In the 1990s, when obstetric fistula became a focus area of international organizations, it seemed the work would never end. 

Fistula patients – women left incontinent from the devastating birth injury – outnumbered surgeons with the specialized skills needed for the repair procedure. A lack of support and resources from the international community, as well as a dearth of data or best practices to guide surgeons, compounded the problem.

“There was a feeling of overwhelming emergency, even a feeling of panic,” said Dr. Steve Arrowsmith, a world-renowned fistula surgeon, and a consulting medical director at Direct Relief. 

During a webinar last month, Dr. Arrowsmith outlined for about 100 participants from global health and obstetrics fields how much progress has been made to end fistula – and what work is left to do.  In order to reach an end to fistula by 2030, which the United Nations has called for, new strategies are needed to capitalize on the gains made to reduce the number of fistula cases worldwide. 

Arrowsmith, Erin Anastasi from United Nations Population Fund, and Paulina Ospina and Jessica White of Direct Relief outlined some of these strategies in the updated and recently published UN guidelines for obstetric fistula, known as the “Orange Manual” by the fistula repair community.   

First published in 2006, UN guidelines for managing fistula were created to recognize fistula as a public health concern, as well as provide a blueprint for solving the issue.  The guidelines were holistic, identifying a multipronged approach for fistula care – calling on the fistula repair community to see each patient as a whole person, requiring not only surgical repair but also quality nursing, rehabilitation, and reintegration support in order to facilitate their return to their lives before the injury.   

With the 2030 UN goal in mind, the Orange Manual was updated, with Dr. Arrowsmith leading the effort of conducting a global consultation of fistula experts and authoring the document. 

During the webinar, several areas of focus were stressed, including lack of knowledge tied to the incidence and prevalence of fistula. 

Previous estimates suggested that over 2 million women were suffering from fistula, which supported a model of expansion of fistula repair, opening new treatment facilities and training new surgeons to assist in repair efforts. Thanks to the achievements made in reducing maternal mortality and morbidity worldwide, revised estimates now suggest there are approximately 500,000 women awaiting repair of a fistula.   

Instead of continuing to expand programs, investing in new repair facilities, and training new surgeons specifically for the issue of fistula, resources need to be consolidated, allowing for collaboration and quality of care to become the principal focus.  Refocusing priorities in this manner provides a large and ongoing volume of cases to existing fistula repair surgeons, allowing them to maintain and improve their skill sets and to repair increasingly complex cases.  

The current model of expansion of fistula repair, coupled with a decrease in the number of women suffering from fistula, runs a risk of creating a scenario whereby surgeons lack adequate patient loads required to build or maintain their skillset. The proposed approach of consolidation of care by existing surgeons will mitigate this issue while still offering a full range of surgical expertise for repairing the most complex fistula cases.  

When asked what the biggest obstacle health providers  are currently facing in reaching the UN mandate to end obstetric fistula within a decade, Dr. Arrowsmith reiterated the need to think innovatively, and to “not approach the issue in 2021 with the same mentality that we had in the 1990s.” 

In identifying ways in which the fistula repair community could move the needle on fistula eradication, Dr. Arrowsmith cited the importance of technology in networking, for sharing ideas and evidence-based practices of care. 

Jessica White of Direct Relief expanded on the idea of technology as a tool by providing an overview of the Global Fistula Hub, an online tool supporting the fistula repair community with open data, data visualizations, publications, and relevant community updates and events.

Want to learn more? Visit the Global Fistula Hub to find resources, including the Orange Manual and a recording of the webinar.