Addressing needs for fistula training in

Subsaharan Africa
Serigne Magueye GUEYE, MD, FWACS
Professor of Urology and Fistula Master Trainer
President of PAUSA and Chairman Fistula Committee SIU
University Cheikh Anta Diop , Dakar – Senegal
serigne.gueye@ucad.edu.sn
 Outline
• To provide an overview of fistula training and
treatment interventions from a global perspective

• What ? Where ? Who ? How ?

• Challenges
• Opportunities in OF training and care
• Lessons learned from different programs
• Perspectives
What is Subsaharan Africa ?
 North Africa /Sub-Saharan
differences
NORTH AFRICA SUB-SAHARAN AFRICA (RSA excluded)

 Middle Income (MIC) Low Income Countries

 Political Stability  Recent or Current Conflict

 Urology Training  Few Urology Training

Established Programs
 Adequate # of  Insufficient # of Urologists

Urologists
 Distribution of urologists in West Africa

Country Number of urologists Population (millions)

NIGER 3 11.058.000
NIGERIA 35 131.859.731
GHANA 7 19.894.014
BURKINA FASO 4 13.902.972
BENIN 3 07.513.946
TOGO 3 05.399.236
MALI 5 10.685.000
MAURITANIA 5 02.990.000
SENEGAL 33 11.658.000
COTE D’IVOIRE 12 17.298.000
GUINEA CONAKRY 7 9.402.000
The GAMBIA 1 1.641.564
GUINEA BISSAU 1 1.345.479
SIERRA LEONE 1 5.100.000
LIBERIA 1 3.317.176
CAP VERT 2 405.163
______________________________________________________________________
TOTAL 120
 Obstetric Fistula in SSA

Worldwide : over 2 million cases

80-90% in sub-Saharan Africa

50-100,000 new cases/year

 The present of Fistula training and care
in Subsaharan Africa (1)
 Lack of integration into Reproductive Health programs
 Outreach campaigns irregularly depending on funding support

and / or availability of “fistula experts”

 Fistula experts are mainly dedicated and skilled expatriates

 Few local surgeons involved in fistula activities

 Availability of “non utilized” human resources amenable to

fistula care and training (Urologists, O&G, Surgeons)

 “Fistula tourism” is not rare : Ethical issues +++

 Problem of sustainability of fistula services

The present of Fistula training and care in
Subsaharan Africa (2)
 Fistula training not well structured

 Some in-country initiatives : outreaches

 Trans-boarder activities not coodinated

 Urologists, especially in Francophone Africa should

play a key role in Fistula care and training
 Who should do fistulas repair?

 Specialists :
 0bstetrician and Gynaecologist
 General surgeons
 Urologist surgeons

 Medical Doctors with surgical skills after OF

training
 Need for competence based training curriculum
 Motivation, Committment and Dedication
 What about surgical nurses ?
Very controversial !!!
 Thousands of fistula cases are waiting for surgery in
Africa, the specialists are not able to do for the next
decades

 Surgical nurses, in many developing countries, have

proved to be good in C section and other general
surgery procedures.

 Can they do simple VVF repair if well trained ?

 Notrecommended by the International Fistula Working
group (Dar es Salam, Tanzania Aug 31 – Sept 2, 2009)
 Where ?

District hospital
Central / Teaching hospital

Fistula center / hospital

 How fistula repair is being organized in
subsaharan Africa ?
 Outreach surgical camp

 Integration into normal surgical list

 Referral to specialized centers

 How to improve fistula care ?
Training is a key component!
 Manpower development / building
 Reduce Backlog of women waiting for fistula repair
services

 Availability of a Competency-based training manual

(FIGO and partners)
 Piloting will start soon in 6 selected countries
 Evaluation of pilots (end of march)
Fistula training needs to be streamlined

 Assessment of training needs

 Identification of Surgical expertise, Infrastructure

and training centers

 Collaboration with academics to implement the

competency-based training curriculum
 Integration into postgraduate programs
 Certification / recognition for “fistula surgeons”
 Curriculum development

Competency-based training manual

«Better to teach someone how to fish rather

than giving him one fish everyday »
Chinese proverb
 THE GLOBAL TRAINING AND
EDUCATION INITIATIVE
S Elneil and M Muleta
On behalf of FIGO and partners Team
IFWOG meeting, Dar es Salam, Tanzania, Aug. 31 – Sept 2, 2009
 The Issues
 No standardization
 Apprenticeships variable

 No assessments

 Timing of training ill determined

 No classification

 No audit

 Limited publications
 Multiple Non-unified Training
Manuals
 WHO
 Individual surgeons
 Country led projects
 Part of ongoing curriculums of medical training in
O&G or Urology
 UNFPA in progress
 PAUSA (supported by UNFPA)  joined FIGO group
 The surgeon's initiative
2006/2007
• AAFH manual of training commenced

2008 onwards
- Initiative for PAUSA curriculum (supported by UNFPA)
- FIGO and partners
ISOFS
PAUSA
South Asia O&G Society
Engender Health, UNFPA (funding)
EAU International Committee
 The Commitee Members
• Lord Naren Patel (Global FIGO)
• Prof Sayeba Akhter (Bangladesh, Surgeon)
• Prof Serigne Magueye Gueye (Senegal, PAUSA, SIU, Surgeon)
• Prof Hamid Rushwan (Global FIGO)
• Dr Andrew Browning (Ethiopia, Surgeon)
• Ms Suzy Elneil (FIGO, Surgeon)
• Dr Mulu Muleta (Ethiopia) CHAIR (FIGO, Surgeon)
• Dr Thomas Rassen (Kenya, ISOFS, Surgeon)
• Prof. Charles-Henry Rochat (Benin, Suisse, Surgeon)
• Dr Kees Waaldijk (Nigeria, ISOFS, Surgeon)
• Invited 2009:
• Joseph Ruminjo (Engender Health) ; Luc Debernis (Global UNFPA)
Aims of the Competence-based fistula manual

• To complete development of a modular globally accepted fistula

manual

• To develop a unified global fistula classification with ISOFS

• To develop a training manual with objective assessments, that is

also accredited globally

• To provide audit and research tools to ensure evidence-based care

and provide a publication base

• To empower the well trained field-dedicated fistula surgeons,

and provide advocacy
 MODULE ONE
EPIDEMIOLOGY OF FEMALE GENITAL
FISTULA
 OBJECTIVES

At the end of this module the trainee should be

able to:
1. Define Genital fistula and describe its magnitude.
2. Explain the aetiology of female genital fistula and
pathogenesis of obstetric fistula
3. Explain all genital and extra genital complications
of obstructed labour
 MODULE TWO

DIAGNOSIS
OF FEMALE GENITAL FISTULA AND
CLASSIFICATION
 Objectives
At the end of this module the trainee will
be able to:

 Diagnose female genital fistula

 Outline classification of female genital fistula
 MODULE THREE
Management of uncomplicated vesico-
vaginal fistula
 Objectives

At the end of this module the trainee should be

able to:

1. Describe ways of immediate management of vesico-

vaginal fistula
2. Describe and carry out pre-operative care
3. Describe the surgical techniques and perform simple
vesico-vaginal fistula repair
4. Provide basic post operative care and identify
post-operative complications
 MODULE FOUR
Management of more complicated
fistulas
 Objectives
At the end of this module, the trainee will
be able to:

 Identify the types of complicated fistulas

 Describe surgical techniques of repairing complicated

urinary fistulas
 MODULE FIVE

Management of Recto vaginal Fistula

 Objectives

At the end of this module, the trainee will be able to

 Describe and provide pre operative management

of RVF
 Repair simple RVF and sphincter ani trauma
 Describe surgical techniques of complicated RVF
 Describe and provide post operative care
 MODULE SIX

COMPLICATIONS OF FISTULA
REPAIR
 Objectives
At the end of this module, the trainee will be able to:
1. Prevent intra-operative complications, detect them
when they do occur and determine management
2. Identify immediate postoperative complications
and outline their management
3. Identify late postoperative complication and
outline their management
 MODULE SIX B

Prognostic factors and outcomes

 Objectives
By the end of this module the trainee should
be able to:

 Evaluate the surgical outcome

 Identify the prognostic factors

 Implementation
 Set up training teams
 Identification of potential trainees in each region

 Adoption of the competence-based training

manual
 Develop capacities of training centers

 Rotational Workshops

 Evaluation/Modification at intervals
 Rationale for zonal distribution
 Geography - Demography
 Infrastructures
 Existing OF programmes or centers
 Existing manpower (trainers, trainees, ….)

 Identification of training center(s) in each zone

 Share of human ressources

 Organization of Trans-boarder activities

Proposal for 4 prospective training zones
in West Africa

 Zone 1 : Cap Vert, Gambia, Guinea Bissau, Mauritania,

Senegal
 Zone 2 : Cote d’Ivoire, Guinea, Mali, Liberia, Sierra
Leone
 Zone 3 : Benin, Burkina Faso, Ghana, Niger, Togo
 Zone 4 : Nigeria

 NB : This zonal distribution should be replicated in each

African sub-region following the same rationale
Prospective training zones in West Africa
15 ECOWAS countries + Mauritania

1
1

1
3 3
1 2
2
2 2 3
3 4
2 3
1
 Collaboration

PAUSA : PanAfrican Urological Surgeons Association

FIGO : Fédération Internationale de Gynécologie et d’Obstétrique
SAGO : Société Africaine de Gynécologie et d’Obstétrique
ICS : International Continence Society
ISOFS : International Society of Fistula Surgeons
AFU : Association Française d’Urologie
BAUS : British Association of Urological Surgeons
 What are the challenges?

• “find patients”
• Often hidden and not aware of treatment opportunities
• Role of NGO’s and Civil society
 Improve equipment of training centers
 Involve more surgeons and staffs for training and care
 Need for prevention and more targeted reintegration
programs
 Sustain funding to support OF programs
 What are the opportunities ?

 More awareness on OF
 Governments - Stakeholders
 NGOs – Civil societies
 Population : Education and Communication
 Specialists societies and associations

 Development of training programs (consensus)

 Better involvement of local surgeons

 Availability of funding to support OF programs

HOW WE RUN FISTULA SURGICAL
TRAINING WORKSHOPS
FISTULA SURGICAL TRAINING WORKSHOP
TANGUIETA , BENIN
SEPT 28 – OCT. 8, 2009

Pr Serigne Magueye GUEYE (Senegal) - Pr AKPO César (Benin)

ONG ESSOR
BENIN
 Methodology
 Lectures and interactive discussions
 Distribution of handouts and electronical files

 Residents and consultants in O&G, Surgery,

Urology
 Surgical demonstrations by instructors

 Hands-on training : « Learning by doing »

 All participants operated at least one case

 Supervison by instructors
Lectures and interactive discussion

Withe Medical doctors With nurses and midwives

Diagnosis and Evaluation : Pr Akpo + particpants
Demonstration by instructors

Pr Akpo Pr Gueye
Participants working under supevision
Participants working under supervision
Participants in charge
 Surgical outcome in Tanguieta
 Number of VVF : 32 cases (31 operated and 1
cystolithotomy
 Immediate surgical outcome of VVF (31)

 Good : 30 cases
 Urine leakage : 1

 Surgical outcome after 2 months

 Overall success rate : 23/31 (74,19%)

 Failure: 8 (will be operated in march)
Le même groupe sera repris 6 mois plus tard dans un but
d’évaluation des acquis et de renforcement des capacités
Training workshop in Senegal in 2008 - 2009
_________________________________________________________
Site Targets
_________________________________________________________
HOGGY (2) O&G + Surgeons + Uro
MBOUR (1) Gynaecologists + Uro
ZIGUINCHOR (3) Gynae + Surgeons + Uro
TAMBACOUNDA (2) Gynae + Uro + MD’s
KOLDA (1) Surgeons + Uro
__________________________________________________________
Number of patients operated during outreaches : 108 cases
Number of patients operated during the last 4 months : 55 cases
Fistula care and training in Senegal
Fistula care and training in Senegal
Fistula training in Kigali, Rwanda

The same group of trainees is being followed up.

Next Workshop in Kigali January 2010
 Support from Ministry of Health and partners is
mandatory

Participants and stakeholders Stakeholders + instructors

UNFPA country Office invited other partners as World bank, WHO,
USAID along with the Ministry of Health and the Regional Prefet
 Lessons learned
 OF care « overshadowed » by other activities
 Fistula cases at end of surgical lists, often postponed
 No long term follow up of patients after
surgical repair
 Lack of trained human ressources
 difficulty to keep them on-site
 Training not always translated to fistula services

 Need motivation, committment and dedication

 The future for OF care (1)
 Prevention
 Improvement of awareness on obstetrical fistula
– Policy, Public Health, Communication
 Integrating OF in National Reproductive Health plans

 Training
 Manpower building and development
 Implementation of FIGO and partners training manual
 Reinforcement of institutional capacities
•
 The future for OF care (2)
• Research
• Development of research protocols on OF

• Collaboration : International
partnerships
• (Societies and Associations, Universities
and Colleges, UN agencies, NGOs, …)
 Conclusion
 Develop national capacity
 Give priority to training trainers

 Encourage training that is translated to fistula services

 Integrate OF into Reproductive Health programs
 Develop prevention plans
 Prevention thru safe motherhood is the way
towards elimination of obstetrical fistula