Tanzania: Still a Long Way to Go to Eliminate Fistula in Tanzania

The World marked the International Day to end obstetric fistula. While countries are making efforts to have a world where no woman dies because of fistula, this might remain a farfetched dream for Tanzania, which is still facing several challenges in dealing with the condition.

With 3,000 new cases of fistula every year and very few experts to handle them, Tanzania ends up with a backlog of untreated cases every year.

An average of 1,036 fistulae were repaired annually between 2003 and 2015 and the backlog of untreated fistulae has been increasing every year. Experts have it that the numbers will keep rising if joint and deliberate efforts are not mobilised to handle the situation.

"The backlog is really devastating. The capacity for performing fistula surgeries in Tanzania for now is approximately 1,500 cases a year. We therefore have an annual backlog of around 1500 cases," says Dr James Chapa, who is an Obstetrician/Gynaecologist/Fistula Surgeon and International Federation of Obstetrician and Gynaecologist (FIGO) accredited trainer.

"The Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) with its satellite centres is managing around 70 per cent of all the surgeries in Tanzania. The remaining 30 per cent of the surgeries are managed by other health stakeholders," says Dr Chapa.

Scarce resources

The doctor says lack of resources, both financial and human, expertise, political commitment and awareness are the major reasons that create the back log.

Fistula, according to Dr Chapa is caused by unattended, prolonged and obstructed labour associated with delays in seeking and receiving appropriate and adequate birth care. Prolonged pressure of the baby's head crushes the base of the bladder against the back of the pubis, which results to urine leakage.

"The World Health Organisation estimates 50,000 -100,000 new cases of fistula each year worldwide, while treatment capacity is less than 20,000 cases a year. There is a large unmet need for treatment. Fistula is most prevalent in sub-Saharan Africa and Asia," says Dr Chapa.

Dr Chapa says the best way to support these women is by strengthening preventive measures that include use of family planning to avoid early and unplanned pregnancy, discouraging early marriages and provision of health education on the importance of delivering at a health facility. Today only 51 per cent of women deliver in the hands of a trained personnel. Dr Chapa also suggests improving maternal health care as a remedy to the problem. He says if these measures are taken, we will reduce the number of new fistula cases.

Enough surgeons are needed as well as centres to perform surgeries. The doctor wishes that every regional hospital could perform these surgeries. If this is achieved, he says, the backlog will be reduced. He says currently only around 16 surgeons from about 10 centres are performing fistula surgeries all over Tanzania.

Fistula and poverty are interlinked. The majority of women affected by fistula in Tanzania are very poor, they can't afford treatment costs as well as transport to CCBRT in Dar es Salaam. This is why CCBRT in collaboration with partners decided to come up with a solution for this by providing patients with free transport to the hospital, free treatment, meals and accommodation.

This has been a relief to the poor women, most who come from upcountry for treatment.

I met Eva Mgala, 35, at CCBRT recently where she had come for her second fistula surgery. She was able to travel from Kavufuti village in Rukwa's Sumbawanga District to Dar es Salaam, thanks to the free transportation assistance.

Eva had her first surgery to correct the hole in her rectum in December last year. Both her bladder and rectum had been affected during her first pregnancy five years ago. Doctors repaired the rectum hole first and now she is at the hospital for her second surgery to correct the leaking bladder.

Social stigma

After Eva suffered fistula, she was abandoned by her husband who could not bear with the smell resulting from the leakage from both the rectum and the bladder. She had lost her child in the process of labour and was devastated when her husband decided to leave her. She later remarried but like her first husband, her second husband abandoned her too.

All this time, Eva had no idea what was causing her troubles until when she consulted the doctor. She also visited several traditional healers but none of the medications they prescribed worked.

Eva remarried for a third time. Although she was lucky this time, her husband would make negative comments about her situation every time he was drunk.

"When my husband and I learnt about the support by CCBRT we were all excited. However the excitement, ended after I learnt that the treatment for urine leakage had to wait. Doctors recommended that I should return to CCBRT for the second surgery after five months. So here I am waiting for my second surgery," says Eva, eager to lead a normal life again.

Dr Chapa says that there are different types of fistula surgeries depending on the type of fistula. They range from simple to complex vaginal repairs to abdominal repairs of ureteric fistulas, high vesico cervical vaginal fistula and also urinary diversions for irreparable fistulas.

He says the most difficult fistula surgery is that of urinary diversion where an artificial urinary bladder is made in the sigmoid colon and ureter is implanted to it. This is done to patients who have irreparable fistulae. After surgery this patient will be passing both urine and stool rectally but she will be dry.

Commenting on the challenges he faces in his work, Dr Chapa mentions cultural beliefs that make some patients to shun going for treatment believing they had been bewitched or cursed. Another challenge is having to deal with high numbers of patients turning up for treatment.

As a trainer for fistula surgeons, Dr Chapa also faces the challenge of having to deal with trainees who have language problems, especially those coming from francophone countries, as the training is conducted in English.

The country does not have a college for training of trainers but the International Federation of Obstetricians and Gynaecologists (FIGO) provides training of trainers and gives accreditation to become trainers.

"Until now FIGO have trained 14 fistula surgeons from Nigeria, Ghana, Burundi, DRC, Gambia, Senegal, Nepal, German and Congo Brazaville. We are currently training two surgeons, one from Nepal who is in advanced level and who is undergoing a 4 weeks training and one beginner from Congo Brazaville who is undergoing training for 6 weeks," says Dr Chapa.

I asked Dr Chapa whether it was easy doing what he does and he said that his work needs dedication and commitment.

"It somehow affects your social life as you may find yourself using much of your time thinking about these patients, thinking about their sufferings and how to help them."

However, he believes that there is no satisfaction in the obstetric carrier than wiping tears of a woman with fistula and bringing a big smile to her face after all the physical, emotional and social suffering that they go through.

Dr Chapa has worked as an obstetrician/gynaecologist for five years and as a Fistula surgeon for three years. He has been a fistula surgery trainer for one year now, at CCBRT.

Source: The Citizen