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

Healing in Malawi: An Update on our Surgical Obstetric Fistula Program

Photo: L. Santaniello

In December 2016, we launched a partnership with the UNFPA Malawi, the Malawi Ministry of Health, and local district hospitals to help treat women in the southern region who are suffering with obstetric fistula and to train surgeons in fistula surgery. It is estimated that over 2 million women suffer with this condition and for every 1 woman treated, 50 remain untreated. IMR is committed to treat the women affected, often the poorest and most marginalized, for free. Importantly, our commitment goes beyond surgery and extends to training surgeons and nurses in this field. This includes pre- and post- operative care and patient safety.

Last April, Liz Santaniello, MSN, FNP-BC and I worked at the Mulanje District hospital. We evaluated 30 women with fistula and treated over 25 with very successful outcomes. IMR held a day-long training workshop for surgeons and nurses in Mulanje.

WHAT IS AN OBSTETRIC FISTULA? Obstetric fistula is a debilitating child birth injury that results from prolonged obstructed labor (it can often be several days) and the inability to obtain a timely and safe operative delivery, in almost all cases, a cesarean section. These injuries have severe complications, leading to a hole between the bladder and vagina, or the rectum and vagina, resulting in constant urine or stool leakage, and in some cases, 15-20%, incontinence of both. Since the injury is vast, leading to tissue death and scarring, we often see damage to pelvic organs, infertility, leg paralysis (footdrop), skin ulcers and more. This injury also leads to social isolation and depression.

Over 90% women lose their babies during birth. This was true in Mulanje also. Some are fortunate, as were Emily and Christine, in Mulanje, both were healed after we repaired severe birth trauma in the form of a fistula and ruptured anal sphincter. They both were able to continue to breastfeed their babies. They’ll return home to family once  healed and  counseled on ways to prevent this from recurring in next pregnancies: good prenatal care and delivery in a hospital, preferably by cesarean section.

Photo: A. Sleemi

WHAT DO WE DO IMR has surgeons who have advanced specialty training in how to repair these devastating and often extensive pelvic injuries. Our surgeons have spent years training in the best centers in the world with the most experienced fistula surgeons. Our fistula surgeons return frequently to work with the world’s experts to continue advance their surgical skills to help women. We are also educators, with decades of teaching students, residents and fellows worldwide. Patient care and teaching are our passion.

WAYS TO HELP We’ll be returning to Malawi later this year to continue training local surgeons and transforming women’s lives with surgical repairs of fistulas. None of our work in Malawi, Liberia, Haiti or Puerto Rico could happen without your support. Please make a tax-deductible donation here.

-Ambereen Sleemi, MD, MPH, FACOG
Executive Director, Surgical Director

Supporting Surgical Access to Restore Women's Lives in Malawi

by: Ambereen Sleemi, IMR Surgical Director

In early December this year, I travelled to Malawi in partnership with the United Nations Population Fund (UNFPA- Malawi) to assess a surgical need for obstetric fistula surgery in the southern part of the country. Mulanje is a town nestled in the foothills of Mulanje Mountain. It's an area known for large tea plantations and borders Mozambique. It is also an area that is near five hotspots for development of maternal mortality, obstetric fistula and birth trauma in the region.

IMR was invited to help assess the feasibility of refurbishing a hospital ward in the Mulanje District Hospital. This ward would be renovated and reopened as an obstetric fistula word complete with a dedicated operating room. We would also help train and support hospital staff in surgical and nursing care.

My trip started in the capital Lilongwe with a visit to the only fistula ward in the country, the Bwaila Fistula Care Center, established in July 2012. It’s a wonderful model to inspire the proposed center in the south. A large operating room and open, well-lit ward offer services of repair and hope. A room for rehabilitation services with instructions on literacy and trade was just adjacent to the ward.

The Bwaila Fistula Ward opened in 2012

I was invited to the National Fistula Task Force meeting, a group that included staff from the hospitals where surgeries are performed, a Ministry of Health representative and other important participants in the fight to end obstetric fistula. I was impressed with the dedication of all members to moving forward in the efforts to prevent fistula with safe access to maternal health, and the need for surgical repair, including re-integration and rehabilitation services.

I next went to the Mulanje District Hospital, about 4.5 hours south via road. I traveled with Grace Hiwa, the the UNFPA point person on obstetric fistula. Grace is a former midwife and very impassioned advocate for the women and girls suffering from obstetric fistula. We met with administrators of the hospital and a had a detailed tour, focusing on the ward that is being considered for transformation into an obstetric fistula ward.

Proposed future fistula ward in Mulanje. It needs work, but has amazing potential to heal women and restore dignity.

I returned to Lilongwe and met with the UNPFA Country Representative, Dr. Dan Odallo. Dan is a committed advocate for reproductive health rights for women and girls. He knows the issue of obstetric fistula well, including the associated stigma. We had worked together in Eritrea a few years ago on this very issue.

IMR's work ahead is great. We are committed to expanding surgical capacity, finding partners and funding for the rehabilitation and transformation of this ward into a safe and effective place to care for women with fistulas. We also look forward to working with UNFPA, the Ministry of Health and partners to train healthcare providers in caring for women with fistula.