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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)

Training Session for Health Workers on Prevention and Recognition from Ethiopia
Fistula Care's implementing partner in Ethiopia, IntraHealth International, has developed materials to train health care workers on obstetric fistula prevention, identification, and pre-repair care. The course contains a participant handbook, a facilitator manual, 10 modules, a variety of visual aids, and supplementary handouts. (All items are in English.)

Training Manual for Community Liaisons from Niger
This training manual, developed in Niger, is designed to enhance the knowledge of community liaisons on maternal and newborn health, including: the status of maternal and newborn health globally and in Niger; health services to promote maternal and newborn health; skilled birth attendance and danger signs; family planning; and obstetric fistula. The training manual also addresses communication techniques to promote maternal and newborn health. The participant handbook was designed to facilitate awareness-spreading activities of community leaders in maternal and neo-natal health as well as obstetric fistula. (All items are in French.)

Promoting Maternal Health and Preventing Obstetric Fistula: A Training Curriculum for Village Health Teams in Uganda
This training manual is designed to complement and reinforce existing training materials for village health teams (VHTs) in Uganda. It builds upon the content of the Uganda Ministry of Health’s existing training materials for VHTs and provides additional content and tools to support VHTs in their efforts to monitor and promote maternal health in their communities. The four-day training workshop equips members of VHTs with the knowledge, skills, and tools they need to promote healthy practices before, during, and after childbirth and to monitor maternal health care–seeking and pregnancy outcomes in their communities.
Files: English (PDF, 1.7MB)

Communities for Improving Maternal Health: A Guide to Training Village Committees in Maternal and Child Health in Guinea
This five-day training guide was developed in Guinea to give village safe motherhood committees the knowledge, ability, and tools necessary to spread awareness within their community of the risks of pregnancy and childbirth, including obstetric fistula, in addition to promoting maternal health through access to care before, during, and after childbirth. In particular, the training focuses on three problems linked to poor maternal health: giving birth at home without access to skilled care in an emergency; lack of antenatal care and preparation for childbirth; and poor engagement of men during pregnancy and childbirth.
Files: French (PDF, 1.8MB)

Journal Articles

Determinants of Postoperative Outcomes of Female Genital Fistula Repair
This paper described the predictors of fistula repair outcomes three months postsurgery among 1,274 women who underwent fistula repair. Small bladder size (adjusted RR 1.57, 95% CI 1.39–1.79), prior repair (adjusted RR 1.40, 95% CI 1.11–1.76), severe vaginal scarring (adjusted RR 1.56, 95% CI 1.20–2.04), partial urethral involvement (adjusted RR 1.36, 95% CI 1.11–1.66), and complete urethral destruction or circumferential defect (adjusted RR 1.72, 95% CI 1.33–2.23) all predicted failed fistula closure. Women with a closed fistula at the three-month follow-up were included in an analysis of predictors of residual incontinence (n=1,041). Prior repair (adjusted RR 1.37, 95% CI 1.13–1.65), severe vaginal scarring (adjusted RR 1.35, 95% CI 1.10–1.67), partial urethral involvement (adjusted RR 1.78, 95% CI 1.27–2.48), and complete urethral destruction or circumferential defect (adjusted RR 2.06, 95% CI 1.51–2.81) were significantly associated with residual incontinence. The prognosis for genital fistula closure is related to preoperative bladder size, previous repair, vaginal scarring, and urethral involvement.
Link: English
Abstract: French (PDF, 561KB)

Factors Influencing Choice of Surgical Route of Repair of Urinary Fistula and the Influence of Route of Repair on Surgical Outcomes: Findings from a Prospective Cohort Study
The abdominal route of genitourinary fistula repair may be associated with longer term hospitalization, hospital-associated infection, and increased resource requirements. This paper examines: the factors influencing the route of repair; the influence of the route of repair on fistula closure three months following surgery; and if the influence of the route of repair on repair outcome varied by whether women met published indications for abdominal repair. Published indications for abdominal route of repair (extensive scarring or tissue loss, genital infibulation, ureteric involvement, trigonal, supratrigonal, vesico-uterine or intracervical location, or other abdominal pathology) predicted the abdominal route [adjusted risk ratio [ARR], 15.56; 95% CI, 2.12–114.00]. A vaginal route of repair was associated with increased risk of failed closure (ARR, 1.41; 95% CI, 1.05–1.88); stratified analyses suggested elevated risk among women meeting indications for the abdominal route. Additional studies powered to test effect modification hypotheses are warranted to confirm whether the abdominal route of repair is beneficial for certain women.
Link: English
Abstract: French (PDF, 561KB)

Development and Test of Prognostic Scoring Systems for Surgical Urinary Fistula Closure
This paper describes the testing of the diagnostic performance of five existing classification systems (developed by Lawson, Tafesse, Goh, the World Health Organization [WHO] and Waaldijk) and a prognostic scoring system derived empirically from our data, to predict fistula closure three months following surgery. Among existing systems, the scoring systems representing the WHO, Goh and Tafesse classifications had the highest predictive accuracy: AUC 0.63 (95%CI: 0.57–0.68), AUC 0.62 (95%CI: 0.57–0.68) and AUC 0.60 (95%CI: 0.55–0.65), respectively. The empirically derived prognostic score achieved similar predictive accuracy (AUC 0.62, 95%CI: 0.56–0.67); it included significant predictors of closure found in the other classification systems but contained fewer nonoverlapping components. Differences in AUCs were not statistically significant. The prognostic values of existing urinary fistula classification systems and the empirically derived score were poor to fair. Further evaluation of the validity and reliability of existing classification systems to predict fistula closure is warranted, with consideration given to a prognostic score that is evidence-based, simple, and easy to use.
Link: English
Abstract: French (PDF, 233KB)

Non-Inferiority of Short-Term Urethral Catheterization Following Fistula Repair Surgery: Study Protocol for a Randomized Controlled Trial
Providing fistula repair services in developing countries presents numerous challenges, including limited availability of operating rooms, of equipment, of surgeons with specialized skills, and of funding from local or international donors to support surgeries and subsequent postoperative care. Finding ways of providing services in a more efficient and cost-effective manner, without compromising surgical outcomes and the overall health of the patient, is paramount. Shortening the duration of urethral catheterization following fistula repair surgery would increase treatment capacity, lower costs of services, and potentially lower the risk of health care–associated infections among fistula patients. There is a lack of empirical evidence supporting any particular length of time for urethral catheterization following fistula repair surgery. This study will examine whether short-term urethral catheterization (over the course of seven days) is no worse (by more than a minimal relevant difference) than longer term urethral catheterization (over the course of 14 days) in terms of the incidence of fistula repair breakdown among women with simple fistula who presented at study sites for fistula repair service. If no major safety issues are identified, the data from this trial may facilitate the adoption of short-term urethral catheterization following repair of simple fistula in sub-Saharan Africa and Asia.
Link: English
Abstract: French (PDF, 561KB)

Outcomes in Obstetric Fistula Care: A Literature Review
Consensus about basic definitions of clinical success does not yet exist. Opinions vary widely about the prognostic parameters for success or failure. Commonly agreed upon definitions and outcome measures will help ensure that site reviews are accurate and conducted fairly. To properly compare technical innovations with existing methods, agreement must be reached on definitions of success. Standardized indicators for mortality and morbidity associated with fistula repair will improve the evidence base and contribute to quality of care.
Link: English


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 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 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 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)

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 Death Reporting Form from Uganda
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, adapted from a Fistula Care global document by the Uganda Ministry of Health, includes guidance for investigating and reporting mortality related to fistula surgery; instructions for preparing a fistula death investigation report; and reporting forms.
Files: English (PDF, 548KB)

Infection Prevention: A Reference Booklet for Health Care Providers
This reference handbook is a quick desk reference on important infection prevention (IP) topics: handwashing, gloving, aseptic technique, use and disposal of sharps, instrument processing, housekeeping, and waste disposal. Designed for use by a wide range of health care workers in low-resource settings, this comprehensive booklet introduces the importance of good IP practices and provides step-by-step instructions for performing critical IP procedures.
Files: English (PDF, 900KB)

Infection Prevention Posters
A facility’s general cleanliness and hygiene are vital to the health and safety of staff, clients, visitors, and the community at large. These posters cover waste disposal and housekeeping, decontaminating and cleaning instruments and other items, hand hygiene, use of gloves, sterilizing instruments and other items, and high-level disinfection.
Files: English (PDF, 1.6MB) and French (PDF, 1.6MB)

Medical Waste Management Compliance Checklist
This checklist facilitates annual monitoring of medical waste management at Fistula Care–supported sites.
Files: English (PDF, 535KB) and French (PDF, 552KB)




© 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.