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)

Evaluation of Community-Level Fistula Prevention Interventions in Guinea
The purpose of the evaluation was to explore whether the establishment and support of Village Safe Motherhood Committees led to measurable outputs in terms of enhanced community capacity and support systems and whether enhanced community support systems were associated with desired population-level outcomes, such as knowledge about obstetric risks, birth preparedness, and use of maternal health services. The study showed measureable differences between intervention and comparison villages in terms of community capacity—namely, the knowledge and activities of community-level committees and individuals involved in maternal health promotion. In addition, significant differences were observed at the population level in terms of women's exposure to community-level maternal health promotion efforts and their knowledge about maternal health and obstetric fistula.
Files: English (PDF, 978KB) and French (PDF, 1.0MB)

Family Planning-Integrated Fistula Care Evaluation and Case Study
The prevention component of the Fistula Care project has included family planning (FP) as an important measure for helping women and couples affected by fistula. Fistula Care’s approach to integrating FP services involves a five-step process that is adaptable to each facility’s capacity for integration. This report includes an in-depth case study of the Fistula Care Nigeria program’s efforts to integrate FP with fistula services. The Nigeria case study includes results from: interviews with key informants about the integration process; observations of patient-provider counseling sessions; focus group discussions; and provider self-assessments. Results of other countries’ experiences using the FP integration framework are also presented. The report also reviews the trends from Fistula Care quarterly reporting from supported sites on FP counseling and the numbers of FP acceptors, by method.
Files: English (PDF, 3.0MB) and French (PDF, 562KB)

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 (339KB)

Key Findings and Recommendations: A Multi-Center Retrospective Review of Data Collection Procedures and Data Quality of Indications for Cesarean Deliveries
To determine if cesarean indications could easily be extracted from patient records for periodic review and whether a simple indication classification system such as the one proposed by the Immpact/International Federation of Obstetrics and Gynecology (FIGO) group to track trends would be useful for hospitals we support, Fistula Care carried out a retrospective record review study. The objectives of the study were to: 1. Identify the indications for a sample of cesareans, specifically to determine if obstructed labor and other related indications were recorded in client files 2. Identify other key details about the cesarean delivery (e.g., timing of cesarean, use of the partograph, cadre of provider who performed the cesarean), using a standard data collection tool, to identify areas for improvement 3. Review data reporting procedures to identify any challenges to recording and reporting quality data on cesarean indications at facilities 4. Assess providers’ perspectives about the organization of cesarean services and data management.
Files: English (PDF, 833KB) and French (315KB)

Risk and Resilience: Fistula Report
This study explores the many dimensions of fistula through the experiences and views of girls and women living with fistula, as well as their families and communities and the health workers who care for them.
Files: English (PDF, 767KB)

Sharing the Burden: Ugandan Women Speak About Obstetric Fistula
Women's Dignity Project and EngenderHealth carried out a study in four rural districts of Uganda to bring to light the social, cultural, economic, and medical complexities of obstetric fistula. This study provides evidence on the need for broad-based and sustained action to address maternal morbidity and mortality in Uganda.
Files: English (PDF, 478KB)

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)

Traumatic Gynecologic Fistula as a Consequence of Sexual Violence: A Literature Review
This literature review surveys the landscape of information on traumatic gynecologic fistula in conflict settings. Though limited in scope by the lack of documented evidence, the literature review makes it clear that future efforts to address traumatic fistula should include increased surveillance to assess wither this problem exists in all countries where systematic sexual violence has occurred and confirms the need for collective discourse on traumatic fistula.
Files: English (PDF, 42KB)

Use of the Partograph: A Literature Review on Effectiveness, Training, Modifications, and Barriers
The purpose of the review was to identify and summarize the available literature on the use and efficacy of the partograph (including information on the attitudes of health care providers toward the partograph) and to identify and evaluate training strategies and barriers to its use.
Files: English (PDF, 342KB) and French (PDF, 236KB)