Uganda - Campaign to End Fistula

REPORT OF THE BASELINE ASSESSMENT OFOBSTETRIC FISTULA IN UGANDASUBMITTED TOUNFPAUGANDA COUNTRY OFFICEBy:Dr. Apollo KarugabaConsultant,P.O. Box 25985,Kampala.Tel: 077 424582E-mail: abkarugaba@yahoo.com7 th May 2003

iTABLE OF CONTENTSTABLE OF CONTENTS..................................................................................................... iLIST OF ACRONYMS ..................................................................................................... ivACKNOWLEDGEMENT .................................................................................................. vEXECUTIVE SUMMARY ............................................................................................... viBACKGROUND ................................................................................................................ 12.0 TERMS OF REFERENCE.............................................................................. 52.1 Objectives of the Study........................................................................................... 52.2 Specific Objectives ................................................................................................. 53.0 METHODOLOGY: ................................................................................................ 63.1 Ethical Control........................................................................................................ 63.3 Preparation for the Study ........................................................................................ 64.0 RESULTS ............................................................................................................... 74.1 Policy ......................................................................................................................75.0 INDIVIDUAL HOSPITAL ASSESSMENT.......................................................... 85.1 Mulago National Referral and Teaching Hospital.................................................. 85.2 Mengo and Rubaga Missionary Hospitals .............................................................. 85.3 Nsambya Catholic Missionary Hospital ................................................................. 95.4 Kitovu Catholic Missionary Hospital ..................................................................... 95.5 St. Francis Mutolere Hospital ............................................................................... 105.6 Kagando Hospital.................................................................................................. 105.7 Mbarara Teaching Hospital................................................................................... 115.8 Fort Portal Referral Hospital................................................................................. 125.9 Hoima Referral Hospital....................................................................................... 135.10 Gulu Hospital........................................................................................................ 135.11 Lacor Catholic Hospital ........................................................................................ 145.12 Arua Hospital........................................................................................................ 145.13 Nebbi Hospital ...................................................................................................... 145.14 Kuluva Hospital .................................................................................................... 155.15 Lira Hospital ......................................................................................................... 155.16 Amai Hospital (Lira District)................................................................................ 155.17 Soroti Hospital ...................................................................................................... 155.18 Mbale Hospital...................................................................................................... 165.19 Kamuli Hospital.................................................................................................... 165.20 Jinja Hospital ........................................................................................................ 165. 21 AMREF Flying in Doctors: Dr. Tom Raassen..................................................... 175. 22 Masaka Regional Referral Hospital...................................................................... 175. 23 Kabale Regional Referral Hospital ....................................................................... 176.0 PROVIDER ASSESSMENT................................................................................ 186.1 Special Hands-on Training in VVF Management ................................................ 186.2 Distribution of Categories of Service ................................................................... 186.3 Adequacy of Training ........................................................................................... 186.4 Needs for Hands-on Training................................................................................ 196.5 Performance Assessment for the Year 2002 by Respondents .............................. 19

9.9 Attitudes of Health Care Providers Towards Fistula Patients .............................. 359.10 Characteristics of Patients with Fistula................................................................. 369.11 Medical Schools Training Curriculum.................................................................. 369.12 Financial Support to VVF Programmes................................................................ 369.13 Health Management Information System ............................................................. 369.14 Potential for Collaboration, Coordination and Research ...................................... 369.15 Job Description and Satisfaction........................................................................... 369.16 Advocacy and IEC ................................................................................................ 3710.0 RECOMMENDATIONS...................................................................................... 3811.0 HOSPITAL SUMMARY FORM ......................................................................... 42LIST OF INSTRUMENTS............................................................................................... 46LIST OF KEY INFORMANTS........................................................................................ 53PROVIDER/FACILITY ASSESSMENT......................................................................... 56PATIENT INFORMATION............................................................................................. 60KEY INFORMANT INTERVIEW .................................................................................. 62MINISTRY OF HEALTH HEADQUARTER GUIDE.................................................... 64DEVELOPMENTAL PARTNERS GUIDE..................................................................... 64PHYSICAL INSPECTION OF THE FACILITY............................................................. 65REFERENCES ................................................................................................................. 67iii

ivLIST OF ACRONYMSAIDS - Acquired Immune Deficiency SyndromeAMREF - African Medical and Research FoundationDDHS - Director of District Health ServicesDNO - District Nursing OfficerHMIS - Health Management Information SystemHIV - Human Immunedeficiency VirusIEC - Information Education and CommunicationIV - IntravenousIVP - Intravenous PyelogramR.V.F. - Recto-Vaginal FistulaRH - Reproductive HealthUDHS - Uganda Demographic and Health SurveyUK - United KingdomUNICEF - United Nations Children’s FundUNFPA - United Nations Population FundVVF - Vesico-Vaginal FistulaWHO - World Health Organization

vACKNOWLEDGEMENTFirst and foremost I wish to thank UNFPA, for taking the lead, Ministry of Health andother development partners for picking interest, in this neglected most severe form ofmaternal morbidity.In a special manner, am grateful to UNFPA for assigning me this responsibility andchallenge as a Consultant.My sincere gratitude to all those who participated in this study, all respondents, serviceproviders, patients and key informants for availing this study their valuable time andcooperation.All my colleagues who assisted me in one way or another especially Robinah oursecretary, we all share the pride of the outcome of this study.Dr. Apollo KarugabaConsultant.

viEXECUTIVE SUMMARYThe study was sponsored by UNFPA with the overall goal to increase knowledge andunderstanding of the magnitude of the obstetric fistula, among stakeholders, includingexisting capacity and gaps in preventing and treating obstetric fistula in Uganda.“Obstetric fistula occurs as a result of a prolonged and obstructed labour. The pressurecaused by the obstructed labour damages the tissue of the internal passages of thebladder and/ or rectum and with no access to surgical intervention, the woman can beleft permanently incontinent, unable to hold urine or faeces, which leak out through hervagina”.The study was conducted between 19 th February and April 6 th 2003. It was crosssectional, qualitative and quantitative in nature.A total of 114 key informants who included Directors of Health Services and NursingOfficers at the District, Directors and Heads of Hospitals and Departments, Staff from theMinistry of Health Headquarters, relevant authorities of Development Partners and Non-Governmental Organisations, were interviewed. Forty seven service providers (doctorsand nurses) involved in management of VVF currently were also interviewed usingForm 1 to find out their level of skilled training, performance and handicaps in themanagement of VVF.Thirty patients with VVF who were found lying in hospital wards were also interviewedto establish their characteristics, social and economic problems using Form II.Finally, a physical inspection of each National and Regional Referral Hospital wasperformed to establish the adequacy of theatre space, equipment and other suppliesincluding laboratory and X-ray facilities using Form 4 and summarised on Form 5.It was striking to find out that the government had a well laid out policy on themanagement of VVF although it had had poor dissemination or distribution tostakeholders leading to no or hardly any implementation. It is therefore, recommendedthat National Policy Guidelines and service standards for reproductive health be urgentlyprinted and distributed to stakeholders.The magnitude of fistula could not be estimated in this study because of its limited scopeto National and Regional Referral Hospitals, lack of data on VVF and the fact that veryminimal activities were taking place in these hospitals. Because nothing or little iscurrently done for VVF patients they tend to keep away from the hospitals and stay in thecommunities where it is difficult to identify them except on rare occasions of “VVFCamps”.

viiThese were major constraints identified in this study:a) Lack of skills among health care providers to manage VVF.On average every Regional Hospital had one gynaecologist resident at the station.Except in four of them, all had no special training or skills to repair fistula. Thereis urgent need to train all of them either by bringing experts here, which is morecost effective or by sending our doctors to Addis-Ababa or Nigeria fistula centresfor training.b) Lack of equipment and other suppliesAll Regional Hospitals had no specialised equipment for repair of VVF. Othersupplies like consumables and drugs were irregular and unpredictable. It isimportant as a matter of urgency to equip the two teaching hospitals (Mulago andMbarara) and create four other regional centres for VVF care and training atKagando hospital (Western), Kitovu hospital (Central), Soroti hospital (Eastern)and Arua hospital (Northern). The service can be spread to other regionalhospitals in the long run.c) There existed generally poor knowledge of the cause and remedy of fistula in thecommunity leading to poor access and utilization of existing services. Otherfactors like poor transport and communication facilities were prevailing. It isimportant to educate our communities including health care providers to sensitizeand mobilise them to assist victims of VVF to seek treatment in health facilities.d) The cost of health care was not affordable by many people especially women whohave a low social and economic status. On average a single VVF operation costsan equivalent of US$ 200 – 300 which is too much for the VVF patients who inmost cases are poor and have no income.It is only recent (1999) that the Ministry of Health, Development Partners, Non-Governmental Organisations and Women Activists, have started advocacy on the healthand social consequences of VVF. It is gratifying to note the vigilance lead by UNFPA insponsoring this particular important study.The training curricula in all health provider training institutions at both pre-service andin-service training lacked competence based hands-on-training in fistula management.There is need to review all the curricula and particularly for the postgraduate to providefor examinable skills and competence in management of fistula. It is also important toextend the training to “selected medical officers” to repair selected uncomplicated cases.This would relieve pressure of work on the specialist and reduce waiting periods for thepatients.There was no funding programmes established for VVF cases. It is crucial that specifictargeted funds be mobilised by Government and development partners for any activity tobegin. All schemes of health financing need to be explored ranging from communityloan scheme to health insurance scheme and donations.

viiiThere exists great potential for collaboration and coordination through the Ministry ofHealth, of all development partners, non-governmental organizations and womenactivists. Many aspects of fistula need to be researched to bring more understanding ofthe problem.The women who suffer this diverstating condition are of low educational standards andfrom poor socio-economic groups. Programmes which enhance “girl child” educationand economic empowerment of women and communities will go along way in mitigatingthe problem. This will reduce rejection and misery which these women have to undergoin society.Finally, in order to maintain morale among the trained professionals the health carefacilities should be provided with adequate equipment and supplies specific for VVF carewithout neglecting motivation of staff.Averting future cases of VVF depends on treating the present ones well, sustainedinvestment in low level health facilities in the communities, so that there exists efficientand affordable or even free health care. It is important for Uganda to have accurateinformation on critical health problems through well supervised data collection at alllevels, especially for VVF, currently not captured in the National Data.

3High levels of childhood malnutrition may have serious consequency on the outcome ofpregnancy arising from small poorly developed pelvises which can result in difficultlabour – from cephalopelvic disproportion.There is no accurate data on the incidence of VVF although the problem has beenreported throughout Africa and the Indian sub-continent. It is a rare occurrence indeveloped countries because of their improved health and transport facilities to accessemergency obstetric care.There is need to increase family and community awareness on the determinants of VVFespecially early marriage, childhood malnutrition, and assistance to women duringpregnancy and childbirth.In many health settings there are extensive demands on staff rendering services and yetthe care for VVF is also intensive and demanding, requiring total commitment to themanagement of VVF.a) The ultimate prevention of obstetric fistula is timely intervention to relieveobstructed labour by caesarian section. There should be skilled staff inperforming safe caesarian section alongside those to repair fistulaeb) Effective and appropriate post delivery care is vital in preventing VVF formationby resting the bladder though continuous bladder drainage and early institution ofantibiotic therapy. This reduces the size of fistula and the degree of fibrous tissueformed both of which determine the prognosis of fistula repair.A successfully repaired VVF is life-changing and restores a woman’s health and socialstatus because the woman can be accepted and return to her husband, family andcommunity. She can play her role as a wife and mother because she can marry andbecome pregnant provided she understands the need for hospital delivery where operativefacilities are available.In Uganda only 38% of all the pregnant women are assisted by a skilled (birth) attendantat childbirth. This very low rate of assisted deliveries combined with delay by themothers deciding to seek appropriate care, delay in arriving at a treatment facility anddelay in receiving adequate treatment, compounds the problem of fistula formation.On the social aspect the low status of women, lack of access to control resources andlimited access to education compound the problem of poor pregnancy outcomesincluding VVF. It is important to note, at this juncture, that little attention is attached toadolescent pregnancy even though 70% of Ugandan mothers experience their firstpregnancy by the age of 19 years.Since VVF is a result of neglected obstructed labour, a factor, already addressed by safemotherhood initiative, programs to address fistula should be integrated in the existing

4sexual and reproductive program but a special programme to address the already existingfistulae would be given priority and special funding.The solution may not lie in mere increase of access and quality because there are manyeconomic socio-cultural and psychological barriers, which hinder women utilizing healthservices. These dictate more study and investigation, through artistic, socio-scientificessential health research.There is need to address issues of behaviour change, effective communication strategiesbetween women and service providers, as well as community education, mobilisation andinvolvement in ensuring safer pregnancy.

52.0 TERMS OF REFERENCE2.1 Objectives of the StudyThe overall goal was to increase knowledge and understanding of the magnitudeof the obstetric fistula among stakeholders, including existing capacity and gapsin preventing and treating obstetric fistula in Uganda.2.2 Specific Objectives(a)(b)(c)(d)(e)(f)(g)(h)(i)(j)Assess the existence of policies regarding obstetric fistula.Estimate the numbers of fistula reported at the health units and theirrelative catchment areas.Analyse and comment on adequacies of services providedEstimate the number of skilled persons currently practicing, where theyare based and the volume of work they are currently handling.Assess the curricula of medical training schools and the depth of trainingbeing undertaken on fistula.Assess facilities currently available e.g. theatre space, and the necessaryrequirement and supplies for fistula repairs.Examine existing sources and adequacy of financial support fromGovernment and other partners to the management of fistula in thecountry.Assess, or establish if there are instruments available to collect data onfistulae and what could be done to improve these instruments.Establish existing and potential partners including donors, NGOs,researchers, etc. currently involved in fistulae related activities and assessthe existing mechanisms of coordination.Make appropriate recommendations.

63.0 METHODOLOGY:This study was mainly cross-sectional quantitative and qualitative in nature.This work was conducted by employing a variety of methods:1. Document or literature review from the Ministry of Health, UNFPA, WHO,District and development partners on fistula in Uganda and elsewhere.2. Conducting key informant indepth interviews with the Ministry of Healthheadquarters, and medical training schools staff, district authorities anddevelopment partners.3. Performed physical inspection of facilities available and identified gaps formanagement of fistula at each health unit visited.4. Interviewed service providers currently involved in the management of fistula toestablish their training, acquired skills and handicaps.5. Collected data on fistulae from records and through interviewing patients withfistula currently undergoing or waiting for treatment at:a. Mulago national referral hospitalb. Nsambya, Rubaga and Mengo missionary hospitalsc. Mbarara teaching hospitald. Regional hospitals at Mbale, Soroti, Masaka, Hoima, Kabale, Arua, Gulu,Jinja and Fort Portal hospitalse. Kitovu hospital, Kagando hospital, Nebbi hospital, Kamuli hospital, Lirahospital, Mutolere hospital and Lacor hospital were included because of theirinterest and work in fistula activities.3.1 Ethical ControlGiven the highly sensitive nature of VVF confidentiality was assured and every effortwas made to interview the patients in privacy and personal questions minimized.3.3 Preparation for the StudyA series of meetings were held between the client and the Consultant to harmonizestrategies and logistics for the study. The Consultant developed and pre-tested the toolsand discussed them with the client. During data collection the Consultant briefed theclient and the National VVF Task Force on the progress of the study.

74.0 RESULTS4.1 PolicyIn the year 2001, the Ministry of Health, Community Health Department in theReproductive Health Division formulated the National Policy Guidelines andService Standards for Reproductive Health Service. Obstetric fistula wasobserved as a silent morbidity among Ugandan women with physical andpsychological trauma but arising little interest and attention. No data on theprevalence is available and very few hospitals and specialists offered someservices for the victims, and therefore, the following policy objectives wereformulated:a) Integrate the management of VVF/RVF into existing RH services, at alllevels of health care depending on facilities available and providercompetence.b) Improve access to the management and rehabilitation of clients withVVF/RVF.c) Eliminate or reduce the factors that cause VVF/RVF formation byensuring information dissemination and good obstetric care. “Emphasison Prevention”.On the face of it, the policy is fantastic but the problem lies in the implementationprocess. Because little is available in terms of implementation many of ourrespondents did not even know there was a policy on management of fistula. Itcould also be due to poor dissemination of the National Policy Guidelines andService Standards for RH service document. A few respondents were aware ofthe traditional practice of fistula management by the specialist obstetriciangynaecologists mainly based in National Referral and Regional ReferralHospitals.Among the government strategies to implement the policy were:• Training of service providers in counselling and referral of fistula victims• Pre- and in-service training of service providers in pre- and post-operativeprocedures for fistula.• Integration of the management of fistula into existing RH services at regionaland referral hospitals.• Development, printing and dissemination of training curriculum serviceguidelines and manuals for prevention and management of fistula.• Upgrading HMIS format to capture data on fistula.• IEC: the development printing and dissemination of IEC materials on fistula• Advocating for the removal of gender bias and isolation of the victimsThe existence of this policy on VVF was unknown to many respondents especially atdistrict level. There is need to disseminate the document to all stakeholders and ensureits implementation.

85.0 INDIVIDUAL HOSPITAL ASSESSMENT5.1 Mulago National Referral and Teaching HospitalAlthough this is the largest hospital with four operating rooms and over 15Gynaecologists and 20 Surgeons of quality training and skills, only 9 cases of vesicovaginalfistula had been repaired during the year 2002. This was not withstanding thefact that 33 cases had attended the Gynaecological outpatient clinic. Theoreticallytreatment is supposed to be free but patients admitted that they had to incur expenses inthe form of gifts or motivation to the staff in order to expedite the process. They had tomeet expenses of all the necessary investigations and any drugs that were prescribed andnot obtainable from the hospital. Many doctors interviewed agreed that they lackedconfidence due to inadequate skills. The operations were very long and difficult, lastinga minimum of four hours and had no financial or other benefits to the surgeons.The nursing staff stated that they were often very few on duty and on many occasions onenurse would be expected to look after 70 or more patients including post operativevesico–vaginal fistula patients, thereby giving inadequate attention to the patientsrequiring intensive observations.Curricula for medical and nursing schoolsThere is no curricula which provided for hands-on training in fistula. This was coveredtheoretically as a complication of obstructed labour.Similarly at Postgraduate level there was no specific requirement to acquire skills in themanagement of the fistulae. It depended on whether the trainee had a chance to beattached to work with a consultant who was keen on fistula repair. Both doctor and nursetrainees had a high probability of finishing their training without witnessing a case offistula treatment particularly if allocated on a ward where the consultant had no interest infistula repair.RecommendationA special wing of one of the wards be assigned to the fistula cases with a specialequipped theatre and team of motivated and interested staff to care for fistula patients.This unit would render service and provide training to other members of staff within oroutside Mulago and at the same time provide opportunity to fistula patients to betreated without competing for space with other more urgent patients.5.2 Mengo and Rubaga Missionary HospitalsIn the year 2002, no fistula or few if any fistula patients were treated or seen at theoutpatient clinics. The main reason advanced was that these were paying hospitals andthe fistula patients were so poor that they could not afford the hospital charges. Eventhough the surgeons would be interested they would not have enough clients to keep thembusy. Although both hospitals had a scheme to subsidize the poor, there was no specificfund for the fistula patients because the condition is not classified as being urgent and

9hence would never qualify for subsidy or exemption. Each hospital has two seniorconsultant gynaecologists.5.3 Nsambya Catholic Missionary HospitalLike the other two hospitals, Nsambya had no patients in the wards or at the outpatientclinics. However, early this year the hospital started what is known as the “VVF Week”.The first VVF week attracted 13 cases all of which were repaired and only 2 failed toheal. The VVF Week is a joint effort by Nsambya hospital and a visiting surgeon Dr.Brian Hankook from the U.K., to offer free treatment to VVF patients. The hospitaloffers free bed space and the surgeon brings equipment and drugs and also performs thesurgery free of charge. On average it costed about 300,000/= per patient (equivalent toUS$200) and provided hands-on training on VVF repair to two gynaecologists atNsambya hospital.On average very few patients can afford this fee let alone VVF patients who are normallyvery poor and unemployed.RecommendationFor paying hospitals, a special fund for VVF patients should be created to offset theexpenses incurred in their treatment, if possible, including the surgeon’s fees wherethere are no volunteers.Population served by Mulago, Mengo, Rubaga and Nsambya Hospitals by districtDistrict Males Females TotalKampala 593,802 625,749 1,219,551Kalangala 20,625 13,851 34,476Kiboga 118,380 112,851 231,231Luwero 235,942 243,980 279,922Mpigi 208,524 206,005 414,529Mubende 350,774 346,159 696,933Mukono 389,439 398,893 788,332Wakiso 449,455 464,656 914,111Kayunga 144,113 151,981 296,094Nakasongola 64,655 63,471 128,126Total 2,575,709 2,627,596 5,203,305Uganda Population and Housing Census – Preliminary Report 20025.4 Kitovu Catholic Missionary HospitalThis is a hospital doing commendable work in fistula treatment. Visiting VVF surgeonsled by Dr. Brian Hankook come periodically to the hospital and conduct VVF repair onpatients free of charge. Because of their good reputation, at the last VVF weekconducted between 24 th February and 7 th March 2003 a total of 60 patients reported with

10leakage of urine and 40 were successfully repaired. In the year 2002 a total of 41 patientswere operated. Next VVF week will be conducted September 2003.RecommendationKitovu hospital can be supported to be a Regional Training Centre to offer both patientcare and Surgeon/Nurse training in view of high degree of awareness and largenumber of patients.5.5 St. Francis Mutolere HospitalThis hospital is in Kisoro district about 18 km from Rwanda boarder and 10 km from theDemocratic Republic of Congo boarder.A total of 16 cases were operated on in the year 2002. This hospital derives its clientsfrom both Kisoro (Uganda) Rwanda and The Democratic Republic of Congo. Each VVFoperation costs a total of about 40,000/= still not affordable by the majority of patients,though comparatively cheaper than other urban hospitals in other regions. The patientscannot access the hospital. There is one resident gynaecologist with very dedicatedNursing staff. He could be persuaded to participate in a mobile team which could assistother districts in the region of Kabale, Rukungiri, Kanungu who have similar problems.The hospital has an adhoc subsidy or exemption of fees for the poor but with no clearguidelines especially for VVF patients. It was apparent that there was need to increaseawareness on the VVF treatment in the community.5.6 Kagando HospitalThis is a Church of Uganda founded missionary hospital in Kasese district of WesternUganda, with highly motivated and committed staff. They generate local revenue anddonor support from the United Kingdom and United States. They have their own hydropowerand water generation stations.They received visiting surgeons two times last year spearheaded by Dr. Hodges Andrew,once a resident gynaecologist at the hospital, and Dr. Ralph Settatre.The hospital has trained medical officers without postgraduate qualifications to performVVF repair with astonishing results.Dr. Timothy Makumbi - one of the trained medical officers, now on a postgraduatecourse in surgery at Makerere University performed 24 VVF repairs of which 14 (58%)were successfully done and patients cured.Dr. Robinson Sebuwufu is a Resident Medical Officer who has carried out 17 VVFrepairs and 13 (76%) have been successful.

11VVF week was carried out between 28 th February and 11 th March. A total of 16 VVFrepair was carried out and only two failed to heal giving a success rate of 87.5%.To minimize hospital expenses, the patients were not given routine prophylacticantibiotics but instead received a bolus dose of intravenous Gentamycin 160mg preoperativelyand patients received tablets of Panadol and Valium post-operatively. Onlyhaemoglobin level estimation and blood grouping was carried out in a form of preoperativepatient evaluation. Each patient on average contributed about 35,000= at theend of her hospital stay. Only two patients came from Kasese district, 8 from Ibanda and6 from Kamwenge district.Recommendation1) Kagando hospital can be used as a service and training centre for Westernregion and the team can be used as a mobile VVF team in the region to serveKabarole, Kamwenge, Kyenjojo, Kasese, Bundibugyo and Kibale districts.2) Use of prophylactic antibiotics in VVF post-operative patients need furtherstudy.3) VVF surgery and training could be extended to other doctors with knowledge ofthe anatomy of the pelvis, thereby demystifying the myth of “VVF difficultsurgery”. Well selected medical officers can be trained to repair selected casesof VVF with good results and this will tremendously reduce on waiting bypatients and heavy workload on specialists.5.7 Mbarara Teaching HospitalOnly one gynaecologist performs VVF surgery at this great teaching institution. Lack ofinterest and skills created a “Fear” and repair failure among the surgeons. This leads tofear to perform the operation, failure to gain confidence and skills and concomitantfailure of exposure to skills to all the trainees passing through the institute. Only 8 caseswere repaired in the year 2002. A consultant stated that “there are many VVF patientsfrom the communities all the way from Hoima, Masindi, Kasese, Mbarara, Bushenyi,Kabarole and Tanzania”. After one successful operation three or four other patientsalight from the same area asking for the surgeon who repaired the “successful case”.Skills, interest and courage is what is important in VVF repair and are cross-cutting asenior anaesthetic officer observed.One senior nurse commented that VVF is not taken to be a serious illness because thepatients walk around and apparently looks well. No body appreciates her suffering withleaking urine – “Ekitakuriho” meaning “what does not concern you may not botheryou.”

12Population served by Mbarara Teaching HospitalDistrict Males Females TotalMbarara 537,672 555,716 1,093,388Ntungamo 182,645 197,164 379,809Bushenyi 356,932 381,423 738,355Total 1,077,249 1,134,303 2,211,552Uganda Population and Housing Census – Preliminary Report 2002RecommendationMbarara Teaching Hospital should be facilitated to start a centre for service andtraining in VVF management so that its products are well prepared to fight VVFmorbidity.5.8 Fort Portal Referral HospitalThis hospital serves Kasese, Bundibugyo, Kamwenge, Kyenjojo and Kabarole districts.There is only one gynaecologist and has performed only two VVF repairs in the 2002with 50% success. He had no exposure during postgraduate training and learns throughself-instruction. He has not been able to carry out a lot of surgery because of shortage ofNursing Staff and attributes the break-down of one of the repaired VVF due to lack ofstaff and poor nursing post-operatively. He maintains that there are many VVF patientsin the community but that they do not come to hospital because they are not assistedimmediately or expeditiously. Many patients come and are worked on while those withVVF continue to wait endless. When the patients are discharged and asked to come againthey do not return and the problem of leakage of urine is a domestic shame shared by thepatient and probably her mother.At Virika a nearby Missionary Hospital, a gynaecologist had not settled down to organise hissurgery as he had just returned from study leave. He too thinks there are many patients fromKasese and Kamwenge districts.Population served by Fort Portal Regional Referral HospitalDistrict Males Females TotalKabarole 181,629 179,162 360,791Bundibugyo 102,852 108,764 211,616Kasese 259,012 271,006 530,018Kamwenge 130,422 136,880 267,302Kyenjojo 189,798 190,7442 380,540Total 2,575,709 2,627,596 5,203,305Uganda Population and Housing Census – Preliminary Report 2002While there are hopes that the theatre at Fort Portal hospital will be renovated, the present singleoperating room gives little chance for VVF repair, bearing in mind the possible presence of othermore urgent operations. Therefore, is not suitable for a regional VVF training and service centre,unless all elective operations are suspended for that period.

135.9 Hoima Referral HospitalThis hospital serves Masindi, Kibaale, Kiboga and Hoima districts. There are twogynaecologists with one at the level of a senior consultant. The maternity gynaecologicalward is extremely crowded and they have only a single operating room. Two patientswere admitted on the ward leaking urine and another one leaking faeces in the vagina allfollowing childbirth. “One lady had been with the problem for 16 years since her firstdelivery but had conceived and delivered 7 more children without any problem andwithout her husband realizing the problem”!! She lost her husband one year ago and Isuspect she only came to hospital in anticipation of getting married when she is cured.The medical superintendent who is a general surgeon appreciated the problem exists inthe communities and says we can increase demand by improving the services. A seniormedical officer at Kagadi Hospital, 80 miles from Hoima hospital confidently stated that“you call for them you will be overwhelmed like what happened when we called for cleftpalate and we had long ques of patients. They don’t come because they know nothingwill be done for them”.Population served by Hoima Referral Regional HospitalDistrict Males Females TotalHoima 173,159 169,883 343,042Kibaale 204,888 207,897 412,785Masindi 233,729 232,475 466,204Total 1,077,249 1,134,303 2,211,552Uganda Population and Housing Census – Preliminary Report 20025.10 Gulu HospitalThis is a regional referral hospital for Northern region with a specialist gynaecologist. They referall VVF cases to Lacor Missionary Hospital. Lack of equipment and supplies was stated as abottleneck to surgery. I suspect that this is augmented by lack of skills and interest to repair afistula.Population served by Gulu Regional Referral HospitalDistrict Males Females TotalGulu 236,434 243,062 479,496Apac 342,939 347,348 690,287Kitgum 140,044 144,591 284,635Kotido 302206 303,116 605,322Lira 371,002 380,127 751,129Moroto 98,145 96,628 194,773Nakapiripirit 78,284 76,966 155,150Pader 153,220 158,668 311,888Total 1,722,274 1,750,406 3,472,680Uganda Population and Housing Census – Preliminary Report 2002

145.11 Lacor Catholic HospitalThis is a missionary founded catholic hospital with a wide range of curative andpreventive services. A consultant obstetrician gynaecologist has been trained in VVFrepair at both Nigeria and Zimbabwe Universities. He is keen on VVF surgery. Thepatients are not charged hospital fees but the costs are met by AMREF Kenya and thepatients only meet their transportation to the hospital and up keep. During the year 2002a total of 50 cases were treated with over 90% successful operations. Dr. T. Raassenconducts VVF clinic camps and surgery. The patients came from Gulu, Lira and Apacbut ethnically widespread. There are no specialised VVF equipment available as thevisiting surgeons normally carry their own equipment.5.12 Arua HospitalThis is a regional referral hospital. At the last VVF camp conducted early March 2003only 11 patients turned up for surgery. Available records showed that another 14 patientshad been seen but had not received treatment. A commissioner clinical services at theministry of health and formerly employed at the hospital attributes the low turn up to thereduced numbers of VVF in the community. The VVF camps have been going on since1993. However, he could not ascertain that there were effective measures enough forreduced formation of new cases!!! The patients come from as far as Sudan andDemocratic Republic of Congo.Population served by Arua Regional Ref erral HospitalDistrict Males Females TotalArua 402,175 432,075 834,250Adjumani 83,844 84,120 167,964Nebbi 207,580 226,932 434,512Moyo 102,986 99,305 202,291Yumbe 128,043 126,364 254,407Total 924,628 968,796 1,893,424Uganda Population and Housing Census – Preliminary Report 2002Recommendation.Arua hospital should be facilitated to serve as a regional fistula center for the Northernregion5.13 Nebbi HospitalThis is a district hospital for Nebbi district. Dr. Tom Raassen of AMREF Kenyaconducts VVF camp clinics twice a year and last year 18 cases were operated on. Amedical officer, based at this hospital, performs VVF surgery with good results havingbeen trained by Dr. Raassen.

155.14 Kuluva HospitalThis is Church of Uganda Missionary founded hospital. Although there had been priorinformation that VVF surgery was conducted in this hospital, we were not able toestablish any cases performed at this hospital.5.15 Lira HospitalThis is a district hospital where VVF Camps are held by Dr. T. Raassen and Dr. BrianHankook. The hospital lacks basic equipment particularly a Gynaecological table andgood lighting. The resident gynaecologist has been trained in VVF repair by the visitingsurgeons since 1999; but has never repaired a case on his own. He says his majorhandicap was the non-specialised equipment. In the year 2002 a total of 40 cases wereoperated on and only one case failed to heal.5.16 Amai Hospital (Lira District)No cases of VVF have ever been operated in this hospital although we receivedinformation to the effect that good work on VVF was being carried out.5.17 Soroti HospitalThis is a regional referral hospital with a resident consultant gynaecologist. A surgeonhas been trained in VVF repair at Katsiria Nigeria and has his own personal VVFequipment. The hospital has no equipment for VVF and has no gynaecological table.The available records revealed that one case was operated in the year 2002. However, atthe gynaecological clinic a total of 60 cases had been seen without receiving definitesurgery. No satisfactory reason was advanced for not assisting these poor patients.Population served by Soroti Regional Referral HospitalDistrict Males Females TotalSoroti 180,416 189,711 370,127Kumi 189,203 204,068 393,271Katakwi 129,480 137,824 267,304Kaberamaido 64,496 67,419 131,915Total 563,595 599,022 1,162,617Uganda Population and Housing Census – Preliminary Report 2002Recommendation.Soroti hospital could be used as a training centre for Eastern region because there isalready a trained doctor who only needs encouragement.

165.18 Mbale HospitalThis is a regional referral hospital near the boarder with Kenya. The resident consultantgynaecologist has his own personal kit of VVF equipment. Most of the patients comefrom Kapchorwa and Pallisa Districts. In the year 2002 only 4 cases were operated on.While this hospital is a teaching site for clinical officers it had no partogram in use in thelabour ward.Population served by Mbale Regional Referral HospitalDistrict Males Females TotalMbale 356,755 364,487 721,242Sironko 140,276 142,625 282,901Tororo 265,007 274,455 544,109Pallisa 253,007 269,241 522,248Kapchorwa 96,604 96,437 193,041Busia 109,953 117,892 227,845Total 1,221,602 1,265,137 2,491,386Uganda Population and Housing Census – Preliminary Report 20025.19 Kamuli HospitalThis is a Church of Uganda founded hospital. It has a small single room for operation.Dr. Brian Hankook conducts VVF surgery twice a year and trains the resident doctors.Currently Dr. Stella Nakiwala a medical officer, is undergoing training in V.V.F. repair.In the year 2002 a total of 41 cases were operated and only one case failed to heal. Thepatients only come when the visiting surgeon is coming.5.20 Jinja HospitalA referral hospital for Jinja, Iganga, Bugiri and Kamuli districts. It has three residentgynaecologists with a senior consultant but none of them is motivated enough to operate on VVF.Dr. Benon Wanume community practice specialist repairs VVF but is handicapped by lack ofspecialised equipment and a gynaecological table. Only one case was operated in the year 2002.Population served by Jinja Regional Referral HospitalDistrict Males Females TotalJinja 193,034 198,266 391,300Iganga 344,756 369,879 714,635Kamuli 344,124 362,687 706,811Mayuge 159,434 167,395 326,829Bugiri 201,457 213,316 441,773Total 1,242,805 1,311,543 2,581,348Uganda Population and Housing Census – Preliminary Report 2002

175. 21 AMREF Flying in Doctors: Dr. Tom RaassenThese doctors fly and work in Kenya, Tanzania and Uganda on a similar program like the“VVF Week” arrangement. In Uganda they operate in Gulu district at Lacor hospital,Arua hospital in Arua district and Nebbi hospital in Nebbi district.In Kenya and Tanzania, the patients are transported by AMREF and treated in hospitalswhere the AMREF doctors find them and the cost of treatment settled by AMREF. InUganda the patients transport themselves to the centres where the doctors have madeprior arrangements to operate them. This means only those who can afford transportcosts can access this treatment.Recommendation.Dr Raassen can be used to train the national core team if logistical arrangements allow.5. 22 Masaka Regional Referral HospitalIt has one resident gynaecologist who is keen on VVF repair. He occasionally joins theKitovu hospital VVF camps where he has acquired some skills in the repair of VVF. Hehas operated on 10 cases in the year 2002. The hospital is constrained by equipment andtheatre operating space.Population served by Masaka Regional Referral HospitalDistrict Males Females TotalMasaka 380,503 392,162 772,665Sembabule 91,091 90,963 182,054Rakai 230,184 237,031 467,215Total 701,778 720,156 1,421,934Uganda Population and Housing Census – Preliminary Report 20025. 23 Kabale Regional Referral HospitalThis hospital has two gynaecologists. The hospital has one operating room and lacks agynaecological table. There is no equipment for repair of VVF. Only two cases wereoperated in the year 2002.Population served by Kabale Regional Referral HospitalDistrict Males Females TotalKabale 216,419 245,366 461,785Kisoro 100,812 120,866 221,678Rukungiri 134,119 144,004 278,123Kanungu 99,790 106,101 205,891Total 551,140 616,337 1,167,477Uganda Population and Housing Census – Preliminary Report 2002

186.0 PROVIDER ASSESSMENTA total of 47 doctors countrywide were currently involved in management of fistula preoperativepreparation ranging from performing and assisting at the operation and postoperativecare and counseling, were interviewed. They all responded affirmatively thatthey were involved in hands-on (practical) management of fistula. However thoseparticipating in the prenatal and intra natal care of mothers, who may in any caseparticipate in prevention of fistula were excluded from the study.6.1 Special Hands-on Training in VVF ManagementTrainedNot trained4 (8.5%) 43 (91.5%)Only 4 (8.5%) doctors two Gynaecologist and two Surgeons admitted having beenspecifically trained through a designed VVF training curriculum in a recognized trainingcentre (Nigeria, Addis Ababa and Zimbabwe). The training extended to Ugandan doctorsby visiting VVF surgeons was considered informal as no laid down curriculum was used.The rest of the service providers are not trained and expressed a desire to be trained.Nurses were randomly deployed even when specially trained.6.2 Distribution of Categories of ServiceCategory Number PercentageAnaesthesia 2 4.2%Surgery 28 59.6%Nursing 25 53.2%Prevention 17 36.2%Advocacy 7 14.9%Responses were obtained for more than one function by a single respondent. However, itis important to note that there are a few providers in anaesthesia and advocacy servicesand not by study design.6.3 Adequacy of TrainingCategory Adequate Not AdequatePre-service 7 (14.9%) 28 (59.6%)In-service 6 (12.8%) 23 (48.9%)Pre-service training included undergraduate training for doctors and certificate trainingfor Nurses and Midwives while in-service included postgraduate training and Masterslevel for doctors and Bachelor of Nursing for Midwives and Nurses.

19The training curriculum never spelt out the duration (hours) and competences at bothlevels and training remained on adhoc basis.6.4 Needs for Hands-on TrainingAll respondents expressed a desire for instructed teaching on fistula management. Eventhose who had received formal instruction on fistula management were of similar feelingbecause some of them were not in constant practice while others had not performed asingle case operation in the last one year.6.5 Performance Assessment for the Year 2002 by RespondentsEstimated cases: 0 – 5 6 – 10 11 – 15 16 – 20 ≥20Number of Respondents: 25 (53.2%) 5 (10.6%) 3 (6.3%) 2 (4.2%) 12 (25.5%)6.6 Reasons for Non-treatment of FistulaReason: Skills Equipment Costs Irreparable damage No theatre spaceNumber: 17 (36.2%) 47 (100%) 8 (17.0%) 5 (10.6%) 1 (2.1%)All respondents quoted lack of equipment as a contributing factor but others were quickto add that one could improvise. Lack of skills was a hidden factor which probablycrisscrossed because theatre facility availability was only mentioned by one person.Apart from transport and personal expenses affordability of cost is a minor factor sincemost of the public institutions “did not charge” any fee for fistula operation.6.7 Cost of treatment per person per single operationCost per 1000: Ushs. 10 – 50 60 – 100 110 – 200 210 – 300 ≥310Institution: 11 Nil 4 2 5The cost of drugs, surgeons fee and bed occupancy ranged from 10,000= in the cheapestinstitution to 400,000/= in the most expensive institution.On average the lowest fees started from 100,000=. Only two institutions (hospitals) hada special fund for fistula treatment (Nsambya and Kitovu) and four hospitals had ageneral fund for those who cannot afford to pay out but other illnesses took priority overfistula cases. In Kagando hospital the cost was minimized by not administeringantibiotics routinely post operatively.

21delivery with complications of prolonged or delayed delivery and the consequences. Therole of involving and specifically addressing men was highlighted with the example ofMen’s access clinic in Rubaga Hospital. At this clinic men are educated and sensitizedon their roles and responsibilities in the care of pregnant women and their babies.6.13 Role of Central GovernmentResponse: Community Policy Supplies and Training /Education Formulation Equipment MotivationNumber: 8 (17.0%) 3 (6.4%) 11 (23.4%) 15 (31.9%)Many respondents felt it was the responsibility of central government to provide fundsfor supplies, drugs and equipment as well as staff training and motivation.Policy guidelines should be put in place to direct community education and mobilisationand disseminated to reach rural areas.6.14 Community attitudes towards leakage of urineAttitude: Sympathy Rejection Witchcraft STINumber: 3 (6.4%) 28 (59.6%) 3 (6.4%) 4 (8.5%)The commonest attitude is to isolate or reject the victim leaking urine because of theammoniacal smell. A nursing officer who has worked for 20 years on Mulago Ward 5Asaid, “they are neither visited nor do they have attendants” that is why they are left ontheir own in the hospital.6.15 Presence of protocols or guidelines on management of fistulaOnly Kagando Hospital had well displayed protocols on management of fistula postoperatively.6.16 Educational activities to increase awarenessThere were no activities to increase awareness either to the public or among professionalsexcept for isolated departmental meetings at Nsambya hospital for continued medicaleducation programmes which were not deliberate for fistula.6.17 Visiting SurgeonsDr. Brian Hankook - UKDr. Tom Raassen - AMREF KenyaDr. Andrew Hodges - UK

226.18 Geographical and Ethnical Distribution of Fistula in UgandaEthnicityDistrict of OriginWestern:Mutoro (2)Kabarole, SembabuleMukonjo (4) Kasese (3), Sembabule (1)Bamba (1)BundibugyoMukiga (5)Kabale (2) Ibanda, KamwengeKambuga (Rukungiri)Munyankole (1)Mbarara, SembabuleMunyoro (3)Hoima, Kibaale, KamuliEastern:Adola (1)Munyole (1)Mugisu (2)Teso (1)Samia (1)KapchorwaPallisaSironko, Mbale? KenyaBusiaNorthern:Langi (5) Apac (3) Lira (2)Lugbara (4) Arua (2) Nebbi (1) Congo (1)Alur (1)HoimaCentral:Ganda (13) Rakai (2) Sembabule (2)Masaka (2) Mpigi (3)Luwero (1) Kalangala (1)Wakiso (1) Mukono (1)Nyarwanda (3)Masaka Sembabule LuweroThis study does not show any clear ethnic of geographical preponderance probablybecause of small sample size. However, in Uganda there are some tribes by virtue oftheir genetic constitutions or geographical disadvantages are more prone to obstructed

23labour. For example, the Bakonjo from Kasese and Bundibugyo districts are geneticallyof small stature and hence small pelvises, while the Bakiga in Kabale and Rukungirireside in a hilly terrain with hardly any transport and communication (see Engozi form ofambulance for transporting patients).The Baganda are genetically known to have typical gynaecoid pelvises with reducedoutlet parameters of the pelvis.Rural Scenery of Kabale

Typical Road up the hills off Kabale24

Engozi – Common ambulance south western region25

267.0 CHARACTERISTICS OF PATIENTS WITH FISTULAA total of 30 patients with VVF were found admitted in the wards either waiting forsurgery or recovering from surgery and were interviewed using questionnaire number 2.7.1 Age distributionAge: ≤15 16 – 20 21 – 25 26 – 30 ≥310 8 (26.6%) 7 (23.3%) 5 (16.7%) 10 (33.3%)There were young girls average age 21 years. At the time of this study, those abovethirty one years had lived with the disease an indicator of the degree of neglect orinaccessible services. There should be introduced programmes that target delay ofpregnancy and sexuality among young (adolescent) girls.7.2 Marital StatusStatus: Married Single Separated WidowsNumber: 10 (33.3%) 10 (33.3%) 9 (30.0%) 1 (3.3%)Only 33% of the women were in stable marriage. Instability in marriage or spouserelationship is common among women with fistula.7.3 Menstrual patternMenses: Regular Irregular AmenorhoeaNumber 26 (86.7%) Nil 4 (13.3%)A few women exhibit amenorrhoea with VVF and may be due to pituitary damagedisorders or severe genital tract sepsis as a result of prolonged labour.7.4 Parity distributionParity Primepara 2 – 4 ≥5Number: 20 (66.7%) 6(17.5%) 4 (13.2%)The majority (69.3%) sustained the fistula in their first pregnancy. Although mothersgain false confidence after the 3 rd delivery that nothing can go wrong, 13.2% of thewomen had more than 5 deliveries. Among the multiparious women, obstructed labourfrequently results in ruptured uterus other than VVF.7.5 Educational Standard:Education level: None P1 – 3 P4 – 7 Secondary Post SecNumbers: 6 (19.8%) 7 (23.1%) 15 (49.5%) 2 (6.6%) 0

27Only 2 women had gone beyond secondary level indicating low educational and socioeconomicstatus. The education of the girl child and economic empowerment of womenhave been associated with improved childbirth outcome.7.6 Duration of Leakage of UrineDuration: ≤3 months 3 – 6 months 7 – 12 1 – 5 yrs ≥6 yrsNumbers: 2 (6.6%) 3 (10.0%) 5 (16.7%) 9 (30.0%) 11 (36.7%)More than half of the women (66.6%) had been leaking urine for more than one yeareven some over 20 years. This again confirms failure to access appropriate treatment.7.7 Antenatal Clinic AttendanceAttended Not attended Health Centre Hospital Seen by22 (73.3%) 8 (26.7%) 18 (60.0%) 4 (13.3%) Dr. (1); MW (21)7.8 Anticipation of Complication at DeliveryYes No Advice Given6 (19.2%) 16 (63.3%) 6 (19.2%)Although a good proportion of women attended the antenatal clinic, were examined by atrained midwife and their pregnancies progressed normally during antenatal period, therewas no prediction of possible difficulty in delivery except in 6 (19.2%) women who wereadvised to deliver in hospital or referred as appropriate. Therefore, health facilitydelivery should be mandatory regardless of normal antenatal course of any pregnantwoman in order to avoid unprecedented complications during labour.7.9 Duration of LabourTime: ≤6hrs 7 – 12hrs 13 – 24hrs ≥24hrsNumbers: Nil Nil 6 (20.0%) 24 (80.0%)The majority of women 80% had labour lasting more than 24 hours well beyond normallabour duration.7.10 Mode of deliveryDelivery Caesarian Spontaneous Vaginal Assisted VaginalNumbers: 14 (46.2%) 12 (39.6%) 4 (13.2%)The high operative (caesarian 46.2%) rate among these women is indicative of obstructedlabour which can only be relieved by operative intervention regardless of the status of thebaby particularly in unskilled hands for destructive operation in case of a dead foetus.

287.11 Condition of the baby at DeliveryCondition Stillborn AliveNumbers: 25 (83.3%) 5 (16.7%)All the women laboured for more than 12 hours up to even more than 48 hours. Themother and the baby are worn out by the labour process. Commonly the baby succumbsto the stress of labour and dies before delivery.7.12 Hospital stay after DeliveryTime: ≥24hrs 1–2days 3–5days 6–10days ≥10daysNumbers: 1 (3.3%) 3 (10.0%) 9 (30.0%)Only 43% of the women delivered in hospitals. It could not be established for how longthey had in labour in hospital before surgical intervention.7.13 Time interval between delivery and onset of leakage of urineTime: Less than 3 days Immediately after More than 4 daysNumbers: 11 (36.7%) 10 (33.3%) 9 (30.0%)Immediate leakage of urine was reported among 10 women who had delivered bycaesarian section. Those who leaked within 3 days and after the operation are anindicator of poor postpartum care. Ideally they should have had continuous bladderdrainage for at least 10 days which intervention is well known for healing small fistulaeand reducing the size of fistula during postpartum recovery.7.14 Postpartum CounsellingOnly 7 (23.1%) women had received an explanation on how and why they sustained theinjury of a fistula. No attempt or bother was made to explain the women, up to the timeof the interview regardless of their having been admitted to the ward. This showed grossinsensitivity on the part of health providers on the problem of fistula and poorinterpersonal communication skills.7.15 Funds available for Treatment expensesUshs. ≥30,000 40,000 50,000 ≥60,000Numbers: 24 (79.2%) 2 (6.6%) 2 (6.6%) 2 (6.6%)The majority of women (79.2%) had less than 30,000/= with them to contribute to theirtreatment. This was far short by 10 times what they would on average require. Thisconfirms that these women are of low income and poor economic status.

298.0 KEY INFORMANT INTERVIEWSAn in-depth interview was conducted among 24 persons who included the DistrictDirector of Health Services, the District Nursing Officer or District Public HealthNurse/Visitor. These were selected because of their experience and work which requirethem to interact with grassroot people at rural health units and have access to all datacollected from the whole district. They are also involved in district planning andimplementing policy and projects in their district. The senior staff of the Ministry ofHealth headquarters and heads of development partners were similarly interviewed.8.1 Attitudes and beliefs of families and communitiesPregnancy and ChildbirthThis is a source of joy among stable couples or family but could be a source of miserywhen untimely like among the Bakiga “a curse to the girl if she conceived outsidemarriage”.A normal woman is expected to have a normal vaginal delivery and women who fail toconceive or deliver are inferior in society or have been bewitched. They will spend timeand money to get a child at any cost, as infertile women are denied family privileges.Operative Abdominal Delivery (Caesarian Section)Most women and communities are scared of abdominal operative delivery. It is neverwelcome and remains for weak women who cannot prove their womanhood. Everythingwill be done to avoid caesarian section and this would include going to hospital late wheneverything has failed. Many women believe if one goes early to hospital it can lead toher being operated early because “the health workers are impatient and do not wait forlong enough”. In Kabarole district among the Batooro, a woman in labour should bebrave and make no noise regardless of the severity of pain in order not to alarm people athome. She can be hidden in a banana plantation or bush to keep her away from people.Among the Banyankole if a mother is in labour in the hospital she must remain quietotherwise any “noise made during labour in a hospital alerts health workers to ‘cut’her”. Delivery is a private affair only close female relatives like her mother or motherin-laware supposed to be near and see her private parts unlike in hospital where privateparts are exposed for every one to see and later narrate stories.A lady from Kamwezi said that even if it meant “Kushatuka akahago” i.e. to rupture herbladder, she would never go to hospital to expose her private parts as health workerswould later talk about her natural anatomy of her genitalia.A few women deliver in health units in Mbarara district because they fear unnecessaryexposure of their private parts in hospital, a midwife at Kabuyanda said. Lying in supineposition during childbirth is not acceptable. They prefer to stand or squat while clothesare hanging and this reduces exposure of private parts as opposed to lithotomy or supine positionsimposed in health units.

30Provision of quality care may contribute to the desired goal of increasing demand for theutilization of health services for antenatal care especially supervised delivery andpostpartum care by skilled attendants. This is only possible if cultural and individualrights are sensitively respected by health providers.Leakage of Urine after DeliveryThis is a serious disaster to occur to any childbearing woman as it lives her with anoffensive smell. This isolates her from the rest of her family members and society andshe is rejected by her spouse because of the smell and wetting of the bed. These womenare sent back to their parents’ homes to be taken care of and even there, only theirmothers feel concerned. So the illness is concealed from the public and remains betweenthe mother and her daughter who at times is given food to eat alone so that others cannotdetect the problem. Since she will be mobile with no obvious illness or weakness,society is ignorant of the physical and psychological effects.8.2 Major Social Problems Associated with FistulaThe commonest problem is stigmatization and rejection of the victim by families andsociety. The victim lives a solitary life like an outcast. This obviously results in spouseseparation or divorce in case of married couples and unless the problem is rectified therelationship breaks up completely and the victim may never marry again. She remainseconomically handicapped with limited independence and hence a failure in life.There are family conflicts with each one accusing the other of witchcraft and beingresponsible for the misfortune. Sometimes these conflicts can erupt into violence.8.3 Community Perception of FistulaIn all regions of Uganda the community had little or no understanding of the cause andavailable remedy for fistula. The victim is first treated with traditional medicine beforeconsulting health units. The traditional healer may take years treating the condition andmoving from one traditional healer to another. When they eventually decide to come tothe health units, they have been stripped of all their assets and revenue by the traditionalhealer, and sometimes cannot even afford transport cost to the health facility.Failure to get assistance at health units or failure to cure the fistula by surgery furtherundermines the community confidence in the essence of going to health facilities at all.Two members of the Association of Uganda Women Medical Doctors cautioned that“before sensitizing the communities about issues of fistula, there should be goodpreparation for managing the fistula so that the little existing confidence of thecommunities in the health care system is not eroded”.

31Communities must be made aware of the cause, social consequences and availabletreatment of fistula especially the dangers of unsupervised deliveries by a skilledattendant. Men should increasingly participate in the care of pregnant women during andafter childbirth. Communities should have capacity to respond to women’s needs duringpregnancy and childbirth. There should be stimulation for increased demand for utility ofhealth services so that women deliver in health facilities. “Enhanced communityparticipation in maternal and neonatal health care services”.8.4 Funding and Resource Mobilisation for Fistula ManagementNeither the central or local government allocates special funds for management of fistula.However the Ministry of Health and Development Partners are even prepared to have are-focus of fistula management with a view of allocating special funds from their budgetsand mobilizing resources from other sources. UNFPA has taken lead in this direction andnoble duty.8.5 Measures to Improve Service Delivery for Management of FistulaEfforts should be made to prevent formation of more or new fistula by ensuring qualityAntenatal Care; good care from a skilled attendant of labour, delivery and immediatepostpartum period. This is only possible with effective supervision of service providersand putting measures in place for immediate referral of mothers who need furthertreatment from specialised facilities. The communities should be sensitized andmobilised to encourage pregnant mothers to deliver in health units with skilledprofessionals.A consultant obstetrician and gynaecologist had this to say “A good referral systemshould take into consideration speed of transferring from one place to another, safety ofthe client, sustainability of the system as well as the cost benefit to both parties and thecomfort of the client. An effective referral system must prevent delay in seeking help,delay in reaching a facility where care is offered and delay in receiving medical care ofgood quality at the facility”.There is urgent need to manage existing cases of fistula in order to instill confidence inthe community. Special programmes like fistula camps designed for the treatment offistula at regional level were suggested. If these are conducted in regular hospitalfacilities all other elective surgery should be suspended to give chance fistula patients tobe worked on, during the period stipulated for the fistula camp.These same camps can be used for training doctors, nurses and midwives. However, theissue of motivation of service providers was sounded out loudly.8.6 Adequacy or Efficiency of Health Facilities to Manage FistulaeIt was evident that there were few trained doctors and nurses to competently managefistulae. Above all these were handicapped by lack of equipment, drugs and other

32supplies. The problem is compounded by the poor socio-economic status of the fistulapatients who cannot supplement their treatment or even access free treatment.8.7 Curricula for Training Doctors and Nurses in Management of Fistula1) Pre-service training for both Doctors and Nurse/Midwife is inadequate anddoesn’t expose the trainee to acquire desired skills to manage fistula.2) In-service Training including postgraduate training is not systematic and thereforethere is a great probability that many specialists have no competences inmanaging fistula.3) Communication skills and attitudinal change.The management of fistula patients require a more humanistic approach and this demandsthat the service provider listens, sympathizes and assists the fistula patient to cope withthe problem.

339.0 KEY FINDINGS9.1 PolicyThe National Policy Guidelines and Service Standards for Reproductive Health Servicesprovides a specific policy on fistula management, but there are prominent gaps indissemination and implementation. Many service providers and policy makers were notaware of its presence.9.2 Magnitude of FistulaIt was difficult to estimate the numbers of fistulae reported at health units because ofabsent or/and inaccurate records. Many patients preferred to remain in the communitiesbecause they received little or no assistance at health facilities.9.3 EquipmentAll regional hospitals were not well equipped to manage fistulae. They lackedspecialised VVF equipment, supplies and drugs.9.4 Provider Skills for Managing FistulaThere is no trained manpower to manage fistula in the Uganda health facilities. Themajority of work was done by people who have acquired experience on the job throughdiscovery and, self-instruction or volunteers from abroad. This does not guaranteequality service for VVF patients.9.5 Poor access and utility of servicesMany patients with fistula do not seek hospital treatment until treatment with traditionalmedicine has failed. This could be due to the belief that fistula is associated withwitchcraft or the little confidence communities have in the health services.9.6 Referral SystemThere were no clear guidelines on the type of transport or communication system to use.Transport was distributed without taking into account the terrain and geographicalfeatures of the areas. In the mountainous of the South-Western Uganda such as Kabaleand Kisoro districts the bicycle ambulance was considered inappropriate while it couldserve very well in the more flat areas of Eastern and Northern Uganda. In many hospitalsthere were wreckages of vehicles previously working as ambulances lying in compoundsabandoned in disrepair due to small faults.

34Bicycle Ambulance (hind view)Broken down neglected Ambulance in a hospital compound – Kisoro

35Suzuki Maruti Ambulance – More Appropriate for Rural Setting9.7 Cost of Health CareThe treatment cost of fistula remains expensive because of long hospital stay, relativelylow success rate and the low economic status of women. On average a successfuloperation on first attempt costs about US$ 200 – 300 and some patients may require morethan one attempts at operation, while the average stay in hospital is 21 days but somecould stay in hospital for as long as one year.9.8 Community Awareness and Involvement in Fistula CareMost community settings, individuals or groups do not know the major cause of fistula,its prevention, impact and available remedy. They associate leakage of urine withwitchcraft and sexually transmitted infections. They resent and reject individuals withfistula who end up stigmatized and segregated from families and communities.9.9 Attitudes of Health Care Providers Towards Fistula PatientsThe majority of service providers feel sympathetic to the fistula patient but arehandicapped in terms of skills, facilities and financial support, to assist the patients. Fewobstetric fistula occur within the health facilities, rather many of the patients arrive athealth facilities when they have already sustained the injuries. However, many healthcare providers lack interpersonal communication skills to interact with patients.

369.10 Characteristics of Patients with FistulaThese were young girls average age of 21 years with low educational standards and poorsocio-economic background which compromised their access to health care.9.11 Medical Schools Training CurriculumAll training curriculae for doctors, nurses, and midwives at pre-services or in-servicelevels lacked competence based provision for hands-on-training in fistula management.The Postgraduate training curriculum in particular, does not guarantee acquisition ofskills in VVF management by the graduate specialist.9.12 Financial Support to VVF ProgrammesThere was no evidence of specific financial allocation for VVF activities from Central,Local Governments or Development Partners except for adhoc arrangements byindividuals hospitals and doctors.9.13 Health Management Information SystemThere is no systematic information gathering about fistula in Uganda. Therefore, it isdifficult to exactly ascertain the magnitude of fistula problem in Uganda. However, the“VVF Week” program with minimal community mobilization yield good results inpatient turn up, indicating that there are many more cases in the communities. Since themajority of deliveries take place at home, it is incumbent that the information isobtainable from gynaecological attendance and operation theatre registers is notrepresentative of the situation on ground.9.14 Potential for Collaboration, Coordination and ResearchThe Ministry of Health, development partners and women rights activists have realisedthe health and social consequences of VVF and have agreed to address them. CurrentlyUNFPA has taken the lead and this study is the first of such initiatives.No evidence was found on any research performed or on-going except for individualdoctors case documentaries.9.15 Job Description and SatisfactionMany health care providers in Uganda have no distinct job description in regard to fistulacare and many earn meagre salaries and have to supplement their living through otherincome generating activities. This denies patients of dedicated and skilled workersbecause of the little financial gains from the poor fistula patients.

379.16 Advocacy and IECAdvocacy/IEC activities at community, district and national levels were weak and needstrengthening.Although the central government has devolved powers and services to the localgovernment, the Ministry of Health has the responsibilities of issuing policies andguidelines to the districts. Both central and local governments are not sensitized aboutcauses, prevention and impact of fistula to allow them to adequately budget and financefistula activities.

3810.0 RECOMMENDATIONS10.1 Immediate Recommendations(ii)(iii)(iv)Mulago National Referral hospital and Mbarara Teaching hospital be immediatelyfacilitated and strengthened with manpower to train VVF management for pre andin-service providers.A core team of four (4) surgeons and four (4) nurses/midwives be trained toconduct VVF camps and in-house training of “medical officers”. Four VVFRegional Management Centres be established, equipped and facilitated atKagando Hospital (West), Arua Hospital (North), Soroti Hospital (East) andKitovu Hospital (Central). The selected sites have functional capacity and acritical mass of clients and would serve as training centres for service providers.Review of medicinal school postgraduate curricula for obstetrics and gynaecologyto introduce fistula management as an examinable subject with measurable ordefined skills and competences.(v) A National Coordinator for VVF programmes be appointed on contract basis for 3years. The coordinator should be a full time job occupied by a Senior ClinicalSpecialist.(vi)(vii)HIMS data collection tools should be upgraded so as to specifically capture dataon VVF/RVF.The National Policy guidelines and service standards for Reproductive Healthservices should be effectively disseminated to all stakeholders, using availablechannels of communication.10.2 Mid-term Recommendations(i)(ii)(iii)(iv)All health sub-district units be equipped and staffed to cater for emergencyobstetric care especially theatre facilities for emergency caesarian section andvacuum extraction.Review of training curricula for Doctors, Nurses and Midwives in labourmonitoring and appropriate interventions, with emphasis on prevention ofobstetric fistula.Advocacy for community participation in health related matters especiallyobstetric fistula.Introduction of referral systems that are reliable and efficient in terms of transportand communication, for all women during pregnancy and childbirth.

39(v)(vi)The provision of transport to collect patients from designated centres to hospitalsfor repair like in the case of AMREF would access the service to those who cannot afford transport.Introduction and enforcement of a financial scheme such as a community loan orcontributory fund to assist the disadvantaged to access health care for theirailments particularly miserable women with obstetric fistula.• Establish a community loan scheme for support of reproductive and otherhealth services.• The consultants support supervision program by the ministry of health shouldparticularly focus and specific funds put aside for VVF camps as the case isfor Orthopaedic Surgery.• Health Insurance(vii)Review of allocation of funding for managing current VVF case load should beencouraged at all levels of administration including appropriate referral systems.(viii)(ix)(x)Establish Biannual regular “Regional VVF Camps” at regional referral hospitals.Strengthening community education and mobilization with enabling communitylegislation, building confidence in health care facility utility and examiningcultural practices and beliefs particularly the role played by the traditional birthattendant.Satisfy need to refocus our training priorities.• In-service specialised training which aims at providing skills in managementof obstructed labour and prevention of VVF as well as appropriate hands-onskills in management of fistula. The training could be conducted here inUganda using experts from Ethiopia or Nigeria fistula hospitals or the traineesbeing sent to the centres in Addis-Ababa and Nigeria. The in-country trainingis more cost effective.• The pre-service training curricula for doctors, clinical officers, midwives,nurses and other support staff should emphasize such skills as will improveprevention of fistula formation particularly community education,mobilisation and involvement in management of fistula.(i) All postgraduate students in obstetrics, and gynaecology should receive hands-onskills in repair of VVF and be required to be assessed on their competence.

40(xi)(xii)Detailed protocol and guidelines on management of obstructed labour andrepaired fistulae should be developed, including communication skills for thehealth staff and distributed to all health facilities.Center(s) of Excellency in VVF CareGovernment and development partners should consider center(s) to serve womenwith VVF. This can act as a nucleus from which outreach teams can travel allover the country to offer services and support to less privileged individuals in therural areas.10.3 Long-term Recommendations(ii)(ii)(iii)(iv)(v)(vi)(vii)There is need to train health professionals involved in the management ofobstetric fistula using locally adapted guidelines and standards.The following interventions should be strengthened to ensure access of services.• The provision of transport for referral,• Adequate staffing,• Financial logistics,• Supplies and appropriate equipment.All regional referral hospitals should be equipped with VVF specialisedequipment. Efforts be made to introduce regional training and service centres toimpart improved skills in the treatment of obstetric fistula – hands on in-servicetraining.Every effort should be made to put in place programmes or activities that offersupport and rehabilitation to women with fistulae within their communitieswithout enhancing stigmatization.Communities and rural health workers should be sensitized on the cause andprevention of obstetric fistula, so that women who sustain obstetric fistula aremobilised and motivated to go for surgery.The government should encourage Education of the “girl child” and “economicempowerment of women and their communities”.High profile should be given to the cause and prevention of obstetric fistula andthis could increase the number of women coming for delivery in health units.(viii) Prevention of formation of new fistula by implementing the safe motherhoodobjectives:• Provide guidance to health care providers in the delivery of quality maternaland newborn care services at all levels.

41• Enhance quality of safe motherhood services- Pre-conception care e.g. Nutrition and adolescent health;- Antenatal care- Intrapartum care- Emergency obstetric care- Postnatal care• Provision of adequate accurate information education and counselling servicese.g.Adolescent Sexual Reproductive Health• Integrated maternal and newborn service into National health System.(ix)Review clinical procedures that create barriers or delay in management of fistulapatients• Timing of pre-operative assessment under general anaesthesia• The role of post operative chemoprophylaxis• Routine pre-operative laboratory investigations

4211.0 HOSPITAL SUMMARY FORMForm 4Name of HealthUnitKITOVUHOSPITALJINJAHOSPITALMBARARATEACHINGHOSPITALCategory(subcountiesserved)MJinjaDistrictRC/SsetBasic EquipmentFistulaAnesthetic3 NA A A1NA A NASuture OB/GYNMr Nsiimwe PMr. AgelMr NyolyaWasswa G.Msheilia4 NA A A MugerwaMehayoMillan M.Staffing by NameSurgeonMidwives /NursesPower Water Theater SterilisationNO. VVFrepairedYesNoLaboratoryMaura Lynch NamutebiBakaki Wilson Victor A A 2 A 26 28 NA NAEkwaruAnyamaWanumeDr. BarugaSOROTIHOSPITAL R 2 NA A A Mr. Egwau Mr. Kirya AX-rayunitA A A A 1 - A AA A 2 A 8 12 NA NAA A A 1 60 A AKAMULIHOSPITALLIRAHOSPITALMR3 NA A A2 NA A ADr. NakusalaMr. MatovuDr. BukenyaDr. KashabaMr. Adupa Odyek B.Mr. NamOkelomA.A A A A 41 1 A AA A A A 40 85 A AAMAIHOSPITALM1 NA NA ADr Oremo RDr Asanyo JApili A.Alele R. A A A A - 3 A AKEY: R - Referral M - Missionary T - Trained NO. - NumberA - Adequate NA - Not Adequate AC - Available at Cost

43Name of HealthUnitST. FRANCISMUTOLEREMBALEHOSPITALCategory(subcountiesserved)MRKAGANDOHOSPITAL MMENGOHOSPITALHOIMAHOSPITALMRC/SsetBasic EquipmentFistulaAnesthetic2 NA A A2 NA A A4 NA A AV.V.F. HOSPITAL SUMMARY Form 4Suture OB/GYNNdagijinaDamianoMr MugondiMr Kagawa3 NA A NAJ. SenyongaJ. Mukwaya2 NA A AM. KasujjaKadamaKakaireOthmanKisegerwaDr P. Okong3 NA A NADr. R.ByaruhangaA. KiizaJ. BukenyaNA A NA J. MukasaJ. MbasirikireFORT PORTAL R 2 NA A ANSAMBYAHOSPITALMRUBAGAHOSPITAL MStaffing by NameSurgeonMr TuundeMr BalyejjusaMakumbiTimothy (T)Robinson (T)SebuwufuBumbaHerbertMidwives /NursesMbumbaBettyKasininiJoachimBusingyeMiriamPower Water Theater SterilisationNO. VVFrepairedYesNoLaboratoryX-rayunitA A 2 A 16 1 NA AA A A A 4 - A AA A 2 A 23 16 A AA A 3 A Nil Nil AC ACMoro A A 1 A 8 3 Ca NADr. EkwaroDr. NasangaA A 1 A 2 Nil AC NA3 A A 3 A 13 Nil AC ACJ. MukasaDr. Baruga 3 A A 3 A 2 Nil AC ACKEY: R - Referral M - Missionary T - Trained NO. - NumberA - Adequate NA - Not Adequate AC - Available at Cost

44Name of HealthUnitMULAGOHOSPITALCategory(subcountiesserved)RC/SsetBasic EquipmentFistulaAnesthetic6 NA A NASuture OB/GYNV.V.F. HOSPITAL SUMMARY Form 4C. NakabitoC. BiryabaremaNabunyaMutyabaStaffing by NameSurgeonOworiFrancisS. KaggwaMidwives /NursesPower Water Theater SterilisationNO. VVFrepairedYesA A 4 A 9No33+LaboratoryMASAKAHOSPITALR 2 NA A NA D. Murokora 1 A A 2 A 10 2 AC ACKABALEOsindeR 2 NA A NAHOSPITALAliaA A 2 A 2 AC ACARUAHOSPITALR 2 NA A A Olaro C. Dramatua A A A 4 11 14 A NANEBBIDROTT B.- 1 NA A AHOSPITALA A A A 18 13 A NAKULUVA M 3 NA A A Kerchan P. A A A 0 0 A AGULUOtim TomR 3 NA A AHOSPITALA A A1 A 0 00 A NALACOROdongoM 2 NA A AHOSPITALA A A A 50 16 A AKEY: R - Referral M - Missionary T - Trained NO. - NumberA - Adequate NA - Not Adequate AC - Available at CostACX-rayunitAC

ANNEXES45

46LIST OF INSTRUMENTSList of Instruments for VVF Repair(Ideally four sets should be obtained for each team)No. Name of Instrument Catalogue Ref. No. No. needed1. Sims Speculum double ended medium 17/1847/2 12. Sims Speculum double ended large 17/1847/3 13. Langenbeck retractor modified 3.5cm x 1.5cm 14. Auvards weighted speculum large 17/1840/2 15. Lawrence needle holder light weight 11/1745 16. Mayo Hegar needle holder Tungsten carbide 11/1796/5 17. Mayo Hegar needle holder Tungsten carbide 11/1796/3 28. Kelly artery forceps straight (16cm) 11/1514/2 69. Mosquito artery forceps straight (12.5cm) 11/1512/6 310. Mosquito artery forceps curved (12.5cm) 11/1512/1 311. Grille artery forceps straight (16cm) 11/1505/3 412. Female metal catherter FG 12 3 Gauge 113. Female metal catherter FG 16 3 Gauge 114. Mayo chambered scissors straight (16.5cm) 11/0085/2 115. Kocher artery forceps straight (20cm) 11/1516/5 116. Kocher artery forceps straight (18cm) 11/1516/4 117. Littlewoods Tissue forceps (18.5cm) 11/6077/ 318. Judd Allis Tissue forceps (19.5cm) 3 to 4 11/6075 719. Silver Probe with eye (15cm) 11/1660/2 120. Silver Probe with eye (12.5cm) 11/1660/1 121. McIndoes dissecting forceps(15cm) 11/1663/1 122. McIndoes dissecting forceps toothed 1:2 (15cm) 11/1663/2 223. McIndoes Scissors curved (18cm) 11/0082 124. Byd scissors semi sharp(18cm)(slight double curve) 11/3022 125. Kelly artery forceps (curved) (16cm) 11/1514/4 2

47Other Supplies for Operating RoomSN Name Type/Size Quantity1 Spinal Set includingSpinal needles Various 200Gloves Size 6 to 8 2000Gauze Swabs Squares 3000Marcaine 5mg/ml ⇒ 2ml 100 ampsXylocaine 50mg/ml ⇒ 2ml 100 amps2 Other drugs for theatreKetamine 20Episkapron (cylokapron 5ml = 500mg) 100 mg/ml 100Adrenaline 200Oxytocin 1003 Suturing materialsa) 2/0 silk with or without needle Box 400b) 2/0 chromic with no needle Box 400c) 3/0 chromic with needle Box 200d) 0 chromic with needle Box 200e) 0 chromic with no needle Box 200f) 2/0 nylon with no needle Box 200g) 2/0 Vicryl with needle Box 200h) 3/0 Vicryl with needle Box 1004 Different fistula needlesJ Shape needle round body No 10,9,8 50 eachDennis Brown Small / Med 20 of eachHalf circle cutting needles Different sizes 50Butcher needles No 8,9,10 20 of each5 Gauzes Roll 100Tiny swabs Hand made 100Vaginal packs Hand made 100Surgical swabs Hand made 1006 Foley catheters No 14, 16 200 of each7 Ureteric Catheters No 5 508 Ureteric Catheters No 6 40Ureteric Catheters No 7 109 Gloves Size 6½, 7, 7½, 8 1000 each10 Gowns Medium, large 2011 Caps / Masks Disposable 30012 Drapes: FenestratedLeggingsSmall fieldsLargePairThree13 Trolley Instrument 114 Mayo table Instrument 115 Bowl stand wit bowl 116 Gallipot Metal 4 per set17 Kidney dish Metal small 1 per set6618

48Basic Laboratory RequirementSn Item Amount1 Syringes 10002 Needles 10003 Lancets 5004 Tourniquet 25 Slides 20006 Cover slides 10007 Test tubes8 Heparinised haematocrit tube9 Sealing clay10 Applicator sticks11 Stool specimen container with lid 20012 Urine specimen container with lid 30013 Counting chamber – impmroved Neubauer 114 Cover glass for counting chamber 115 ESR – Westergren ESR stand with pipettes 116 Safety bulb pipettes – rubber Several17 Microscope 1 or two18 Haemtocrit centrifuge 119 Tube centrifuge 120 Shaker 121 Refrigerator 122 Urinalysis strips – com 5 or 9 20 bottles23 Micro-haematocrit reader 124 Tally counter – manual five place 125 Staining rack – metal 126 Timer 127 Blood grouping tiles28 Coplin jars – glass29 Drop bottle – Amber Glass (125 ml)30 Wash bottles – plastic (500ml)31 Centrifuge tubes – plastic conical32 Pipettes (1ml, 2ml, 5ml, 10ml)33 Immersion oil34 Pregnancy test kit 3035 Rapid Plasma Reagin Kit / for VDRL 5036 Blood grouping reagentsAnti – AAnti – BAnti – DCoombs reagentEnough for 50 patients37 Stain – Gram Iodine

Stain – Crystal VioletStain – Carbol FuschinStain – FieldStain – Wright38 HIV Screening Kit 5039 Sodium Chloride40 Sodium Citrate41 Plain specimen tube with lid (10ml)42 EDTA specimen with lid (5ml)43 Acetic acid44 Xylene45 Acetone46 De-ionizer47 Blood bag 350ml 50 – 10049

50Supplies and Equipment (* Optional)SN Item Type/Size Quantity1. Soap Non scented 1002. Washing towel 1003. Scissors for nail cutting* 24. Blade or shaver 2005. Pajamas* Female 1006. Drawsheet for under patients 4007. PVC sheet Plastic or rubber 1008. Blankets if cold Washable 1009. Sheets Cotton 60010. Bed Available11. Mattress covered with PVC Check12. Pillow with PVC 1 per bed13. Pillow cases 40014. Bed table* If possible15. Bed cradle / for rectal fistula cases only 2 – 316. Mosquito net 1 per bed17. Water bottle Plastic 10018. Drinking glass Plastic 10019. Plates* Plastic 10020. Bowls* Plastic 10021. Slippers* Optional 10022. Night dresses* Optional 20023. Shawl* Optional 10024. Rubbish bins for: a) linen2b) Sharps & needles etcc) Plastic glovesd) Incinerator itemse) Biodegradable itemsHard plastic 444225. Ketrex 3 tubes stat 30026. Syringes: 2cc5cc10cc20cc50cc100010005000500100027. Board for Chart 1 per bed 4428. Bowl for: WashingSitz bathPlasticMetal – large1 per bed4After Admission & Pre-operative29 Enema Set / can and tubing 330 Castor Oil / laxative All patients31 Phenobarbitone for premed 100 mg All patients33 Foley catheters No. 12,14,16 200 of each

5134 Ureteric catheters No. 5, 6 100 of each35 Medicine cup and tray* 1 tray 44 small cupsPost operative37 IV fluids: N/S5% D/S5% D/W200010001000Ringers Lactate 100039 IV Cannulae Size variety 50040 Antibiotics: Good supply of each requiredAmpicillin IM and oralChlorampenicol oralGentamycin IMZenacifBactrimFuradantin41 Other medicines:• PethedineParacetamolMetrocopromide500mg500mg80mg / amp750mgper prescriptionPost op42 IV stand or hook 543 Kidney dish, bag for urine or urinal bottle 50 or more44 Plastic pail for urine waste (by beds) 5045 Supply of: Nursing CareGauzeCottonGlovesNon sterile46 Container for sterilizing the following: 1Forceps4Scissors4Sponge holders2Metal Catheters2Sims speculum3Probe247 Bowl for swabbing 348 Trolley for swabbing 149 Bedpan 4450 Solutions:CetrimideDettolAlcoholBoric Acid / or salineAcriflavine (see recipe)Bonney’s Blue or Methylene BlueGentian Violet51 Adhesive tape Rolls 2052 Transparent tape Rolls 201000 swabs10 rolls30020 litres5 litres2 litres20 litres5 litres2 litres2 litres

5253 Sphygmomanometer 154 Stethoscope 255 Thermometer Oral 2056 Emergency drugs & try / post op 1 of each57 Speculum – medium Sims 258 O 2 Cylinder* Medium size 159 Suction machine* Electric or manual 160 Infra Red Lamp* 161 Medicine cupboard Locking 169 Instrument cupboard Locking 170 Linen cupboard* Large 171 Filing cabinet* Locking 172 “Dangerous Drugs A” Box Double lock 173 Fistula Card – sample given 10074 Vital Signs Chart 30075 Fluid Balance Chart 30076 Treatment Book / Nursing care 177 Pencil, Pens, Markers Various79 Treatment Sheet 50080 Boilers for: Bedpans* Stainless steel 1Instruments*Enema Sets*Stainless steelStainless steel1181 Refrigerator for medicines* 1For babies or children of mothers havingsurgery*1 Bottles* Plastic 22 Teats* Rubber 43 Nappies or diapers* Disposable 204 Clothes* Various5 Shawls* Warm 26 Toys* Soft VariousOther1 Torch Rechargeable 12 Light bulbs for ward Several3 Extra diesel for generator As required4 Catheter clamps Several5 Laundry detergent Plenty6 Bleach Plenty7 Disinfectant Plenty9 Food:1 Milk powder for each woman2 Fruiut for each woman3 Supplement local kitchen

53LIST OF KEY INFORMANTS1. Prof. Francis Omaswa Director General Health Services2. Dr. Tom Raassen AMREF Flying VVF Surgeon3. Dr. Gideon Kikampikaho Deputy Director – Mulago Hospital4. Dr. Sam Kalisoke Ag. Head Obs/Gyn. Mulago Hospital5. Dr. Mehayo Director – Mbarara Teaching Hospital6. Dr. Margarita Millan Ag. Head Obs/Gyn Mbarara Hospital7. Mrs. Vanice Katusiime District Nursing Officer Mbarara8. Dr. Amooti Kaguna DDHS Mbarara District9. Dr. Yesero Kalisa Medical Officer Kisoro Hospital10. Dr. Michael Baganizi Ag. Medical Director Kisoro Hospital11. Dr. Vincent Ndizihiwe DDHS Kisoro District12. Dr. Joseph Bukenya Director Rubaga Hospital13 Dr. Olive Sentumbwe World Health Organisation-RH Advisor14. Dr. Christopher Kyohere Director Mengo Hospital15. Dr. Sam Tumwesigire Director Kabale Hospital16. Dr. Justus Katungu DDH Kabale District17. Mrs. Mary Betubiza DNO Kabale District18. Ms. Ndagijimana Senior Nursing Officer Mutolere Hospital19. Dr. Cuthbert Agelor Medical Director Mutolere Hospital20. Dr. Henry Kakande Senior Consultant Obstetrics/Gynaecology21. Dr. Wasswa George Ssalongo Consultant Obstetrics/Gynaecology Mb’ra Hosp22. Dr. Msheillia Obstetrician/Gynecologist Mbarara Hospital23. Dr. Mugerwa Obstetrician/Gynaecologist, Mbarara Hospital24. Dr. Pius Okong Senior Consultant Nsambya Hospital25. Dr. Juliet Nbisirikire Senior Consultant Rubaga Hospital26. Dr. Romano Byaruhanga Consultant, Obs/Gyn Nsambya Hospital27. Dr. Jumba Mukasa Head of Department Rubaga Hospital28. Dr. Senyonga Kyanda Head of Department Mengo Hospital29. Dr. Josephine Mukwaya Consultant Obstetric / Gynaecology30. Miss Rose Nakayiza Nursing Officer Mulago31. Mr. Charles Tindyebwa Senior Anaesthetic Officer Mengo Hospital32. Mr. Elias Balinda Theatre Assistant Mulago Hospital33. Theresa Twesigomwe RH Trainer, Masaka District34. Jane Rose Tusiime RH Trainer Mbarara Hospital35. Victor Namutebi Nursing Officer Kitovu Hospital36. Dr. Janex Kabarangira UNICEF Health Officer

37. Dr. Osinde Obstetrician/Gynaecologist Kabale Hospital38. Dr. Alia Godfrey Obstetrician/Gynaecologist Kabale Hospital39. Miss Jane Turyasingura Nursing Officer Kabale Hospital40. Dr. Damiano Ndagijimana Consultant Mutolere Hospital41. Mr. Charles Munafu Programme Officer AMREF42. Miss Majorie Rugwiza District Public Health Nurse – Kabale43. Miss Kagame District Public Health Nurse – Kisoro44. Dr. Herbert Bumbi Director Kagando Hospital45. Miss Betty Mbambi Registered Midwife Kagando Hospital46. Mr. Kiiza Senior Anaesthetic Officer Hoima Hospital47. Dr. Moro Senior Consultant Surgeon Hoima Hospital48. Dr. Masitula Kasujja Senior consultant Obstetrician Hoima Hospital49. Dr. Kadama Obstetrician / Gynaecologist Hoima Hospital50. Mr. Bwambale Erikana District Health Inspector Kasese51. Dr. Kapuru Asinja Ag. Medical Superintendent Bweera Hospital52. Dr. Kasiima Kibiito Health Sub-district Hospital Kabarole53. Dr. Muhumuza Simon Bukuku Health Sub-district Hospital Kabarole54. Dr. Kayita Gerald Bwijangu Health Sub-district Hospital Masindi55. Mrs. Sempebwa District Nursing Officer Kabarole District56. Mr. Ntegyereize District Health Inspector Kabarole District57. Dr. Malo Joshua Bulisa HSD Hospital Masindi District58. Miss Nambuya Tofa Nursing Officer, Hoima Hospital59. Miss Betty Kyakuhaire District Nursing Officer Masindi60. Mr. Kajura William District Health Educator Masindi61. Dr. Tinkason Ahmed Medical Superintendent Masindi Hospital62. Dr. Dan Murokora Obstetrician/Gynaecologist Masaka Hospital63. Dr. Abiriga Jim Senior Medical Officer Masindi Hospital64. Dr. Kaggwa Ssenjovu Medical Officer Kiryandongo Hospital65. Mrs. Mijumbi Senior Nursing Officer Kiryandongo Hospital66. Dr. Kakibogo Senior Medical Officer Kagadi Hospital67. Dr. Bateganya Medical Superintendent Kagadi Hospital68. Dr. Abdu Tusubira Medical Officer Kagadi Hospital69. Dr. James Olowo Medical Officer Kagadi Hospital70. Dr. Monday Araali Medical Officer Mbarara Hospital71. Dr. Othman Kakaire Obstetrician/Gynaecologist Fort Portal Hospital72. Mr. Africanus Rwegyemura Senior Nursing Officer Fort Portal Hospital73. Mr. Gabriel Balinda Senior Anaesthetic Officer Mulago Hospital74. Dr. Mutyaba Obstetrician/Gynaecologist Mulago Hospital54

75. Dr. Sam Zaramba Director, Curative–Community Services MOH76. Dr. Jacinta Amandua Commissioner, Clinical Services MOH77. Dr. Jack Elgon DDHS Nebbi District78. Dr. Paul Onek DDHS Gulu District79. Dr. Patrick Onzima DDHS Arua District80. RN/MW Beatrice Dramatua Nursing Officer Arua Hospital81. Mr. Morris Kwatch Senior Anaethetic Officer, Nebbi Hospital82. Dr. Emilton Odongo Consultant gynaecologist Lacor Hospital83. Dr. Kerchan Patrick Kuluva Hospital84. Mrs. Joyce Aciro RH District Nursing Officer85. Dr. Okwana Nicholas DDHS Soroti District86. Dr. Fred Kirya Surgeon Soroti Hospital87. Dr. Geofrey Egwau Consultant Gynaecologist Soroti Hospital88 Miss Imelda Opolot Amuge Assistant Health Visitor89. Mrs. Wandawa Jeniffer District Nursing Officer Mbale90. Dr. Ojwang Conrad Medical Officer Mbale Hospital91. Miss Ekido Lossira Nursing Officer – Mbale Hospital92. Dr. Mildred Latigo RH Regional Coordinator Eastern93. Dr. Kusolo Peter DDHS Lira District94. Miss Apio Janet Enrolled Nurse Amai Hospital95. Dr. Robert Oremo Amai Hospital Lira96. Dr. Adupa Drake Consultant Gynaecologist Lira Hospital97. Miss Odyek Beatrice Registered Nurse Lira Hospital98. Miss Isabirye Rose Registered Nurse Kamuli Hospital99. Dr. Nakiwala Stella Medical Officer Kamuli Hospital100. Mrs. Adupa Onen Rose Nursing Officer Jinja Hospital101. Dr. Benon Wanume Medical Superintendent Jinja Hospital102. Dr. Tigawakana David DDHS Kamuli District103. Mrs. Florence Aziga Nursing Officer Mulago Hospital L/S104. Miss Rosemary Byenkya Nursing Officer Mulago Hospital 5B105. Miss Kato Nursing Officer Mulago Hospital 5A106. Miss Sarah Kabenge Nursing officer Mulago Hospital OPD(G)107. Dr. Busingye Consultant Infertility Clinic Mulago Hospital108. Miss Nakatte Grace Nursing Officer Mulago Hospital (Gyn Theatre)109. Miss Docas Odongo Aciro Nursing Officer Mulago Hospital (Gyn Theatre)110. Miss Tibifumura Goreth Senior Nursing Officer Mulago Hospital111. Miss Harriet Nakimera Registered Nurse Mengo Hospital112. Miss Regina Namatovu Registered Midwife Mengo Hospital (Theatre)113. Dr. Christine Biryabarema Uganda Women Doctors Association55

56OBSTETRIC FISTULA (VVF)PROVIDER/FACILITY ASSESSMENT.Form 1NAME OFHOSPITAL……………………………………………REGION…………………..……ADDRESS BOX………………………………………E-MAIL………………………..RESPONDENT’S NAME……………………………………………………………….QUALIFICATIONS……………………………………………………………………..1. Do you take active part in management of fistula?………………………………………………………………………………………2. Have you been trained specifically in management of fistula? (Hands on training infistula repair/care)?………………………………………………………………………………………3. If yes: Where?………………………………………………………………....For how long?……………………………………………………………….………By whom?…………………………………………………………………………..4. What aspects of management are you involved in?a. Surgery……………………………………………………………..………….b. Nursing post operative………………………………………………………...c. Prevention (post delivery)…………………………………………..………..d. Advocacy / IEC………………………………………………….…………...e. Others…………………………………………………………….………….5. If NO to Q2.a. Is your pre-service training exposure adequate for you to manage fistula?………………………………………………………………………………

57b. Is your exposure at postgraduate or specialist level adequate to manage fistula?………………………………………………………………………….………c. Do you think you need specialized training in management of fistula?……………………………………………………………………….…………6. How many cases were you able to manage last year?…………………..…………a. How many were successful (closed the fistula)?……………………………...b. How many failed (woman leaked urine post operatively)?…………………...c. Was failure detected immediately after the operation or after 72 hourspostoperative?…………………………………………………………………………………7. How many cases of fistula do you think went through this hospital withouttreatment due to :a. Lack of skilled personnel………………………………………..……………b. Lack of equipment………………………………………………….………..c. Damage not repairable…………………………………………….…………d. Patient could not afford costs………………………………………………e. Others ………………………………………………………………………8. If 7 (d) is applicablea. How much does it cost to treat a fistula in this hospital?………………………………………………………………………………b. Do you have provision for subsidy or exemption for the poor?……………………………………………………………………...………9. Is your support staff competent in managing patients with fistula?……………………………………………………………………………………10. If competent do they require update of skills?……………………………………………………………………………………11. Does your unit have adequate specialized equipment for treating fistula?a. Gynecological operation table………………………………………..…..…..b. Good adjustable light…………………………………………………………c. Special scissors………………………………………………………..……..d. Special blades………………………………………………………..……….

58e. Clamps………………………………………………………….……………..f. Catheters………………………………………………………………………g. Suture material………………………………………………………………...h. Consumables…………………………………………………………………..i. Others………………………………………………………………………….12. Do you have accessory investigationsa. Urinalysis……………………………………………………………………...b. Renal Function Tests (RFT)…………………………………………………...c. Radiography…………………………………………………………………...d. Cytoscopy………………………………………………………………….…..13. In your opinion how can fistula be preventeda. At the hospital…………………………………………………………………b. At the health center…………………….……………….……………………..c. Family and community (probe for nutrition, early marriage and skilled attendantat labour)………………………………………………………………….………………14. What role should the government play in the management of fistula?………………………………………………………………………………………15. Are there other institutions or individuals you know who are involved in repairingfistula?………………………………………………………………………………………16. Is there a particular place, which seems to have greater numbers of fistula that cometo your unit?………………………………………………………………………………………17. What is the attitude(s) of leakage of urine among the local community here?………………………………………………………………………………………18. Are there guidelines or protocol that relate to the prevention or treatment of fistula inthe facility?………………………………………………………………………………………19. Are there educational activities to increase awareness on fistula (I.E.C. material)?a. Television………………………………………………………………………...b. Radio……………………………………………………………………………..

59c. Drama…………………………………………………………………………….d. Posters / Brochures………………………………………………………………e. Others ……………………………………………………………………………20. Do you get visiting specialists to treat fistula in particular?………………………………………………………………………………………21. If yes to Q 20,a. Who are they (names)?…………………………………………..……………..…………………………………………………………………………..……………………………………………………………………..……………………b. From where?………………………………………………….……………………………………………………………………………….……………………………………………………………………………………….………………c. Who is the funding agency?…………………………………………..………..……………………………………………………………………………………………………………………………………………………………………22. What are their basic specialties: surgery / obstetrics and gynecology /urology?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………23. Do you know of other women who have had this condition in the community buthave not had a chance to come to hospital?……………………………………………………………………………………24. Physical inspectiona. Theater……………………………………………………………………...b. Labour ward………………………………………………………………...c. Equipment available for fistula repair………………………………………d. Post-operative care facility (ward)………………………………………….

60OBSTETRIC FISTULA (V.V.F)PATIENT INFORMATIONForm 2Name: ………………………………….Age: ……………………………………Marital status:…………………………..Tribe……………………………………County………………………………….LNMP………………………………….Date of 1 st admission………………………..Date of 1 st repair…..………………………...Living with husband………………………..Separated:…………………………………...Height (cm)…...…………………………….District of origin…………………………….Parity:………..Stature………………………Education standard:NoneP1-3P4-7SecondaryPost secondary1. How long have you been leaking urine/faeces?……………………………………………………………………………………2. How many days after delivery did you start leaking urine/faeces?……………………………………………………………………………………3. How was the baby delivered?a. Vaginal:……………………………………………….……………………..b. C/S:……………………………………………………..……………………c. Assisted vaginal……………………………………….…………………….4. Was the baby born alive?……………………………………………………………………………………5. Where did the delivery take place?a. Hospital/Health unit…………………………………………………………b. Home………………………………………………………………………..c. TBA…………………………………………………………………………d. On the way………………………………………………………………….

616. If in hospital what treatment did you get (Indwelling catheter/antibiotics)?…………………………………………………………..………………………7. How long were you in labour?……………………………………………………….…………………………8. After how many days were you discharged after the delivery?…………………………………………………………………….……………9. Have there been any attempts to treat you for this condition?………………………………………………………………….………………How many times?……………………………………….……….………………10. Did you attend antenatal clinic?……………………………….……………….If yes;a. Where?……………………………………………………………………...b. By who?…………………………………………………………………….11. Did the service provider anticipate any difficulty in delivery?………………………………………………………………………………….12. What advice did he/she give you?…………………………………………………………………………………13. If NO, in 10, why not?…………………………………………………………………………………14. Do you easily mix with other people (Probe for social problems)?………………………………………………………………………………….15. Have you been explained to how you acquired this problem by anybody?………………………………………………………………….………………16. How much money do you have to contribute to the expenses of your treatment?…………………………………………………………………………………….17. If you are successfully treated what will you do to assist your self and others notto have the same problem?…………………………………………………………………………………….18. Do you know any woman who has this same problem who has not had a chance tocome to hospital?………………………………………………………………………….………….

62OBSTETRIC FISTULA (V.V.F)Form 3KEY INFORMANT INTERVIEWName of KI :Age : Sex :1. What attitude(s) does the family or community have towardsa) Pregnancy and childbirthb) Leakage of urinec) Operative delivery2. What major problems might leakage of urine be associated with?a) Witchcraftb) Separationc) Rejection3. Do you think this condition is treatable in hospitals?4. Does the community think it can be cured by traditional medicine or witchcraft?5. Do you know what fraction of funds spent on health is devoted to the treatment ofthis condition?a) Local Government (in your budget)b) Donor

636. Suggest important areas of service delivery that need improvement in order toreduce or eliminate this complication of childbirth. (Order of importance)7. What part can your institution play in reducing the victims of this complication?8. Do you think there are adequate facilities to treat this complication?a) Availability at what levelb) Affordabilityi. Transportii. Treatment cost9. Can you make a comment on the training of Doctors and Nurses to manage thiscomplication?a) Undergraduateb) Postgraduatec) In-service specialised courses10. Do you have other institutions or organizations involved in the management offistula?a. Researchersb. Donorsc. NGO’s

641. What is the policy?MINISTRY OF HEALTH HEADQUARTER GUIDE2. How are you implementing the policy?3. Do you have suggestions of how the policy can be improved?4. What resources are you specifically putting into the implementation of this policy?5. Where can developmental partners be of assistance?6. Is the issue of fistulae among the priorities of the Reproductive health program in theministry of health?DEVELOPMENTAL PARTNERS GUIDE1. Are you involved in prevention and management of fistula?2. What are you exactly doing?3. If not involved, what is the problem and why are you not involved?4. Do you consider fistula a health problem in this country?5. How best can you be involved?6. What portion of your budget is allocated to this problem?7. What coordination mechanism can be out in place for developmental partners toparticipate in this activity effectively?

65PHYSICAL INSPECTION OF THE FACILITY(Establish Presence and status of the items)Form 51. Power• Standby generator2. Water source• Tap water3. Labour ward• Wall clock• Partogram• Register• Protocols / guidelines for obstructed labour4. Theater• Number of operating rooms• Gynecological table• Theater light (adjustable)• Autoclave5. Equipment• McIndole Scissors• Blade sizes NO’s:11,12,15• Sim’s speculae• Auvards speculum• Number of C/S sets:• Sizes of Chromic Catgut• Anesthetic machines: EMO BoylesGases: Ether, NitrousOxide, Oxygen, Halothane6. Post operative room• Privacy (Ward or special bed)• Urinary bladder catheters• Urine collecting bags or jars (transparent or translucent)• Protocols/guidelines (VVF care)7. Laboratory backup• Urinalysis• Blood analysis(Renal function tests)

668. X-ray (IVP)9. Cytoscopy10. Examine for numbers of VVF cases (year 2002)• Admission and discharge registers of gynecological ward• Operation theater register

67REFERENCES1. Ampofo. K. 1990: Epidemioloyg of Vesico-Vaginal Fistula in Northern Nigeria.West African Journal of Medicine 9(2); 98 - 1022. Bangsev M: Report of the Meeting of VVF Partners in East Africa and theWomen’s Dignity Project – 8-11 th August 19993. Bangsev M. et al; A comprehensive Approach to Vasico-Vaginal fistula – aProject in Mwanza, Tanzania4. Bangsev: New Year’s Newsleter – January 20005. community Mobilization Strategy and Community Mobilization Law (Draft Billfor Limited Circulation) September 20006. Ebanyat F. “Challenges in the implementation of Reproductive Health:Experiences within a sector wide approach in Uganda. Department ofReproductive Health and Research7. Ginzel a: Obstetric fistula, an Obstetric Complication in remote areas – Riskfactors epidemiology, Socio-cultural aspects, Prevention and treatment – withspecial aspect to female genital mutilation8. Guidelines for Monitoring the availability and use of obstetric services:WHO/UNICEF. UNFPA publication Oct. 19979. Kelly J. Kwast BE, 1993. Epidemiologic Study of Vesico – Vaginal fistula inEthiopia: International Urogynaecology Journal 4: 278 - 8110. Maternal and Health and Safe Motherhood Program – WHO/MCH/MSM/91 - 511. Maternal and Newborn Health Making Pregnancy Safer – Uganda Country ReportRHR WHO12. Ministry of Health National Health Policy: Sept. 199913. Ministry of Health - Health Sector Strategic Plan 2000 / 01 – 2004 / 05. August200114. Ministry of Health – Annual Health Sector Performance Report 2000 / 2001. Sept200115. National Supervision Guidelines for Health Services – MOH. July 200016. Raassen Tom: AMREFs VVF programme: 2001

6817. Raassen Tom: VVF Surgery Report 199918. Reproductive Health Division 5-year Strategic Framework 2000–2004. July 200019. Sexual and Reproductive Health Minimum Package for Uganda20. Tanzania Fistula Survey 200121. The Community Component of the Safe Motherhood Programme Uganda – MOH22. The National Policy Guidelines and Service Standards for Reproductive HealthServices, Ministry of Health. May 200123. The National Supervision Guidelines for Health Services: Department of QualityAssurance – July 200024. The Uganda Safe Motherhood Needs Assessment Survey: MOH GTZ UNFPAUNICEF WHO. February 1996.25. Training Curriculum on Safe Motherhood for Community Owned ResourcePersons: Content Outline and Lesson Plans January 200226. Uganda Maternal and Neonatal Program Effort Index MNPI27. UNFPA release July 200128. Weissaman E. at al: Uganda Safe Motherhood Program costing studyMOH/WHO 99.929. VVF Training Program – Draft guidelines and Budget Women’s Dignity Project1999