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The Commitment of Health Workers

The first time I met them, they seemed like any other group of health workers—pleasant faces looking up to greet me even though I had interrupted their meeting. But I would soon understand their dedication to helping women with obstetric fistula receive the care and surgery they need to relieve years of suffering and discrimination.

These were the mentors and trainers for the Fistula Care project that is implemented by IntraHealth in the rural Amhara Region of Ethiopia. I was there to work with, coach, and learn from them while we field-tested a new training package for other health workers. The aim of the training is to provide health workers the skills to educate communities about obstetric fistula and the importance of antenatal care and skilled attendance at birth, and to identify and care for women who have developed fistula.

A fistula is a hole in the birth canal that results in continuous leakage of urine and/or feces. It is most often caused when blood supply to the tissues of the vagina and bladder is cut off by prolonged, obstructed labor. Left with incontinence, women with obstetric fistula are often abandoned by their husbands and families, unable to work, and rejected by their communities. Fistula affects girls and women almost exclusively in resource-poor settings of Africa and South Asia. But fistula can be repaired in up to 90% of cases, provided women have access to a trained fistula surgeon at a hospital. After surgery and post-operative care, women need counseling and support to address emotional damage and facilitate their social reintegration.

My colleague back in North Carolina, Dr. Martha Carlough, and I had drafted this training package to standardize fistula training provided by IntraHealth International and other organizations. Using the materials already employed by our Ethiopian fistula mentors and trainers, we added the detailed session plans, participatory learning activities, evidence-based reference and presentation materials, and assessment instruments.

After spending two days reviewing and practice teaching with the new training package, the fistula mentors came alive as they facilitated 21 health workers’ learning about fistula during a three-day workshop to field-test the training package. Ethiopian trainers are accustomed to a lecture style of teaching with PowerPoint slides, but this training package pushed them to minimize the lecture and instead facilitate activities for participants to contribute their own experience and practice new skills. Activities included counseling role plays, case studies using the partograph tool to monitor labor, and identifying key health education messages about antenatal care, labor and delivery, and prevention of obstetric fistula. During review sessions at the end of each day, the trainers demonstrated their commitment to quality of training and quality of health care with their insights on how to improve the training design and materials.

When not training other health workers and giving community talks about the prevention of obstetric fistula, fistula mentors are caring for fistula patients in IntraHealth-established pre-repair centers located on the grounds of health centers in Ethiopia’s Amhara region. These pre-repair centers prepare women for fistula surgery by providing basic care including treatment for malnutrition, anemia, and opportunistic infections, as well as counseling about what to expect with their surgery and post-operative rehabilitation.

On visits to our pre-repair centers before the field-testing workshop, I met the staff and their fistula patients. Each pre-repair center is staffed by a midwife or nurse who is our fistula mentor/trainer, a nurse aide who is a cured fistula patient, and a driver who transports staff and patients from communities to the pre-repair center and the fistula hospital for surgery. I learned about the lives of the fistula patients, the experiences that led to and followed the patients’ fistula injury, and their joy in finding compassionate care at our pre-repair center in preparation for their fistula surgery. I met the drivers who are dedicated to the comfort of the fistula patients they transport on bumpy unpaved roads to the health facilities. I heard our fistula mentors—Ali, Emebet, Menna, and Wondwossen—talk about the reasons they do this work, for example:

“The mothers I am helping could be my mother, and I would not want my mother to suffer like women with fistula.” –Wondwossen

“Most of the mothers who suffer from fistula are isolated and discriminated from her family and community. I do what I do because I’m able to provide them a positive outcome. My vision is to see most mothers have skilled attendance at their births so that fistula no longer occurs.”–Ali

I left Ethiopia thinking that with the dedication of these and other health workers, maybe Ali’s vision can be achieved.

IntraHealth’s fistula care work in Ethiopia is supported by the USAID-funded global Fistula Care Project, which is led by EngenderHealth.