Pursuing a Standard of Care for Training New Fistula Surgeons


This article is part of a series by RH Reality Check with contributions from  EngenderHealth, Guttmacher Institute, the International Women’s Health Coalition, the Fistula Foundation, the United Nations Population Fund (UNFPA), and the Campaign to End Fistula.  All articles in this series represent the views of individual authors and their organizations and can be found at this link.

Millions of women living with obstetric fistula suffer in silence. Shunned by their friends, families, and even their husbands, many are condemned to lives of isolation.

But today more women living with fistula are seeking treatment at health clinics, realizing there is a solution for their condition. As fistula survivors begin to move out of the shadows, the field of fistula care is expanding in kind. The growing demand for repair surgeries urgently calls for the development of a standard of care for training skilled fistula surgeons.

Because fistula has been hidden from society for so long, the surgeons available to repair them were initially scarce. While there are skilled fistula surgeons who work across Africa, Asia, and the Middle East, they mostly operate independently, each developing his or her own approach. As a result, the training of new surgeons to perform fistula surgery has also varied significantly. The absence of training standards has caused new surgeons to learn varying surgical techniques, perhaps making mistakes that could be avoided if a codified set of lessons or best practices were available.

The exciting news is that at last there is a standardized curriculum for obstetric fistula surgical training, owing to the leadership of the International Federation of Gynecologists and Obstetricians (FIGO) in partnership with the Royal College of Obstetricians/Gynecologists, the International Society of Obstetric Fistula Surgeons (ISOFS), the Pan African Urological Surgeons Association (PAUSA), and other associations. Recognizing the imperative for standardized training for fistula surgery, a core committee of fistula surgeons, trainers, and academics leveraged support from organizations like EngenderHealth and the United Nations Population Fund to develop a standardized training curriculum.

This step is key to achieving a shared idea of what fistula surgery should look like and how best to perform it. Fistula surgery can be complex, requiring considerable skill and experience. No two fistulas are completely alike – the location of the hole varies, as does its size and the scarring or loss of surrounding tissue. Newly trained surgeons run the risk of misjudging their skills, either attempting less than they could – or worse – attempting too much and jeopardizing the safety of the very women they aspire to serve.

The training curriculum articulates what fistula surgical training should be, which means that we can now assess the performance of both trainer and trainee and conduct appropriate follow-up of the surgeons who have been trained. Standardization also allows us to train more surgeons while identifying what fistula surgeons can safely undertake at a given level of skill or experience. We can also objectively evaluate training outcomes and surgeons’ knowledge and skills. All of this is critical for the bigger picture of making sure that trained fistula surgeons are able to provide quality repairs for women suffering from obstetric fistula around the globe.

Of course, the development of the curriculum does not signal the end of the journey. The curriculum needs to be rolled out and implemented in programs around the world. Quality fistula training also requires more than just an accepted curriculum: It requires a sound training environment with non-surgical staff, equipment and supplies, operating space, and utilities like running water and electricity. Nevertheless, curriculum standardization is a great start and bodes well for increasing our collective capacity for repair. With 2 million women suffering from fistula and another 100,000 joining their ranks annually, standardized surgical training in fistula repair is a critical first step.

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