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.

April in Ukraine

By: Dr. Ambereen Sleemi, Executive Director

Josh and I traveled to Uzhhorrod in western Ukraine this past April, bordering Slovakia and close to Hungary. A collaboration with several local Ukranian organizations and medical teaching institutions led to a most fruitful visit. The trip was a culmination of months of planning and coordinating with partners both in the US and in Ukraine.

We met with Dr Volodymyr Smolenka, rector of the Uzhhorod National University and renowned neurosurgeon, as well as Dr. Oleg Devinyak, the dean of the medical school. We got an in- depth tour of the medical school, including the simulation lab and classrooms, with an overview of curricula and how students education has been affected by the ongoing conflict.

Dr. Smolenka in the OR

Dr. Oleg (medical school dean) Mariya, Josh, and Ambereen

A tour of a local lab that gives much support to victims of the war followed by a visit to the National maternity hospital gave further insight into the challenges of supporting medical needs during these difficult times. We also met the head of the Ob/Gyn department and staff, hearing concerns of the care of the local population and IDP’s who have come to this city to flee the war.

This was followed by a meeting with the local Ukraine non-profit community organization Heart to Heart, which gave important insight into how orgs have pivoted to meet the needs of the community, those wounded by war as well as IDP/s, many who have made their way to Uzhhorrod, swelling the pre war population substantially. A tour of a local warming centers supported by Zonta’s Ukrainian clubs during fuel and electrical outages this past winter, was another illustration of how the conflict affects all in Ukraine.

Thankful to meet with Uzhhorrod’s National law school Dean Yaro and faculty to discuss how local laws and the medical community can support women who are survivors of both intimate partner violence and rape as it is being weaponized in this war. As IMR is committed to caring for the vulnerable and marginalized, this issue is important for us to support in any way we can. We learned much about legal and law enforcement guidelines and will plan to work collaboratively to further how the medical community can collaborate in these efforts.

Dean Yaro and the law school faculty

Press conference with local partners and local journalists

We were invited to speak to members the local Zonta Uzhhorrod and Lviv clubs, med students and community members on IMR’s past and ongoing work and how we fit into partnerships in local projects. We also presented at a local press conf (watch it on youtube in Ukrainian ) along with our local NGO colleagues and answered questions about our plans to work with the local medical and community groups to support medical education and community health, including our goal to work with local Zonta chapters and Heart to Heart to care for women who are survivors of IPV and rape.

We’re returning this November to work with local medical institutions to enhance medical education and provide support to a new pilot program providing women IDP’s gynecologic and psychologic care. We extend a heartfelt thanks to all who welcomed us so warmly and a special thanks to Mariya, our IMR Ukrainian youth ambassador in Uzhhorrod and Pete Bober, Zonta member. We thank you for your ongoing support and have much more to do! Please consider a donation here.

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

Giving birth should not cost your life: Labor and loss in Haiti

“We have a problem, her blood pressure is really high, she has a severe headache and swelling. Oh, and she’s in her third trimester.” These are words that would make any clinician caring for a pregnant woman very concerned. 

Imagine spending months anticipating the birth of your child, whether it be your first or your fifth. Because of your geography or lack of funds, you have no access to a clinic or to medications, blood tests, ultrasounds, or medical support to guide you through this universal process. For most pregnancies around the world, thankfully the outcomes are joyful. But in a number of cases, the situation can turn catastrophic. 

High blood pressure in pregnancy (pre-eclampsia), hemorrhage, and infections are the most lethal causes of maternal mortality around the world, including Haiti. In Haiti, almost 60% of women give birth without a skilled attendant. This translates to a patient population that is high risk and the highest maternal death rate in the Western Hemisphere (World Bank, 2017). If there’s a complication during childbirth, the results can be dire for mom and newborn. 

Road to Destra

Magdala being transferred to St Boniface Hospital, a few hours south of Destra

When we partnered with GOALS Haiti in Destra, our mission was to train primary healthcare workers and provide medical care to the people who call this northern coastal village home. There is affordable healthcare that is geographically close by, however in an area where poverty and inequality are the norm, getting basic healthcare is almost unattainable. During the January pilot launch of our clinic, we saw nearly 200 people, ranging in age from eight months old to 99 years old. One of them was Magdala J., a mom of three who was pregnant with her fourth child and obviously towards the end of her pregnancy. Magdala gave birth to her other three children with no skilled care at home, as almost all the women did in Destra. However, this pregnancy would be different from the others. She came to the clinic because she was experiencing headaches, swelling and generally not feeling very well. The baby had been moving fine and she was able to do her daily work and care for her children. She just felt a little off. Thankfully, she came in that day and had her blood pressure checked. It was abnormally high. This can reflect a condition called preeclampsia (or toxemia), one of the top killers of pregnant women in the world. The treatment is delivery— a life-saving measure for mom and baby alike.  When asked more specifically at the clinic, it turns out Magdala was exhibiting the most common symptoms of preeclampsia: headache, swelling, visual changes, and upper abdominal pain. Since we have an ongoing relationship with St. Boniface Hospital, an institution that provides very low cost/free care, we made arrangements to have Magdala transferred that day. Our colleague at St. Boniface, Dr. Germinal, is a capable and skilled OB/GYN so we knew she would be in good hands. 

Born too soon

We got word a few days later that she had an emergency cesarean delivery and the baby was transferred to the neonatal intensive care unit, which is rare in that region. Luckily,  she was in a hospital that could perform an emergency delivery safely and had a nursery that could take care of a premature baby that had been stressed in utero by the effects of preeclampsia. It was estimated that Magdala was around 32-33 weeks pregnant when she delivered, an age when many babies born in Haiti do not survive. We returned to Haiti recently and followed up on the baby who is now healthy, at home and both are doing fine. We're thankful that we held the clinic in January and that Magdala had confidence in our ability to care for her— she and the baby both survived a condition that is life-threatening. 

Through our partnership with GOALS Haiti, we were able to educate the community about health issues such as Magdala’s, and we’ll continue to involve local citizens who will be part of our efforts to bring better healthcare and awareness to Destra. We look forward to our return this September.

Ambereen Sleemi, MD, MPH

All photos used with permission.

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.