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Increasing Access to Fistula Services : Organization of Services :

Resources & Tools

Curricula and Training Modules

Counseling the Obstetric Fistula Client: A Training Curriculum
Counseling is an integral part of comprehensive fistula care services. The curriculum guides nurses, midwives, and physicians to help their clients make informed and voluntary decisions about their care. The curriculum addresses counseling needs related to fistula prevention, treatment, and social reintegration. Service providers can also find information about how to engage with the client’s family and how to link the client to supportive organizations in the community.
Files: English (PDF, 2.5MB) and French (PDF, 2.8MB)

Counseling the Traumatic Fistula Client: A Supplement to the Obstetric Fistula Counseling Curriculum
Clients seeking care for traumatic fistula—fistula caused by sexual assault—need access to counseling that addresses the complex effects of their condition. This supplement complements the counseling curriculum to address the physical, social, and psychological impacts specific to traumatic fistula. The supplement also provides information on how health care providers working with traumatic fistula clients can seek support for themselves.
Files: English (PDF, 3.2MB) and French (PDF, 3.2MB)

The Prevention and Management of Obstetric Fistula: A Curriculum for Nurses and Midwives
Nursing and midwifery are both integral to comprehensive obstetric fistula care services. The goal of this curriculum is to train nurses and midwives so that they have the knowledge, skills, and attitudes that will enable them to prevent obstetric fistula and care for clients who are living with obstetric fistula. This comprehensive curriculum, developed by the East, Central, and Southern Africa Health Community, with support from USAID and Fistula Care, addresses several critical areas: preventive care; surgical treatment and postoperative recovery; information; education; family and community involvement; counseling; and data collection and use. It also presents learning activities and competency-based skills checklists that help nurses and midwives develop real-world skills for the clinical environment.
Files: English (PDF, 4.1MB) and French (PDF, 5.7MB)

Global Competency-Based Fistula Surgery Training Manual
This training manual, developed by the International Federation of Gynecology and Obstetrics (FIGO), in collaboration with the International Society of Obstetric Fistula Surgeons, UNFPA, EngenderHealth, and the Royal College of Obstetricians and Gynaecologists, addresses the need for surgeons to develop the necessary skills for fistula repair. The purpose of this manual is to enable dedicated physicians to acquire the knowledge, skills, and professionalism they need to prevent obstetric fistula and provide proper surgical, medical, and psychosocial care to women who have fistula.
Files: English (PDF, 1.9MB) and French (PDF, 4.2MB)

Data for Decision Making in Fistula Care: A Supplemental Module for Facilitative Supervision
In keeping with its commitment to quality improvement, Fistula Care promotes the use of data for decision making. This series of training modules provides clinical supervisors, service providers, and national-level stakeholders with skills to review and interpret data in order to strengthen health systems and services. The document includes guides for discussion and interactive activities, as well as handouts and other tools to teach lessons about data gathering, analysis, and application. The modules supplement EngenderHealth’s facilitative supervision tools, which emphasize team problem solving and communication.
Files: English (PDF, 2.8MB) and French (PDF, 2.6MB)

Training Manual for Health Center Management in Niger
This training manual, developed in Niger, is intended as a guide for community health committees to develop and implement solutions and activities through community action plans or to strengthen currently existing action plans. The manual was developed following the implementation of community health committee workshops focused on maternal and neonatal health and fistula prevention in three regions: Mayahi, Dosso, and Niamey.
Files: French (PDF, 241KB)

Evaluation and Research Studies

Community-Based Screening for Genito-Urinary Fistula in Nigeria: A Novel Approach
The true prevalence and incidence of obstetric fistula remains difficult to determine, for several reasons. To respond to this lack of data, in collaboration with Stanton-Hill Research LLC, Fistula Care designed a study to (1) quantify the backlog of obstetric fistula cases within selected local government areas (LGAs) of Kebbi and Cross River states, by conducting community-based screenings in these LGAs; (2) explore the feasibility of reporting minimum estimates of prevalence and incidence of fistula at the district and state levels; (3) assess the questions in the Demographic and Health Surveys (DHS) fistula module; and (4) document the methodology for use in other districts or states. The prevalence in the study for current fistula-like symptoms was 28% (n=75). Verification assessment by clinical exam shows that the DHS question combined with the follow-up questions in the DHS fistula module has 92% sensitivity and 83% specificity, with 47% positive predictive value and 98% negative predictive value. These results suggest that it is a fairly good measurement of identifying the women who currently have fistula. This strategy for identifying the backlog of women in need of fistula repair surgery seems feasible, including use of trained nurse-midwives to conduct the screening.
Files: English (PDF, 940KB) and French (PDF, 248KB)

Estimating Costs to Provide Fistula Services in Nigeria and Ethiopia: Key Findings
This summary of studies carried out in Nigeria and Ethiopia introduces a cost analysis tool to assist facility managers in assessing the costs for fistula repair services, which could then help them make decisions about resource allocation. Measuring, understanding, and documenting the costs of services can help managers improve the cost-efficiency of services and demonstrate funding needs to facilities, governments, and donors. Analyzing financial inputs is an important step in increasing the institutional and financial sustainability of fistula services.
Files: English (PDF, 297KB) and French (PDF, 311KB)

Guinea Fistula Care Program Evaluation
In 2011, Fistula Care undertook a two-part evaluation of the Guinea program: 1) to assess the accomplishments and effectiveness of the facility-based prevention and treatment services (i.e., the supply side); and 2) to explore whether the establishment and support of village safe motherhood committees at the community level had led to measurable change in knowledge and use of maternal services at the population level. Findings from the community evaluation are presented in a separate report. The supply-side evaluation used multiple data collection methods, including site assessments, observation of services, record reviews, interviews with key stakeholders, and interviews with a convenience sample of fistula patients. Findings from this review show that capacity for fistula treatment has increased over time, and there is some evidence of an increased enabling environment for sustaining services at the policy and program levels. The Guinea team has worked to strengthen the ability of district-level hospitals to provide quality fistula prevention services, such as family planning and partograph monitoring. This work needs to be replicated at the primary health care level, with appropriate and timely referral to district and regional health facilities for obstetric complications and emergencies.
Files: English (PDF, 2.2MB) and French (PDF, 339KB)

Strengthening Health Systems Through the Levels of Fistula Care Framework
This paper presents findings from a literature review of the peer-reviewed and grey literature, exploring the application of Fistula Care’s Levels of Fistula Care Framework (repair, prevention and reintegration) as a health systems strengthening group of interventions. The methodology offers a comprehensive approach for reviewing the literature that can inform how to address institutionalization of rationalized health systems strengthening for fistula services.
Files: English (PDF, 486KB) and French (PDF, 83KB)

Project and Meeting Reports

Levels for Facilities-Based Services for Fistula Care
To address the complexity of fistula repair services, Fistula Care developed a framework for a network of sites to facilitate prevention, diagnosis, limited treatment and referral, treatment of simple cases, treatment of complex cases, and the establishment of a site or sites capable of providing training. This document describes in detail the three levels of facility-based care that Fistula Care envisages.
Files: English (PDF, 35KB) and French (PDF, 34KB)

Meeting the Needs of Women with Fistula Deemed Incurable: Creating a Culture of Possibility
In September 2011, EngenderHealth’s Fistula Care project and the Harvard Humanitarian Initiative convened a meeting of international expert fistula practitioners to identify areas of consensus on minimum global standards for complex fistula care in low-resource settings. This report outlines programmatic and research gaps and priorities and includes specific recommendations to assist ministries of health, professional associations, and other key institutions in developing their own guidelines.
Files: English (PDF, 622KB) and French (PDF, 36KB)

Urinary Catheterization for Primary and Secondary Prevention of Obstetric Fistula: A Consultative Meeting to Review and Standardize Current Guidelines and Practice
Evidence from the work of Dr. Kees Waaldijk in northern Nigeria suggests that women with obstetric fistula who present soon after the injury may heal spontaneously if the bladder is drained with a catheter. It is estimated that early management with a catheter could lead to closure of the fistula in 25% of cases. This important finding has the potential to allow some women to avoid the need for surgical repair of their fistula, which is both traumatic for women as well as a huge drain on scarce resources. Thus, the concept of treating fistula conservatively, and perhaps even preventing it by catheterization during or immediately after prolonged or obstructed labor, offers a promising alternative approach. This consultative meeting brought together a group of experienced Nigerian and international fistula surgeons, representatives of national and international professional nursing and midwifery associations, relevant officials from the Federal Ministry of Health, as well as national and international staff from the EngenderHealth-led Fistula Care project. The goal was to review current guidelines and practices, to discuss knowledge gaps, and to develop recommendations for standardized approaches to urinary catheterization for prevention and nonsurgical treatment of fistula. In preparation, Fistula Care conducted a review of literature pertinent to this topic and conducted an informal survey of current practices among Nigerian fistula service providers. Participants agreed on a simplified approach to catheterization for early management of fistula. The resulting recommendations will be disseminated to the Nigerian Ministry of Health and other relevant stakeholders, to facilitate the development and implementation of standardized national (and global) guidelines.
Files: English (PDF, 1.1MB) and French (PDF, 517KB)

Traumatic Gynecologic Fistula: A Consequence of Sexual Violence in Conflict Settings
In consultation with the Addis Ababa Fistula Hospital, the Ethiopia Society of Obstetricians and Gynecologists, and Synergie des Femmes pour les Victimes des Violences Sexuelles, the ACQUIRE Project cosponsored an international consultative conference on traumatic fistula in 2005. The meeting allowed participants to share current knowledge on traumatic fistula, discuss existing programmatic interventions, identify key success, challenges, and gaps, synthesize lessons learned, and develop recommendations and strategies.
Files: English (PDF, 487KB)

Technical Briefs

Fistula Pre-Repair Center Model in the Amhara Region of Ethiopia
This brief provides readers with an overview of U.S. Agency for International Development (USAID) support to three pre-repair centers in the Amhara Region that are part of a partnership with the Amhara Regional Health Bureau and the Bahir Dar Hamlin Fistula Hospital.
Files: English (PDF, 466KB) and French (PDF, 638KB)

Beyond Repair: Involving Communities in Fistula Prevention and Reintegration—Experience from Kissidougou, Guinea
This brief discusses engaging local government and community members in treatment and prevention of fistula and reintegration of fistula survivors.
Files: English (PDF, 1.7MB) and French (PDF, 3.3MB)

Making Mobile Phones Work for Women with Fistula: The M-PESA Experience in Kenya and Tanzania
This brief discusses the work of the Freedom from Fistula Foundation in Kenya and Comprehensive Community Based Rehabilitation in Tanzania. Both programs use an innovative combination of mobile banking and community education to provide free fistula treatment to women who need it.
Files: English (PDF, 2.2MB) and French (PDF, 665KB)

A Collaborative Network to Improve Access to Fistula Treatment in Nigeria
This brief describes the pooled effort strategy that the Nigeria team has been leading to expand access to fistula repair services.
Files: English (PDF, 3.9MB) and French (PDF, 599KB)

Community-based Screening for Obstetric Fistula in Ebonyi State
In 2007, the Mother and Child Care Initiative (MCCI) was launched in Ebonyi State, Nigeria, under the leadership and support of the governor’s wife, the Honorable Mrs. Josephine Elechi. In 2008, prior to the construction of a new obstetric fistula center in the state, MCCI coordinated with local governments to deploy a specialized medical team to conduct community-based screening for obstetric fistula throughout Ebonyi State, to estimate the potential backlog of women needing fistula repair surgery. This technical brief describes the planning process for the community screening and the results of this effort.
Files: English (PDF, 981KB) and French (PDF, 1.2MB)


Facility Assessment of Fistula Treatment and Prevention Services: Guidelines for Planning, Conducting and Disseminating Findings
This package of materials provides instruction for how to carry out a site assessment. Forms include: Proposal Guidelines; a Tip Sheet for Planning the Assessment; a Site Assessment Tool; and Presentation of Findings: An Outline for the Assessment Report.
Files: English (PDF, 410KB) and French (PDF, 819KB)

Facility Assessment of Fistula Treatment and Prevention Services: Site Assessment Tool
This tool includes a set of 284 questions designed to assess the availability and quality of services for fistula prevention and treatment services. It also includes a list of standard fistula facility equipment and supplies recommended for fistula surgical services. The tool is divided into five sections: General Facility Information (92 questions); Fistula Services (53); Maternity Services/Department (74); Family Planning Services/Department (38); and Equipment, Supplies, and Medications (27).
Files: English (PDF, 1.0MB) and French (PDF, 1.2MB)

Fistula Care Training Strategy, Guidelines and Standards
There is a crucial need to initiate and sustain fistula programs that increase access and that strengthen the capacity of centers to provide high-quality services for repair and care of women living with obstetric fistula and traumatic gynecologic fistula. To do this, it is important to pay particular attention to the quality of training and to proactively determine how, and if, training fits into other elements of a program's performance. This training strategy seeks to create a uniform training approach and improve the quality of training and subsequent service delivery. It provides an outline for how programs can develop detailed training guidelines and standards.
Files: English (PDF, 449KB) and French (PDF, 444KB)

Standard Fistula Facility Equipment and Supplies
This document provides a comprehensive list of equipment and supplies necessary for fistula surgery, broken down into the following categories: fistula repair instruments; expendable supplies; operating theater equipment; and theater accessory equipment/furniture.
Files: English (PDF, 231KB)

Fistula Facilitative Supervision and Clinical Monitoring for Service Delivery
This checklist facilitates the supervision and monitoring of fistula repair service delivery. Forms include: Facility Information; Fistula Service Delivery at Facility; Monitoring of Counseling Services; Notes from Client Interviews; and Summary Notes and Recommendations from the Supervision and Monitoring Visit.
Files: English (PDF, 409KB) and French (PDF, 383KB)

Fistula Facilitative Supervision and Clinical Monitoring Supplement: For Training Site and for Training Follow-Up
This checklist facilitates the supervision and monitoring of training activities relating to fistula services provision. Forms include: Facility Information; Training Follow-Up for Fistula Surgery and Perioperative Care; Training Follow-Up for Fistula Counselors; Additional Supervision/Monitoring for a Fistula Training Site; and Summary Notes and Recommendations from the Supervision and Monitoring Visit.
Files: English (PDF, 324KB) and French (PDF, 320KB)

Job Aid: Fistula Diagnosis
This job aid assists health care providers to diagnose obstetric fistula in women who present with urine leakage. It contains a list of questions aimed at accurately diagnosing whether the woman has obstetric fistula, whether she requires surgical repair, and the complexity of the repair. It also provides advice for preparing for obstetric fistula repairs. A chart with this information is also available.
Files: English (PDF, 231KB) and French (PDF, 228KB)

Job Aid: Fistula Diagnosis Poster
This poster assists health care providers to diagnose obstetric fistula in women who present with urine leakage. It contains a list of questions aimed at accurately diagnosing whether the woman has obstetric fistula, whether she requires surgical repair, and the complexity of the repair. It also provides advice for preparing for obstetric fistula repairs. A brochure with this information is also available.
Files: English (PDF, 766KB), French (PDF, 831KB), and Bangla (PDF, 225KB)

Fistula Registration Form
This tool from Uganda collects bio-data information on fistula clients and provides guidance to providers for observing and recording client history, symptoms, and examination results, as well as developing a management plan for the client.
Files: English (PDF, 247KB)

Patient Record Form
This tool from Mali collects bio-data information on fistula clients and provides guidance to providers for observing and recording client history, symptoms, results of the fistula surgery as well as developing a management plan for the client. The tool also includes an informed consent form to be signed by the client.
Files: French (PDF, 159KB)

Fistula Client Card
This tool from Uganda allows for case management of fistula clients at facilities by tracking information about admission, diagnosis, and treatment, along with providing space for describing follow-up visits.
Files: English (PDF, 65KB)

Informed Consent in Fistula Care
Informed consent is a critical component of quality fistula care services. This booklet for service administrators, staff, and supervisors provides guidance on counseling patients before fistula surgery. Clients may find the provided information helpful in making an informed decision on care.
Files: English (PDF, 630KB) and French (PDF, 617KB)

Informed Consent Form
This form is a template for service providers that can be used or adapted for providers to counsel fistula patients before surgery.
Files: English (PDF, 34KB) and French (PDF, 36KB)

Fistula Treatment Complications: Reporting Guidelines
These guidelines provide information for reporting fistula surgery related complications and includes definitions, assumptions, and lists of select major, minor, and long-term complications that can occur.
Files: English (PDF, 255KB) and French (PDF, 301KB)

Protocol for Auditing and Reporting Mortality Related to Fistula Surgery
Fistula surgery–associated death is a rare event, but it has been known to occur. Systems should be in place to understand what happened and to prevent similar occurrences. This protocol includes guidance for investigating and reporting mortality related to fistula surgery: a reporting timeline, and detailed instructions for preparing a fistula death investigation report.
Files: English (PDF, 386KB) and French (PDF, 475KB)

Fistula Quarterly Reporting Form
The Fistula Care quarterly reporting template includes instructions, indicator definitions table, complications reporting guidelines, and six forms for facilities to report data on services provided. Forms include: clinical indicators for fistula surgery; fistula repair training for surgeons/physicians; training events by topic and cadre; community outreach and advocacy events; family planning services; and obstetric services.
Files: English (XLS, 535KB) and French (XLS, 547KB)


© 2013 EngenderHealth.

This resource was made possible by the generous support of the American people through the U.S. Agency for International Development (USAID), under the terms of the cooperative agreement GHS-A-00-07-00021-00. The information provided on this resource is not official U.S. Government information and does not represent the views or positions of the USAID or the U.S. Government.