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Samia Hussain , MD Lauri Romanzi, MD

Samia Hussain , MD Lauri Romanzi, MD Aga Khan University, Hospital Weill Cornell Medical Center Karachi, Pakistan New York City, USA Pakistani National Women’s Health Forum 2011. Obstetric Fistula MDG-5 INTERVENTIONAL EFFICACY regarding campaign to end fistula . ONE NATION’S PROFILE.

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Samia Hussain , MD Lauri Romanzi, MD

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  1. SamiaHussain, MD Lauri Romanzi, MD Aga Khan University, Hospital Weill Cornell Medical Center Karachi, Pakistan New York City, USA Pakistani National Women’s Health Forum 2011 Obstetric FistulaMDG-5 INTERVENTIONAL EFFICACY regarding campaign to end fistula.ONE NATION’S PROFILE

  2. “Every minute, a woman dies in pregnancy or childbirth, and for every woman who dies, 20-30 others will survive but with morbidity, one of which is obstetric fistula” Source: G. Lewis, WHO Press.

  3. Obstetric Fistula • PREVENTABLE CONDITION. • Obstructed labour-related induration and necrosis results in genito-urinary and/or colo-genital fistula. • Urinary, Fecal incontinence • Stillbirth • Foot drop • Vaginal defect • Fibrosis stenosis - cloacal defect • Psychosocial sequelae Source: Campaign to End Fistula Printed Materials

  4. Epidemiology Global • Estimates of 2-7 million women affected globally • Estimates of >75,000 new cases each year. • Estimates of 3-5 cases per 1000 pregnancies. • Prevalence in developed countries approaches 0. Source: Aust N Z J Surg 2000; 70: 851–854 WHO IMPAC OF Manual: Clinical Management and Program Development 2006

  5. Epidemiology VVF: U.S.A./U.K. & Nigeria • *UCLA: 20 yr, 43 fistulae, 2 obstetric • ~ 40,000 deliveries/20 yrs = 0.005% OB VVF rate *Goodwin WE Scardino PT, 1980; #Lawson J 1989

  6. Epidemiology RVF: U.S. • 23,986 VD • 404 4th degree tear • 2 resulting in RVF • 0.5% 4th degree • 0.008% all VD • 20,500 VD • 1040 3rd or 4th degree tear • 101 (10%) wound breakdown • 67 surgically revised • 6.4% severe tears • 0.3% all VD • 0.1% overall RVF Goldabar 1993; Venkatesh 1989

  7. Scenario in Pakistan • 52% of women give birth without skilled help.* • 70 % of women in Pakistan delivered their babies at home.** • At high risk for obstetric complications including obstructed labor and fistula. *SOURCE: Demographic and health surveys, selected countries various years. Macro International, Calverton, M.D 2005. **Report on the Proceedings of the 2nd Asia and Pacific regional workshop on strengthening fistula elimination in the context of maternal health. 19-21 April, 2006

  8. Pakistan National Incidence • Approximately 5,000 to 8,000 new cases of Obstetric Fistula occur each year in Pakistan. • Source: Thematic Evaluation of National Programmes and UNFPA experience in the Campaign to end fistula; HERA and ICRH. Final synthesis report. March 2010

  9. Prevention Strategies • Public awareness • Skilled birth attendants • Access to Emergency Obstetric Care • Community training • Repair physical damage through Medical/Surgical intervention and psychological damage through counseling.

  10. Millennium Declaration • Millennium Declaration • In 2000, 189 nations made a promise to free people from extreme poverty and multiple deprivations. This pledge became the eight Millennium Development Goals to be achieved by 2015. In September 2010, the world recommitted itself to accelerate progress towards these goals.

  11. Millennium Development Goals Eight MDGs 21 quantifiable targets measured by 60 indicators. Goal 1: Eradicate extreme poverty and hunger Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 4: Reduce child mortality Goal 5: Improve maternal health Goal 6: Combat HIV/AIDS, malaria and other diseases Goal 7: Ensure environmental sustainability Goal 8: Develop a Global Partnership for Development

  12. MDG 5 Specifics Goal 5: Improve maternal health Indicators Target 5a: Reduce by three quarters the maternal mortality ratio 5.1 Maternal mortality ratio 5.2 Proportion of births attended by skilled health personnel Target 5b: Achieve, by 2015, universal access to reproductive health 5.3 Contraceptive prevalence rate 5.4 Adolescent birth rate 5.5 Antenatal care coverage (at least one visit and at least four visits) 5.6 Unmet need for family planning UNDP role as coordinator of the UN development system to support the mandates of other agencies.

  13. PAKISTAN MDG REPORT 2010

  14. PAKISTAN MDG REPORT 2010

  15. Campaign to End Fistula • United Nations Population Fund (UNFPA), goals include:* • Universal access to reproductive health services by 2015 • Universal primary education and closing the gender gap in education by 2015 • Reducing maternal mortality by 75 per cent by 2015 • Reducing infant mortality • Increasing life expectancy • Reducing HIV infection rates • UNFPA IN PAKISTAN:** • 7 Regional Centers • 7 Referral Centers *Source: Campaign to End Fistula Printed Materials **Source: Thematic Evaluation of National Programmes and UNFPA experience in the Campaign to end fistula; HERA and IRCH. Final synthesis report. March 2010

  16. Campaign to End FistulaPakistan • 7 Regional Pakistani Treatment Centres • (1) Koohi Goth Women Hospital in Karachi; • (province: sindh)  • (2) Nister Hospital in Multan; • (province: punjab) • (3) ShaikhZaid Women Hospital in Larkana; • (province: sindh) • (4) Lady Reading Hospital in Peshawar; • (province: NWFP) • (5) Pakistan Institute of Medical Sciences in Islamabad; • (province: punjab) • (6) Lady Wallington Hospital in Lahore; • ( province: punjab) • (7) Sandamen Provincial Hospital in Quetta. • (province: balochistan)

  17. Pakistan OF Program Obstetric Fistula in Pakistan: 5,000 to 8,000 new cases of occur each year • UNFPA Pakistan 2005 • 7 regional treatment centers • 1170 OF repairs (‘06-08) • 390 total/yr • 55 cases/center/yr • 1030 OF repairs (’09-11) • 440 total/yr • 63 cases/center/yr *Thematic Evaluation of National Programmes and UNFPA experience in the Campaign to end fistula; HERA and ICRH. Final synthesis report. March 2010

  18. “Sex, lies and pitfalls of overblown statistics”John Kay’s report on the International Festival of Statistics in DublinFinancial TimesAugust 23, 2011 • “Always ask yourself the question: ‘Where does the data come from?... • How did the researchers find this out? • Beware tautological explanations • Be careful of data defined by reference to other documents that you are expected not to have read • Statistics are only as valid as the sources from which they are drawn and the abilities of those who use them…”

  19. Reality test: ROI • UNFPA Pakistani OF incidence (5000-8000) • ? • 7 UNFPA Fistula Centers • Maximum 65 cases/center/yr • 55 MD, 192 staff* • Accurate incidence/prevalence • Barriers to care • And/Or • Optimize utilization of the 7 centers • *Service expansion to include all female pelvic floor disorders • *Doctors include general doctors, anaesthetists, OG/GYN, urologist, physical medicine, Staff: Nurses and operating theatre staff • Source: Thematic Evaluation of National Programmes and UNFPA experience in the Campaign to end fistula; HERA and ICRH. Final synthesis report. March 2010 • *Walker and Gunasakera, 2011

  20. MDG 9: authenticity mandates accuracy We need not look far for examples of efficiency In resource-poor communities

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