**USAID Bureau for Global Health**

**Fistula Strategy**

**2003-2008**

**Summary**

***Strategic plan***

The goal of the USAID Bureau for Global Health (GH) strategy is to
reduce the prevalence and severity of obstetric fistula. The objective
for GH is to advance and promote best practices and programs to prevent
and repair obstetric fistula. To reach this objective, GH will improve
the data base on the extent and severity of obstetric fistula, increase
public and community awareness of the medical and social consequences of
the problem, improve quality of care for prevention and repair, and
support advocacy and improve policies that promote access to care that
will prevent fistula.

***Projected Results (5 Year Vision)***

-   Programs to prevent obstetric fistula will be strengthened

-   Hospitals will be upgraded with surgical centers for training in
    repair of fistula

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**Background**

***Description and Magnitude of the Problem***

Complications of pregnancy and childbirth are a leading cause of death
and disability among women of reproductive age in developing countries.
In addition to more than 500,000 maternal deaths annually, it is
estimated that 15 million to 20 million women develop disabilities as a
result of pregnancy and child birth. One of the most devastating is
obstetric fistula that affects an estimated 2,000,000 women worldwide
(WHO, 1989). This calculation could be a significant underestimate. The
problem predominantly affects women in Sub-Saharan Africa and South
Asia. Each year, an additional 50,000-100,000 estimated women are
affected. UNFPA, EngenderHealth, and the Averting Maternal Death and
Disability Program have and are now conducting assessments in a number
of African countries to better define the nature and extent of the
problem in Africa. Less is known about prevalence in South Asia but work
has begun to assess the situation in Bangladesh.

Obstetric fistula is an abnormal opening between the vagina and the
bladder or rectum (or both). Fistula, when connected with pregnancy, is
a result of extreme pressure and tissue damage during prolonged or
obstructed labor as the fetus attempts to pass through the mother's
birth canal. If a timely Caesarean section delivery is not available to
end the ordeal, the baby is usually stillborn. The fistula that has
formed permits the uncontrollable passage of urine and feces into the
vagina.

Women who suffer from fistula have not only, in most cases, lost their
babies, but also constantly leak urine and feces, producing a foul odor.
In addition, some of these women also suffer neurological damage that
can affect their ability to walk. Women with fistula usually feel shamed
or disgraced, and are often deserted by their husbands and cut off from
family, friends and daily activities, resulting in a life of isolation
and destitution.

***Determinants of Fistula Disability***

The young and the poor are disproportionately affected. The women most
at risk include the very young, women having their first birth, and
women whose growth has been stunted due to malnutrition and childhood
illness. Women who live in rural areas without access to services and
women who use home delivery and traditional care are at highest risk.

***Prevention***

In the industrialized world, obstetric fistula is almost unknown. The
reason is that most cases have been prevented. Access to skilled care
including surveillance in labor is key. Whether or not a woman delivers
at home, or in a health facility, there is time to detect prolonged
labor and take action before the mother has prolonged, significant
pressure on soft tissues to cause damage to her internal urinary,
intestinal and reproductive systems.

One proven tool is the *partogram* that assists midwives and doctors to
plot the progress of labor, as well as the condition of the mother and
fetus, in labor. If any deviation from normal progress is noted on the
*partogram*, the birth attendant is given a visual cue to be on the
alert and to take action. This tool can be used in all settings where
there is a skilled birth attendant and will allow timely initiation of
transfer of the laboring mother, if necessary, and get her to a place
where assisted delivery can be performed. In addition to skilled
attendants and availability of emergency obstetric care, there needs to
be a functioning referral system in place so that timely transfer to
life saving care, in most cases a Caesarean section, can be achieved.

***Fistula Repair***

In the event that prolonged or obstructed labor is not detected in time
to prevent the problem, surgical repair is possible, but often
inaccessible. A large proportion may have a relatively "simple" tear
that requires relatively straightforward surgical repair. Complicated
cases of fistula involving extensive tissue damage and scarring need
sophisticated surgical expertise. For all cases of repair, surgical
expertise needs to be coupled with excellent postoperative care,
including high quality nursing care, as well as psychosocial support.

***Rehabilitation***

Women who come for repair are often ashamed. Likewise, they are
typically unemployed and have been rejected or isolated by their
families. They lack support systems and persons to help them with this
personal catastrophe. Experts working with fistula patients have found
it essential to support skills training and psychosocial reintegration
to move beyond only surgical repair to social rehabilitation. In some
cases, these women are reintegrated with their communities. In other
cases, especially where repairs are not completely effective, they need
to develop new community systems to cope with the problem.

***USAID's approach***

Since 1989, USAID has actively and substantively supported programs to
prevent disability from obstetric fistula. The programs has been
designed to be integrated with other programs that address the major
causes of maternal death and disability and that have the greatest
potential for widespread public health impact. The programs have
included:

-   ***Increased access for women to emergency obstetrical care*** \--
    USAID supports strengthened skilled care facilities, provider
    training and referral, and policy development to address financial
    barriers that prevent women from seeking treatment.

-   ***Public awareness*** -- USAID promotes public awareness campaigns
    that urge women to postpone marriage and childbearing until after
    the teenage years.

-   ***Community training*** -- USAID supports community awareness about
    the problem of prolonged labor and preparation for emergencies.
    Community members who are usually present or assist at birth are
    taught to recognize the danger signs of prolonged labor, which can
    lead to obstructed labor, fetal death, and fistula. Men, as the
    common decision makers for use of hospital services, are included in
    the community education.

-   ***Increased attendance of skilled personnel at delivery** \--*
    Giving birth without a skilled attendant is a risk factor for
    fistula. USAID has substantively supported the improvement in
    quality of care by doctors, nurses and midwives in use of the
    partogram, recognition of prolonged labor, and referral to
    facilities that can provide surgery. USAID has become increasingly
    involved in workforce issues that affect the number and actual
    deployment of skilled attendants to locations where they are needed.

-   ***Advocacy and awareness*** \-- USAID raises awareness to advocate
    for increased attention to fistula and action. As an example, USAID
    has commissioned the Population Reference Bureau publication *Hidden
    Suffering: Disabilities from Pregnancy and Childbirth in Less
    Developed Countries* that highlights obstetric fistula.

**Results Framework**

In 2004, USAID will expand its efforts to address the problem of
obstetric fistula. It will add to its current program, additional
efforts to improve the evidence on the nature and extent of the problem
and expand its programming to include fistula repair and linkage with
rehabilitation support.

**Enhanced Role for USAID Bureau for Global Health**

-   Improve data base concerning the predisposing causes, prevalence and
    severity of obstetric fistula disability

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-   Support data gathering, studies and analysis that improve evidence
    on the extent and severity of the problem

-   Identify best practices to address prevention and treatment

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-   Improve public and community awareness about causes and medical and
    social consequences and

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-   Disseminate information about obstetric fistula in public forums, in
    written publications, and through the media to stimulate effective
    programs for births with a skilled attendant and to reduce stigma
    for those disabled by fistula

-   Promote delayed marriage and childbearing through media messages and
    community and NGO activities.

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-   Improve services for prevention and treatment of obstetric fistula

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-   Promote access for all childbearing women to birth attendants with
    appropriate skills, including use of the partogram, within an
    enabling environment with appropriate supplies, equipment and drugs

-   Improve quality of care for labor and delivery through standard
    setting, training, supervision and support, and quality improvement
    systems

-   Support functioning referral systems, including communications and
    transport, to get women with prolonged /obstructed labor to
    emergency obstetrical care, including Caesarean section capability

-   Improve quality of emergency care for labor augmentation and
    assisted/surgical delivery through standard setting for response to
    prolonged labor and monitoring and evaluation of treatment and
    related outcomes

-   Support standard setting for best practices, training, quality
    assurance at centers of excellence for surgical repair

-   Support linkage to social rehabilitation of affected women

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-   Improve advocacy and policy support for improved access to safe
    delivery and care for obstetric complications

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-   Advance policy dialogue and formulation to change laws and norms to
    support family planning and delayed marriage and childbirth

-   Improve access to emergency care through policy reform that
    addresses barriers to care including fee policies

**Geographic Focus**

Overall, special attention will be placed in Sub-Saharan Africa and
South Asia where there magnitude and severity of the problem is
greatest. Assessments on the extent of the problem will be focused in
South Asia since considerably more has been done in Africa. Programming
will be advanced where maternal mortality and disability is especially
high and where the need is not being addressed by other partners.

**Mechanisms and Funding**

USAID will implement the obstetric fistula strategy through a variety of
existing and new procurement mechanisms. These include a new maternal
and neonatal health program under design, as well as two ongoing
activities\--The Futures Group/Policy Project and
EngenderHealth/ACQUIRE.

**Partnerships**

The Bureau for Global Health will work with USAID missions in countries
where there is a high prevalence of obstetric disability\--taking
advantage of targets of opportunity to work in surgical centers that
USAID is supporting. In this way, USAID will be able to maximize its
results to expand local capability in surgical repair.

UNFPA and WHO have taken an active role in addressing this problem and
USAID will work closely with them. Additionally, USAID will work other
partners, including skilled surgeons and local NGOs for surgical repair.