analysisBy Mike Miesen
A hospital providing free fistula repair operations is slowly but steadily reaching and treating more and more women across Tanzania.
Last autumn, Agnes, a 26-year old hairdresser living in Mwanza, Tanzania, was pregnant with her second child. She went into labour on the way to visit family in the south of the country and rushed to the nearest public hospital.
That hospital, like too many in Tanzania, was overcrowded, under-resourced and understaffed. Alone and unexamined, Agnes' relatively common birth complication - obstructed labour - wasn't noticed by the too-few nurses on shift until after a long and agonsing wait.
When she was finally examined, she was scheduled for an emergency caesarean section. The procedure was a success, and her new baby girl, Aditha, was born. But because Agnes' obstructed labour wasn't dealt with in time, an obstetric fistula - a hole between the birth canal and the bladder (known as VVF) or rectum (RVF) - had formed.
Worldwide, an estimated two million women currently live with obstetric fistula, with 50,000 to 100,000 women developing it each year.
It is a disease borne of poverty and lack of access to appropriate maternal care, and the global burden falls entirely on women who live in poor countries with inadequate healthcare systems such as Tanzania.
In this East African nation, the healthcare system is severely lacking and, according to New England Journal of Medicine, the country has the lowest number of physicians per capita in the world at just 80 per 10 million.
Recalling her experience of working at a large public hospital in Dar es Salaam, Dr Brenda D'Mello reveals that it was common to see "three, four, five, six women on a bed, every space in between filled with the women. Women were delivering on the floor," she says.
"You would get women who needed a caesarean section, more than one at a time, but with only one theatre. So you end up numbering them by priority," she explains. "The problem with labour is the woman is not going to die... so you can actually wait longer and longer and longer."
Women who develop obstetric fistula leak urine and faeces uncontrollably, but given the stigma around the condition, social consequences can be equally severe.
"[Women] are told the myth that surrounds fistula - that you have been unfaithful and this is a punishment," explains D'Mello. "Admitting that you have a fistula is kind of opening up this whole stigma... so even declaring that you have a fistula is really not acceptable."
Agnes says she was constantly "wet" from the leakages and explains that she couldn't resume her normal life. "I could not work. I felt bad. It was isolating," she says.
Clean, calm and quiet
Many women with obstetric fistula have to live with the condition untreated, but Agnes was one of the lucky ones.
On the recommendation of the doctor at the hospital where she gave birth, she visited the Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT) in Dar es Salaam, where she met Dr D'Mello who works there as an obstetrics and gynaecology specialist.
CCBRT is a 230-bed disabilities hospital that was set up as an NGO in partnership with the Ministry of Health. It is nothing like its public peers.
CCBRT's walls are painted with pictures of animals and children with disabilities; the wards are quiet, calm, bright, and well-ventilated; the place just feels clean. There's even a kids playground.
CCBRT provides care for patients with many types of disabilities - such cleft lip and palette, burns, club foot, and more - but it is particularly well-known for its fistula repair operations.
CCBRT accepts voluntary donations to fund its operations, but it also works under an arrangement whereby the fees paid by middle-class and wealthy Tanzanians subsidises the treatments of those who are less well off. Children under five and women with obstetric fistula meanwhile are guaranteed free treatment.
In one of the two obstetric fistula wards - a bright, inviting space filled with a number of nurses chatting with patients - Agnes sits on her bed in a blue hospital gown with Aditha playing at her side. She underwent an operation two weeks ago and is now happily recovering.
"There is a big difference," she says, comparing CCBRT to public hospitals. "[At CCBRT], doctors and nurses really care about the patients. The food is nice. Nurses are loving to patients."
"I get fresh linens every day," she continues. "When I soil [them] I get new ones. It's a very clean environment."
Reaching up, reaching out
CCBRT has had many successes, particularly regarding maternal and child health, and is planning a major expansion next year that will allow it to deliver 15,000 babies each year. But the hospital has not been without its difficulties.
One of the largest hurdles to providing fistula care is simply that women don't know it's available. Another is that Tanzania is a vast country, and getting to Dar es Salaam is inordinately expensive for many. In fact, just a few years ago, the hospitals' surgeons stood ready but its beds were empty.
The way CCBRT mitigated these issues was by creating a unique model that draws on referral networks, M-PESA mobile payment technology, and relationships with far-flung hospitals.
For example, around 550 former patients have been trained as 'ambassadors' to sensitive their often remote communities about obstetric fistula and seek out people suffering from the condition as well as other disabilities treated by CCBRT.
When an ambassador finds a patient, they inform a CCBRT staff member, who uses Vodacom's M-PESA mobile money platform to send enough Tanzanian shillings to cover the cost of a bus ticket. The ambassador is then sent a small "finder's fee" of about 10,000 Tanzanian Shillings ($6) to cover the costs of transport and to serve as a small incentive.
CCBRT has also assisted in the training and implementation of fistula repair programmes in Kigoma, Arusha and Moshi, helped by funding from the Vodacom Foundation. Before 2012, all patients had to be sent to Dar es Salaam, but now they are sent to whichever location is closest.
CCBRT's efforts to reach more patients has been an unabashed success. In 2009, before it developed this outreach model in 2009, CCBRT did 163 fistula repair surgeries; now the rate is over 700 per year, including more than 500 at the flagship hospital alone.
The hospital has expanded its activites, reached out to more and more communities, and created countless happy patients - not least Agnes.
Back in her ward, she is slowly but steadily recovering. "I feel good," she beams when asked how she feels two weeks on from her surgery. She will stay at the hospital for a few more weeks to ensure that the surgery was successful before returning home.
Agnes doesn't know yet whether she will become an official ambassador, but it seems certain that she will at least become an unofficial one. "I expect to tell all women who have this problem to come to CCBRT," she enthuses.
Mike Miesen is a Business Strategy Analyst at Gradian Health Systems. He writes about health policy and development at mikemiesen.com and you can follow him on twitter @MikeMiesen.