The persistence of obstetric fistula in the world today provides ample evidence that health systems are failing women. Each year, more than 350,000 women die from complications of pregnancy, childbirth or unsafe abortion, and for every woman who loses her life, some 20 more suffer a delivery-related injury or illness. Obstetric fistula is among the most devastating of these injuries because it results in a lifetime of chronic pain and incontinence and often abandonment and complete destitution. The good news is that fistula repair surgery can restore dignity and health to hundreds of thousands of women now suffering fistula. Across Africa and Asia, where fistula is most common, talented and dedicated surgeons are doing just that.
But knowing how to repair fistula is only half the battle. A multitude of players are needed to meet the demands of fistula care, from talented surgeons, skilled nurses, and anesthetists to hospital administrators, program managers, curriculum writers, advocates, community groups, politicians, and donors. The challenge lies in connecting those actors with the women who are in need of their support.
Providing comprehensive care for fistula survivors demands a coordinated group effort, from finding women in need of repair, to transporting them to services, to reintegration to community life following surgery. To make all of this work, and to transform the lives of women with fistula, the many dedicated players must share a vision, communicate well, build consensus and complement one another’s efforts. Together we are much more powerful and will have a far greater impact on the health of women globally.
Indeed, this is already happening – and successfully. I am the director of the Fistula Care Project, which is managed by EngenderHealth and funded by USAID. Our organization has been a member of the International Obstetric Fistula Working Group (IOFWG), coordinated by UNFPA, since it was founded. By bringing together partners from the international, national, and local levels, this informal collaboration is building bridges across disciplines, helping us share lessons learned, identify gaps in what we know, and propose, implement, and evaluate effective solutions. Through the IOFWG, Fistula Care is able to create alliances with organizations and individuals with different perspectives, see where our interests intersect, and together commit to ending fistula through a holistic approach to prevention, treatment and rehabilitation. It is arguably the most effective partnership I have seen in 35 years in the reproductive health field.
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Just as collaboration and cooperation are imperatives globally, so too are they needed at the national level. Nigeria is one example where such progress is being made, driven by a government commitment to significantly improve maternal health. One out of every ten maternal deaths in the world takes place in Nigeria, which also experiences high rates of obstetric fistula A number of factors contribute to these figures, and as part of a larger response five years ago, the Nigerian Federal Ministry of Health launched the 2005-2010 National Plan for Obstetric Fistula, a strategy coordinating the work of actors across federal, state, and local levels. The broad aims of the plan are to prevent fistula from happening while also increasing access to care through advocacy, research, improved efforts to encourage health-seeking behaviors and shape cultural norms, better rehabilitation and reintegration services, and more effective mechanisms for partnerships and coordination, among other strategies. A recent review of the Plan showed state and federal level commitment, with dedicated surgical teams providing services to women, but there is still much to do.
In support of the National Plan, Fistula Care facilitated the formation of a clinical peer-support network in Nigeria, to increase access to repair services and standardize and improve the quality of those services across health centers. What this means in practice is that periodically 3-5 fistula surgeons meet at one center, where they are able to help a greater number of women, learn from each other, and because the group of surgeons has varying levels of skill they are able to handle a range of surgeries from simple to complex. These pooled efforts also raise awareness in communities, tackling the backlog of cases that most centers experience, and strengthen the skills of all involved. Surgeons and other health professionals also meet quarterly to discuss clinical issues and share what they have learned. This collaboration brings more women around the country into health centers, offers them better support and services when they walk through the door, and strengthens the skills of clinicians in the process.
Granted, collaboration isn’t the silver bullet for ending or treating fistula. Many other obstacles exist. No matter how well we work together, availability of resources and the political will to address this issue are still key to effective solutions. Competing priorities will always plague conditions such as fistula, which, although severely debilitating, is not treated as a life-threatening emergency. Investments are needed in many areas, such as to improve the quality of care at hospitals, to expand reintegration services to help women transition to normal life after surgery, and to spread awareness about the importance of seeking help during pregnancy to prevent fistula from occurring.
Through partnerships, including that of USAID, in Nigeria alone Fistula Care has supported more than 5,000 repair surgeries since 2007. Globally, since 2005, this number is fast approaching 18,000 across USAID-funded sites. Although we have a long way to go before reaching the millions who have fistula and the thousands more women who develop fistula each year, this is an important step forward and can strengthen and improve quality of care across health systems around the globe. The women whose lives are transformed by these surgeries remind us every day why we do what we do. With effective coordination and meaningful strategies in place, we achieve far more together than each of us does as an individual or organization.