Obstetric Fistula

 

Welcome to the programmatic area on obstetric fistula within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. This is one of the subareas found in the women’s health part of the sexual and reproductive health (RH) section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. Obstetric fistula is a source of physical and psychological suffering, in addition to cultural and economic isolation, for large numbers of adolescent girls and women in low-income settings around the world.  A complication from prolonged or obstructed labor, the resulting lesion(s) between a woman’s vagina and bladder, and/or rectum, can leave a woman with a range of problems—from leakage of urine and feces to recurring infections, infertility, severe vaginal tissue damage, and paralysis of the lower legs (World Health Organization, 2006a).  Needs assessments and monitoring and evaluation are essential components of programs to prevent and treat obstetric fistula. Key indicators to monitor and evaluate obstetric fistula can be found in the links at left.   Full Text Obstetric fistula (OF) is a source of physical and psychological suffering, in addition to cultural and economic isolation, for large numbers of adolescent girls and women in low-income settings of the world.  A complication from prolonged or obstructed labor, the resulting lesion(s) between a woman’s vagina and bladder and/or rectum can leave a woman with a range of problems from leakage of urine and feces to recurring infections, infertility, severe vaginal tissue damage, and paralysis of the lower legs (WHO, 2006a).  The pain and suffering can be so extreme that some women resort to suicide. The UNFPA Campaign to End Fistula estimates that at least two million women are living with OF worldwide and up to 100,000 new cases occur each year (UNFPA, 2010).  In most cases, OF is preventable and treatable.  The immediate cause is generally very long or obstructed labor in which the constant pressure of the infant’s head against the pelvis reduces blood flow to the soft tissue around the bladder, vagina and, rectum resulting in a hole or fistula between the adjacent organs and in most cases, a stillbirth.  If the women had received timely obstetric care, the baby would have been delivered by caesarean section or assisted vaginal delivery, which probably would have saved the life of the infant and prevented the conditions leading to OF.  Less common causes of OF are sexual abuse and rape, complications from unsafe abortion, surgical trauma, and gynecological cancers and related radiotherapy treatment (WHO, 2006a). Underlying risk factors for OF include early marriage and childbearing, inadequate family planning and birth spacing, poor nutritional status, harmful practices such as female genital cutting, sexual violence, lack of education, poverty and low status of women.  In developed countries where antenatal care (ANC) and essential or emergency obstetric care (EmOC) are more readily available, the prevalence of OF is low, whereas the lack of these services in resource poor settings increases risk of labor complications, late or inadequate medical care, and resulting OF.      The determinants of maternal morbidity and mortality, as well as infant deaths, are the same that cause OF and, therefore, strategies designed to prevent and treat OF should be an integral part of global and country-level maternal and newborn health strategies. Improving access to care and knowledge about OF are important first steps is reducing OF. It is also important that OF plans be integrated into broader reproductive health and poverty-reduction strategies (WHO, 2006). The UN Millennium Development Goals (MDG) most directly related to OF are #5 Improve maternal health and #4 Reduce child mortality. In 2003, UNFPA and its global partners united to launch the Campaign to End Fistula.  Currently working in 49 countries, the campaign focuses on three key areas: preventing fistula, treating affected women, and supporting women as they recover from surgery and rebuild their lives (UNFPA, 2010).  Beginning in 2004, the EngenderHealth ACQUIRE project, supported by USAID, focused on training surgeons and strengthening the capacity of sites to provide quality OF surgery.  The USAID Fistula Care Project expanded the scope of work to increase and strengthen the number of sites providing OF services, in addition to supporting prevention through advocacy, increased attention to provision of EmOC, family planning services, and identifying OF women post-surgery to assist them with rebuilding and reintegrating their lives (note: the Fistula Care Results Framework is available at EngenderHealth, 2009).  In 2006, WHO developed a comprehensive list of short-, medium- and long-term objectives, essential components for OF prevention and treatment strategies, and models for delivering OF repair services (WHO, 2006a).    Needs assessments and monitoring and evaluation (ME) are essential components of programs to prevent and treat OF.  Selected indicators from the WHO (2006b) list of 17 reproductive health indicators for global monitoring (e.g., percentage births attended by skilled health personnel, numbers of facilities with basic or comprehensive essential obstetric care), as well as, indicators for monitoring obstetric care (e.g., rates of treated obstetric complications, caesarean rates, and case-fatality rates) can be useful for identifying needs and monitoring OF programs (WHO, 2006a).  Core lists of indicators specific to OF have been recommended and are in the process of being tested and revised. The WHO (2006a) list of 19 OF indicators are grouped into four areas: epidemiological prevalence, service delivery, training, and quality of care. The 13 indicators selected for this database are a subset of the WHO (2006a) list that still cover the four areas and reflect the continuing work on refining core OF indicators by the CDC/DRH led Data, Indicators, Research Committee of the International Obstetric Fistula Working Group.    ME plans and data collection for the OF indicators need to be integral to the strategy from the beginning, clearly planned for how they will be performed, and with robust data collection systems in place.  In addition to ME, audits of clinical care can help ensure the highest quality of care.  Further research is needed on the optimal time for OF repair (i.e., as soon as necrotic vaginal tissue is cleared or two to three months after the OF occurred) and the effectiveness of the types of repair undertaken (WHO 2006a).  Ideally, such research can be built into the national strategies.  __________ References: EngenderHealth, 2009, Fistula Care: Annual Report October 2008 to September 2009, Washington, D.C.: USAID. http://www.engenderhealth.org/search2/search.php?query=obsteric+fistulacategory=2results=20search=1x=18y=5  UNFPA, Campaign to End Fistula, Dispatch; Nov. 2010. New York: UNFPA.  http://www.endfistula.org/sites/endfistula.org/files/pub-pdf/sep-chap_fistula-may24.pdf UNFPA. 2004, Program Manger’s Planning Monitoring and Evaluation Kit, Part II: Indicators for Reducing Maternal Mortality, New York: UNFPA.http://www.unfpa.org/monitoring/toolkit/Tool6_2.pdf   WHO, 2006a, Obstetric Fistula: Guiding principles for clinical management and programme development, Geneva: WHO.http://whqlibdoc.who.int/publications/2006/9241593679_eng.pdf WHO, 2006b, Reproductive Health Indicators Reproductive Health and Research Guidelines for their generation, interpretation and analysis, Geneva: Who. http://whqlibdoc.who.int/publications/2006/924156315X_eng.pdf  

Obstetric fistula prevalence

Definition:

The number of females (girls and women) age 10 and older who are living with obstetric fistula (OF) in a defined area per 1,000 females age 10 and older.

This indicator is calculated as:

(An estimate of the number of females age 10 and older who are living with an OF in a defined area/ Total number of females age 10 and older who live in the same area) x 100

Data Requirements:

To calculate the prevalence of OF, one needs an estimate of the number of females in a defined area who are living with OF and the number of females age 10 and older who live in the same area.

Data should be disaggregated by young women/girls under age 18, and women age 18 and above.

Data Sources:

Facility-based medical records provide data on women who have presented at the facility with OF. However, women who do not access facilities are excluded from this data.  These are usually women in remote and rural areas with home births unattended by a skilled provider - i.e., those at most risk for OF (Tuncalp et al., 2015).

Community-based surveys generally provide wider coverage and better representation of a regional or national population.  However, such surveys can be expensive or time-consuming.  

Population-based special studies or surveys, such as the DHS, gather information on OF, however, there are limitations with self-reporting and restricted age limitations.

To obtain data for the numerator, a survey such as DHS or RHS with well-developed and -tested questions specifically about OF can be used to estimate the number of women of reproductive age (15-49 years old) in an area living with OF.  The only way to obtain information on females younger than age 15 or older than age 49 is to conduct a special survey. 

A survey using the direct sisterhood method can be used to calculate the denominator. However, it is better to obtain information about the number of females age 10 and older from census data or from intra-censal projections.

Purpose:

The prevalence of OF provides a sense of the magnitude of the problem of OF, including how adequate/accessible maternity services were in the past and the current need for surgical care and reintegration services.  Understanding the overall burden of morbidity that exists in the country from this medical condition can have positive implications for policy development and advocacy efforts.

Issue(s):

It is difficult to obtain an accurate estimate of the number of OF cases for several reasons.  Because OF is believed to be a statistically rare event, a large sample size is required, which is often prohibitively expensive. Still, all community based studies of reproductive health should explicitly ascertain and report the clinical presence or absence of fistula, even when the sample size is small (Adler, Ronsmans, Calvert and Filippi, 2013).

Women with OF are less likely to live in the mainstream of society and may be difficult to locate. Identifying women with OF using questions can be problematic, as women without OF can have a history of symptoms similar to those with OF, such as occasionally leaking urine, caused by other conditions.  Others may be too embarrassed to report incontinence.  This can lead to overestimation and underestimation of the burden of OF, respectively (Tuncalp, et al., 2015). Thus, it is important to use questions that have been pilot-tested and found to have high predictive value. Ideally, these questions should have been validated with a clinical examination.

Although the DHS questionnaires for some countries include standard modules with OF questions, not all DHS questionnaires ask about OF. Furthermore, the DHS captures only women of reproductive age and excludes young adolescent girls as well as older women.

References:

Adler A. J., Ronsmans C., Calvert C., and Filippi V.  2013. Estimating the prevalence of obstetric fistula: a systematic review and meta-analysis. BMC Pregnancy and Childbirth 2013, 13:246.

Tuncalp O, Tripathi V, Landry E, Stanton CK, and Ahmed S.  2015. Measuring the incidence of obstetric fistula: approaches, needs and recommendations. Bulletin of the World Health Organization. Jan 1, 2015; 93(1): 60-62.

Existence of a national ostetric fistula policy or strategy

Definition:

The existence of a national obstetric fistula (OF) policy or strategy either as a stand-alone document or integrated into national health or reproductive health policies or strategies.

Data Requirements:

Evidence of a stand-alone national OF policy/strategy, or of a national policy/strategy that includes OF

Data Sources:

Actual policy/strategy document with evidence of approval (or submission for approval)

Purpose:

This input indicator measures the extent of government support for prevention and/or treatment of OF.  It is meant to capture earlier stages of support for the policy continuum, whereas other indicators can capture a policy included in an implementation or action plan or if a policy has been funded and implemented. In many cases it takes time to strengthen the policy environment and in the meantime, policies drafted reflect a measure of support for OF. Although individual OF programs and organizations may perform in a highly effective manner, a supportive policy environment with an official OF policy/strategy helps better allocate and share the scarce resources available to eliminate OF.

Development of a national OF policy/strategy depends on the country context.  Whether a country develops a stand-alone policy or includes OF in broader national policies, such as sexual and reproductive health, education, gender-based violence, or roadmaps for reducing maternal and neonatal mortality, the development of such policies often entails a multi-year process.   Furthermore, policy development and strategic planning and implementation at the national level often requires the participation of various government ministries (e.g., finance, planning, information, education, interior ministries), as well as NGOs, women’s groups, religious and civic organizations, and the private sector.

Issue(s):

A policy that has not been revised for five or more years may not accurately reflect the policy needs in the country.  Therefore, even if a national OF policy exists, evaluators may wish to evaluate if it is still current and relevant.

Obstetric fistula data collected in the HMIS database

Definition:

The inclusion of obstetric fistula (OF) data on prevention, diagnosis, treatment (i.e. surgical, medical, and psychosocial care), and reintegration services in a country’s existing health management information system (HMIS).

Data Requirements:

OF data included in the HMIS database and reported for one or more time points. The indicator may be further stratified by country region if the HMIS is operationally decentralized and separate systems exist autonomously at the regional level.

Data Sources:

HMIS database

Purpose:

This indicator intends to measure whether the health information data system includes reporting on OF cases. Inclusion of OF data reporting in the HMIS indicates a move toward more standardized reporting of diagnosed and treated OF cases and the tracking of OF information from facility and/or program levels to the national level.

The minimum data reported are the number of OF patients who received treatment over a given period of time. However, the more OF data is reported and included in the HMIS database, the more information is available about the overall burden of morbidity that exists in the country from this medical condition, which can have positive implications for policy development and advocacy efforts.  Furthermore, the inclusion of OF data in the HMIS can streamline the commodity security and logistics cycle and avoid potential stockouts of essential medicines and supplies to treat and care for OF patients. 

Issue(s):

Data may be reported for one or more, but not for all regions in the country.  Also, hospitals frequently report to different parts of the ministry of health within the national health information system.  For example, data on OF prevention are reported separately from data on treatment. This variation in location of reporting can affect how or if specific hospital data will reach the HMIS and how policy makers use the data.

Number of doctors trained in obstetric fistula repairs

Definition:

The number of doctors who have been trained in conservative and surgical management of fistulas, incurred during childbirth or because of inflicted trauma, within a given timeframe (generally the last calendar year).

Data Requirements:

Training records. Data can be disaggregated by sex, type of specialty (e.g. general surgeon, obstetrician/gynecologists, urologist), type of facility (e.g. public, private, non-governmental, community-based), and by district and urban rural location.  If a refresher training is being conducted, the corresponding indicator should be “Number of doctors receiving a refresher training in obstetric fistula repairs”.

If targeting and/or linking to inequity, classify trainees by areas served (poor/not poor) and disaggregate by area served.

Data Sources:

Training reports

Purpose:

 

Successful treatment for women suffering from obstetric fistula (OF) includes the surgical repair of fistulas from trained providers. This process indicator is a proxy for the readiness of doctors to treat obstetric fistula. Based on the Fistula Care project’s Fistula Treatment Training Strategy (EngenderHealth, 2008), the training program should include elements of medicine and surgery as well as the service delivery system.  Specific components of a training program might include:

The duration of training in simple repair surgery varies with the doctor’s initial surgical skills and professional background.  For specialists (surgeons, obstetrician/gynecologists, urologists), initial trainings generally last 2–12 weeks.  For general practitioners with a minimum of three years of surgical experience, the training is 4-12 weeks.  Because fistulas vary greatly in complexity and difficulty of repair, a gradual increase beyond 12 weeks is envisaged for skill and surgical efficiency, starting with simple cases and then progressing to moderate then high complexity cases.

Effective follow-up is crucial and integral to training. Typically, trainees need two or more follow-up trainings before they become fully confident in their surgical skills at a particular competence level, even for simple fistula surgery.  The Fistula Care project has developed a Fistula Services Facilitative Supervision and Medical Monitoring form for training follow-up (EngenderHealth, 2008).

The International Federation of Gynecologists and Obstetricians (FIGO) coordinated the production of a training manual, the Global Competency-Based Fistula Surgery Training Manual, aimed at healthcare providers from low- and middle-income countries involved in the prevention and management of OF (FIGO, UNFPA, 2011). The training curriculum articulates what fistula surgical training should be, which allows both trainer and trainee performance to be objectively evaluated and appropriate follow-up conducted of the surgeons who have been trained. Standardization also allows more doctors to be trained while identifying what fistula surgeons can safely undertake at a given level of skill or experience (Rushwan and Ruminjo, 2011). The manual was pilot tested in several centers in 2011 and is currently being rolled out.

Issue(s):

 

The indicator does not provide information about the quality of the training or the quality of services provided by the trained doctors.  To assess mastery of knowledge and skills, evaluators should also collect data for the indicator, “Surgical competency upon completion of OF training”. 

This indicator captures only number of doctors trained, however, training reports should record the other cadres of individuals trained in fistula including nurses, non-nurse counselors, anesthetists, physiotherapists, facility management/administration, support staff, and community liaisons (including NGOs and community-based organizations).

References:

 

EngenderHealth, 2008, Fistula Care Training Strategy. http://www.fistulacare.org/pages/pdf/Training/FistulaTrainingStrategyEngenderHealthFistulaCare070708formatted.pdf

EngenderHealth, 2008, Fistula Services Facilitative Supervision and Medical Monitoring for Training Sites and Training Follow-up. http://www.fistulacare.org/pages/pdf/Training/FistulaSupervisionandMonitoringforTrainingsiteandtrainingfollowupApril08formatted.pdf

FIGO, UNFPA, 2011.  Global Competency-Based Fistula Surgery Training Manual.  http://www.figo.org/sites/default/files/uploads/wg-publications/fistula/FIGO_Global_Competency-Based_Fistula_Surgery_Training_Manual_0.pdf 

Rushwan H. and Ruminjo J., 2011.  “Pursuing a Standard of Care for Training New Fistula Surgeons”.  RH Reality Check. http://www.rhrealitycheck.org/blog/2011/03/04/pursuingstandard-care-training-fistula-surgeons

Number of facilities with functioning obstetric fistula surgical treatment capacity

Definition:

The total number of service delivery sites in a country where surgical repair for obstetric fistulas (OFs) are regularly provided.

To be included as a “functioning” OF treatment facility, the site must have:

*For the purposes of a standard definition, performance of at least one surgery to repair OF(s) over a three month period will be considered “regular” provision. A notation may be made indicating periodic capacity for surgical OF repair services.

Data Requirements:

Service provision data from service delivery sites providing OF care in a country

Data Sources:

Health information management systems; facility-based surveys; comprehensive emergency obstetric care needs assessments; service provision assessment (SPA) surveys

Purpose:

This indicator deals with access to services and the supply side of OF repair.  It is used to assess whether adequate numbers of sites provide surgical repair services for genital fistulae resulting during childbirth or because of inflicted trauma. While no international standards exist regarding the acceptable number of facilities providing surgical fistula repair services, wherever OF is a prevalent issue, repair services should be available.  Identifying geographic areas and thereby existing health facilities that should be offering OF repairs and assessing their capacity to provide these services forms the basis of the evaluation, development, or expansion of fistula programs.

Issue(s):

Evaluating the regularity with which surgical repair services are provided may be difficult. Patterns and frequencies of fistula repairs may fluctuate based on changing service provision capacity – such as when specially trained surgeons visit the facility or when special medical teams bring with them necessary medications and supplies. Additionally, materials and supplies available at facilities may vary with supply cycles. For example, if facilities are stocked at the beginning of the fiscal year and surgeries exhaust supplies by mid-fiscal year, unless the facility is restocked, it cannot be counted among the facilities with functioning OF surgical treatment capacity for the entire year. Moreover, the measurement of OF surgical treatment capacity provides no information about the quality of the surgical repairs or what the facility’s success rate is.

Surgical competency upon completion of obstetric fistula training

Definition:

 

“Competency” refers to a trainee’s ability to perform obstetric fistula (OF) surgical repair according to a set standard.  Formal standards/requirements for qualifying as a competent provider (in this case, doctor) are established by the ministry of health (MOH) in each country program. Critical steps are identified in clinical skills check lists and providers must perform all of these steps correctly, completely and consistently to be deemed competent (EngenderHealth, 2008).

This indicator is calculated as:

(Number of trainees demonstrating surgical competence upon completion of OF training / Total number of trainees observed and/or tested) x 100

Data Requirements:

 

Training records. Data can be disaggregated by sex, type of staff (e.g. nurse, doctor, midwife), type of facility (public, private, non-governmental, community-based), and by district and urban rural location.

Data Sources:

 

Observation at various stages during and after the training event; knowledge pre and post-test forms, along with clinical skills check lists.  The Fistula Care project has a Fistula Services Facilitative Supervision and Medical Monitoring form for training follow-up (EngenderHealth, 2008).

Purpose:

 

This output indicator measures what doctors can actually do in the workplace as a result of the training. It emphasizes progress in mastery of specified knowledge, attitude, and skills related to OF repair.

Surgical competency of OF is based on three levels.  At the skills acquisition level, doctors receive knowledge and skills to diagnose, classify fistula, and refer, but are not yet competent to perform fistula surgery.  At the competence level, trainees learn how to diagnose, classify, and perform actual fistula surgery.  Because fistulas vary greatly in complexity and difficulty of repair, a gradual increase in length of training is required for skill and surgical efficiency, starting with simple cases and then progressing to moderate then high complexity cases.  At the proficiency level, doctors must be able to do most of the high complexity fistula cases safely, efficiently, and in correct sequence for key steps, and deal with unexpected complications during surgery (EngenderHealth, 2008).  It should take at least three months to gain competency in the standard management of OF, 12 months in their advanced management, and 24 months in their expert management.

The International Federation of Gynecologists and Obstetricians (FIGO) co-ordinated the production of a training manual, the Global Competency-Based Fistula Surgery Training Manual, aimed at healthcare providers from low- and middle-income countries involved in the prevention and management of OF. Because there is now a standardized training curriculum that articulates what fistula surgical training should be, both trainer and trainee performance can be objectively evaluated and surgical competence assessed. The manual was pilot tested in several centers in 2011 and is currently being rolled out (FIGO, UNFPA, 2011).

Issue(s):

 

Because formal standards and scores required for qualifying as a competent provider are established in each country program, there may be some variation among field programs, with requirements for qualifying as competent being about 85% on “must know content” knowledge assessments and in clinical practice, in addition to performing all critical steps competently.

References:

 

EngenderHealth, 2008, Fistula Care Training Strategy. http://www.fistulacare.org/pages/pdf/Training/FistulaTrainingStrategyEngenderHealthFistulaCare070708formatted.pdf

EngenderHealth, 2008, Fistula Services Facilitative Supervision and Medical Monitoring for Training Sites and Training Follow-up. http://www.fistulacare.org/pages/pdf/Training/FistulaSupervisionandMonitoringforTrainingsiteandtrainingfollowupApril08formatted.pdf

FIGO, UNFPA, 2011.  Global Competency-Based Fistula Surgery Training Manual. 
http://www.figo.org/sites/default/files/uploads/wg-publications/fistula/FIGO_Global_Competency-Based_Fistula_Surgery_Training_Manual_0.pdf

Met need for surgical treatment among women diagnosed with obstetric fistula seeking surgical repair services

Definition:

The percent of all women seeking surgical repair services for and diagnosed with obstetric fistula (OF) who receive surgical treatment for the condition, within a given timeframe (generally annually) and by facility.

This indicator is calculated as:

(Number of women surgically treated for OF / Total number of women diagnosed with OF in the same time period) x 100

Although successful first attempts at fistula closure should be around 85%, of which 90% should be without incontinence (WHO, 2006), repeat surgeries are sometimes needed for complex cases.  Regardless of whether a woman has had one or multiple surgical repairs, and regardless of the outcome of the surgery, she should be counted once in the numerator.

Data Requirements:

Total number of OF diagnoses in a given time period; total number of women treated for OF within same timeframe.  Data should be stratified by health facility and possibly type of facility (e.g. public, private, non-governmental, community-based), but could be aggregated to obtain a regional or national percentage.

Unlike the indicator, “Met need for emergency obstetric care”, where UNICEF/WHO/UNFPA has set the minimum acceptable level of “met need” as 100 percent, no minimum acceptable level of “met need” has been established for OF surgical treatment, which is likely to be just under 100 percent. A small percentage of OF cases (particularly complex rectovaginal fistulas) are inoperable because of patient comorbidity or disease-related factors.  A small number of other OF cases do not require surgical treatment because they are simple, small, and the woman presents for care immediately after delivery (within a few hours or at most, days).  These situations make up the minority of OF cases diagnosed at facilities and generally do not have a significant impact on the actual percentage of “met need”.  However, among facilities with high case loads of OF repairs, evaluators may choose to exclude these cases from the denominator.

Data Sources:

Facility records

Purpose:

It has been estimated that more than 2 million women are living with OF, although it is impossible to determine the true extent of this problem (WHO, 2006).  The girls and women who suffer from OF usually live in abject poverty and in remote villages, shunned or blamed by society and unable to seek appropriate medical care.  Thus, it is extremely difficult to accurately measure the prevalence or incidence of OF when so few have access to health care.  By capturing the met need for OF treatment among the women who reach a health facility, this outcome indicator provides a measure of the capacity of health facilities to meet the needs of women who require surgical treatment for OF.

Analysis of this indicator over time can be used to assess significant changes in programs. Reductions in met need that were once high should prompt closer examination of changes in staff, treatment protocols, availability of essential medicines and supplies, etc. Comparison of the indicator across facilities may reflect facility-specific issues that require improvement.

Issue(s):

Although this is a measure of access to care among health facility clients seeking OF surgery, the indicator does not address quality of services.  Furthermore, meeting a women’s need for surgical repair of an OF is just one aspect of the treatment and healing process.  Because each OF patient has emotional, psychological, and economic needs, this indicator should be complemented with the indicator, “Percent of women who have been treated for obstetric fistula who receive reintegration services” to gauge the full range of care provided to women presenting with an OF.

References:

WHO: Department of Making Pregnancy Safer.  2006.  Obstetric Fistula: Guiding principles for clinical management and programme development.  http://whqlibdoc.who.int/publications/2006/9241593679_eng.pdf 

 

Percent of women presenting with obstetric fistula who have a successful first repair, by facility

Definition:

 

Percent of OF first repair surgeries, by facility, resulting in fistula closure and urinary continence among all vesico-vaginal fistula first repair surgeries performed in that facility in a given timeframe (generally one year).

The outcomes of vesico-vaginal fistula repair surgeries may be categorized as:

The most favorable outcome is closed and dry, which may be evaluated at different times following the surgery. The outcome assessment is best done when preparing for hospital discharge.

This indicator is calculated as:

(Number of first-time fistula repair surgeries performed in a given period resulting in closure and urinary continence after the surgery, excluding women who subsequently died / Total number of fistula first repair surgeries performed in the same time period) x 100

Data Requirements:

 

Total number of OF repair surgeries performed in a given time period, if the surgery was a first attempt or subsequent surgery, and identified outcome of the surgeries (closed and dry, closed and wet, or non-closure). Ideally, the closure rate should be 85%, of which 90% should be without incontinence (WHO, 2006), but success depends on the complexity of the condition.  Therefore, this indicator should be stratified by the type of fistula repaired (simple or complex).

Some programs may decide to report surgical outcomes separately: closed and dry, closed and wet, or not closed. However, only the patients with fistula closure and urinary continence and only those presenting for surgical repair for the first time should be considered in the numerator of the indicator.  Outcomes followed by death should also be excluded from the numerator regardless of the conditions of the fistula prior to death. Deaths should be captured in a separate indicator: case fatality rate of OF repair surgery. A similar classification system and indicator can be derived for recto-vaginal OFs. Additionally, the number of diagnosed patients treated and the number of successful subsequent surgeries (closed and dry) should be reported separately.

Data Sources:

Facility-based surveys; hospital discharge logs; medical records review

Purpose:

 

There is a decreasing possibility of success with each successive attempt at OF repair. Not only does this indicator capture the outcome of fistula repair programs at the individual level, based on the first attempt at repair surgery, it can also serve as a basic quality of care measurement and a powerful advocacy tool reflecting the success of an OF surgical repair program.

For comparability purposes, this indicator should always report the time at which the outcome of surgery was evaluated. When assessed at hospital discharge, calculation of this indicator is straightforward.

Analysis of this indicator over time can be used to assess significant changes in programs. Reductions in success rates that were once high should prompt closer examination of changes in staff, treatment protocols, and/or patient characteristics. Comparison of the indicator across facilities may reflect facility-specific issues that require improvement.

Issue(s):

 

Outcome may be evaluated at additional times including:

Evaluation of outcomes after hospital discharge may require special studies. These evaluations of outcome are important as urinary incontinence can resolve 3 to 6 months following surgery with regular pelvic exercises. This would require adequate postoperative counseling and follow-up visits. Facilities should use these strategies to improve their success rates.

Inoperable cases are excluded in the calculation of this indicator as they would not be candidates for fistula repair surgery, although they may undergo and benefit from other types of surgery such as urinary diversion. These would not be considered fistula repair surgeries.

Surgical outcomes depend on characteristics of the providers, the facility and the patient. The former two include factors such as surgical dexterity and experience of the providers, quality of postoperative care, and infection control practices of the facility, which can be modified. However, patient-specific characteristics such as age, parity, nutritional status, and complexity/severity of the fistula are less modifiable. It is recommended to always disaggregate the surgical success rate by the complexity/severity of fistula.

Another limitation is that the indicator is strictly defined among surgically repaired cases.  A quality of care OF indicator for women who only received catheter treatment for fresh fistula could be included.  Adding the catheter-only treatment has implications for defining the characteristics of OF surgical sites, data sources, and disaggregation.  More practical experience with a more inclusive surgical and catheter treatment indicator is needed.  Until then, success rate should be reported separately for surgical repairs and catheter-only repairs.

Percent of women who have been treated for obstetric fistula who receive family planning or birth spacing counseling

Definition:

The percent of women who have been treated for obstetric fistula (OF) (whether surgical or not) during a given timeframe (generally quarterly) who received counseling on their reproductive intentions, which includes discussion of birth spacing and family planning (FP) methods, as part of the package of reintegration services.

This indicator is calculated as:

(Number of women treated for OF who received FP or birth spacing counseling / Total number of women treated for OF) x 100

Data Requirements:

Total number of women who received treatment for OF either through catheter management or surgical intervention, regardless of outcome; number of women counseled on FP and birth spacing.  Evaluators may wish to collect data on other types of reproductive health counseling received, such as prevention and treatment of sexually transmitted infections, antenatal care, and delivery with a skilled provider.

Data should be disaggregated by:

If targeting and/or linking to inequity, classify outlets where counseling is taking place by location (poor/not poor) and disaggregate by area served.  Exit interviews can be conducted with clients to determine client's poverty status.

Data Sources:

Exit interviews; facility and program records at sites that are providing fistula treatment services.  If services are provided through referral, then the records of the providing institution or organization can serve as the source.

Purpose:

The injury to a woman’s genital tract – either through childbirth or inflicted trauma – resulting in a fistula requires adequate time to fully heal.  Thus, as part of comprehensive OF treatment, it is critical for health care providers to discuss with women who have had fistula repairs the woman’s reproductive intentions and how to avoid or postpone pregnancy for at least nine months following surgery. The Fistula Care project has developed a useful booklet, Family Planning for Women and Couples following Fistula Repair (EngenderHealth, 2010) to address this concern.  This indicator can assess both access to counseling services as well as the quality of reintegration services with regard to the inclusion of FP and birth spacing counseling.

Understanding the reasons that women have not received these services may require further analysis.  It may signify a lack of providers, non-existent or inadequate counseling on FP counseling, or logistical problems such as a poorly-executed referral system.

Issue(s):

Because this data is currently not being gathered on a routine basis, it may be difficult to collect the information before the indicator is more widely used.  Also, women treated outside of the recognized national treatment sites will likely not be captured. For referrals, it may not be possible to determine if the woman actually received the services and/or may require alignment of records from both treatment and referral sites, which in some cases could result in double reporting.

Without conducting provider observations, which have their own biases, one cannot assess from this indicator the quality of the FP and birth spacing counseling itself.

References:

Women’s Dignity Project, EngenderHealth, 2006.

Fistula Care project, 2010.  Family Planning for Women and Couples following Fistula Repair. EngenderHealth and USAID.  http://www.fistulacare.org/pages/pdf/FC_Tools/Family_Planning_booklet12.15.2010.pdf

Percent of obstetric fistula treatment facilities that provide social reintegration services

Definition:

The percent of obstetric fistula (OF) treatment facilities that provide onsite social reintegration services or provide referrals for these services, by type of services provided and spatial distribution of facilities.  Treatment of OF can either be through catheter management or surgical intervention.

The minimum reintegration service package, as defined by WHO’s guiding principles, should include counseling on what fistula is, how the injury was sustained, future risk factors and how to prevent fistula from occurring again, including the use of family planning and good obstetric care (2006). However, the essential components of reintegration services have not been universally agreed upon due to insufficient evaluation of existing services as well as scarce data on the factors associated with successful reintegration.  Therefore, users of this indicator will need to define what reintegration services to include in the national/program context.  The following are examples of other reintegration services that are currently being provided or have been recommended:

Availability of the service requires several factors to be present.  The facilities that offer reintegration services should have:

Where possible geographic mapping of sites is helpful to determine coverage.  In this case, geographic distribution may focus more on the referral site locations (e.g. non-governmental organizations or other existing programs) rather than the location of treatment sites.

This indicator is calculated as:

(Number of sites providing defined social reintegration services onsite or through referral / Total number of sites providing fistula treatment services) x 100

Data Requirements:

Number of sites country-wide providing OF treatment; number of treatment sites providing or referring for reintegration services; types of reintegration services provided either directly or through referral; geographic location of the sites including organizations engaged in referrals.

The number of sites assessed will likely be too small for useful disaggregation, but in some contexts it may be interesting to compare private vs. public facilities.

Data Sources:

Facility-based survey; program reports; national geographic mapping of health facilities

Purpose:

Treating OF requires a holistic approach which requires more than surgical and medical care.  Women with this condition have been traumatized and require services to address their emotional, psychological, and economic needs. Unfortunately, there are few experiences in specific reintegration programs upon which to draw, given the limited resources allocated to fistula care and the scarcity of people working on the long-term needs of these girls and women (WHO, 2006).  Nonetheless, there is a common understanding of the importance of this support and including a core reintegration indicator in OF programs may help initiate national dialogue to define and include reintegration services.

This process indicator can assist with understanding the availability and coverage of reintegration services.  It provides information on what percent of sites are providing the requisite nationally recommended services.  The information collected to calculate the indicator can also assist with program planning and may show where additional interventions are needed.  Geographic mapping will allow understanding of where there are coverage gaps for certain populations.  It may also be useful to compare findings with the indicator, “Percent of women who have been treated for obstetric fistula who receive family planning or birth spacing counseling”, to more fully understand whether services are actually available and offered to women after treatment.

Over time once services are established it can be used to monitor whether the services are maintained.  However, trend analysis of the indicator may be difficult as reintegration is an emerging area and the types of services offered will likely change based on new evidence.

Issue(s):

The evidence-base on the essential interventions and modes of service delivery for reintegration is weak.  Comparison within and between countries may be difficult due to wide variations in the types of services offered.  Also, quality of reintegration services cannot be determined by this indicator.

References:

WHO: Department of Making Pregnancy Safer.  2006.  Obstetric Fistula: Guiding principles for clinical management and programme development.  http://whqlibdoc.who.int/publications/2006/9241593679_eng.pdf  

Percent of women who have been treated for obstetric fistula who receive reintegration services

Definition:

The percent of patients treated for obstetric fistula (OF) who received reintegration services either onsite or elsewhere (e.g. non-governmental organization or other program).  Treatment of OF can either be through catheter management or surgical intervention.

To-date, there is no defined set of reintegration services.  According to the WHO, at a minimum, reintegration services should include counseling on what fistula is, how the injury was sustained, future risk factors and how to prevent fistula from occurring again, including the use of family planning and good obstetric care (2006). Other example of reintegration services that are currently being provided or have been recommended include:

This indicator is calculated as:

(Number of women treated for OF who received one or more reintegration services / Total number of women treated for OF) x 100

Data Requirements:

Number of women treated for OF; number of women served by reintegration services. Data can be disaggregated by the types of reintegration services provided (and if they were provided directly or through referral) as well as the woman’s personal characteristics (e.g. age, marital status).

Data Sources:

Facility-based survey; program reports

Purpose:

OF affects some of the most marginalized members of the population—poor, young, often illiterate girls and women in remote regions of the developing world.  After the initial medical intervention to treat the fistula, they require emotional, psychological and economic support to address their long-term needs, help them reintegrate into their families and communities, and continue life with dignity.  This outcome indicator measures what percent of treated women are receiving these essential services.

At a minimum, postoperative care should include counseling on family planning and birth spacing.  It may be useful to compare findings from this indicator with the indicator, “Percent of women who have been treated for obstetric fistula who receive family planning or birth spacing counseling”, to more fully understand whether this specific reintegration service is actually available and offered to women after treatment.

Issue(s):

Because the essential components of reintegration services have not been universally agreed upon, there is no minimum standard that can be used as a benchmark to measure provision of reintegration services against.  Therefore, the type and extent of reintegration services received by the women included in the numerator can vary greatly.  Also, the quality of reintegration services cannot be determined by this indicator.

While facility data can be useful, it generally only gives information on girls and women before their repair and not their experiences on returning home afterwards. Exceptions may be in cases where women come for follow-up examinations or where explicit measures are taken to find women post-repair.  Some facilities, such as the Addis Ababa Fistula Hospital in Ethiopia, provide a comprehensive package of OF treatment, rehabilitation, and prevention.  However most facilities providing OF treatment have minimal resources to follow up with patients or provide reintegration services onsite. 

An additional constraint to collecting data is the significant time and expense required in gathering information on women once they have left the facility. Women may travel up to 1,000 kilometers to seek repair. As such, once healed, they return to far-off villages in remote regions making follow-up difficult.  Many girls and women do not even return home, healed or not healed, because of taboos surrounding fistula.  They may have been forced to flee their villages when they got the fistula or were not welcomed back upon returning, which makes client follow-up extremely challenging (WHO, 2006).

References:

WHO: Department of Making Pregnancy Safer.  2006.  Obstetric Fistula: Guiding principles for clinical management and programme development.  http://whqlibdoc.who.int/publications/2006/9241593679_eng.pdf