New initiatives in evidence-based learning in obstetric fistula surgery in the developing world
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Volume 3 Issue 1 March 2010
New initiatives in
evidence-based
learning in obstetric
fistula surgery in
the developing world
SOHIER ELNEIL AND
MULU MULETA
Obstetric fistula is a problem commonly encoun-
tered in the developing world that results in debil-
itating urinary and/or faecal incontinence. Sohier
Elneil, a UK urogynaecologist, and Mulu Muleta,
a fistula surgeon from Ethiopia, chart a history of
fistula care and outline progress made.
Historically, many women suffered fistulas in
Europe and the USA, until the middle of the
last century. However, with social, economic
and health developments, this condition all
but disappeared in the developed world.
It still poses a major problem in Africa and
Asia, where access to modern obstetric care,
including caesarean section, can be limited.1,2
Over the course of a lifetime, one in 12
women in Africa will die in pregnancy or
labour, particularly in the rural areas.3 This
A woman
is a phenomenal figure, akin to three jumbo fistulas, particularly in West Africa,4 the horn awaiting surgery
jets full of passengers crashing fatally every of Africa5 and the Indian sub-continent.6–8
24 hours. More startlingly, for every woman
that dies in labour, at least 20 lives are Conservatively, it is estimated that there are
destroyed by terrible injuries sustained during two to three million women with obstetric
obstructed labour. Long distances combined fistula still awaiting surgery. The success of
with high cost of care and poor nutrition the repair depends on meticulous surgery,
make women more vulnerable to obstetric excellent nursing care and prevention of
Volume 3 Issue 1 1
New initiatives in evidence-based
learning in obstetric fistula surgery in the
developing world
complications.9–11 However, the number of tional Society of Obstetric Fistula Surgeons
capable and dedicated surgeons remains a (ISOFS), which was formed in September
major stumbling block in the management 2008.
of this condition.
The global effort started to take shape at the
In Africa and Asia, initiatives were under- start of this century, with the formation
taken by doctors from differing surgical of the International Working Group on
backgrounds, nurses and philanthropists, to Obstetric Fistula (IWGOF) established by
combat this debilitating problem. Their the UNFPA (United Nations Family Plan-
philosophy was to provide a dedicated centre ning Association), the World Health Organ-
of excellence to treat these women from ization (WHO), the International Federa-
their native country and surrounding states.12 tion of Gynecology and Obstetrics (FIGO),
They also provided training and education Engender Health, multiple international
but several problems persisted. These in- non-governmental organisations and, more
cluded a lack of consensus on fistula classifi- recently, ISOFS. Their first priority was to
cation, working in isolation and little or no try reaching an agreement on a globally
evidence-based medicine in decision mak- accepted fistula classification. Once adopted,
ing. Consequently, training in fistula surgery a classification system would be an invaluable
was often thought to be patchy, inadequate tool for training, communication and multi-
and unfocussed. Most importantly, though, centre research. Their second priority, in
there was no way to assess trainees or to tandem with the Royal College of Obstetri-
determine their suitability. As a consequence, cians and Gynaecologists (RCOG), was to
patient outcomes were very poor in some strengthen and support evidence-based
arenas. In addition, fistula surgery was highly learning in obstetric fistula surgery.
politicised in the developing world, which
often hampered progressive thoughts and Until the IWGOF came together, only a
ideas. Fortunately, with increasing awareness handful of units were appropriately equipped
of these situations, many agencies poured to provide training to a satisfactory level with
money into initiatives of fistula care, with
the focal point being the need of the local
healthcare providers. This was an impressive there are two to three
start but global consensus remained the key.
million women with
To achieve global agreement, several imped-
iments needed to be overcome. These obstetric fistula still
included coordination of clinical efforts to
prevent duplication of care, open commu- awaiting surgery
nication channels to enable better coordina-
tion of efforts to ensure well-managed and experienced trainers, adequate number of
targeted service provision, a universally cases and satisfactory training facilities.
accepted fistula classification to enable Although they did an excellent job in equip-
accurate communication between units and ping young surgeons with the necessary skills
surgeons about the conditions that they are to return to their own countries to further
treating and the input of fistula surgeons extend this work, some were hampered by
working in the field, such as the Interna- independent bodies, who have taken on the
2 RCOG International Newsletter
New initiatives in evidence-based learning in obstetric fistula surgery in the developing world task of producing a ‘training manual’ in an point that the success of the manual will rest attempt to formalise the training process. but perhaps with the help of ISOFS and the Some of these manuals were disparate and IWGOF a consensus may be reached within imprecise, maybe because of a lack of ex- the next few years. This situation is not un- pertise or direction, and so they were not usual, as similar problems were encountered readily useable in all situations. Understand- when attempts were made to reach con- ably, a unified approach was desperately sensus on classifying gynaecological tumours needed. 20 years ago. FIGO took on the mantle of a unified train- The manual is currently undergoing its ing programme for the group and started a initial trials in pilot studies in parts of Anglo- process, which is now in the piloting phase. phone and Francophone Africa and Asia.The The remit of the FIGO fistula committee initial results should be available within the was to reach a consensus on what a training next year. Thereafter, the training manual manual should include, to contribute to should become available to all fistula units the classification debate and to develop an and institutions for wider use. evidence-based course for a selected surgical or gynaecological trainee, who has attained Although the objectives of this whole at least three years of surgical training in their process were to unify the fistula community, home country.The training structure is mod- to develop standardised training programmes ular, with each module or subject area being and to improve outcomes, it must not be further subcategorised into specific objec- forgotten that this condition is completely tives. Each module can be achieved within preventable. Therefore, the issues which are a stipulated period of time, as determined the basis for it, social and economic develop- by the trainer and the trainee. But, rather ment of girls and women who are ‘at risk’, than this being a didactic process, the trainees need to be tackled. This includes universal were encouraged to follow a path of evi- access to emergency obstetric and medical dence-based training. The main support care and instituting appropriate integrated for the latter was provided by the RCOG. social and economic development pro- Using the agreed information, provided by grammes.This would effectively prevent the the fistula surgeons and other members of problem in the long term but, more impor- the IWGOF, they were able to formulate and tantly, it would be highly sustainable. In the develop learning tools, logbooks and objec- interim period, the holistic approach to tive structured assessments of technical skill medical and surgical treatment, rehabilita- (OSATS) for each module. This is the first tion and community follow-up instituted by time that such an initiative has been devel- many well-known fistula surgeons, includ- oped for a specific internationally recognised ing the tremendous efforts of the Hamlins health problem. Using the manual will not and their team in Ethiopia, Waaldijk and only provide a guide to surgical training but Lawson in Nigeria, Ouatarra and Gueye in will also initiate audit of surgical outcomes, Senegal, Abboo and Kelly in Sudan, Rassen thus facilitating research in the field and in East Africa, and Akhter in Bangladesh, promoting publication in the medical and have brought obstetric fistula to the forefront nursing literature. For the manual to be fully of the world’s medical media. Their exact- accepted, a consensus on fistula classification ing work has meant that more women’s lives must be reached. It is on this last awkward are being rebuilt. By embracing WHO’s Volume 3 Issue 1 3
New initiatives in evidence-based
learning in obstetric fistula surgery in the
developing world
mantra of ‘health security for women References
throughout the life-span’, in tandem with 1. Gifford RR, J Marion Sims (1813–1883) and
the new initiatives, we can improve the the vesicovaginal fistula. J S C Med Assoc
quality of all women’s lives. No more so is 1971;67:271–5.
this needed than in a woman suffering from 2. Gessessew A, Mesfin M. Genitourinary and
a fistula. rectovaginal fistulae in Adigrat Zonal Hospi-
tal, Tigray, north Ethiopia. Ethiop Med J
Sohier Elneil 2003;41:123–30.
Consultant Urogynaecologist 3. Muleta M, Fantahun M,Tafesse B, Hamlin EC,
University College London NHS Kennedy RC. Obstetric fistula in rural
Foundation Trust, London, UK Ethiopia. East Afr Med J 2007;84:525–33.
4. Wall LL, Fitsari ‘dan Duniya. An African
Mulu Muleta (Hausa) praise song about vesicovaginal fistu-
Senior Fistula Surgeon las. Obstet Gynecol 2002;100:1328–32.
Ministry of Health, Ethiopia 5. Leke RJ, Oduma JA, Bassol-Mayagoitia S,
Bacha AM, Grigor KM. Regional and geo-
graphical variations in infertility: effects of en-
vironmental, cultural, and socioeconomic
factors. Environ Health Perspect 1993;101 Sup-
pl 2: 73–80.
6. Coyaji BJ. Maternal mortality and morbidi-
ty in the developing countries like India. In-
dian J Matern Child Health 1991;2:3–9.
7. Rao KB. How safe motherhood in India is.
J Indian Med Assoc 1995;93:41–2.
8. Hafeez M, Asif S, Hanif H. Profile and repair
success of vesico-vaginal fistula in Lahore. J Coll
Physicians Surg Pak 2005;15:142–4.
9. Browning A. Obstetric fistula: clinical consid-
erations in the creation of a new urethra and
the management of a subsequent pregnancy.
Int J Gynecol Obstet 2007;99 Suppl 1:S94–7.
10. Waaldijk K. Immediate indwelling bladder
catheterization at postpartum urine leakage:
personal experience of 1200 patients. Trop Doct
1997;27:227–8.
11. The Hamlin Trust: a good medical cause. Med
J Aust 1974;2:830.
12. Gueye SM, Ba M, Sylla C, Diagne BA, Men-
sah A. [Vesicovaginal fistulas. Etiopathogenic
and therapeutic aspects in Senegal]. J Urol
(Paris) 1992;98:148–51 [French].
4 RCOG International Newsletter
Editorial
DAVID NUNNS MD MRCOG
As obstetricians and gynaecologists, we form getting involved. Can you be an advocate? A
a small but important part of the worldwide new Advocacy Subgroup of the International
effort to prevent mothers dying from child- Office has been set up and is developing its
birth. Why a small part? There are so many agenda and there will be more information
facets to maternal mortality that all cannot be on this exciting development in months to
addressed under one organisation and there come. Please put 1 July 2010 in your diary
are failings in providing care from the com- for the RCOG event Reducing Maternal and
munity level to the hospital.The three delays Newborn Deaths – a follow-up meeting to
is the classic model: delay one – knowing the 58th RCOG study group. This is
when there is a healthcare problem at the an important meeting looking at ways of
community level; delay two – travel to health addressing the complex social, economic and
care; and delay 3 – getting quality health care. clinical causes of maternal and neonatal
Tackling all these delays is crucial and mortality.We hope to see you there and that
‘strengthening health systems’ is the buzz you have a good spring and summer.
phrase that becomes important when tack-
ling a dysfunctional health system to which David Nunns MD MRCOG
all stakeholders should work. The third Editor, RCOG International News
delay is our remit and the RCOG Inter Email: david.nunns@nuh.nhs.uk
national News aims to bring you articles
relating to this topic from College activity.
In this edition, Olivia Roberts discusses ways
of working internationally for short-term
placements and Kate Alldred, who is the Reducing Maternal
current Eleanor Bradley Fellow in Uganda, and Newborn Deaths
give us an update on what is evolving into a
Millennium Development Goals 4 & 5
long-term sustainable project.
Follow-up meeting to the 58th RCOG Study Group
For most of us in the UK, international travel in collaboration with Royal Colleges of Anaesthetists,
might not be possible. However, there is Midwives and Paediatrics & Child Health
much that we can do. Advocacy has become
increasingly important for women’s health Thursday 1 July 2010 at the RCOG
in low resource countries, particularly on a
governmental level when political priority Maternal and newborn deaths remain all too common in low-
and input can influence healthcare invest- income countries. The Millennium Development Goal (MDG) for
ment. In a recent survey of the international reduction of maternal deaths (MDG5) is unlikely to be met by
the target date of 2015. MDG4 (reduction of childhood deaths)
members of the RCOG, 89% of respondents
will not be achieved unless neonatal deaths can be reduced.
felt that advocacy was a responsible part of
The Study Group addressed the complex social, economic
being a gynaecologist. This is an important
and clinical causes of maternal and neonatal mortality,
finding of the survey, as most of us do not identifying practical, clinical and organisational solutions. This
have advocacy experience and spend most follow-up meeting will discuss the need for advocacy, training
of our time in direct clinical care. For those and appropriate resource allocation and address the need to
of us in well-resourced countries, we can all consider maternal and neonatal deaths as inter-related
be advocates for our specialty in the wider problems.
world. Lobbying Members of Parliament,
attending meetings related to global mater- To book your place at this important event please visit
nal health, organising local meetings and www.rcog.org.uk/events or call the Conference Office
even joining a liaison group are ways of on +44 (0) 20 7772 6245.
Volume 3 Issue 1 5
Family Planning in Madagascar
Macomia C o m o r o s Mutsamudu
Pemba
Antsiranana The newly established family planning clinic
Mayotte
mapa
ue
Memba Fernao Veloso
Ambilobe
Hell-Ville Iharana is especially important in an area with such
e Ambanja
Mocambique
Mogincual
Analalava
Andapa
Antsohihy
Sambava
Antalaha
dwindling resources. Before the establish-
l Mahajanga Maroantsetra
Moma
Angoche
Marovoay
Mandritsara ment of this local family planning service,
Madirovalo Ambato Boeny
nja
Maintirano
Morafenobe Ambodifototra
a woman in the village of Andavadoaka who
Ambatondrazaka Fenoarivo Atsinanana
b i qu e C ha nn el
Ankazobe
Antananarivo
Toamasina
Moramanga
wanted to access contraceptive services faced
ManiaArivonimamo
Morondava
Ambatolampy
Antsirabe
Vatomandry a 50-km journey on foot through spiny
Mahanoro
ian Morombe
Ambatofinandrahana
Fianarantsoa
Ambositra
forest to Morombe, the nearest town.
an Mangoky Ambalavao
Madagascar
Mananjary
Manakara
Toliara
Betroka
Betioky
Farafangana
Midongy Atsimo
The work done by the clinic empowers cou-
Bekily
Ambovombe
Antanimora
Tolanaro
ples to produce sustainably sized families.
The problem is fairly evident shortly after
one arrives in Andavadoaka. Most families
KOSNATU ABDULAI have more than five children, many more
than ten and half of the village’s population
A family planning clinic was established in Mada- is under 15 years of age. In one clinic, I
gascar in 2007, after an unmet need was identi- counselled a woman who had given birth to
fied by an expedition doctor working with a con- 14 children. These numbers are clearly un-
servation group based there. In this article, Kosnatu sustainable and most couples do not intend
Abdulai discusses the work done by the project, its to have such large families. Not only are such
benefits and the continuing challenges it faces. large families extremely difficult to support,
they also pose a risk to women’s health, with
Andavadoaka is a small fishing village on the high maternal mortality figures (one in 200
southwest coast of Madagascar, not unlike births). Abortion is illegal in Madagascar, so
the many other coastal communities that deaths from unsafe abortions from unwanted
surround it. With the population doubling- and unplanned pregnancies push these
time of Madagascar being approximately 20 figures higher still. For this reason, family
years and a fertility rate of over five births planning is about more than just promoting
per woman, there is increasing pressure on the use of contraception; it is also about
limited coastal resources and the situation in empowering women to make fundamental
which couples cannot provide for their large decisions about their health and their lives.
families is common.
Since the opening of the clinic in August
2007, the project has uncovered a huge un-
met need in the area and has been welcomed
by the people of Andavadoaka. In its first
year, 246 women attended the clinics with
100 months’ worth of combined oral contra-
ceptive, 66 months’ worth of progestogen-
only pills and 125 depot medroxyproges-
terone acetate (DMPA) injections being
administered.
Owing to the success of the family planning
clinic in Andavadoaka, the team is expanding
its services by running satellite clinics.
Surrounding coastal villages in the same re-
A mother and gion of Madagascar face many of the same
baby in challenges as Andavadoaka, including the
Andavadoaka
6 RCOG International Newsletter
Family Planning in Madagascar
same need for access to family planning
services and advice on how to protect them-
selves against sexually transmitted infections.
The establishment and delivery of these
satellite clinics formed the bulk of my work.
With many of the villages up to a day’s travel
away, they proved too far for the team medic
to travel to on a regular basis. It was therefore
our job as medical students to travel from
village to village, armed with an interpreter,
a guide and a great deal of energy and enthu-
siasm. Here, we raised awareness about con-
traception and sexually transmitted infec-
tions, seeking the opinions of the people we
met and establishing where the most appro-
priate place to hold satellite and outreach men and women how to use condoms Children in the
village of
clinics would be, in addition to addressing appropriately and provided free condoms to Andavadoaka
any concerns about the clinics. them. We held meetings in the village with
different groups: men, women, boys and girls,
As well as speaking to the local people, to encourage open discussion about sexual
we also arranged meetings with the village health, decorated T-shirts with condom logos
elders to gain approval for the running of and organised a football match for the local
the clinics in the village. To allow the clinic men against the project’s team with a pres-
to be integrated fully into village life, it was entation about sexual health beforehand.
important that local customs and traditions
such as these were respected. The response Raising awareness about all of the issues
was usually a positive one with the local peo- around sexual and reproductive health has
ple welcoming the services and the elders become one of the most important objec-
agreeing to their provision in the villages. tives of the project. Until recently, the
With the help of our guide and interpreter, prevalence of HIV has been relatively low
we also walked around each village, trying in Madagascar, at less than 2%. This is a
to identify potential sites for running the welcome exception to the trend that has
satellite clinics, taking pictures of possible swept across most of sub-Saharan Africa, with
venues and making valuable contacts in the high prevalence of the disease plaguing much
villages. After each visit to a village, we went of this part of the world. Alarmingly, there
back and reported our findings to the has been a rapid increase in HIV, as well as
medical officer. We hope that the work we epidemics of other sexually transmitted
did in laying the foundations will allow the infections such as gonorrhoea and syphilis.
team to set up these satellite clinics and The current increase in mining and oil
spread the great work they are doing into drilling in Madagascar is drawing labour
surrounding villages. from Southern Africa where HIV is rife.
The worry is that this influx will lead to the
In addition to contraceptive work, the clinic initiation of a HIV outbreak in a country
is also addressing issues of sexual health in where sex education is limited. Raising
the village. I was actively involved in this awareness of sexually transmitted infections
aspect of the project and we used a wide is therefore vital in preventing the HIV
range of fun and interesting ways of trying to pandemic that is already rippling through
get this message across. In addition to provid- much of sub-Saharan Africa from spreading
ing contraceptives to women, we also taught to this island.
Volume 3 Issue 1 7
Family Planning in Madagascar
While the project is doing great work and the planning of sustainable sized families,
making real progress in the area, it does also we are not only improving the health of
face challenges with regard to use of the women but also of the surrounding com-
services. There have been situations where munity by ensuring that the children that
oral contraceptive pills have been sold by pa- are born can be provided for and the eco-
tients and the team recently received reports system upon which these communities
that fishermen have been using condoms as depend upon can sustain the population
a waterproof seal around torches, which they size. Family planning has extensive and far-
have been using to catch lobster at night. reaching implications, not only for the
These examples serve as a reminder about women themselves but for the community
the importance of continued education on and environment around them.
the appropriate use of the service offered,
to both individual women and the wider I would like to thank Wellbeing of Women
community. and the RCOG for their generous award
that allowed me to contribute to this impor-
The work done in the family planning tant and worthwhile project, which is
clinics enabled women to take control of making great steps to allow the women of
their fertility and plan their families.While it Southwest Madagascar to manage their
is important that women take control of reproductive and sexual health.
their own health and are given the tools to
do so, the education and collaboration of Kosnatu Abdulai
others in the community is equally impor- University of Oxford
tant to maintain this. Likewise, by facilitating kosnatu@gmail.com
2009 John M Eisenberg Patient Safety and Quality Award:
Dr Noreen Zafar FRCOG
Dr Noreen Zafa gynaecological care and to empower women
receiving the
to become good decision makers about their
2009 John M
Eisenberg Patient own and their family’s health. Dr. Zafar has
and Quality worked independently to promote wellness
Award
among girls and women, without govern-
ment or any other support. She has over-
come many social taboos in her quest and
has established health awareness programmes
related to precancer screening, teenage gy-
naecological health and reproductive health.
Dr Zafar has initiated nearly a dozen cam-
The RCOG would like to congratulate Dr paigns under the umbrella of the Women’s
Noreen Zafar on being awarded the John M Health Initiative.
Eisenberg Patient Safety and Quality Award
in the International category. The awards If you would like to support Noreen in her
recognise the achievements of individuals and quest to improve women’s health services in
organisations who have made significant and Pakistan, please contact her at noreen_zf
lasting contributions to improving patient @hotmail.com or visit her website for fur-
safety and healthcare quality. ther information – Girls and Women’s Health
Initiative – www.gwhi.org.
Dr Zafar’s vision is to offer high-quality
8 RCOG International Newsletter
Reducing maternal mortality in Sri Lanka
Valparai Thanjavur
Madurai Indian
Cochin
Jaffna Ocean
Palayankottai Gulf of Mannar
Tuticorin Anuradhapura
Trivandrum
Nagercoil Sri Lanka
Kurunegala Kandy
Badulla
Colombo Ratnapura
Galle
PRASANTHA WIJESINGHE
Sri Lanka has a low maternal mortality rate, a
remarkable achievement for a developing country
in the Indian subcontinent. Various factors have
contributed to this low rate, including positive and
sustainable social welfare policies, the control of com-
A field midwife at
municable diseases like malaria, expansion of qual- Sri Lanka has a population of over 19 million an antenatal clinic
ity maternity services with improved accessibility and there are over 3 million estimated eligi-
leading to their greater use and the introduction of ble families. Sri Lanka has achieved a dra-
antibiotics have all contributed. Professor Prasantha matic reduction in MMR from 2000 per
Wijesinghe, who is Chairman of the RCOG 100,000 live births in 1930 to 38 per
Representative Committee in Sri Lanka, explains. 100,000 live births in 2005. At present, post-
partum haemorrhage, pregnancy-induced
Sri Lanka takes pride in a low maternal mor- hypertension, heart disease complicating
tality rate (MMR) when compared with pregnancy and septic abortions are the lead-
neighbouring countries in the Asian region. ing causes for maternal mortality.2 During
This was achieved through years of dedica- the 20th century, commitment towards the
tion and sound policies, eventually leading control of malaria and subsequently the
to improved awareness and use of services introduction of emergency obstetric care
by the community1. A little over 100 years services, have helped reduce the MMR.4,5
ago, Lionel Lee, a British civil servant in Sri
Lanka (then Ceylon), in his report on the Possible causes for low MMR
1881 population census of Ceylon, stated as Over the years, successive governments
follows. ‘The reason for the higher female implemented policies which resulted in a
mortality in the adult age period may prob- high literacy rate through free education,
ably be found in early marriages and conse- empowerment of women and a free health
quent diminished vitality. There is also no service easily accessible to any citizen any-
doubt that mortality in child bearing is where in the country; factors which led to
excessive. It is said that the ascertainment rate women enthusiastically seeking quality ante-
of mortality in Ceylon is one death to 40 natal care and more than 98% of births
from accouchement against one in 185 in taking place in hospitals.Throughout the last
England.The fact that in the vast majority of century, various factors at various time
cases, the women are without skilled assis- periods have led to the reduction in MMR
tance at the time of delivery and that their in Sri Lanka. For example, in the 1930s, the
troubles come upon their unmentionable control of malaria and development of
hovels absolutely devoid of sanitary manage- maternal care services have helped reduce
ment strengthens the opinion that in this is the MMR. Subsequently, the extension of
to be found a very active cause of female trained maternal care services, improved
mortality’.1 accessibility and greater use of these services
Volume 3 Issue 1 9
Reducing maternal mortality in Sri Lanka
and the introduction of antibiotics have all What can be improved to reduce
contributed to the reduction of MMR. At the MMR even more?
present, the supervising and monitoring Sri Lanka was involved in a civil war during
system, improved communication facilities the last 30 years, which affected all aspects
and the establishment of an active maternal of civil life. In 2009, the war ended, shed-
death surveillance system, together with the ding the lights of hope into possible infra-
improved health education of mothers, are structure and healthcare development in the
responsible for the low MMR. war-driven north and east of the country
where the MMR was the highest.
The preventive healthcare system in the
country, comprising medical officers of Even though the hospitals are equipped with
health, public health nursing sisters and emergency obstetric care, the infrastructure
public health midwives, provides antenatal may not be in the optimum condition. The
care for almost all pregnant women. These government should focus their attention
carers provide supplementation and screen more on this aspect.
women for anaemia, hypertensive disorders,
diabetes mellitus and other medical disor- Unsafe abortions contributed to 13.9% of
ders, including cardiac disease. An important all maternal deaths in 2005. Even though it
aspect addressed by the preventive health- is illegal, over 1000 terminations of preg-
care staff on the ground level is the health nancy take place every day in the country.
education of the women about antenatal SLCOG and the family health bureau of the
care, maternal and fetal wellbeing and post- Ministry of Health are involved in the
natal contraception. process of educating the general public of
the hazards involved in illegal terminations
The fact that the majority of women deliver and are conducting pilot projects to train
in hospital with hardly any home deliveries healthcare staff to identify and effectively
has led to a reduction in MMR. All the hos- treat women presenting in life-threatening
pital deliveries are attended by trained health- septic shock following septic abortion. A
care personnel and a consultant obstetrician possible success in this region will help re-
will always be responsible for the manage- duce the MMR even further.
ment of the inward obstetric patients. The
Postgraduate Institute of Medicine (PGIM) Although the community has access to
and the Sri Lanka College of Obstetricians family planning services through the family
and Gynaecologists (SLCOG) conduct train- planning association, preventive healthcare
ing programmes for doctors which lead to a family planning clinics and hospital family
postgraduate degree or a diploma. planning clinics, we see an unmet need of
modern contraception among Sri Lankan
Following the death of an obstetric patient women. This is a possible contributor to
(all deaths including late deaths up to one maternal mortality in women with medical
year after delivery) an institutional and a field illnesses which needs focussed attention in
inquiry will be conducted to find out the the future.
cause of the death. Discussions are held at
institutional, district and at national levels. At present, the supervising and monitoring
Reports developed at national levels indi- system, improved communication facilities,
cating the shortcomings or concerns and the establishment of an active maternal death
highlighting areas for improvement are made surveillance system and the improved health
available to all stakeholders to be used in education of mothers are responsible for the
changing policy and practice where appro- low MMR.The country can achieve an even
priate. lower MMR with further infrastructure
10 RCOG International NewsletterReducing maternal mortality in Sri Lanka
development, provision of family planning References
services, especially to those suffering from 1. Gunasekera PC, Wijesinghe PS. Maternal
serious medical illnesses where pregnancy health in Sri Lanka. Lancet 1996;347:769.
poses a serious risk, reduction of illegal 2 Lee L. Census of Ceylon 1881.Vol. 1. A Gen-
termination of pregnancies and continued eral Report, Colombo. Colombo: Government
efforts to educate the Sri Lankan public on Printer; 1981.
health-related issues. 3. Ministry of Healthcare and Nutrition. Report
of the External Review of the Maternal and New-
P S Wijesinghe born Health Sri Lanka. Colombo; Government
Professor and Chair, Department of Obstetrics Printer; 2007.
and Gynaecology 4. Family Health Bureau, Ministry of Healthcare
Faculty of Medicine, University of Kelaniya, and Nutrition. Overview of Maternal Mor-
Ragama, Sri Lanka tality in Sri Lanka 2001–2005. Colombo: Gov-
prasanthaw@gmail.com ernment Printer; 2008.
5. Gunasekera PC, Wijesinghe PS, Goonewar-
dene IMR. Emergency obstetric care: the key
to further reducing maternal mortality in Sri
Lanka. Regional Health Forum WHO South East
Asian Region 2002;6(2): 22–9.
Joint Meeting on Women’s Health
Royal College of Obstetricians and Gynaecologists
and Kosovo Obstetrics and Gynaecology Association
13–15 May 2010 Pristina, Kosovo
Day 1 Scientific Programme on:
Safety and audit for maternal and perinatal health
Structure and standards of cancer care, screening for gynaecological cancers
Day 2 Workshops on:
Colposcopy
In collaboration with the European Federation of Colposcopy (EFC) and the
RCOG
Eurovision
International Federation for Cervical Pathology and Colposcopy (IFCPC)
Maximising outcomes of infertility treatment modalities
Day 3 Workshops on:
Contraception and reproductive health
In collaboration with the Faculty of Sexual and Reproductive Health and the European
Society of Contraception
Development of guidelines and protocols that conform to local needs
Further information and registration details are available on the RCOG website:
www.rcog.org.uk/events/2nd-rcog-eurovision-conference-kosovo
Volume 3 Issue 1 11A Doctorate in sociology turns to obstetrics
Lucknow Gorakhpur
wah
Darbhanga Guwa we encountered.Villagers started to come to
Kanpur Purnia Rangpur
Patna me with their minor health problems. But
Ganges Katihar Balurghat
when a group of villagers came in the mid-
Ga
Allahabad Varanasi Bihar Ingraj Bazar
nge
s
atna Rewa
Baharampur Dhaka dle of the night to help a woman in child-
Bermo
Murwara Ranchi
Khulna
N birth I was out of my depth. Despite my
Shahdol Kurasia
Jamshedpur
Haora Bangladesh protestations that I knew nothing of child-
Korba Kolkata
Bilaspur Raurkela
Kharagpur
(Calcutta)
birth, they pleaded and insisted. So off I went
Gondia Baleshwar with David Werner’s book, Where There is No
Bhadrakh
Durg Raipur
Rajhara Jharandalli
Cuttack Doctor. Fortunately, as for most births, noth-
Bhubaneshwar
I n d i a ing untoward happened but the fact that vil-
lagers had called me was shocking enough –
LINDSAY BARNES they must have been really desperate.
Lindsay Barnes graduated from Brunel University I decided to call a meeting of all the women
in 1980 and studied for her Doctorate in Jawa- in the village the next night – and around 70
harlal University, New Delhi. Lindsay has no women squashed into our verandah where I
medical or nursing background. She and her hus- put the question to them: “Where do you
band have set up an obstetric and neonatal serv- go when you have problems in childbirth?”
ice from a very poor backward area in the State of No one answered. I had lived in the village
Jharkhand (formerly part of Bihar). Here, she re- five years by then and realised that I had to
counts her experiences and appeals for help from get my head out of the sand. I had no ‘big
the obstetric community. plan’ as to what to do but I tried to deal with
issues one by one in the best way I could. I
I came to India from England in 1982, plan- understood that we had to rely, as far as pos-
ning to spend two years in Delhi to complete sible, on local resources: traditional midwives,
a post-graduation course in sociology. In- knowledge and people. This has proved to
stead, I ended up staying on, trying to pro- one of the strong points of our programme,
vide obstetric services in a backward area of ensuring its sustainability.
Jharkhand – one of the poorest states in east-
ern India. It is an ongoing story that I would We started with yearly health fairs, then
like to share. The village where I live and monthly camps, which grew to weekly clin-
work is in the state of Jharkhand, one of the ics. Now we have clinics three days a week,
poorest in India, and is 25 km from the near- providing services to around 600 women a
est town of Bokaro. The area we live in has month. Most of the women come for ante-
over 100 villages and a population of nearly natal care. Fifteen years ago, antenatal care
200,000 but with no resident doctors.There was unknown of in our area, as it is in most
is a primary health centre with doctors avail- of rural India. The government’s antenatal
able only during the day for outpatient serv- care provides only for tetanus toxoid injec-
ices. There is no government hospital in the tions and iron tablets – if at all. Village
whole district – with a population of nearly women rarely demand antenatal care and
2 million – which provides free or low-cost only access health care for specific problems.
emergency obstetric care for the poor.
In the early days of our programme, most
My involvement with childbirth in the vil- women came in the last month of pregnancy
lages started in 1994. Before this, I had mar- with serious problems: severe anaemia,
ginal involvement in villagers’ health prob- oedema and hypertension, and so on. Nowa-
lems. I had two children of my own by then days, with women accessing care from the
and, given the absence of doctors, I had to early stages of pregnancy, we rarely see cases
learn how to deal with most illnesses that of pre-eclampsia or severe anaemia at the
12 RCOG International NewsletterA Doctorate in sociology turns to obstetrics
time of delivery.We have provided antenatal
care to over 5000 women in the last five
years and there has been only one case of
eclampsia (where the mother was promptly
referred and both mother and baby survived)
and no maternal death from haemorrhage
or anaemia. None of these women suffered
a ruptured uterus or fistula. In an area of In-
dia where the maternal mortality rate is
probably around 500 per 100,000 live births,
this no small achievement.
Now antenatal care has been well established
in the community, there is much peer pres-
sure to go for a ‘check up’ as soon as preg- women now come for unproblematic, nor-
nancy is confirmed. For the young women mal deliveries. In nearby villages a home
of the family, this is a much-valued outing birth is unusual, rather than the norm that it
and an excuse from doing housework.They was ten years ago.
come from villages up to 30 km away, wear-
ing their best, brightest saris. Together with As demand for services has increased, new
investigations, counselling and the check-up, hurdles remain to be negotiated. Each time
they are encouraged to eat roasted gram flour we need to send women for caesarean sec-
on a daily basis: this protein-enriched food tion, we have to make uncomfortable deci-
supplement is a boon to women from fam- sions: costly private clinics or the dirty
ilies where meat, fish and milk are rarely seen crowded government hospital. Or the most
and even pulses are a luxury. uncomfortable one to make: ‘Save the tree,
we will have more fruit next year’, as vil-
With antenatal care being so quickly ac- lagers tell us, when we feel that surgery is
cepted, it was obvious that childbirth would needed to save the baby.
be the next issue to address. None of the
families wanted to go to a private nursing So we embark on our last, biggest challenge
home in the city (where a ‘normal’ delivery of all: to provide obstetric surgery. We have
costs 3000 rupees – more than a whole exhausted our ‘local resources’ to some ex-
month’s income for a poor manual worker) tent here. Outsiders, qualified doctors with
or to the government hospital in the next experience, are needed. I am increasingly
state. Families refused to even think about aware that I will have to extend my hand
where they would go in case of need, be- beyond our village in the hope that there are
lieving this would be a self-fulfilling proph- medical professionals out there willing to ex-
esy. ‘When the time comes, then we will tend their hand too.
think’, was the usual response to the idea of
‘planning for birth’ and, effectively, there was We have achieved much over the years, for
not much of a choice anyway. which I am thankful and satisfied – still I am
hopeful of achieving more. It is much, much
So we have tried, over the years, to make a more than I could have hoped for and I have
real choice available to poor women. We no regrets for the path I have chosen.
now provide 24/7 care for women in child-
birth. We have ‘qualified’ nurses as well as Lindsay Barnes
trained village women available round the lindsay_India@yahoo.co.uk
clock, with an ambulance on hand. Many
Volume 3 Issue 1 13Sexual violence in Zimbabwe
Espunga
uru
os Okahandja
Namibia Francistown Chiredzi Sav and sexual conquests are prized among men.
Botswana Selebi-Pikwe Messina Mabote
Windhoek
Gobabis Palapye
Mahalapye popo
Pafuri
Louis Trichardt
Bride ‘price’ has to be paid before marriage;
Lim
Aminuis Pietersburg
Rehoboth
Stampriet
Aranos
Akanous
Molepolole
Ellisras
Mochudi
Potgietersrus
Ho
Inha
once married, a woman cannot report rape.
Gaborone Nylstroom Chibuto
Maltahohe Gochas
Koes
Mmabatho
Mabopane Pretoria Nelspruit
Brits
Mapu
A man can get away from a rape accusation
Tshabong
Johannesburg Germiston
Bethanien
Aus
Keetmanshoop
Aroab Klerksdorp Vaal
Standerton
Mbabane
Swaziland
by paying bride ‘price’ and marrying the
Welkom
Grunau Karasburg
Upington
Kathu
Kimberley
Kroonstad
Virginia
Vryheid
Glencoe
woman, since polygamy is accepted. This
Orange
Warmbad
Maseru
njemund Vioolsdrif Bloemfontein Pietermaritzburg happens quite often with adolescent rape.
e
Orang
Nababiep Prieska Lesotho
South Africa
Queensburgh
Or
Durban
an
Rape myths are prevalent among men.
ge
De Aar Umzinto
Carnarvon Noupoort Aliwal North Port Shepstone
Calvinia
Middelburg Molteno
Umtata
Graaff-Reinet Queenstown
Port Saint Johns
One of them is that a woman who is dressed
Beaufort West Mdantsane
Vredenburg
Paarl
Oudtshoorn
Uitenhage
East London
Grahamstown seductively or who accepts a date is inviting
Robertson
Cape Town Port Elizabeth
Somerset West Knysna
sex. Another is that women shout ‘rape!’
when they are caught having consensual sex.
STEPHEN P MUNJANJA There are two recent developments which
have further increased the risk to women of
Sexual violence against women is a major public rape. Firstly, the HIV/AIDS pandemic has
health problem and a violation of human rights. made women more vulnerable.The morbid-
It is an international issue and is related to a lack ity and mortality from the disease causes
of access to education and opportunity and to a low family disruption which leaves women dis-
social status in communities. All workers in empowered. Orphanhood is now a well-
women’s health should be aware of the problem in known risk factor for rape. There is also a
their communities, as a wide range of physical, common myth that a man who is HIV-
mental, sexual, reproductive and maternal health positive can be cured of his status by raping
problems can result from violence. Early recognition a virgin.
and reporting is important. Obstetricians and
gynaecologists will not infrequently encounter rape Secondly, food insufficiency, unemployment,
associated problems including injuries. In this displacement and political instability, which
article, Stephen P Munjanja writes on the prob- have happened during the current socio-
lems in Zimbabwe. economic deterioration, have contributed to
a reported increase in rape complaints at
Sexual violence is prevalent in Zimbabwe. In health facilities. A worrying development is
more than 98% of cases, it involves the rape the rise of politically inspired sexual violence.
of females and this will be the subject of this A month before this article was written, the
short article. At health facilities and police non-governmental organisation AIDS-Free
stations across the country, rape is a common World released a report entitled ‘Electing to
complaint but such reports are the tip of rape: sexual terror in Mugabe’s Zimbabwe’,
the iceberg.Various studies have attempted to which documented 341 rapes committed by
estimate the true prevalence in other coun- 241 perpetrators during the violence of the
tries of Southern Africa but this has not yet June 2008 election. Rape was used as a tool
been done in Zimbabwe. The most reliable to target political opponents.Victims ranged
estimates are that the lifetime exposure to from five to 70 years of age. The suspects
sexual violence among females is 23%. In have not been apprehended and some have
South Africa one in four adult men have been heard to boast of their immunity when
committed rape and it is likely to be the they meet their victims.
same in Zimbabwe.
Zimbabwe has adequate laws to deal with
The patriarchal nature of the culture puts sexual violence. The Sexual Offences Act of
women at risk from rape. Women are 2001 is comprehensive and even allows
expected to be unquestioning and submissive for complaints of marital rape to be made,
14 RCOG International NewsletterSexual violence in Zimbabwe
something which is culturally unpalatable. If
HIV is transmitted during the rape, there is
an added penalty if the suspect is convicted.
Women who fall pregnant can seek termina-
tion of pregnancy.The problem is ignorance
about the laws, fear of making reports and
the cultural atmosphere of blaming the
victim. The justice system has traditionally
been unsympathetic towards victims and the
health system does not have the resources to
provide the quality of care required.
Recently, however, there have been some
positive developments. With funds from
donors, among them the Open Society Ini-
tiative for Southern Africa (OSISA), the There are still many challenges ahead. Harm- Staff at the Adult
Rape Clinic,
United Nations Development Fund for ful cultural attitudes and practices should be Parirenyatwa
Women (UNIFEM) and United Nations changed but this will take a long time, Hospital in
Population Fund (UNFPA), adult rape particularly if leaders do not provide good Harare: (l to r)
Sister Magna
clinics have been opened in the major cities examples. The information about Zim- Kurangwa, Sister
of Zimbabwe. Family support clinics for vic- babwe’s laws should be disseminated widely Evelyn Mudzviti
and Police
tims of child sexual abuse have been opened to increase demand on the services. In rural Officer Lina
in Harare and Bulawayo. These clinics offer areas, access needs to be expanded to match Dongo
care and support away from the emergency the services in urban areas. The quality of
and casualty departments of busy hospitals, forensic analysis of the tissues needs to be
which are quite unsuitable for this purpose. improved by the inclusion of DNA testing.
These clinics are staffed by nurses and
doctors who have been specially trained to Finally, the health and justice systems should
provide ‘victim-friendly’ care. The test kits make preparations to take over the funding
needed for pregnancy, HIV, hepatitis and from donors, to ensure sustainability. Expan-
other sexually transmitted diseases are avail- sion of the services to reach every woman
able and so are the antibiotics and antiretro- cannot be done by the nongovernmental
viral drugs for post-exposure prophylaxis. organisations. It is a basic right for survivors
A policewoman is part of the clinic team, to to access good quality care and justice.
provide guidance on the legal processes.
Stephen P Munjanja
As part of these developments, the courts Consultant Obstetrician
and police departments have established Harare Hospital, Zimbabwe
‘victim-friendly’ centres in their stations, spmunjanja@africaonline.co.zw
although this has not yet extended widely
to rural areas.The training of the prosecutors
and policemen have been held together with
that of the health providers and have been
funded by UNFPA and the Sexual Violence
Research Initiative (SVRI) of South Africa.
The initial training of such teams started in
Johannesburg in 2008. National training in
Zimbabwe has started at provincial level and
several courses have been held.
Volume 3 Issue 1 15Mid-level providers at Monze Mission
Hospital, Zambia
Mozambique, has responded to this by train-
ing up Clinical Officers to be Licentiates.
Clinical Officers are the backbone of med-
ical services in countries like Zambia, Kenya
and Tanzania. They undergo four years of
training in basic medicine and surgery and
are often the first health contact for millions
of people.They are able to manage and treat
many illnesses, such as respiratory diseases,
urinary tract infections and malaria, and can
carry out simple surgical and orthopaedic
procedures. They are especially good at
providing health care under difficult cir-
cumstances, such as in remote locations with
Licentiate intake Lake Tanganyika
2009 outside
uilo
Kamina Sumbawanga Iringa limited drug supply and minimal backup. In
Monze Mission Saurimo Kampampi Tukuyu Zambia, about 90 Clinical Officers have
Kas
Hospital Dilolo Kashiba Chitipa Lake Ny
trained as Licentiates since the programme
ai
Rumphi
commenced in 2002. The training is a two-
Lubumbashi Ndola Malawi year programme, including six months
Zambezi Salim
Lilongwe of theory, modules in medicine, surgery,
do
gue
Lusaka Zom obstetrics and gynaecology and paediatrics
ezi
Blantyre M
Zambia Zamb
Senanga
Bindura
and two months of revision.
Kazungula Harare
ndo
Cua Kwekwe Mutare
V
Monze Mission Hospital has been chosen
for the obstetrics and gynaecology module.
PETER BLACKWELL-SMYTH Monze is a tertiary referral unit with an
annual delivery rate of about 2700. The con-
Zambia is a landlocked country in the northern sultant there is Michael Breen MRCOG.
part of Southern Africa. It has a population of Michael has worked in Africa for about
12 million and life expectancy is approximately 20 years and is especially involved in fistula
40 years. The HIV rate is one of the highest surgery. I did a year’s training in the specialty
in Southern Africa, in the region of 15%. The but for most of my professional life I was a
maternal mortality rate is now approximately 750 general practitioner. We had a GP maternity
per 100,000 deliveries and around 43% of unit in our town with about 250 deliveries
deliveries are attended by skilled personnel. Peter a year. Most of these were straightforward
Blackwell-Smyth writes of his experiences in the but we did some assisted vaginal deliveries
country. and the occasional breech and multiple preg-
nancy. I was (and still am) ‘loosely’ attached
Like many developing countries, Zambia has to the obstetrics and gynaecology depart-
a severe medical manpower crisis. The Uni- ment in our local district hospital and am a
versity Medical School opened in 1966 and UK and international instructor with the
has produced about 1200 graduates but fewer Advanced Life Support in Obstetrics group
than 50% of these are working in the coun- (ALSO).
try today, with many working in private prac-
tice in Lusaka, Livingstone and the Copper Michael likes me to come to Monze at the
Belt.The Government of Zambia, like several beginning of each obstetrics and gynae-
other countries including Tanzania and cology module and devote myself fulltime
16 RCOG International NewsletterMid-level providers at Monze Mission
Hospital, Zambia
to the students. This has the advantage that
my only ‘job’ is to teach the students, thus
freeing Michael to run the department and
do his own work, which also includes out-
reach. Admittedly, Michael describes my
work as ‘the blind being led by the partially
sighted’. My programme with the students
involves daily ward rounds with Michael at
7.30am followed by the usual departmental
work in the labour ward, operating theatre,
clinics, scanning and so on. We cover prac-
tical procedures such as induction and aug-
mentation of labour, breech delivery, twins,
operative deliveries, retained placentas, and
more.The caesarean section rate in Monze is Teaching the
about 8–10% so teaching this procedure is an I feel very privileged to be involved in this ALSO assisted
important part of my work. Michael is usu- programme and to work with Michael vaginal delivery
module
ally at hand to cope with serious complica- Breen, who is such an inspiring, enthusiastic
tions such as placenta praevia, abruption and and entertaining colleague, as well as being
tears. We lack many instruments and tech- so committed to improving the health of
nologies used in the UK but nevertheless we women in Africa.
manage effectively. Although we have a
cardiotocograph, there is no paper for it. Peter Blackwell-Smyth
The vacuum extractor is of the bicycle pump Retired General Practitioner
variety and we use a Foley catheter and blackwellsmyth@googlemail.com
child’s balloon for uterine tamponade for
postpartum haemorrhage. The Mirena®
intrauterine system (ideal in an African situ-
ation) is too expensive.
On the gynaecology side, I teach the stu-
dents outpatient assessment, dilatation and
curettage, laparotomies for ectopics, biopsies,
cervical cerclage, and so on. Later in their
programme Michael also teaches them to
perform hysterectomies. By the end of their
attachment, each student will have per-
formed at least one classical caesarean sec-
tion and one caesarean hysterectomy. So far,
about 90 licentiates have been trained in
Monze and the feedback (limited for logis-
tic reasons) is that not only are the students
still performing the procedures in their
own hospitals but also that the referral rate in
obstetrics and gynaecology to tertiary or sec-
ondary hospitals has fallen considerably.
Volume 3 Issue 1 17Report of the RCOG 8th International
Scientific Meeting of Obstetrics and
Gynaecology
EL SHEIKH MOHAMMED
The RCOG 8th International Scientific icine, urogynaecology, fertility problems and
Meeting of Obstetrics and Gynaecology was fetal surveillance. Some highlights included
held 6–9 December 2009 at the prestigious Professor Chervenak discussing the sensitive
Emirates Palace in the coastal capital of the issue of the ethical dimension of the fetus as
United Arab Emirates, Abu Dhabi. The a patient. Professor Gamal Serour presented
meeting was attended by 1200 participants, the Singapore Lecture and tackled the
with the majority from the Middle
East, Africa and South East Asia. 2
The meeting was held in collabo-
ration with Abu Dhabi Health
1
Services (SEHA) and under the Pa-
tronage of Her Highness Sheikha
Fatima Bint Mubarak, wife of the
late Ruler Sheikh Zayed. Her
Highness was awarded the Hon-
orary Fellowship in appreciation of
her role in empowering women in
the area and for her great contri-
bution to the development of
health services for women and 4
children of Abu Dhabi.
Scientific sessions were run in four
streams:
G Fetomaternal
G Gynaecology
G Gynae Cancer/Sexual and
Reproductive Health
G Standards and Profes-
sional Development
8
State-of-the-art lectures
were delivered by 50 Speak-
ers; 62 free communications
and more than 350 posters
were presented by young
doctors, with the greatest in-
put from the Middle East.
Local research work, case re-
ports and practices in the
area were all presented. Ten
plenary sessions included
topics such as obstetric med-
18 RCOG International NewsletterReport of the RCOG 8th International
Scientific Meeting of Obstetrics and
Gynaecology
science and ethics of new technologies in Emirati women, delivered by Professor
improving women’s health.Tahir Mahmood, Rafiaa Ghobash, was a highlight of the
Vice President of the RCOG, captivated us conference. The meeting was an overall
with his update on the pandemic H1N1 success judging by the huge participation 1
virus. Professor Gordon Smith discussed of delegates. Attending a
lecture
causes and consequences of the rising cae-
sarean section rate, which is currently 23% El Sheikh Mohammed 2
Professor Abdel
in the UAE. Chair, RCOG International Representative
Latif Ashmaig
Finally, a talk Committee, UAE Khalifa, Sudan,
on the heritage sheikh@cornichehospital.ae receiving his
Fellowship
and culture of Honoris causa
from the
President
3 3
A refreshment
break
4
Delegates
attending one of
the lectures
5
Professor Gamal
Serour, Egypt,
5 receiving his
6 Singapore
Lecture
7 Commemorative
medal from Dr
Charles Ng,
Singapore
6
New Fellows and
Members
awaiting their
admission
7
The RCOG stand
9 10 8
The platform
party
9
His Excellency Dr
Ahmed Mubarak
Al Mazrouei with
members of the
local organising
committee
10
Delegates
attending the
Welcome
Reception
Volume 3 Issue 1 19You can also read
