Training

• What types of training and education does Fistula Care conduct at health care facilities and within communities?
• What are the prerequisites for surgical training in fistula repair?
• Training surgical teams for fistula repair takes more time than training for other reproductive surgeries. Why?
• Sometimes a particular surgeon is not able to perform all types of surgical repairs. Why?
• Why do nurses receive only one round of training?
• Wouldn’t it be better to decentralize services and train surgeons from every hospital, so that services are closer to where women live?

• Surgical training
• Postoperative management
• Infection prevention
• Quality assurance
• Emergency obstetric care
• Counseling
• Family planning

Awareness-raising events provide information about fistula, encourage community support for fistula services, and advocate for women who have fistula. Such events often reach large numbers of people and a range of constituencies (e.g., health care professionals, community-based organizations, policymakers). Key topics include:

• The causes of fistula
• The availability of and access to fistula repair
• The importance of skilled care at delivery
• Reducing the stigma of fistula and the discrimination women face within the community and the health care system
• Harmful traditional practices that increase the risk of fistula
• The need for women who have had fistula repair to delay pregnancy
• Family planning

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• Completed training in a medical specialty
• At least three years of surgical experience
• Demonstrated interest in providing fistula services
• Commitment to the women and families affected by fistula
• Ability to learn from colleagues about the clinical and social aspects of fistula 
• Ability to immediately apply newly learned surgical skills
• Ability to provide postoperative care to fistula repair clients
• Intention to provide repair services for a reasonable amount of time in the future
• Association with a facility that supports fistula repair services and that has a sufficient caseload to maintain the doctor’s surgical skills

The Fistula Care project primarily trains doctors who live and work in Asia and Africa.

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Training surgical teams for fistula repair takes more time than training for other reproductive surgeries. Why?
Because fistulas vary greatly in type and complexity, surgeons find it challenging to quickly master all types of repair procedures. No two fistulas are alike; they vary in size, location, and complexity. Surgeons must first master the basic techniques before they can move on to more advanced training.

Surgical training supported by the Fistula Care project lasts 2-12 weeks. The doctor performs procedures under close clinical supervision. The skills and backgrounds of surgeons vary, doctors differ in how quickly and easily they learn fistula repair, and the types of cases vary in each training event; thus, evaluation is based on surgical skill, rather than number of cases.

A surgeon becomes eligible for advanced training when he or she has performed a certain number of cases, with increasing degrees of complexity.

The Fistula Care project is collaborating with the International Federation of Gynecology and Obstetrics and other institutions to develop a standardized curriculum for fistula surgery.

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Sometimes a particular surgeon is not able to perform all types of surgical repairs. Why?
The development of expertise in fistula repair requires ongoing experience, successive training, and practice in increasingly complex repairs. After training, some surgeons may only diagnose fistula and make referrals for repair. Those with more extensive training and experience can repair simple cases of fistula, while only the most experienced surgeons repair the most complex cases.

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Why do nurses receive only one round of training?
While fistula surgeons must master different skills for each type of fistula, nurses provide similar care for most fistula clients, regardless of the type of fistula. Consequently, nurses can usually learn the required skills in one relatively brief training event, although they might require occasional updates.

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Wouldn’t it be better to decentralize services and train surgeons from every hospital, so that services are closer to where women live?
As with any skill, fistula surgery requires repetition and practice. If a surgeon rarely sees fistula clients, he or she will have difficulty mastering new types of cases and maintaining repair skills. The clinical quality of services will suffer as a result.

Surgeons whose skills are rusty may even do harm. If a fistula repair is not done well, the next attempt will be more difficult.

Decentralization is not advisable primarily because of the consequences of low patient volume, but there are also other concerns. For example, not all hospitals employ anesthetists, critical members of fistula repair teams.

Although Fistula Care does not recommend decentralization of fistula repair services, the project has developed a three-level framework for engaging health care facilities. All three levels address prevention, but only some provide repair services. Prevention includes provision of family planning counseling and methods, antenatal care, and labor and delivery services delivered by skilled providers.

• Level 1: Facilities primarily focus on fistula prevention; they diagnose and refer cases, but do not perform repairs. These sites may also use catheterization to provide prophylactic treatment to women who have had obstructed or prolonged labor or to treat small fistulas that develop as a result of obstructed or prolonged labor.
• Level 2: Facilities perform simple repairs and provide long-term postoperative care. 
• Level 3: Facilities perform all types of repairs, from simple to complicated, and train visiting surgeons and nurses.

Close collaboration across the levels improves the referral system. The framework engages hospitals in fistula services even when they do not perform repairs.

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