Working to eradicate fistula in Pakistan

Earlier this month, we had the great privilege of visiting IMR partners in Karachi, Pakistan. Our team included our Executive Director and UroGynecologist Dr. Sleemi, her long time mentor Dr. Ralph Chesson, Nurse Midwife and IMR Managing Director Mayano Ochi, and Jacqueline Kirk, who was there to document the stories of the hard work that our partners in Pakistan have put in. IMR has been working in Pakistan since 2022 in our effort to end fistula.

On the outskirts of Karachi is Koohi Goth Women’s Hospital where we spent the majority of our time. Koohi Goth is an incredible facility dedicated to the eradication of fistula where they perform free surgical repairs for women suffering from fistula. Women come from all over the country in pursuit of a treatment that will end their daily suffering due to the urinary and fecal incontinence that fistulas cause. Throughout the week, Dr. Sleemi and Dr. Chesson performed surgery on the patients at the Fistula Center alongside our Pakistani colleagues. Many of the Pakistani surgeons expressed gratitude to have received high quality mentoring and instruction from these two experts.

One of the strong beliefs that Koohi Goth holds is that skilled midwives are the key to fistula prevention. Koohi Goth hosts a 2-year diploma program for midwife students that come from some of the most rural and impoverished areas of the country. They receive their education, along with room, board, and text books all for free. They are even given a small monthly stipend. All of this is in an effort to increase the midwifery workforce who will then return to their villages where they will help save women’s lives and prevent fistulas by identifying abnormal labor and determining when a C-section is necessary. We were honored to have had the chance to instruct these eager students who clearly had so much passion for their studies, both in the classroom and in the clinical setting, .

It was humbling to witness and learn about the challenges that the midwives, doctors, and the patients face in Pakistan. IMR is committed to helping alleviate some of the burden and look forward to returning again next year.

Clinical partnership launched in Gambia

This past October, we returned to Gambia to launch our clinical partnership with the Department of Ob/Gyn at Edwards Francis Small hospital, UNFPA,  and the Ministry of Health in Banjul, Gambia. Our focus was teaching about pelvic floor disorders, obstetric fistulas and more.  Dr. Ambereen was joined by Dr Svjetlana  Lozo, a trained urogynecologist. Lectures were given daily to post graduate trainees and healthcare students, and surgeries were done in the operating room. These included surgeries for obstetric fistula and other urogynecology-related disorders, with a focus on the vaginal approach. Overall, the week was a very successful start to our partnership.

We must thank our hosts, including the department chair, Dr. Keita, and the entire team for making it such a success. Teamwork is the only way safe surgery happens, from the cleaners, sterilizers, nurses anesthetists and all who interact with our patients- from the time they enter hospital doors to their discharge home. We thank our patients for trusting us with their care and we look forward to our return in the upcoming year.

IMR Launches Our Urogynecology and Pelvic Floor Surgery Course in Pakistan

A return visit to Karachi earlier this year coincided with the launch of our urogynecology and pelvic floor surgery curriculum for residents and trainees as well as local physicians.

This introductory course occurred over a week and was very well attended.  In partnership with the faculty of Koohi Goth Women’s Hospital, this is one of several courses we’ll offer, bringing global and local expertise in the field to teach and provide hands-on training. We were honored to have Dr. Sherhah Syed, head of Koohi Goth and renowned women’s health advocate introduce and support our course.

In addition to the course, we were invited to tour one of the oldest maternity hospitals in the province of Sindh, the Sobhrag Maternity Hospital. The hospital was established in the 1920’s to serve the region’s impoverished families, a mission it carries on to this day.

We’re looking forward to a return visit later this year to continue our teaching curriculum for the next generation of vaginal and fistula surgeons.

Fistula Surgeries in Pakistan

March is Women’s History month and it also holds International Women’s Day on the 8th. It’s a chance to celebrate women’s health achievements and focus on ways we can work to increase equity and justice for women across the globe.

IMR started the month with a fistula surgery campaign in the Sindh region in Pakistan. A fistula is a preventable birth injury caused by obstructed labor or as we are seeing increasingly, from difficult cesarean sections in unskilled hands. Koohi Goth hospital is the country’s largest center dedicated to the training and care of women with obstetric as well as other fistulas. The center’s main fistula surgeon is Dr. Shershah Syed, an internationally known fistula surgeon and renowned advocate for women. He is joined by other skilled surgeons trained in repairs and a very capable team of scrub techs, nurses, anesthetists, and staff. The hospital is home to a 2-year midwifery training program that houses, feeds, and trains students from across the country. It’s truly a remarkable place full of dedicated professionals and supported by generous donations. Oh, and did I mention it is completely free. All surgeries, meds, deliveries, midwifery training, room and board, 100% free. All of it. While there, I worked with surgeons who came from across the country to further their vaginal and fistula surgery skills. 

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I was also invited to meet with staff and trainees at other hospitals across Karachi and performed prolapse surgery cases at the Jinnah Public Hospital. Later in the week, I traveled to the interior of Sind province to operate with the welcoming physicians at Sheik Zayed Women’s Hospital in Larkana, a historic city. The Sind province was devastated by historic flooding last year, and more than 6 months later, water still has not fully receded. Several fistula patients there needed surgery and it was an important opportunity to teach residents and students. 

Along the way, I was asked to share my thoughts with local TV and a national radio program. I used this opportunity to speak about health equity, human rights, and the vital role women, like our friend Dr. Shershah, play to advance these rights, especially for the poor and marginalized. I am thankful that IMR is able to partner with Koohi Goth hospital and other institutions that care for women with fistulas. In addition, I feel honored to help train the next generation of surgeons so that the end of fistulas may soon be in sight.

This Women’s History Month, a tax-deductible donation to IMR could go a very long way in our work to bring the best care to places that need it the most. Donate here.

Ambereen Sleemi

Executive Director, IMR

Liberian Fistula Program continues with your Caring Crowd funds

By: Dr. Ambereen Sleemi, Executive Director

I returned from Liberia this past December, completing our 1st phase of our fistula project that was funded through your donations on Caring Crowd. This is a continuation of our ongoing fistula project since 2015. Delivering bags full of much needed suture and antibiotics (not available at Phebe Hospital), evaluating over 40 women for surgery, completing 18 operations and treating at least 5 more with non-surgical therapy. We are set to return in January 2020 to complete the second part of this campaign. Local paper New Dawn Liberia covered our trip, and we meet with Dr Jefferson Sibley, Chief Medical Officer at Phebe Hospital and Dr Bannet Ndyanabangi, the new UNFPA Liberia country representative, securing our commitment to return in early 2020 and every 4 month for the remainder of the year and beyond, hoping to complete at least 50 fistula surgery operations. Surgical training is a large part of our commitment and I had 2 new younger surgeons eager to learn about vaginal surgical approaches and basics of obstetric fistula surgery.

And we got thrilling news! Meet Matina and her newborn. Matina had 2 previous fistula repairs in Liberia with our team in the last few years. She’s been dry and became pregnant. She came to the maternity waiting home and last week had a safe cesarean section and delivered her healthy baby boy. This is part of what your generous donations make possible. Thank you, thank you! Please consider an additional donation so we can bring the best care to the most vulnerable populations around the globe.

The Malawi Fistula Program: Expanding Access to Fistula Surgery and Care

This past May, we returned to Malawi to be a part of a fistula surgery campaign in Lilongwe. It was held at the Bwaila Fistula Center, the major, and only, fistula center in the country. Two local surgeons were part of the surgical training and 30 surgeries were completed. Since the procedures, all patients have had short-term dryness, which is a tremendous outcome.

It was wonderful to see how this center has become a successful model for providing comprehensive care to women with fistula and related conditions, such as anal sphincter trauma. Safety protocols in the operating room and the wards were posted, daily didactic bedside rounds were conducted, and coordinated care from arrival to surgery were in place. From the rehabilitation program, vocational training, and discharge protocols— there were many lessons we can bring to the fistula program at Mulanje District Hospital, IMR’s partner site that we hope to help develop into a facility as successful as Bwaila.

Bwaila operating rooms

IMR volunteer, Liz Santaniello, FNP, cares for patients post-surgery

In addition to providing excellent surgical care, the Bwaila Center has a remarkable reusable pad project that’s part of the rehabilitation center. The pads created through this sewing initiative allow women to manage incontinence from traumatic birth/fistulas and during menses. It is also a means to make and sell a product. There are plans in place to bring this project to several centers, including Mulanje. We’d like to be able to support this and help make it a reality. 

Reusable sanitary pads

For this campaign, our hosts were fistula surgeons: Dr. Rachel Pope and Mr. Chisomo Chalamanda. Our fistula surgeons in training were Gerald and Austine, both with a commitment to fistula repair for some time. We were honored to work with them as well as the wonderful nursing staff on the wards and in the operating room. We also worked with the Malawi UNFPA and Bwaila staff (supported by the Freedom from Fistula Foundation) to plan for one to two return trips to Malawi this year set at Mulanje District Hospital.

The Mulanje District Hospital continues to make preparations to be able to provide fistula care services throughout the year. We are committed to ensuring Mulanje and the southern region of Malawi has trained surgeons and supplies to do this. This includes returning in October to continue surgical training for local surgeons and to work with local partners to create protocols that are similar to the ones in the Bwaila Center, the future referral hospital in Lilongwe. 

 The success of these projects will mean so many more Malawian women can have this life-altering surgery for free. With more trained local fistula surgeons, this will amplify the care we can help give. That is something we all can celebrate.

Ambereen Sleemi

Executive Director

Our team

Fistula program in Liberia continues

In November, we returned from our sixth trip to Liberia where our surgery program is going remarkably well. We continue to work with the Liberian Ministry of Health and Dr. John Mulbah, our partner in Monrovia, to provide equipment, training, and care for women suffering with birth injuries and obstetric fistula (OF). OF is a devastating condition that affects almost 2 million women worldwide and it’s estimated that almost 100,000 new cases develop annually. OF is a condition of poverty and neglect and it affects the most marginalized populations: poor women who are pregnant.

Our work in Liberia started in 2015 after the Ebola outbreak and has been remarkably fruitful with over 150 cases done. We’re committed to training Liberian medical residents and surgeons in pelvic reconstructive surgery and fistula repair as these procedures are highly technical and require skilled surgeons. It’s estimated that each case costs $900 to $1000 per patient. These estimates include the operation, transportation, post operative care, food and all medications and equipment. It is our hope that in 2019, with your generous donations, we will continue our work helping in the recovery of at least another 60 women and continue training new young generation of surgeons who will go on to become vital to the medical care of this country.

Haitian Women's Collaborative Project Update

This past September, IMR returned to Haiti for our third trip this year continuing our pelvic surgery training initiative: the Haitian Women's Collaborative Project. This trip was full of many highlights including operating on 15 patients alongside our Haitian colleagues and students, introducing our new volunteer Amaris Lunde to our care team in Haiti, being interviewed by Radio Television Caraibes, and an invitation for our Executive Director Dr. Ambereen Sleemi to join the Haitian Society of Obstetrics and Gynecology (SHOG) as an honorary member.

The week started at St. Boniface Hospital in southern Haiti, operating and caring for women with pelvic organ prolapse (a condition where one or more of the pelvic organs like the uterus or bladder drop to or through the vagina), vesicovaginal fistulas (a hole that forms in the vaginal wall), and more. Since 2014, we've worked with Haitian OB/GYN resident physicians at St. Boniface, National, and Croix des Bouquet Hospitals as part of their training program to increase their surgical skills. Our focus continues to be on improving a surgeon’s skills using a minimally invasive approach that leads to fewer complications and quicker recovery for our patients and implementing initiatives to increase patient safety in the Operating Room. IMR volunteer Amaris Lunde, a Nurse Practitioner from Portland, OR, assisted and trained Haitian nurses caring for patients in the post-operative period. Senior OB/GYN resident physicians from Port au Prince joined us for the week for training. We then traveled to Port au Prince, joining our longtime local partner Dr. Batsch. Together, we operated on women with obstetric fistula (a hole that forms between the vaginal wall and rectum or bladder due to prolonged, obstructed labor), again focusing on surgical techniques, patient safety, perioperative care and more.

Dr. Batsch and Dr. Sleemi with Radio Television Caraibes

In between their busy schedule operating on patients, Dr. Batsch and Dr. Sleemi were interviewed by Radio Television Caraibes, one of the oldest and most popular Haitian broadcasters, about maternal health, birth complications and obstetric fistula. Many women with fistulas and other pelvic floor disorders suffer silently so the chance to inform the public about these devastating conditions was an opportunity not to be missed. We continued our campaign to raise awareness by meeting with UNFPA Haiti (United Nations Populations Fund) to discuss how to assess prevalence of fistula and pelvic floor disorders in Haiti.

Finally, we would like to congratulate Dr. Sleemi, our Executive Director, who received an official invitation to be an honorary member of the Haitian Society of Obstetrics and Gynecology (SHOG), the professional organization for all OB/GYNs in Haiti. This honor is a reflection of her passion and continued dedication to caring for women of Haiti.

Learning from a Master Surgeon: The Northern Nigerian Realm of Dr. Waaldijk

Documenting all

I was in Northern Nigeria at the end of January for a couple of weeks to visit with one of the world’s most experienced fistula surgeons and see the centers he has established over the last few decades. Dr. Kees Waaldijk is a surgical mentor of mine for over the last 10 years. He single-handedly has done the most fistula repairs of anyone in the world, over 25,000. Dr. Waaldijk is one of the best vaginal and fistula surgeons I have ever worked with. The execution of expertly placed suture, the precision of an incision and the economy of motion (as I teach it to my residents and trainees) is a beautiful thing to witness. That, coupled with meticulous documentation of each operation and outcome, is a good as it gets.

Notes on instruments and inventory

As IMR is preparing to help launch a new fistula ward in southern Malawi in April, it was important to visit with him and see how these centers were planned and how they are run. Over 2 weeks and 1500 km we went to 4 centers in Sokoto, Zaria, Kano and Katsina. All have served as training centers for 100’s of nurses and surgeons, all have high volumes of patients with obstetric trauma and fistulas. It was important to see how these centers have set up the operating rooms, the rehabilitation centers and importantly, training of surgeons and nurses.

Sokoto’s only fistula center

Thoughtful post op ward design

What is the best way to train surgeons in a highly complex surgery like fistula surgery, where the best shot a success is on the 1st attempt? How do you prepare trainees in the anatomy and surgical techniques needed for a vaginal approach.  Much of the same questions are asked when trainees are learning other surgical operations. Focusing on providing the best care and best training possible is our goal. Looking forward to April when we launch the project. Stay tuned.

-Ambereen Sleemi, MD

Treating fistulas in Liberia

This past April, I returned to Liberia for the third obstetric fistula campaign in 9 months. Each visit builds on the previous trip, on the surgical skills taught to the Ob/Gyn residents in Phebe and the care given to our fistula patients, many whom need multiple surgeries to repair pelvic damage due to obstructed labor and fistula formation.

This last trip was funded in part by WAHA International and I am very grateful for their support. WAHA is an amazing organization that is committed to helping women and children worldwide. Our work was also supported by the hospital staff and the Liberian College of Physicians and Surgeons as well as the Ministry of Health. On the ground, in addition to wonderful staff, nothing could have been done with out the help and coordination of Dr. Lise Rehwaldt, an Ob/Gyn and attending in Phebe and the senior Liberian Ob/Gyn residents, Drs. Wheesah, Massaquoi, Geha and Karbah.

The Phebe Hospital and School of Nursing is in Bong County, Liberia, over 100 miles from the capital, Monrovia. It was opened in 1965 with the support of various churches and the Liberian Government . It currently relies heavily on donor assistance. Major departments include medicine, Pediatrics, Surgery nad Ob/Gyn. It was established as a 62 bed hospital with rudimentary Intensive and Critical Care units. It is also a school of nursing in collaboration with nearby Cuttington University.

Phebe has 2 operating rooms and has a dedicated generator. Running water is occasionally present, however, my experience was more with stored water in large plastic containers. There are full-time Nurse Anesthetists and NA students who are highly capable, helpful and always available. The senior Ob/Gyn residents spend the year in at Phebe and and a local Maternity Hospital.

A structured and MOH-approved VVF curriculum allows for a resident to scrub on every fistula case and also for a structured series of lectures based on FIGO’s VVF Training Manual.

After arriving late in the evening into Monrovia, I was met by a driver from the Liberian College of Physicians and Surgeons. I spent the night in Monrovia and left for Phebe, a 3 hour drive, early in the AM. Upon arrival, I settled into a room on the Phebe Hospital grounds spent the day pre-operatively evaluating the women who may need surgery. With Dr. Rehwaldt, and Ob/Gyn based in Phebe and senior Ob/Gyn residents, women were interviewed, examined and scheduled for surgery if deemed candidates for an operation. Lectures that are part of the residents’ fistula training curriculum were given during 2 afternoon sessions.

We are grateful to these Liberian women for trusting us with their care and thankful that IMR can continue to work with Phebe Hospital to train the next generation of Ob/Gyns in Liberia in vaginal surgery and obstetric fistula repairs.

Together with our partners who support us and those on the ground, we can make strides to end fistula in Liberia! Our next trip is planned for fall of 2016. We would love your support to continue our work!

Ambereen Sleemi