References

Is Ending Fistula within a Decade Achievable for Zambia?

Author(s)

Eugine Kaunda
Department of Obstetrics & Gyneacology, Monze Mission Hospital, Monze, Zambia

DOI: https://doi.org/10.55320/mjz.49.1.1105

On 23rd May 2022, Zambia will join the global community in commemorating the International Day to End Obstetric Fistula (IDEOF). The day, set by the United Nations, aims to recognize the struggles of women living with fistula, a devastating health condition caused primarily by prolonged/obstructed labor and, increasingly, by unsafe obstetric or gynecological surgery. IDEOF also recognizes the efforts of governments, maternal health stakeholders, and health care workers to prevent and treat fistula, making progress towards a global goal of ending fistula by 2030. Obstetric Fistula (OF) leads to chronic incontinence of urine and feaces and, in most cases, significant physical and emotional suffering. Women who suffer from OF live in shame as they are constantly soiled and wet, and that they smell. Their pain and shame may be further complicated by infertility, damage to their vaginal tissue that makes sexual activity difficult or impossible and paralysis of muscles in their lower limbs which may require the use of crutches. In most cases, it also tragically leads to delivery of a stillborn neonate. The greater tragedy is that OF can be largely avoided by delaying the age of first pregnancy, prevented bytimely access to maternity and obstetric care, and repaired by surgery.1 OF continues to be a neglected public health and human rights issue. Globally, an estimated 2 million women are living with untreatedfistula and an estimated 50,000 to 100,000 new cases occur every year2 The true incidence and prevalence of OF in Zambia is unknown, though the Ministry of Health estimated that close to 2000 fistula surgical repairs were done over a ten year period prior to 2017 3 .

In view of the present fistula burden in the world and present trend of maternal mortality and morbidity in many African and South Asian countries, the 7th International Society of Obstetric Fistula Surgeons (ISOFS) which was held in Kathmandu, Nepal in December 2018 called on all stakeholders to reinforce efforts in order to achieve the goal of ending fistula prevention and care, with more resource mobilisation and focused attention on stronger partnerships among the different health disciplines, governments development agencies and organizations.

For Zambia to achieve the ambitious goal of ending obstetric fistula by 2030, as declared by theUnited Nations, a strong political will is required in order to accelerate efforts aimed at ensuring access to Sexual Reproductive Health (SRH) information, family planning services and emergency obstetric care by women and girls. Strong health systems are essential in ensuring access tohigh quality SRH services and timely access to emergency obstetric care, but key to ending obstetric fistula areaccess tofamily planning services for adolescents, availability of hospitals with operating theatre capacity within every district, an effective referral system and availability of skilled health personnel. The current political environment is favorable for achieving the goal of ending OF by 2030. In the recent years, progress has been madein ensuring increased access to family planning services. For instance, in addition to static family planning clinics, Community Based Distributors (CBDs) of family planning commodities, including subcutaneous injectable methods have been introduced. However, more efforts are required to ensure more adolescents and young people access family planning services in order to reduce the current teenage pregnancy rate which is unacceptably high at 29 percent.4 Adolescent girls are particularly susceptible to obstructed labour, because their pelvises are not fully developed'. This calls for creation of functional Adolescent Friendly Health Spaces (AFHS) in all districts and health facilities, and it can be achieved by 2026. The construction of district and Mini hospitals which was initiated by the previous government need to be continued by the current one. Availability of at least one district or mini hospital with operating theatre capacity in every district will ensure timely caesarean sections are performed in cases of prolonged labor.

A strong referral system in very key in ensuring access to emergency caesarean section for women and girls with prolonged labor. A study of women treated at Monze Mission Hospital with Obstetric Fistula between 2003 and 2005 indicated that delay at home (first delay) and delay in referral from health centers to hospital (second delay) accounted for 81.7% of all delays that resulted in OF formation5 . A strong referral system entails having enough functional ambulances that can be used to quickly transfer a woman labouring at a health center who develop a complication that requires an emergency caesarean section, including prolonged labour. At the moment, the ambulances are not enough throughout the country. Procurement of ambulances need to be prioritized. Equally, most roads in rural areas are in a bad state and some become impassable during the rainy season, while some bridges get washed away by heavy rains. The current government has significantly increased Constituency Development Fund (CDF) from Kl,600,000 to K25,700,0006 . CDF funds can be utilized to procure ambulances, rehabilitate roads in rural areas and construct bridges. This can significantly reduce the time taken by ambulances to transport patients from remote areas to district and mini hospitals where emergency caesarean sections can be done.

Availability of skilled health workers is essential in ensuring early identification of obstetric complications and prompt referral to hospitals where timely interventions like caesarean section can be performed. Zambia faces a severe shortage of human capital in the health system. The country has about 1.2 physicians, nurses and midwives per 1000 population while the World Health Organization (WHO) minimum acceptable density threshold is 2.3 per 1000 population7 Zambia's health workers' distribution shows geographical maldistribution skewed towards urban areas. In April 2022, the government commenced the recruitment of 11,265 health workers. Though the number is not enough to adequately increase the health worker to population ratio recommended by the WHO, it is a positive way to start. Recruitment of health workers, particularly midwives, medical licentiates and doctors need to be continued every year until the recommended numberof health workers per 1000 population is achieved, preferably in the next five years. Training of Obstetrician Gynaecologists under the Master of Medicine (MMED) at the two public universities and through the Specialty Training Program (STP) at designated STP sites need to be strengthened and sustained in order to ensure adequate numbers of Obstetrician Gynaecologists that are needed to providequality obstetric care and mentorship to the lower levels of care. Fistula Foundation (FF) has been supporting the training of Zambian Obstetrician Gynaecologists as Fistula Surgeons at sites accredited by the International Federation of Gynaecologists and Obstetricians (FIGO) as well as training by apprenticeship during the fistula surgery camps that they support together with the United Nations Population Fund (UNFPA). This needs to be continued so that fistula treatment can become institutionalized at all provincial hospitals.

Partnerships are essential in ensuring access to healthcare, especially in underserved rural areas. The Ministry of Health has continued to receive support from various partners in it's provision ofSRH services. This support has contributed to the progress that MoH has made in it's provision of SRH services. For example, Contraceptive Prevalence Rate (CPR) for modern contraceptives has increased from 33% in 2007 to 48% in 2018, while Skilled Birth Attendance (SBA) increased from 47% to 80% over the same period4 However, more needs to be done in ensuring adolescents who are most prone to developing OF access family planning services, antenatal care and skilled birth attendance. When it comes to supporting OF treatment, two organizations stand out. These are UNFPA and Fistula Foundation. UNFPA has been supporting MoH in carrying out fistula surgeries through the camp model since the early 2000s, while FF which commenced it's operations in Zambia in 2017 had supported 774 fistula surgeries by the end of December 20198 In addition, FF had oriented 199 Safe Motherhood Action Groups (SMAGS), sensitized 637 local leaders and carried out 3,213 outreach activities during the same period. These partnerships are very crucial and will play an important role in ensuring that very few new cases of OF occur, while at the same time, the backlog of OF cases is cleared. Furthermore, the two organizations are supporting MoH in developing an important document, the National Operational Plan for the Elimination/ Management of Obstetric Fistula in Zambia 2022-2026. This operational plan, once fully implemented, will help the country achieve the goal of ending OF within a decade.

Given the current political will and a favorable political environment that has been created as can be seen in the construction of District and Mini hospitals, and if priority can be given to improve healthcare financing, continuous recruitment of health workers, improve capacity for treatment of OF, improvement of the referral systems and support from partners, it is possible for Zambia to end Obstetric Fistula within a decade.

Conflict oflnterest

No conflict of interest to declare

Funding

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Acknowledgements

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REFERENCES

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  3. MOH. Zambia National Health Strategic Plan 2017-2021.
  4. ZSA, MOHand ICF. Zambia Demographic and Health Survey 2018. Lusaka, Zambia, and Rockville, Maryland, USA.
  5. Homes A, Breen M, MacArthur C. Obstetric Fistulae:A study of Women managed at Monze Mission Hospital, Zambia. BJOG2007; 114: 1010-1017.
  6. Zambia National 2022 Budget. [Accessed 2022 April 30]. Available at https://www.parliament. gov.zm/sites
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Medical Journal of Zambia, Vol 49, 1

The Medical Journal of Zambia, ISSN 0047-651X, is published by the Zambia Medical Association.
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