatment conducted during FY 15/16. The Fistula Treatment Barriers Reduction Intervention sought 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. After two years of implementation, the Population Council conducted an end-line evaluation to assess intervention outcomes. The intervention was carried out in Kalungu District and offered treatment services to women at Kitovu Mission Hospital in the neighboring Masaka District. The intervention utilized multiple communication channels for fistula messaging, screening, and referral, a consistent screening algorithm for fistula
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screening, and a transportation voucher to enable positively screened women to travel for free to and from Kitovu Mission Hospital. FC+ and Viamo (formerly VOTO Mobile) partnered to develop a free fistula screening hotline, whereby village health team (VHT) volunteers and women from the community call to find out about fistula – its causes, prevention, and services available. At the community level, VHTs circulated targeted messages about fistula symptoms and available treatment services; and the IVR hotline, widely advertised by VHTs, radio messages, and flyers, screened women for fistula using mobile devices. At primary health care facilities, health workers identified potential fistula clients for referral and facilitated free transportation to appropriate treatment facilities. Positively screened women identified through primary health care workers, VHTs, and the hotline all received 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. A baseline dissemination and monitoring visit by the Population Council and FC+/Global staff was conducted in the first quarter of FY 17/18. The results of the baseline were presented to USAID/Uganda and to representatives from the intervention districts in Masaka and Kalungu through a dissemination meeting for over 50 participants, including District Health Officers (DHOs), Resident District Commissioners (RDCs), health facility staff from lower health centers, Village Health Team (VHT) members, and staff from the treatment site of Kitovu Mission Hospital (see Appendix Z for presentation). Additionally, Population Council conducted in-depth interviews with the intervention facilitators and beneficiaries as key informants to assess implementation fidelity and identify challenges and recommendations for mid-course corrections. The monitoring involved site visits and in-depth interviews with 16 key informants, including three fistula patients who had taken part in the intervention; two staff members from Kitovu Mission Hospital; three PHC providers who had received intervention training; two VHT coordinators; four VHTs; two transportation staff; and two FC+/Uganda staff. The monitoring team also visited Kitovu Mission Hospital and several primary health facilities, where they met with the Deputy Fistula Director, the Fistula Nurse and the focal persons for the study. During the visit, the health facility-monitoring tool and vouchers brought by the transport company were reviewed as well as a walk-through of the fistula treatment site, the post-operation ward, the operating theater, and the waiting ward for post-repaired clients who are pregnant and come to the facility to receive free cesarean section services. Discussions with site staff provided an opportunity to provide encouragement and support, as well as receive feedback on the intervention and possible improvement. During the second quarter of FY 17/18, based on recommendations from a midline assessment of the intervention (see Objective 5 for detail), refresher orientations were provided for all actors in the intervention study, including PHC providers, VHTs, fistula service providers, and drivers. Particular efforts were made to strengthen the linkages between PHCs and VHTs (see Objective 2) based on findings from the midline assessment that revealed weaknesses in referral systems between the two for treatment and prevention activities. FC+/Uganda staff conducted supportive supervision visits, with support from the district VHT coordinator, to 18 participating PHCs. Of 275 VHT members, 216 attended the meeting at their respective catchment facilities. Discussions addressed strengthening linkages and better understanding and implementing the system for referral of clients from the community by VHTs. PHCs shared telephone contacts with the VHTs to ease referral of identified clients to the health care centers. Participants also reviewed data collection tools and filled out summary forms. Plans are underway to continue to hold such joint meetings on a regular basis, as it was a useful way to refresh knowledge as well as recognize the work of the volunteers. A two-tier implementation strategy was developed and deployed at the population and facility levels. In the first tier, population-based awareness raising interventions in the Central 1 sub-Region will convey
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targeted messages about fistula symptoms, treatment availability, and referral mechanisms including a voucher that entitles the woman and a companion to a travel subsidy and priority care at accredited fistula repair facilities. In order to contribute to answering the research questions of the study, a treatment facility client monitoring form was developed to continuously measure the client’s fistula treatment barrier reduction due to the intervention. The form was administered to post-repaired clients at Kitovu Mission Hospital following the camp that was held in May 2018. Six patients from Kalungu District and one patient from Masaka District were interviewed. During the fourth quarter, Population Council and FC+ trained nine research assistants who then traveled to the field for data collection. The research assistants covered 55 health facilities, conducted 120 in-depth interviews, 60 exit interviews and four focus group discussions. Population Council will submit the final research report to FC+ within 60 days after the end of the subaward (i.e., February 28, 2019). At this time, all technical briefs and reports developed to date through this partnership are available at: https://www.popcouncil.org/research/fistula-care-plus. Additional information on this research is provided in Section II, Objective 5.
Objective 4: Strengthened provider and health facility capacity to provide and sustain quality services for fistula prevention, detection, and treatment FC+/Uganda currently supports six treatment sites in Uganda: Kitovu, Kisiizi, and Kamuli Mission Hospitals, Hoima and Jinja Regional Referral Hospitals, and Kagadi General Hospital are supported for fistula prevention and treatment services. A subaward with Kisiizi Hospital was finalized in the second quarter, to be an FC+ supported treatment site providing services in the Regional Health Integration to Enhance Services in South West (RHITES_SW) project area. Orientations were carried out with the clinical, monitoring and evaluation, and finance teams at the hospital. In November 2017, public health services across Uganda were brought to a standstill as health workers held a strike over pay and poor working conditions, disrupting implementation of FC+ activities. After negotiations with the government, services resumed. In order to enhance sustainability of quality of care and, particularly, infection prevention and control (IPC) measures, FC+/Uganda met with IPC committee members at Jinja, Kamuli, Hoima, Bwera, and Kagando Hospitals as well as Rwesande HCIV during the fiscal year to discuss moving beyond a traditional quality improvement (QI) framework to one of quality assurance (QA) strategies. The focus was on operationalizing and adhering to QI and infection control recommended guidelines and practices, and strengthening internal supports for supervision and assessment. Members reviewed data on hand hygiene and cleaning performance at different departments in the facilities. Dialogue between FC+ and the committees focused on the review of plans made in 2017 and made follow on plans for sustaining the best practices as well as reminding the committees of their roles in supporting implementation of the quality assurance functions. The QI and IPC Committees plan to work together to identify quality issues and address them together through regular meetings and organize regular refreshers and updates for staff, students, and cleaners.
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Waste management and partograph monitoring were carried out at all relevant supported sites during the IN MEMORY: fourth quarter. SISTER DOCTOR MAURA LYNCH
During FY 17/18, 1,337 women In December 2017, Sister Dr. Maura Lynch of Kitovu Hospital with severe incontinence symptoms passed away. Sister Dr. Lynch spent over thirty years serving arrived seeking fistula care at FC+ women living with fistula at Kitovu, leading all fistula activities supported sites, of which 522 were at the hospital. It is estimated that between 1993 and 2007, diagnosed with fistula (39%, she performed over 1,000 fistula repairs. She was also a wonderful mentor to many health workers at Kitovu. compared to 47% in FY 16/17). Because the majority of A tribute to her legacy was published on the FC+ blog: FC+/Uganda supported repairs take https://fistulacare.org/blog/2018/01/remembering-sister-maura-lynch/ place through concentrated repair efforts, the mass media and other public announcement approaches often result in large numbers of women who seek services but are ultimately diagnosed with other medical conditions aside from fistula. FC+ supported 465 fistula repair surgeries during this period (99.6% of the 467 women who were diagnosed and eligible for surgery, compared to 305 surgeries in FY 16/17). 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. FC+/Uganda has made a sustained effort with supported sites to institute and support routine repair services; these efforts have begun to bear fruit with a growing number of repairs being conducted through routine service provision. The majority of surgical repairs (78.3%) were still carried out during concentrated repair efforts conducted during this fiscal year by Hoima, Jinja, Kagadi, Kamuli, Kisiizi, Kitovu, and Mbale Hospitals. Routine repairs (21.7% of all surgical repairs) were provided at five of the supported sites: Hoima, Jinja, Kamuli, Kisiizi and Kitovu Hospitals, a marked increase from the four sites and 14.1% of routine repairs provided in FY 16/17 (see Table UGA3 for detail by quarter). Two facilities carried out concentrated repair efforts during the first two quarters that were supported by other donors/organizations: Kitovu Hospital had a concentrated repair effort supported by Medical Missionaries of Mary from Ireland and UNFPA provided support to an effort at Hoima Regional Referral Hospital.
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Figure UGA1: Number of Women Seeking and Eligible for Fistula Treatment, and Number of Surgical Repairs, by Site, FY 17/18
350
300
250
200 Seeking Eligible 150 Repairs 100
50
0 Hoima Jinja Kagadi Kamuli Kisiizi Kitovu Mbale
Table UGA3: USAID-Supported Surgical Fistula Repairs, by Site, By Quarter, FY 17/18
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 17/18 2017 2018 2018 2018 Hoima Regional Referral Hospital 0 8 37 0 45 Jinja Regional Referral Hospital 4 20 2 25 51 Kagadi General Hospital19 0 0 0 30 30 Kamuli Mission Hospital 45 0 38 0 83 Kisiizi Mission Hospital NS 4 39 44 87 Kitovu Mission Hospital 38 49 54 7 148 Mbale Regional Referral Hospital NS NS 21 NS 21 Total 87 81 191 106 465
During FY 17/18, 98.3% of all discharged fistula repairs surgeries were reported as closed, compared to 100% in FY 16/17. 94.8% were reported as closed and continent at time of discharge (compared to 98% in FY 16/17). 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 (1.7%). Etiology data was available for 519 of the 522 diagnosed fistula cases (99.6%). The majority of diagnosed fistula cases were reported to have resulted from obstructed or prolonged labor (89.5%), followed by iatrogenic (9.4%), traumatic (<1%), and cancer, <1%. The percentage of cases identified as iatrogenic in etiology has been around 10% for the last two fiscal years, compared to around 5% in earlier fiscal years. In addition to the surgical repairs reported, 19 women received non-surgical catheter treatment for fistula at Kitovu (17) and Kamuli (2) Mission Hospitals during the fiscal year. 95% of these cases were closed and continent at discharge and 5% were closed and incontinent.
19 Kagadi General Hospital is supported as an outreach site for Hoima Hospital, and is not counted as one of the FC+ official supported treatment facilities.
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Figure UGA2. Outcome Rates for Surgical Repairs, by Site, FY 17/18
100% Not closed
Closed with remaining incontinence Closed and continent
Benchmark closed and continent (75%)
0% Hoima Jinja Kagadi Kamuli Kisiizi Kitovu Mbale FC+/Uganda is providing support integrated into fistula repair efforts for the provision of routine pelvic organ prolapse (POP) services. In FY 17/18, a total of 134 surgical POP treatment procedures, three pessaries and three women receiving physical therapy were reported from Hoima, Jinja, Kamuli, Kisiizi, and Kitovu. FC+/Uganda is supporting the on-going training of three surgeons in obstetric fistula surgery. Two surgeons (from Kamuli Mission Hospital and Jinja Regional Referral Hospital) participated in training throughout this fiscal year, see Table UGA4 for detail. The third surgeon has been out of country as part of a fellowship in renal transplant surgery, and therefore has not participated in training this fiscal year.
Table UGA4: Surgical Fistula Repair Training, By Quarter, October 2017 – March 2018
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 17/18 2017 2018 2018 2018 1st Cont 1st Cont 1st Cont 1st Cont 1st Cont Fistula surgical repair 1 1 0 2 0 1 0 2 1 220 Total 1 1 0 2 0 1 0 2 1 2
As part of fistula treatment and prevention efforts, FC+/Uganda provided training to 103 health care clinicians during FY 17/18, Table UGA5 provides totals for non-surgical trainings of health system personnel by training topic. During the first quarter, to support MoH efforts to scale up the transition from Implanon classic to the new Implanon NXT, based on manufacturing changes, FC+/Uganda carried out training for 29 health workers in Hoima on insertion, removal, and counseling for Implanon NXT and Sayana Press. The training also involved sessions on REDI (Rapport-building, Exploration, Decision-making, and Implementation) a client-centered approach to counseling that has been adopted as the recommended approach in the MoH FP comprehensive clinical skills manual. FC+ has worked with the Ministry of Health to update FP training materials to include content on long- acting methods and informed, voluntary, client-centered counselling applying the EngenderHealth REDI Counseling Framework. Between October 2017 and May 2018, FC+ implemented a health worker training strategy including classroom and practical sessions, and regular onsite follow-up, mentoring, and coaching. FC+ has also supported client education sessions at partner facilities to build awareness of and
20 There were a total of two surgeons trained during the fiscal year. One surgeon participated in first training in the first quarter, and continuing training in the second and fourth quarter. The other surgeon participated in continuing training each quarter of the fiscal year.
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demand for the full range of available methods. Trained health workers report substantial increases in knowledge and confidence, reduction in bias against certain methods, and increased skills for and appreciation of the value of relationship building and high-quality counseling. FC+/Uganda and the MoH carried out a REDI training of 15 FP service providers and supervisors from 12 FC+-supported facilities in the districts of Masaka, Kasese, and Kalungu during the first quarter. Telephone follow up was conducted with trainees during the second quarter to check in, see whether trainees were providing counseling with the REDI framework, and identify any challenges they might be facing in implementation. A similar training was carried out in Hoima and Jinja for an additional 15 health workers in the second quarter, with follow up conducted during the third quarter. FC+/Uganda also worked together with the MoH to carry out other FP and partograph training follow up activities. In the first quarter, visits were made together with MoH trainers and focal persons to FP service providers who had previously received comprehensive FP clinical skills training in Jinja, Kasese, Kalungu, and Masaka Districts. During the second quarter, trainees in Hoima District received follow up visits. Visited facilities showed increased uptake of all FP methods, with significant increases in implant provision. Many facilities had stock outs of Implanon NXT at the time of follow up which affected service provision and providers’ ability to practice insertion skills. Health workers also faced challenges related to data management such as filling registers appropriately, preparing monthly summaries, and compiling HMIS reporting. In the fourth quarter, 30 health clinicians from Lukolo HCIII and Hoima RRH participated in training to strengthen existing FP integrated services and to establish, meaningful internal referral linkages. The trainings included a whole-site mentoring and coaching component to strengthen integration at Fistula Care Plus supported prevention and treatment sites to increase FP service utilization and promote provision of comprehensive services relevant to clients’ desires/needs. During the second quarter, follow up and mentoring/coaching activities were conducted with midwives previously trained on use of the partograph and EmONC at Kamuli Mission Hospital, Lukolo Health Center III, Jinja Regional Referral Hospital, Buseruka HC III, Masaka Regional Referral Hospital, Kiyumba Health Center IV, Kyanamukaaka Health Center IV, Kitovu Hospital, and Kalungu Health Center III. Key activities included reviewing data in maternity registers, on site mentoring and coaching to ensure institutionalization of, and discussing sustainability of partograph use. The team worked with midwives in the maternity wards to review partographs and maternity registers to identify gaps in partograph plotting and documentation and provide immediate support. In Kasese District specifically, FC+/Uganda, in collaboration with the Kasese District Health Office and Partograph champions of Bwera and Kagando Hospitals (Bukonzo East and Bukonzo West HSDs), has previously carried out efforts to scale up partograph use at lower level health facilities and the effects of those efforts at the regional referral hospitals of Bwera and Kagando. Activities have included baseline assessment; training of midwives and follow up at 13 health facilities in Bukonzo East and Bukonzo West. During the second quarter, a supportive supervision team including the FC+/Uganda Medical Associate, National Trainer Uganda Private Midwives, Partograph Champions, and midwives from Bwera and Kagando Hospital visited the facilities and carried out mentoring, discussions, and demonstrations as well as reviewed partographs and actual patient management. During the fourth quarter, partograph reviews were conducted as a follow up assessment, as well as interviews with clinicians. Findings indicated improvements in partograph availability and use, as well as improvements in labor monitoring and maternal and fetal outcomes at the facilities. It was noted during the review that results-based financing may also play a role in improvement of partograph use as it is one of the required indicators.
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As a response to the increasing number of iatrogenic fistula cases in Uganda, the FTWG identified that many medical officers lacked adequate skills to perform cesarean sections. Medical officers had only a three-month internship rotation on the maternity ward, which is too short a time to master most of the important surgical skills involved in cesarean section. The FTWG thus called upon stakeholders in maternal and child health to work together to address this problem. The ACOG ETOO initiative described above is part of these efforts, as is work by FC+/Uganda to develop activities to build capacity of medical officers at supported health facilities in Masaka District to perform safe cesarean section and sterilization procedures. During the second quarter, meetings were held with the consultant gynecologist and obstetrician Surgical training during a concentrated repair at Masaka Regional Referral Hospital to begin effort at Jinja Regional Referral Hospital. Credit: P. Kaduyu planning a mentoring and coaching program. Also to address rising iatrogenic rates, during the third quarter, ten clinicians from Kiyumba and Kyanamukaaka HCIV and Masaka Regional Referral Hospital participated in training to build capacity for safe cesarean section and sterilization procedures. Two obstetrician/gynecologists from Masaka and Mbarara Regional Referral Hospitals facilitated the training. During the concentrated repair effort at Kitovu in January 2018, a team of four staff from Kamuli Mission Hospital came to the facility to observe the quality fistula services offered. The team included one trainee surgeon and three nurses. The nurses were given an opportunity to work with the team at Kitovu during screening, counselling, patient preparation for surgery, the operating theater, and learned how to care for the patient on the ward. The trainee surgeon shadowed expert surgeons in the operating theater and during ward rounds.
Table UGA5: Non-Surgical Health System Personnel Training, Participants by Topic, By Quarter, FY 17/18
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 17/18 2017 2018 2018 2018 FP counseling 15 15 0 0 30 FP methods 29 0 0 0 29 Pre- and post-operative care 0 4 0 0 4 EmONC and labor monitoring 0 0 10 0 10 FP and fistula integration 0 0 0 30 30 Total 44 19 10 30 103
FC+/Uganda supported FP counseling and service provision at 17 sites in Uganda during FY 17/18. 23,510 counseling sessions took place at supported sites and 34,439 CYP were provided, see Table UGA6 for detail, by site. Method mix contributing to this CYP in Uganda was primarily implants (45%), IUD (26%), tubal ligation (9%), Depo Provera (8%), and natural FP (7%).
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Table UGA6: Family Planning Counseling Sessions and CYP, by Site, By Quarter, FY 17/18
Site Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP21 Azur HCIV 231 292 382 1,053 696 1,315 129 562 1,438 3,223 Buraru HCIII 386 93 178 177 157 119 168 226 889 615 Buseruka 195 179 220 37 173 104 148 69 736 389 HCIII Bwera GH 509 967 880 1,455 504 1,970 421 528 2,314 4,920 Hoima RH 864 643 800 485 635 523 598 228 2,897 1,879 Jinja RRH 516 567 809 647 246 665 581 1,058 2,152 2,937 Kagando 615 517 1,092 1,470 963 2,163 465 1,264 3,135 5,415 Kalungu HCIII 358 962 346 636 220 792 214 598 1,138 2,988 Kamuli 244 213 369 554 169 254 229 449 1,011 1,469 Karambi HCIII 176 96 113 134 42 65 159 191 490 486 Kigorobya 211 215 303 244 147 328 134 240 795 1,027 HCIV Kikuube HCIV 170 155 92 412 152 96 208 134 622 796 Kitovu 13 20 11 17 0 0 40 60 64 96 Kiyumba 153 257 94 158 91 131 68 53 406 599 HCIV Kyanamukaka 218 349 119 264 130 141 149 176 616 930 HCIV Masaka RRH 831 1,412 905 1,072 735 654 932 544 3,403 3,681 Rwesande 339 625 401 1,290 231 92 433 984 1,404 2,990 HCIV Total 6,029 7,562 7,114 10,106 5,291 9,410 5,076 7,362 23,510 34,439
During the fourth quarter of FY 17/18, FC+/Uganda in collaboration with Uganda Health Marketing Group (UHMG) provided FP commodities to ten health care facilities whose health workers had participated in capacity building in youth friendly services in Jinja and Kamuli Districts. The distribution followed an assessment to establish which commodities were most needed at the facilities. Distribution included Zinia-P, male condoms, Sayana Press, Depo Provera, Implanon, and Microlut. Supported sites reported an overall cesarean section rate of 27.2% during FY 17/18, based on 44,977 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 3.2% of all labors were prolonged/obstructed, 1% of which received catheterization for fistula prevention.
21 Due to rounding, totals may differ slightly from the sum of individual quarters.
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Figure UGA3. Number of Obstetric Deliveries, by Site, FY 17/18 (n=44,977)
Azur HCIV 2034 Buraru HCIII 116 Buseruka HCIII 453 Bwera GH 3634 Hoima RH 8265 Jinja 6020 Kagadi 1258 Kagando 2822 Kalungu HCIII 411 Kamuli 2151 Karambi HCIII 707 Kigorobya HCIV 1051 Kikuube HCIV 877 Kisiizi 1590 Kitovu 1772 Kiyumba HCIV 442 Kyanamukaka HCIV 342 Lukolo 343 Masaka RRH 9904 Rwesande HCIV 785
Figure UGA4. Cesarean Section Rates, by Site, FY 17/18 0%Vaginal delivery C-Section 100% Azur HCIV Buraru HCIII Buseruka HCIII Bwera GH Hoima RH Jinja Kagadi Kagando Kalungu HCIII Kamuli Karambi HCIII Kigorobya HCIV Kikuube HCIV Kisiizi Kitovu Kiyumba HCIV Kyanamukaka HCIV Lukolo Masaka RRH Rwesande HCIV
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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+/Uganda has instituted regularly scheduled internal clinical data for decision-making (CDDM) meetings. This provides an opportunity for the team to reflect on the project performance, achievements, challenges, and areas needing programmatic attention. In turn, FC+/Uganda supports CDDM meetings at supported treatment facilities, as well as onsite mentoring of staff responsible for data collection and reporting. In the fourth quarter of FY 16/17, CDDM committees were reactivated at supported sites and action plans were created to improve facility collection, reporting, and use of data. During FY 17/18, CDDM committee meetings were held at Kitovu, Jinja, Kamuli, and Hoima Hospitals and included staff from multiple departments within the facilities including the FP unit, medical records, postnatal, laboratory, maternity, surgical, antenatal, and senior management. During meetings, participants reviewed performance data and discussed challenges and possible means of addressing them. Some noted improvements implemented by the facilities included formal plans to hold maternal and perinatal death audit reviews, preparation of daily data summaries, monthly data verification exercises, and display of data visualization with the facility to highlight performance. During the second quarter, FC+/Uganda carried out data quality assessments at supported sites in Hoima, and in Jinja and Masaka in the third quarter. Of particular note was significant improvement in the data quality at Hoima RRH, with an overall reduction in discrepancies and omissions compared to previous years. Kitovu’s record keeping was of very high quality but records staff were unable to access the national DHIS2. Overall recommendations included calling for all facility staff participation in HMIS data management and utilization. The individual tasked with keeping the records should involve departmental staff in compilation of reports and provide feedback on the quality of data submitted. In addition, the records person should lead prompt data quality verification exercises and conduct continuous mentorship to departmental staff in proper utilization of HMIS tools. For facilities that are providing FP services outside the FP unit (i.e. maternity, PNC), it is also essential for the records person to compile FP service statistics from all departments that provide FP services. The Ugandan MoH is revising the various tools used for HMIS primary data collection. FC+/Uganda has capitalized on this opportunity to hold discussions with the MoH to have a list of fistula indicators adapted and included in the national DHIS2 system. Proposed indicators include: number of cases of vesico-vaginal fistula, number of cases of recto-vaginal fistula, and number of fistula clients counseled for FP. These indicators will be an addition to the indicators already in the national system which include the number of women newly diagnosed with obstetric fistula, the number of cases by age group, and the number of women with obstetric fistula cases repaired. Upon completion of the review process, the Obstetric Fistula Theatre Register will be replaced by an Obstetrics and Gynecology Theater Register, which will collect data on all gynecologic conditions including a specific section on obstetric fistula that covers fistula etiology, classification, number of previous repairs and description of surgery. Feedback from the MoH technical team led to development of a fistula treatment register that includes discharge details, follow-up information, and FP uptake. Finally, there is a MOH fistula care card, which captures client details including patient data, medical history, and treatment details. These tools will be coded and printed through the national medical supplies system. 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 enables more meaningful analysis of the fistula data captured through the MoH fistula registration forms at supported sites. It is
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also intended to capture client follow-up information and mortality data. The database is 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 and are utilizing the database. In order to ensure its usability beyond the end of FC+, FC+/Uganda’s M&E team provided support to Kamuli, Jinja, Hoima and Kitovu Hospitals so that the records team adopt and use it whenever any camp or repair is conducted at the facility regardless of the source of support. Data from the database has been analyzed quarterly and compiled into hospital reports which are shared with the MOH and at FTWG meetings, used in presentations to facility staff during CDDM activities and to support planning for an activity involving follow-up of repaired clients to establish outcomes of fistula repair beyond facility discharge. The study on interventions to improve quality of life among women with incurable fistula, in collaboration with TERREWODE, was completed. Data verification and quality assessment were completed in the third quarter of FY 17/18. Data analysis was completed in the fourth quarter of the fiscal year, and findings documented in a preliminary summary, see Appendix OO (also see Section II, Sub- objective 5.4). Study findings, including recommendations regarding optimal tools for QoL assessment and for fistula services supporting WDI, will be documented in a technical brief and shared with partners in Uganda and globally. In partnership with the Private Education Development Network (PEDN) and Aflatoun International, FC+/EngenderHealth adapted the evidence-based Aflateen curriculum (see Objective 2). In FY 17/18, the FC+ core team supported the Uganda team to complete a process documentation of a youth engagement strategy centered on the Aflateen PLUS curriculum. During the process documentation, teachers reported highly valuing the financial education component (e.g. savings tools, planning and budgeting, financial enterprises) of the curriculum; peer educators appreciated the increase in their capacity to make health referrals, and health workers reported increased skills in communicating with and serving adolescents and youth. All cadres of facilitators appreciated the learner-centered/empowerment training approach, which was novel relative to other, more didactic training approaches to which they had been exposed. In considering tangible changes in health knowledge and behaviors, respondents noted a decline in pregnancy-related school drop-outs, increased confidence among youth to seek out information on FP and to request condoms, and an increased ‘savings’ culture and use of savings to address financial challenges such as transportation costs and school fees. Respondents also described supply-side barriers that made it challenging for youth and community members to follow up on referrals (e.g., inadequate supplies at health facilities). These findings have been shared through a briefing to USAID in April 2018, and an abstract summarizing the process dissemination will be submitted for the 2019 Women Deliver conference. FC+/Uganda and supported site staff submitted abstracts that were accepted at the FIGO World Congress to be held in October 2018 (see Appendix MM).
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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 continued through FC+ in Niger in three treatment and prevention sites and six prevention-only sites during FY 17/18. FC+ closed its office in Niger on June 30,2018. FC+ continues to support fistula work in Niger and the West Africa Region through a subaward to the Réseau pour l’Eradication des Fistule (REF). As of September 30, 2018, FC+ provides support to three treatment and prevention sites in Niger: CSME Maradi, CSME Tahoua, and Centre National de Référence pour la Fistule Obstétricale (CNRFO). FC+’s work in Niger is part of a larger West Africa regional focus with the goal of continuing to support Niger as a regional hub for fistula treatment and prevention. Emphasis is on collaboration with regional partners such as WACS, ISOFS, and UNFPA, to strengthen fistula prevention, treatment, and reintegration efforts throughout West Africa. Delays and challenges reconciling the financial reports for subawardee REF led to delays in program implementation during the fourth quarter of this fiscal year. Activities are expected to resume in FY 18/19.
Objective 1: Strengthened enabling environment to institutionalize fistula prevention, treatment, and reintegration in the public and private sectors FC+/WAN continued support in FY 17/18 to the development of regional policy on genital fistula prevention, treatment, and elimination through partnerships with the West African Health Organization (WAHO), West Africa College of Surgeons (WACS), and UNFPA. In October 2017, the Economic Community of West African States (ECOWAS) member countries’ First Ladies Forum was held in Niamey. The program included an experts’ technical meeting, followed by a West Africa Health Organization (WAHO) ministers’ meeting. Recommendations following the meeting included ending fistula in all West African countries; supporting fistula repair facility development; increasing budgets to conduct fistula sensitization activities; and provision of financial support to repaired clients for social and economic empowerment. The First Ladies also made a special request for WAHO countries to define relevant fistula indicators by 2020 and integrate them into their national health information systems. In March 2018, FC+/WA co-organized an international workshop with WAHO, USAID/WA, and UNFPA in Banjul, The Gambia. During the workshop, participants reviewed the indirect and direct causes of fistula and discussed how best to address the causes of fistula through appropriate policies, legislation, and strategies. In particular, iatrogenic fistula, resource mobilization, addressing the current backlog of cases, and use of data for decision making were discussed. Participants provided feedback on the recent Western and Central Africa College of Surgeons (WACS) workshop and weighed in on the role of WACS in regional capacity building. The workshop was an opportunity to introduce the Western and Central African Working Group for the Elimination of Obstetric Fistula (WCAGEOF). A round table Banjul workshop participants, including the First discussion of almost 40 participants included Lady of the Gambia. Credit: SM Gueye.
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donors’ and implementing partners’ responses to addressing fistula, and participants worked together to harmonize national strategies and ensure a committed, coordinated regional response by developing a regional strategy for the elimination of obstetric fistula in Western and Central Africa by 2030. The meeting opening ceremony was led by Her Excellency, the First Lady of the Republic of The Gambia, The United States of America Ambassador in Banjul, and a UNFPA and WAHO representative. The meeting concluded with the development of a Banjul Resolution, which strives for the elimination of obstetric fistula in ECOWAS member countries by 2030 through resources mobilization, capacity building, data for decision-making, and procurement. In June 2018, fifteen Ministry of Health members from ECOWAS countries signed the resolution. In FY 18/19, FC+ /WA will support WAHO to operationalize this resolution in the region, in collaboration with institutions such as UNFPA, WCARO, WACS, and IBD. Through FC+’s subaward with REF, the partner is carrying out community awareness activities via radio, coordinating client care including pre-, intra-, and post-operative care, reimbursement of repair, and client transportation costs. REF, as a national coordinating structure, also has the responsibility to manage routine data collected from clinical partners. REF organizes bi-annual meetings to share data among the fistula community. During the second quarter, a meeting was organized by FC+/Niger and Nigeria staff and partners to harmonize national strategies to end child marriage. The meeting, held in Katsina, Nigeria, included representation from the Nigerien MoH and Ministry of Women and Children’s Protection, and Nigerian Federal Ministry of Women. Recognizing that child marriage constitutes a serious threat to multiple aspects of the life of a child, a Technical Working Group on Ending Child Marriage in Nigeria (TWGECM) was established by the Federal Ministry of Women Affairs and Social Development to support addressing these issues and accelerate the full realization of their human rights. FC+ is a member of this working group. Next steps include a debrief with partners and convening a cross-country stakeholders meeting between Nigeria and Niger in Sokoto state, with all the northwestern Nigerian states represented; see Section III: Nigeria. During the third quarter, the International Day to End Obstetric Fistula (IDEOF) was celebrated in Niger on May 24, 2018. REF brought together key fistula stakeholders and partners with an event at the national fistula referral center in Niamey. Government officials, clinical staff, clients and local artists came together to commemorate the event, along with the Minister of Health of Niger and the First Lady, Dr. Malika Issoufou. Also during the third quarter, FC+/WAN received confirmation of application approval from Direct Relief for all three supported fistula treatment sites for donations of fistula repair modules. As of the end of the fiscal year, distribution is underway with assistance from REF, and Direct Relief is awaiting delivery confirmation from supported 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 In order to learn from and share expertise with other organizations working on fistula in Niger, an agreement 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, was developed and finalized, with implementation beginning in March 2018. The objective of the
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agreement is to share best practices as well as lessons learned. HDI conducted one-day meetings in each integrated health center (CSI), provided refresher training to volunteers, and gathered and analyzed the community level data that was collected. HDI submitted their final narrative and financial report for this activity, which ended June 30th 2018. FC+/WAN has invested, since year two 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 districts were added in the second quarter of FY 16/17. 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 Meeting of community volunteers. Credit: the importance of male involvement in maternal health. FC+/WAN During FY 17/18, routine outreach activities took place through June 30, 2018 with community partners in Bouza and Illela (Tahoua region), and Guidan Roumdji and Madarounfa (Maradi region). A total of 3,626 in-person community outreach events were carried out, reaching an estimated 87,686 participants, information is presented, by type, in Table WAN1. These outreach activities included home visits as well as small and large community groups. With the closure of the FC+/WAN office, these activities have now ended. Through the project’s subaward with REF, messages about fistula prevention, early marriage, and female genital mutilation have been aired on regional radio stations in Tahoua and Maradi in local languages throughout the fiscal year. Estimates of listening audiences were not available at the time of reporting.
Table WAN1: Community Outreach/Education/Advocacy Events, By Quarter, FY 17/18
Type of Event Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 # # # # # # # # # # Events Reached Events Reached Events Reached Events Reached Events Reached Existing 1,407 34,990 1,305 31,361 914 21,335 0 0 3,626 87,686 community activity Total 1,407 34,990 1,305 31,361 914 21,335 0 0 3,626 87,686
Each month, through June 2018, a total of 31 community health center agents in Bouza, Illela (Tahoua region), Guidan Roumdji, and Madarounfa (Maradi region) conducted supervisory visits to community volunteers in their villages, collected data, and provided support and mentoring for carrying out community activities. Quarterly review meetings were held with community volunteers, which are an additional opportunity to build capacity on awareness raising and promotion of reproductive health activities, collect data on activities, as well as to discuss challenges and potential ways to address them. Support for these activities ended with the closure of the FC+ Niger office.
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In March 2018, HDI carried out the first session of refresher trainings for the 360 community volunteers previously trained in Tahoua district, see Table WAN2. REF plans to continue these refresher trainings for community volunteers in Dakoro, Mayahi, Madarounfa, and Guidan Roumji districts in FY 18/19.
Table WAN2: Community Volunteer/Educator Training, Participants by Topic, FY 17/18
Type of Training Oct-Dec Jan-Mar Apr-Jun Jul-Sept Total 2017 2018 2018 2018 FY 17/18
Refresher training for community volunteers 0 360 0 0 0 Tahoua Total 0 360 0 0 0
Obj. 3: Reduced transportation, communications, and financial barriers to accessing preventive care, detection, treatment, and reintegration support Under the REF subaward, FC+ 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 In FY 17/18, 163 women with severe incontinence symptoms sought fistula care services at FC+ supported sites, of which 144 were diagnosed with fistula (88%, compared to 76% in FY 16/17). FC+ supported 150 surgical fistula repairs during this period, compared to 202 surgical repairs in FY 16/17. As noted in Figure WAN1, the number of repairs supported at CNRFO is higher than the number of women seeking and eligible for surgical repair for the reporting period due to addressing the backlog of cases who were identified in previous quarters. The former fistula surgeon at CNRFO had been absent for a prolonged period of time due to illness and ultimately decided to retire, which severely impeded the number of repairs being performed in country. FC+/WAN worked together with REF to ensure that a new surgeon was appointed to this position, with Dr. Idrissa Abdoulaye appointed at the end of the first quarter. This allowed repairs to resume at CNRFO during the second quarter, providing surgery for a number of women who had been waiting. In addition, UNFPA sponsored a concentrated repair effort during the first half of the year at which 24 clients from FC+ supported facilities received repairs. During the fourth quarter, no repairs were supported due to challenges reconciling financial statements with subawardee REF. Support for repairs will resume in the first quarter of FY 18/19. 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.
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Figure WAN1: Number of Women Seeking and Requiring Fistula Treatment, and Number of Surgical Repairs, by Site, FY 17/18
80
60 Seeking 40 Eligible Repairs 20
0 CSME Tahoua CSME Maradi CNRFO
These 150 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. All surgeries performed this fiscal year at CSME Maradi and CNRFO occurred during routine service provision. Nearly three-quarters of repairs at CSME Tahoua (73.8%) took place through pooled repair efforts.
Table WAN3: USAID-Supported Surgical Fistula Repairs, by Site, By Quarter, FY 17/18
Site Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total FY 17/18 2017 2018 2018 2018 CSME Tahoua 7 9 49 0 65 CSME Maradi 3 7 4 0 14 CNRFO 0 45 26 0 71 Total 10 61 79 0 150
In addition to the surgical repairs supported, eight women received non-surgical catheter treatment (catheterization) for fistula during the fiscal year (seven at CSME Tahoua and one at CNRFO), all of whom were closed and continent at discharge. Etiology data was available for 142 diagnosed fistula cases (99% of those diagnosed). The vast majority of fistulas diagnosed were the result of prolonged/obstructed labor (87%, compared to 88% in FY 16/17), followed by iatrogenic causes (6%, compared to 4% in FY 16/17). 4% of diagnosed fistula were the result of traumatic causes and the remaining 2% “other” etiology cases were related to female genital mutilation. Discharged fistula repairs during FY 17/18 were predominantly not simple cases (75%), likely attributable to the backlog of complex cases at CNRFO that were repaired in the third quarter. 77% of all fistula surgery cases discharged in this time period were closed at discharge; with 62% closed and continent and 15% closed and incontinent. 23% were not closed at discharge (compared to 16% in FY 16/17). Outcomes for discharged patients are presented, by site, in Figure WAN2. The reported complication rate across sites was less than one percent.
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Figure WAN2. Outcome Rates for Surgical Repairs, by Site, FY 17/18
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 17/18. As part of fistula prevention efforts, FC+ West Africa/Niger provided training to 35 health system personnel during this period. These included training of 15 health agents in Tahoua in facilitative supervision and training of 20 health clinicians in emergency obstetric and neonatal care. Table WAN4 provides detail on non-surgical trainings for health system personnel.
Table WAN4: Non-Surgical Health System Personnel Training, Participants by Topic, By Quarter, FY 17/18
Topic Oct-Dec Jan-Mar Apr–Jun Jul-Sep Total 2017 2018 2018 2018 FY 17/18 Facilitative supervision 15 0 0 0 15 EmONC 0 20 0 0 20 Total 15 20 0 0 35
FC+ supports FP counseling and service provision at two supported sites in Niger. During FY 17/18, 925 counseling sessions took place at supported sites and 3,468 CYP were provided; see Table WAN5 for detail, by site. Method mix in Niger during this period was primarily comprised of implants (42%), tubal ligation (36%), and IUCD (15%).
Table WAN5: Family Planning Counseling Sessions and CYP, by Site, By Quarter, FY 17/18
Site Oct-Dec 2017 Jan-Mar 2018 Apr–Jun 2018 Jul-Sep 2018 Total FY 17/18 #sessions CYP #sessions CYP #sessions CYP #sessions CYP #sessions CYP22 CSME 201 335 160 543 90 222 0 0 451 1,100 Tahoua CSME 139 798 68 941 267 629 0 0 474 2,368 Maradi Total 340 1,133 228 1,484 357 851 0 0 925 3,468
FC+ supported sites reported an overall cesarean section rate of 60% during the fiscal year, out of 3,012 deliveries. 18% of deliveries were reported to be obstructed/prolonged, with 96% of those cases receiving
22 Due to rounding, totals may differ slightly from the sum of individual quarters.
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catheterization as a prevention intervention. Information on number of deliveries, by site, is presented in Figure WAN3 and cesarean section rates, by site, are presented in Figure WAN4.
Figure WAN3. Number of Obstetric Figure WAN4. Cesarean Section Rates, by Site, Deliveries, by Site, FY 17/18 (n=3,012) FY 17/18 0% 100%
CSME Tahoua 50 CSME Tahoua 1,166 CSME Maradi 66
CSME Maradi 1,846 Niger Total 60
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 FP, 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 volunteers, and facility staff) jointly analyzed problems and proposed locally relevant solutions to improve uptake of maternal, preventive, and FP services. FC+ is conducting a program learning assessment on the SWTs in Niger to understand the outputs and outcomes resulting from SWTs and inform future FC+ or EngenderHealth implementation of the SWT approach. In the first two quarters of FY 17/18, post SWT interviews were conducted with community volunteers to assess knowledge, follow up on action plan completion, and collect feedback. Data entry was completed in the third quarter. A report on this program learning assessment will be finalized and shared in the first quarter of FY 18/19. As part of routine efforts to strengthen the use of data for decision making, the FC+/WAN M&E officer met 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. These activities concluded with the closure of the FC+/WAN office in June 2018. Under their new subaward, REF will manage this process in FY 18/19.
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