Johns Hopkins Bloomberg School of Public Health: The INFO Project

Case Study: Addis Ababa Fistula Hospital

The Addis Ababa Fistula Hospital in Ethiopia—also known as the Hamlin Fistula Hospital, after its founders Drs. Catherine and Reginald Hamlin—began in 1959 as a ward within a local maternity hospital. During its first year of operation, the Hamlins treated 30 cases of fistula. In 1974 they established a separate facility dedicated to fistula surgery. Over 25,000 women have had fistulas repaired at the hospital (7, 45).

Currently, the hospital treats about 1,200 patients a year (19). Services are free, as are room and board, even for patients who require a long recovery period. Counseling helps women cope with their condition and rejoin their families and communities.

Women with especially severe cases who will continue to depend on the hospital for long-term health care and supplies are provided with housing and work on the hospital grounds. Women suffering with foot-drop (paralysis of muscles in the lower legs), which often requires long-term physical therapy, also may receive accommodation in special wards (7, 19). Forty former fistula patients are trained in nursing and surgical skills.

The hospital trains Ethiopian postgraduate doctors as well as doctors from other countries. Most spend two months in residence, and there are two interns at the hospital at all times (19).

Some members of the staff make regular trips to regional sites within Ethiopia to treat fistula. These traveling units consist of complete medical teams, including doctors, nurses, and all necessary equipment and supplies (19). The hospital teams also have performed fistula repair operations and trained medical staff in other countries, including Chad, Kenya, Sierra Leone, Tanzania, Togo, and Uganda, and as far away as Bangladesh and India (8).

Funds to support the hospital’s work come from a variety of donors. The total budget is about US$550,000 per year. The Ethiopian government provides some salaries and duty-free privileges. The hospital recently obtained additional funding, which enabled it to establish permanent outreach activities in five regions (45). Further information is available at www.fistulahospital.org.

Case Study: International Campaign Strives To End Fistula

The International Campaign to End Fistula began in 2003, with the goal of drawing attention to obstetric fistula both as a medical issue and in its social and economic dimensions. The campaign builds on earlier but little-recognized efforts by doctors and other medical practitioners in sub-Saharan Africa to address the serious problem of fistula.

The international campaign focuses on the regions thought to have the highest numbers of fistulas—sub-Saharan Africa, South Asia, and parts of the Near East and North Africa. Fistulas occur in other developing regions as well, but estimates are few. The long-term goal is to make fistula as rare a problem in developing areas as it is in developed countries today (49, 61).

The international campaign is sponsored by UNFPA in cooperation with WHO, the International Federation of Gynecology and Obstetrics (FIGO), the Averting Maternal Death and Disability Program of Columbia University’s Mailman School of Public Health, EngenderHealth, the Women’s Dignity Project (Tanzania), and other nongovernmental organizations (NGOs) (62). Also, UNFPA country offices are forming partnerships with government agencies, health professionals’ associations, and national and international NGOs to raise awareness of fistula and to help prevent and treat it.

Such partnerships inform health professionals, policy-makers, community leaders, and the public about fistula prevention and treatment, as well as the importance of good maternal health care. Further information about the campaign is available on the UNFPA web site at www.unfpa.org/fistula. Information about obstetric fistula also can be found on the Worldwide Fistula Fund web site at www.wfmic.org; the EngenderHealth web site at www.engenderhealth.org; the Women’s Dignity Project web site at www.womensdignity.org; and the African Medical & Research Foundation (AMREF) web site at www.amref.org.

Assessing country needs. To help identify the incidence of fistula in various countries and the capacity of existing health facilities to treat it, UNFPA and EngenderHealth conducted initial needs assessments in nine sub-Saharan countries—Benin, Chad, Malawi, Mali, Mozambique, Niger, Nigeria, Uganda, and Zambia (63). In Tanzania the Women’s Dignity Project conducted a similar assessment, and other assessments have been conducted in Bangladesh, Djibouti, Eritrea, Kenya, Ghana, and Rwanda (13, 14, 32, 68, 75). As of mid-2004 similar reviews are underway in Burkina Faso, Mauritania, Senegal, Sierra Leone, Sudan, Togo, and Yemen (73).

Most assessments are based primarily on interviews with fistula care providers and patients in hospitals and treatment centers, as well as government health officials and policy-makers. While the assessments are not nationally representative surveys, nor are they comparable, they can help policy-makers and program managers understand and deal with the problems in each country.

Some sub-Saharan countries that have completed needs assessments are starting to carry out national strategies for fistula prevention and treatment (59). Also, in South Asia UNFPA organized the first regional conference on fistula, held in Bangladesh in December 2003 and attended by more than 50 participants from Bangladesh, India, Nepal, and Pakistan. Plans are for Bangladesh to establish South Asia’s first national fistula center, which eventually will be able to offer information and training about fistula treatment throughout the region (60).