May 2011

T C E F

GlobalFistula initiatives

will be mappedpage 7

TanzaniaMobile phoneshelp fightfistulapage 3

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What is fistula?Obstetric fistula is a childbirth injury caused by prolonged, obstructed

labour, without timely medical intervention—typically a Caesarean

section. During unassisted prolonged labour, the sustained pressure

of the baby’s head on the mother’s pelvic bone damages soft tissues,

creating a hole—or fistula—between the vagina and the bladder and/

or rectum. The pressure deprives blood flow to the tissue, leading to

necrosis. Eventually, the dead tissue sloughs off, damaging the original

structure of the vagina. The result is a constant leaking of urine and/or

feces through the vagina. It’s estimated that over 2 million women live

with the condition in the world, with up to 100,000 new cases every year.

Fistula is both preventable and, in most cases, treatable.

COVER PHOTO: Mbathio LO, 43, goes home after a successful fistula repair at the Grand Yoff Hospital in Dakar. She lived with fistula for 25 years, not initially knowing that it was a treatable condition. Healed, she now wants to open a restaurant. Photo: Etienne Franca, Campaign to End Fistula, Senegal, 2010.

According to a 2010 USAID report, in Ethiopia, 93 per cent of women

deliver at home, in most cases without the assistance of a skilled attendant,

thus increasing their vulnerability to childbirth complications and disabilities,

including obstetric fistula. The situation is dire, and experts believe that

cultural birthing practices will only change from within communities.

Berhidda Redda, 33, a fistula survivor from Adiweyane, a small village

about one hour from the capital of the Tigray Region in Northern Ethiopia,

is living proof. Despite the many health-related challenges she faced, Ms.

Redda is now helping bring positive changes to her own community.

“I lived with my young daughter in a one-room house surviving off a

small plot of land that I farmed myself,” Ms. Redda says. “My husband

divorced me 18 years ago when he discovered that I had developed

fistula during my first pregnancy. Everyone in my town knew me as the

woman who was ‘cursed’ with fistula.”

For those working closely with fistula survivors, discrimination and

divorce are familiar outcomes; it is extremely difficult to find purpose and

means of subsistence even after being healed.

Although Ms. Redda was able to get treatment, she continued to live with

the stigma and shame of this condition. But thanks to Healing Hands of Joy’s

Safe Motherhood Ambassador Training Program, a project that empowers

fistula survivors and trains them as advocates for better maternal health, she

was able to regain confidence in herself and fight for respect in her village.

“Before surgery, I was discriminated against by neighbors and even my

family. Now, things are slowly getting better because I’ve learned fistula is

not a disease caused by doing something outside of the law of God but is a

curable condition. I want to know more about it and help others,” she says.

When Healing Hands of Joy established a new training centre for

fistula survivors in Mekelle, Ms. Redda was welcomed into the first class

of Safe Motherhood Ambassadors.

“We had been giving birth at home. We had not been going to health-

care facilities. We only went there when it was too late. My plans are to

ensure that women in my community become literate, and to discourage

underage marriage and home birthing,” she says.

For the next four weeks, Ms. Redda worked hard to learn the cur-

riculum HHOJ designed in partnership with the Tigray Health Bureau,

including maternal health lessons in the causes of fistula, prevention

methods, and the benefits of institutional delivery.

Ms. Redda not only wanted to know more about the causes of fistula,

but also wanted to help prevent other women from suffering the same

fate. With her strength, determination and desire to learn, she can be an

agent of change in her community and fill an essential gap in providing

voluntary maternal health counseling.

Ms. Redda is now working in her community, monitoring pregnant

women and confidently sharing her story to prevent other mothers from

suffering as she had. She is also proud to be a business owner. With the

training and a small start-up business fund that she’ll repay after one

year, she has opened a store in her home where she sells coffee, baskets,

scarves, biscuits, matches and other supplies.

Safe motherhood ambassadorby Allison Shigo, Healing Hands of Joy

These are times of change for the Campaign to End Fistula.

With new and reinvigorated partnerships, the Campaign will

work even harder towards eliminating the devastating condition

of obstetric fistula.

A crucial step in the coming months and into the future will be

to develop a vision of the “who, what and where” for fistula.

Building on the excellent work done by other institutions, UNFPA

will be working closely with the Fistula Foundation, Direct

Relief International and other partners to undertake a mapping

exercise, compiling information on fistula centres, experts and

activities globally.

This is an ambitious and exciting project, and we hope it will

provide valuable insight into what is happening with fistula across

the world, as well as filling many information gaps.

Another priority for 2011 is a more coordinated approach to the

global response to fistula—prevention, quality treatment, social

reintegration, research, data and advocacy—to ensure that

the Campaign moves forward in a spirit of collaboration, with

internationally agreed upon goals.

In this and upcoming editions of Dispatch, the reader will find

more and more articles highlighting the great achievements of our

many partners in the field, as well as the difficulties they face and

their plans for the future. These features will also portray the real

faces and stories that make the work on fistula very challenging,

yet extremely rewarding. Enjoy the reading!

Gillian Slinger

Coordinator, Campaign to End Fistula

Editorial

Read more: www.endfistula.org

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Using mobiles to fight fistulaDar es Salaam, Tanzania

Highlights

Spearheaded by UNFPA in collaboration with many partners and sup-

ported by numerous generous donors, the Campaign to End Fistula

has quadrupled in size during the last seven years. From its original 12

countries, the Campaign has now expanded to cover 49 countries in

Africa, Asia, the Arab States, Latin America and the Caribbean.

As a result of this growth, more and more women are able to access

the care they need to prevent and treat fistula, and to return to full and

productive lives after fistula treatment with the support of govern-

ments and partners.

UNFPA coordinates and serves as Secretariat for the Global

Campaign to End Fistula and for the International Obstetric Fistula

Working Group (IOFWG), which represents over 50 national and

international institutions.

Since the Campaign was launched in 2003: • Morethan20,000womenhavereceivedfistulatreatmentandcare

with support from UNFPA.

• OverhalfofallCampaigncountrieshaveincorporatedfistulain

national policies and plans.

• Additionalcountriesarerevisingtheirexistingreproductivehealth

national policies to ensure the full integration of obstetric fistula.

In 2010, with UNFPA support:• Morethan5,000womenandgirlsaccessedfistulatreatmentin

nearly 40 countries.

• Over1,800surgeonsandhealthworkersweretrained.

• Fistulasurvivorsin18countriesworkedtosensitizecommunities,

provide peer support and serve as advocates for fistula prevention

and improved maternal and newborn health at community and

national levels.

• TheUnitedNationsSecretary-GeneralReport,“Supporting Efforts

to End Obstetric Fistula,” released in October 2010, noted great

progress in addressing fistula, yet called for more support and

intensified action to end fistula.

• TheresolutionSupportingEffortstoEndObstetricFistula was

adopted by consensus at the United Nations General Assembly,

with 172 supporting countries, and called for renewed focus and

additional resources for fistula.

• Enhancedglobalandnationalmediacoverageandadvocacy

helped increase political focus on maternal health issues,

including fistula.

• TheCampaigntoEndFistulawasoneoffewinitiativesworldwide

featured in the MDGGoodPracticespublication.TheCampaign

was cited for its innovative and comprehensive approach,

combining programmatic, technical and advocacy intervention and

awareness-raising on how to prevent and treat fistula. A young fistula survivor who benefited from the project. “The Ambassador called the Hospital, received the money and then he got us the bus tickets. There were six of us so we took a bus from Mbeya up to Mbongo, and then a driver was waiting to pick us.” Photo: Lisa Russell, Tanzania, 2011.

Thecountry’slargestprovideroffistulasurgery,Comprehensive Community

BasedRehabilitationinTanzania(CCBRT), is revolutionizing the fight against

fistula through mobile phone technology to make services more available to

womenlivingwiththecondition.Thegoalistofacilitatetransportationfor

fistula patients seeking treatment, so that more women can access surgery.

According to UNFPA, an estimated 3,700 new cases of obstetric fistula

occurinTanzaniaeveryyear,butonlyabout1,000gettreated.“Sadly,

most women living with the condition do not know that treatment is avail-

ableortheyjustcan’taffordit,”explainsCCBRT’sChiefExecutiveOfficer,

ErwinTelemans,whoisalsoresponsibleforthemobilephoneinitiative.

AttheirhospitalinDaresSalaam,CCBRTprovidesfistulasurgeryfree

of charge, but until recently, the high cost of transportation and accommo-

dation prevented fistula survivors in remote villages from seeking treatment.

Since late 2009, however, the non-governmental organization began using

Vodafone’smobilebankingsystemM-PESA—Mfor“mobile”andPESAfor

“money” in Swahili—to help patients overcome transportation costs.

Supported by UNFPA, the institution embarked on a pilot project,

usingM-PESAtosendmoneytofistulasurvivorssothattheycantravel

tothehospitalinDaresSalaamfortheirrepairsurgery.Themoney,which

isprovidedbytheproject,issentbyCCBRTviaSMStofistulavolunteer

ambassadors, who may be former patients, health workers, or staff of

non-governmental organizations, to identify and refer women suffering

from fistula for treatment.

TheambassadorscanretrievethemoneyatthelocalVodafone

M-PESAagentandbuybusticketsforthepatients.Whenthepatient

arrives at the hospital, the ambassador receives a small incentive.

Sincethestartoftheproject,thefistulaambassadors’networkhas

expanded to all regions of the country and the number of women who

have been able to access fistula surgery increased by 65 per cent. In

2010, fifty-four ambassadors referred 129 women for fistula repair via

M-PESA.TheprojectisprofiledinaFistulaCaretechnicalbrief;to

learn more, please visit http://www.fistulacare.org/pages/resources/

publications/technical-briefs.php.

It is early morning, and my bed is dry!

We are very thankful.

We’ve been isolated.

We’ve been far away from this world.

Thank you doctor for bringing us back;

Back to the world of the living.

Two young women sang this poem in a farewell ceremony before

taking the plane back home. They were part of a group of 15 patients who

had travelled well over 1,000 km from South Somalia for fistula repair at

the Boroma Fistula Hospital in Somaliland. The majority of patients were

only in their mid-twenties, but some had already been living with obstetric

fistula for up to 12 years.

One of the patients, Rahimo Buno, 26, had developed a fistula and

lived with it for nine years. “I was in labour for seven days,” recalls Ms.

Buno. “My baby died. Then I noticed I was leaking urine. I didn’t know

what was wrong with me and it just didn’t stop…. I used to love going

out and seeing friends but that changed.… I no longer felt able to go to

weddings or the mosque; even going to the market was difficult. I was so

self-conscious of my smell, ashamed of spoiling my clothes, and aware

of what others thought of me.”

The ongoing armed conflict and instability in South and Central

Somalia make it very difficult to improve obstetric care or to provide

onsite fistula repair services. Yet this is an area with one of the highest

maternal death rates in the world, an indicator of high incidence of

post-partum complications, such as obstetric fistula. The relative stability

in Somaliland has allowed fistula treatment services to be provided in

several hospitals.

“For women coming from Southern and Central Somalia, the main

problem is transport,” explains Essam Elsayed, medical coordinator for

the Women and Health Alliance International (WAHA) in Somaliland.

“In the first fistula surgery initiative that we carried out in May 2010,

three women came all the way from Mogadishu to Somaliland by public

bus. It took them three days to arrive, travelling in difficult conditions.

One told us how she was thrown off the bus several times because the

passengers were upset by the smell of urine. Another one told us that she

was charged twice the ticket price for the same reason,” Dr. Elsayed says.

Following this experience, WAHA started financing and organiz-

ing transport for women from south and central Somalia to come to

Somaliland for the repair of obstetric fistula and other post-partum

injuries. Ms. Buno is part of the third group of patients brought to

Somaliland for surgery in 2010.

Patients are identified by midwives in Mogadishu and Kismayo and

then diagnosed by a Mogadishu-based doctor who organizes their trans-

port to Somaliland. WAHA covers all costs so that treatment and travel

are entirely free. In 2010, over 100 women from Somaliland and Southern

Somalia were operated with the support of WAHA in partnership with

Boroma Fistula Hospital and Edna Adan Maternity Hospital.

Fighting fistula in East AfricaKamuli, Uganda Childbirth Injury Fund

Extending fistula care in Somaliaby Kate de Rivero, WAHA International

When asked about the progress made in the fight against fistula, Brian

Hancock, a British surgeon who has been working in Africa for more than 40

years, is blunt: “There is no sign of reduction either in the new cases, or in

the enormous backlog that we can’t really address with the human resources

available now.”

Obstetric fistula has been eliminated in countries where good obstetric

care is available. “It is a tragic fact that a woman in sub-Saharan Africa is

about 100 times more likely to die in labour than in developed countries,” he

comments, quoting recent UN statistics.

A leading cause of maternal death, obstructed labour can only be

relieved by timely medical intervention, usually a Caesarean section,

without which the woman usually dies. If “lucky,” she will survive after

days of agony, often resulting in a dead baby and injuries that can have a

devastating effect on her life.

Even the smallest fistulas cause incontinence, which in turn can lead to

social isolation, depression and the breakdown of family and community life.

For Dr. Hancock, who is also the chairman of the Uganda Childbirth Injury

Fund, prevention must be the main goal, closely followed by education and

improved transport options and hospital facilities. “But the problem will be

with us for a long time. There will be a need to train many more surgeons,”

he asserts.

Having done more than 1,300 fistula repairs during his career, Dr.

Hancock knows about the real situation in many countries where fistula

is prevalent. He usually spends three months a year abroad, partnering

with other institutions and rural hospitals in several East and West African

countries to both perform surgery and train new professionals.

“I rarely operate without at least one trainee present,” Dr. Hancock says,

explaining that, according to his experience, although the necessary equip-

ment is usually minimal, fistula surgery is highly demanding, encompassing

different techniques and specialized training.

“Only a quarter of the cases are suitable for beginners. Another quarter

are extremely complex and it takes a long time to build up experience—I

would say at least 100 surgeries before a professional feels comfortable

attempting most repairs,” he estimates.

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Fistula surgery at Kamuli. Photo: Gillian Slinger, Uganda, 2010.

A vision in whiteLusaka, Zambia

Survivors get back on their feetDRC/ Liberia/ Republic of the Congo

It takes more than an operation to get fistula survivors on their feet. First,

there’s a recovery period, two weeks on average, so that the patients can

heal after surgery. But it’s often a job or a livelihood that really helps them

reclaim their lives.

Because so many fistula survivors have been abandoned, excluded

or shunned—often for years—a job or a business opportunity can mean

renewed social connections and a sense of purpose, as well as a much-

needed livelihood.

In the Democratic Republic of the Congo, former fistula patients are

becoming skilled beauticians and dress makers. In Liberia, fistula survivors

are making and selling soap, flowers, baked goods, dresses and fabric. In

the Republic of Congo, there’s an individualized approach with a focus on

business and management skills.

In all three countries, the women also receive coaching on the life skills

that can help them become successful and overcome their tragic pasts.

“I lost all hope. I was abandoned by every member of my family. Now,

some of them are beginning to relate to me,” says Nyamah Kollie, 39, one

of the fistula survivors who benefited from the programme in Liberia after

living with the

condition for

almost 20 years.

The change

in Rebecca

Mambweni’s

life is striking.

She was just 23

when she went

through days of

agonizing labour

before a dead

fetus was pulled

from her uterus.

The trauma

to her birth

canal left her

incontinent.

“I lived for a

year with fistula. I just stayed at home with my mum. Sometimes I could

see her crying. No one wanted to be around me. My in-laws abandoned

me,” she says. “They didn’t want to pay for an operation to fix me. All I

could do was stay home. I couldn’t go outside just in case I urinated on

myself. When I went outside people would laugh at me, pointing. It was

like a prison. I sometimes felt it would just be better if I died and just be

quiet somewhere else.”

Now, following her surgery and training as a beautician in the DRC,

she is employed and optimistic about her future: “I work in this salon, the

Salon of Hope. One day I’d really like to have a salon of my own. I’d really

like all those people that laughed at me to see me now. I just want to live a

normal life,” Ms. Mambweni says.

dispatch

Sarah Sukwa, 18, got married before turning 15. She left her father’s

home and went to live next to her mother-in-law in a village nearby. Ms.

Sukwa was very happy with her new husband, who worked in a small

farm. When she got pregnant right after her marriage, he would even help

her with the heavier domestic tasks.

When she realized that her labour had started, she informed her

mother-in-law, who then sent for the traditional birth attendant. Her

mother-in-law told Ms. Sukwa that she should deliver at home as most

girls in the village do, assuring her that even women as young as 14 did so

without a problem.

Ms. Sukwa was in labour for two days, without food or water. No sign

of the baby. Then her mother was sent for.

On the third day of labour, when her mother arrived, Ms. Sukwa

demanded that they take her to the nearby health centre, 15 kilometres

away. She was weak and scared that she and the baby might die. Her

husband took a bicycle and went to the health centre to seek advice.

They rang for an ambulance, which took Ms. Sukwa to the hospital.

However, it was too late—her baby was dead.

Two days later, her husband took her back home on his bicycle. Ms.

Sukwa noticed that she was leaking urine uncontrollably, but she was

too weak to return to the hospital. She didn’t know then that she had

developed fistula.

Unfortunately, there are many other stories like this in Zambia.

According to national authorities, at least 500 new cases of obstetric

fistula occur in the country every year, a rough estimate based on the

number of women seeking treatment at various health centres across

the country. However, most hospitals keep no documentation, and only

a few have complete records. So the figures reflect health personnel

estimates and claims that “…there are many women living with fistula in

the country.”

Besides the lack of data, fistula survivors receive little help from district

and provincial health facilities due to the limited capacity to provide com-

prehensive care. The people have to travel long distances on poor roads

to reach health facilities, and rural centres are few and understaffed.

“We depend entirely on donors’ assistance to sustain the fistula

programme,” says Mary Nambao, Reproductive Health specialist at

the Ministry of Health. “At the moment, there is inadequate funding for

prevention and integration of obstetric fistula within the larger maternal

health initiatives in the country,” she explains.

To raise public awareness about the problem, some safe motherhood

action groups supported by the government have been engaged to educate

communities in reproductive health matters, including fistula prevention.

The members, who are identified by the community, encourage women

to seek skilled attendance during delivery, use modern family planning

methods to space their children, and avoid unplanned pregnancies.

Nevertheless, government plans to scale up the initiative are being

hampered due to the lack of resources. Another challenge is the insuf-

ficient mobilization of community leaders around the importance

of preventing fistula.

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Rebecca Mambweni benefited from a programme that teaches fistula survivors and employs them as beauticians and dressmak-ers. Photo Robin Hammond, Panos/Campaign to End Fistula, DR Congo, 2010.

Small and quite slim, M.* turns her eyes away when asked about the

nightmare she experienced just a year ago. Before even turning 13, she

was raped and got pregnant. She did not understand what had happened

to her. Suddenly, instead of the usual tenderness of her family, M. was

treated with harshness and confined to her house.

In shame, the family kept the secret about the rape and pregnancy. M.

could not go out with her friends anymore, and she was forced to drop out

of school. She saw her body changing and suffered in silence. One day she

had terrible convulsions and, without medical assistance, she delivered a

stillborn baby at home. Weak and traumatized, M. survived through the pain

of the almost unbearable experience. But her ordeal was just beginning.

Shortly after labour, she realized with horror that she was leaking

urine and feces. Her clothes constantly soiled, she was rejected by her

extended family. Her parents tried to help her, but they didn’t know that

her condition could most probably be cured.

M.’s story is not uncommon in Mauritania, where it’s estimated that up to

10,000 untreated cases of fistula exist, according to local experts. Although the

national authorities are committed to scaling up the efforts to eliminate fistula

that have been carried out in the country since 2005, many challenges remain.

“One of the priorities is to raise awareness about the condition,”

explains the chairwoman of the Midwives Association of Mauritania,

Addellah Fatimetou. To break the silence surrounding fistula, UNFPA has

established a partnership with the Midwives Association, a network of

non-governmental organizations working to eliminate fistula in the country

as well as journalists interested in population and development.

“They have helped pass the message on to communities, health

workers and society in general,” says former UNFPA Representative in

Mauritania, Diene Keita. A video telling the story of a fistula survivor is

used during awareness campaigns and social mobilization.

Another goal is to improve access to emergency obstetric and

newborn care in the country, in particular emergency obstetric care,

including additional equipment and human resources.

“So far, eight maternity clinics have been equipped and two operating

theatres have received support to strengthen prevention efforts,” says the

head of the National Reproductive Health Program, Mahfoud Ould Boye.

Since 2008, 150 health workers, including doctors, midwives and nurses

with obstetric skills, have received training on how to manage fistula cases.

Although there are three fistula centres in the country, they are not fully

operational. In 2010, 178 patients were treated. Twenty fistula survivors

benefited from social reintegration support after surgery and follow-up to

develop income-generating activities.

M. was among them. When she was identified by the fistula pro-

gramme, she was in a hopeless condition. After a successful surgery, she

received the support she needed to go back to her family and community.

She resumed her studies and now makes periodic visits to the boarding

centre of Sebkha, where she was treated and cared for until she recovered. Her

shy smile is a source of hope for other patients and a strong motivation for staff.

*Real name has been omitted by request.

6

Restoring hopeNouakchott, Mauritania

It all started in my home country, El Salvador. As a doctor, I was assigned

to one of the main national maternity hospitals. Because of the hospital’s

many resources, all the complicated cases were sent there. This gave

me the opportunity to learn how to respect all patients and discover the

joys of helping women deliver their babies. For me, every single one of the

approximately 35 daily deliveries we handled was unique.

Now I am facing another side of medical practice: I’m working in a

small clinic in the heart of Athens, Greece. Here, we provide free medical

consultation for migrants—something they can’t get elsewhere. But we

don’t have surgical facilities.

I am astonished by the huge differences between countries, especially

regarding complications. According to the UN, every day in 2008 about

1,000 women died of complications during pregnancy and childbirth.

Some 570 of those deaths occurred in sub-Saharan Africa and 300 of

them in South Asia, compared to only five in high-income countries.

But there are other sad outcomes. Sometimes, the woman is too small

to allow the baby to pass. The fact is that when the delivery starts and the

baby can’t come out, a surgical intervention is the only way to save the

lives of the mother and the baby, and to prevent injuries. If the head of

the baby stays for too long in the vagina, the pressure starts to block the

blood vessels, so no oxygen is received, and the tissue lacking oxygen

develops necrosis and eventually sloughs off.

If we consider the number of new cases of fistula every year, knowing

that each fistula is almost always preventable, we can see how limited the

access is to maternal health care in our world.

My desire is to continue working so that every pregnant woman can

choose to have a delivery in a safe environment, no matter what part of

the world they are from, and regardless of whether they are single, who

they are married to, or where they live. This is something worth striving for.

Aleida Marroquin is an obstetrician-gynecologist from El Salvador. She worked with Médecins Sans Frontières in maternity projects in Jahun, Nigeria and South Sudan, and with Medecins du Monde in a clinic for migrants in Athens, Greece. Aleida will start fistula surgery training this year in Ethiopia.

My journey as a doctorby Aleida Marroquin

Patients’ relatives waiting outside the maternity ward. Ahuk (in red, next to Dr. Marroquin), developed a severe infection after obstructed labor. Both her sister (in blue, also pregnant) and her mother stayed with her while she was in the hospital. Photo: Janine Issa, South Sudan, 2009.

dispatch7

MappingUNFPA will be working closely with the Fistula Foundation, Direct

Relief International and other partners to undertake a mapping exercise,

compiling information on fistula centers, experts and activities globally.

The idea is to develop “the big picture” on current activities, needs

and gaps relating to fistula in the world. A testing round of sample

questionnaires was already circulated among key partners in the

Campaign.

According to Lindsey Pollaczek, who is leading the mapping effort at

Direct Relief International, the survey will provide a more comprehensive

understanding of where women are currently going for fistula care

and how many are currently being treated. The information, which will

be updated continuously, will also guide strategic planning for fistula

initiatives in the future and will further connect key people and agencies

working in the field. EngenderHealth, Women and Health Alliance

International (WAHA) and the International Society of Obstetric Fistula

Surgeons (ISOFS) are key partners in the initiative, which will add to

the excellent work done by others, such as the Geneva Foundation for

Medical Education and Research (GFMER).

Regional Conference“The government will establish a National Task Force on Fistula to

move from a campaign-based to a permanent service-based approach

for the management of this stark health challenge,” said Assad Hafeez,

Director-General in the Ministry of Health, during a regional fistula

conference in Karachi from 4-6 March 2011.

The conference brought together 3,000 experts in the field of obstetric

fistula, including 11 international fistula surgeons. It covered a range of

issues, from safe motherhood to social reintegration of fistula survivors,

providing an opportunity to reach consensus on priorities and draw

attention to the linkages between fistula and poverty, inequality, gender

disparity and poor education. The participating surgeons also operated

on complex fistula cases while they were in Pakistan.

Women’s DayOn International Women’s Day, singer and actress Natalie Imbruglia,

spokesperson for the Campaign to End Fistula, raised her voice to draw

attention to the many women who still suffer with obstetric fistula. In

an emotional video testimony, she talked about her missions during the

past five years and the many special women she has met in her fight

against this terrible condition.

Reality CheckThe RH Reality Check blog ran a series on prevention, care and

treatment of obstetric fistula, with contributions from various institutions,

including EngenderHealth, Guttmacher Institute, Human Rights Watch,

the International Women’s Health Coalition, the Fistula Foundation

and UNFPA. The series, which highlighted the importance of more

comprehensive approaches to fight fistula, was published in conjunction

with renewed efforts to increase support to address obstetric fistula.

NEWS

A new set of priorities for the global fight against obstetric fistula was the

focus of the 2010 meeting of the International Obstetric Fistula Working

Group (IOFWG). Specialists from around the world gathered in Dakar,

Senegal, last December to discuss ways to move the fistula agenda forward

and eliminate the condition. The meeting was held immediately before the

International Society of Obstetric Fistula Surgeons (ISOFS) Conference.

New initiatives on prevention, treatment and research were highlighted by

the group, which works to ensure global coordination of partner efforts for all

issues relating to fistula. Updates on fistula activities included a session led

by EngenderHealth on current fistula research, and the formulation of a list of

research recommendations to overcome research gaps and strengthen data

base on fistula. Findings of the mid-term evaluation and the new three-year

vision for the Campaign were shared with working group members.

While there was a strong presence of medical and surgical organizations,

participants recognized the urgent need for engaging with more advocacy

and social reintegration partners in the future. This will include human rights

groups, as it was the recognition of fistula as a neglected medical and human

rights issue that initially gave rise to the global Campaign to End Fistula.

The meeting was held on a positive high note. Never has the political

focus on maternal health and fistula been higher, thanks in large part to the

advocacy efforts made in recent years by the Campaign to End Fistula and

its partners.

“It was an excellent opportunity for health-care providers and experts

from some of the world’s most affected nations to share key lessons

from the work on the front lines of maternal health and obstetric fistula,”

explained the Campaign coordinator, Gillian Slinger. The Dakar meeting also

shed light on promising practices that are being carried out by the many

partners of the Campaign.

One of the hosts of the meeting, Professor Serigne Gueye, a leading

fistula expert and also one of the organizers of the ISOFS Third Annual

Conference, highlighted the increased collaboration among partners

and specialists from different backgrounds.

The UNFPA Representative in Senegal, Rose Gakuba, was delighted

with the initiative to have back–to-back obstetric fistula meetings, which

gave the opportunity to share lessons learned and experiences, and to

bring coherence to the global efforts in this area.

Nine new partner organizations joined the group during the meeting: the

Bangladesh Medical Association, Fistula Foundation Nigeria, Health and

Development International, Human Rights Watch, Médecins Sans Frontières

(Belgium), Obstetrical and Gynecological Society of Bangladesh, the

Uganda Childbirth Injury Fund, Women and Health Alliance International,

and Women’s Hope International.

More than 20 journalists from national, regional and international

media attended a press conference with fistula experts at the meeting and

followed the stories of fistula survivors as they underwent treatment and

returned to their communities. Their coverage helped raise visibility about

the importance of expanding treatment. The next IOFWG meeting will be in

October 2011.

Working Group meetingDakar, Senegal

UNFPACampaign to End Fistula605 Third Avenue, New York, NY 10158email: fistulacampaign@unfpa.org

dispatch is a biannual newsletter highlighingdevelopments in the Campaign to End Fistula

Why the Campaign?Every year, 7-10 million women suffer severe or long-lasting illnesses or disabilities caused by complications during pregnancy or childbirth, including obstetric fistula.

Obstetric fistula is a preventable and in most cases, treatable childbirth injury that leaves women incontinent, ashamed and often isolated from their communities.

There are at least 2 million women living with obstetric fistula in the developing world, and up to 100,000 new cases occur each year.

In 2003, UNFPA and its global partners united to launch the Campaign to End Fistula.

The Campaign is now present in 49 countries, having raised over $40 million toward the goal of eliminating fistula.

The Campaign, with its many partners around the world, focuses on three key areas: preventing fistula, treating affected women, and supporting women as they recover from surgery and rebuild their lives.

For more information, please visit: endfistula.org.

Editorial Process: Etienne FrancaDesign and Printing: Prographics, Inc.

Contributors:Muhammad Ajmal, Erin Anastasi, Assane Ba,Yves Bergevin, Luc de Bernis, Joséphine Kawende Bora, Emily Dally, Triana D’Orazio, Abubakar Dungus, Vincent Fauveau, Neil Ford, Esperance Fundira, Omar Gharzeddine, Kate Grant, Serigne Gueye, Brian Hancock, Calixte Hessou, Sennen Hounton, Katja Iversen, Janet Jensen, Peter Johnson, Diene Keita, Richard Kollodge, Jeannette Biboussi Kouangha, Laura Laski, Geeta Lal, Amar Ould Mohamed Lemine, Jenipher Mijere, Julita Onabanjo, Duah Owusu-Sarfo, Aleida Marroquin Parducci, Friedrike Paul, Lindsey Pollaczek, Kate De Rivero, Allison Shigo, Sandy Singer, Gillian Slinger, Sawiche Wamunza.

Campaign Donors (since 2003)Americans for UNFPAArab Gulf Programme for UN Development Organizations Bill & Melinda Gates Foundation through EngenderHealth European Voice Government of AustraliaGovernment of AustriaGovernment of Canada Government of FinlandGovernment of IcelandGovernment of Ireland Government of Japan (through the UN Trust Fund for Human Security) Government of LuxembourgGovernment of New Zealand Government of Norway Government of Poland Government of the Republic of Korea Government of Spain Government of SwedenGovernment of SwitzerlandJohnson & Johnson Kingdom of Spain, Autonomous Community of CatalunyaOne by One United Nations FoundationVirgin UniteWomen's Missionary Society of the African Methodist Episcopal ChurchZonta International UNFPA wishes to acknowledge with gratitude the multi-donor support generated towards strengthening and improving maternal health in the world. Our appreciation is also extended to the numerous partners and individual donors for their collaboration and support to the Campaign to End Fistula since its inception.

Campaign to End Fistula countries

Mauritania

SenegalGambiaGuineaBissau Guinea

Mali

GhanaTogo

Benin

Nigeria

Niger Chad

Congo

Sudan Yemen

India

Nepal

Bangladesh

Pakistan

Afghanistan

Djibouti

Eritrea

Somalia

Kenya

BurundiRwanda

Uganda

Ethiopia

AngolaZambia Malawi

MozambiqueMadagascarZimbabwe

SouthAfrica

Lesotho

Swaziland

DemocraticRepublicof Congo

UnitedRepublic ofTanzania

CameroonCentral African

Republic

Gabon

SierraLeone

EquatorialGuinea

Liberia

Côted’Ivoire

BurkinaFaso

Haiti

CARIBBEAN

The opinions expressed by the persons interviewed and original authors do not necessarily reflect the newsletter editorial position, the official position of UNFPA, or recognition of geographic boundaries or countries.

A major effort by over 20 partners—includ-

ing United Nations agencies, donors and

non-governmental organizations—will

produce the first ever State of the World’s

Midwifery Report, which is expected to

shed light on critical resource gaps.

Although it is widely recognized that the

role of midwives and others with mid-

wifery competencies is crucial in promoting

women’s and children’s health, an overview of midwifery in the world has

thus far been lacking.

“This strong global partnership is calling unprecedented attention to the

critical importance of optimizing the practice of midwives, thus ensuring

their ability to provide a host of integrated preventative and treatment

services that are essential to maternal health, including sexual and

reproductive health issues like fistula prevention,” says Peter Johnson,

Director of Global Learning for Jhpiego, an international non-profit health

organization affiliated with Johns Hopkins University and UNFPA partner

in midwifery training initiatives.

The report, which will be launched on June 20th at the Congress of

the International Confederation of Midwives in Durban, South Africa,

is considered a key advocacy tool for human resources for health,

particularly midwifery, providing new information, global analysis and

data on midwifery in 60 countries with high maternal mortality.

“The health of women and their newborns has increasingly taken

centre stage in global development discussions since the launch of

the United Nations Secretary General’s Strategy on Women’s and

Children’s Health, in September 2010,” says the chief of the Sexual

and Reproductive Health Branch at UNFPA, Laura Laski. “The new

midwifery report will provide new evidence about midwifery in the

priority countries identified by the strategy and will guide our work,”

Dr. Laski adds.

Furthermore, midwives have a key role in monitoring the progress

of labour, recognizing when it is obstructed and referring pregnant

women to emergency obstetric care in time, which helps reduce the

incidence of obstetric fistula while safeguarding the well-being of

both mother and baby.

New report highlights midwifery

THE STATE OF THE

WORLD’S MIDWIFERY2011

DELIVERINGHEALTH,

SAVINGLIVES