Supporting Surgical Access to Restore Women's Lives in Malawi

by: Ambereen Sleemi, IMR Surgical Director

In early December this year, I travelled to Malawi in partnership with the United Nations Population Fund (UNFPA- Malawi) to assess a surgical need for obstetric fistula surgery in the southern part of the country. Mulanje is a town nestled in the foothills of Mulanje Mountain. It's an area known for large tea plantations and borders Mozambique. It is also an area that is near five hotspots for development of maternal mortality, obstetric fistula and birth trauma in the region.

IMR was invited to help assess the feasibility of refurbishing a hospital ward in the Mulanje District Hospital. This ward would be renovated and reopened as an obstetric fistula word complete with a dedicated operating room. We would also help train and support hospital staff in surgical and nursing care.

My trip started in the capital Lilongwe with a visit to the only fistula ward in the country, the Bwaila Fistula Care Center, established in July 2012. It’s a wonderful model to inspire the proposed center in the south. A large operating room and open, well-lit ward offer services of repair and hope. A room for rehabilitation services with instructions on literacy and trade was just adjacent to the ward.

The Bwaila Fistula Ward opened in 2012

I was invited to the National Fistula Task Force meeting, a group that included staff from the hospitals where surgeries are performed, a Ministry of Health representative and other important participants in the fight to end obstetric fistula. I was impressed with the dedication of all members to moving forward in the efforts to prevent fistula with safe access to maternal health, and the need for surgical repair, including re-integration and rehabilitation services.

I next went to the Mulanje District Hospital, about 4.5 hours south via road. I traveled with Grace Hiwa, the the UNFPA point person on obstetric fistula. Grace is a former midwife and very impassioned advocate for the women and girls suffering from obstetric fistula. We met with administrators of the hospital and a had a detailed tour, focusing on the ward that is being considered for transformation into an obstetric fistula ward.

Proposed future fistula ward in Mulanje. It needs work, but has amazing potential to heal women and restore dignity.

I returned to Lilongwe and met with the UNPFA Country Representative, Dr. Dan Odallo. Dan is a committed advocate for reproductive health rights for women and girls. He knows the issue of obstetric fistula well, including the associated stigma. We had worked together in Eritrea a few years ago on this very issue.

IMR's work ahead is great. We are committed to expanding surgical capacity, finding partners and funding for the rehabilitation and transformation of this ward into a safe and effective place to care for women with fistulas. We also look forward to working with UNFPA, the Ministry of Health and partners to train healthcare providers in caring for women with fistula.

Building Anesthesia Capacity and Knowledge in Acute Care

By: Vipul Shah, MD

I am a critical care physician and anesthesiologist who recently had the opportunity to travel to Liberia with the support of IMR. I had met IMR’s Dr. Sleemi during a prior trip when we overlapped during our time at Phebe Hospital in Bong County. Since that time, I have been involved in helping to develop the nurse anesthetist program at Phebe, as well as creating an acute care curriculum in collaboration with IMR's Dr. Josh Schiller. The purpose of my most recent trip was to scout auxiliary sites where the nurse anesthetists could attain a wider breadth of clinical experience, as well as find interested Liberian partners for the acute care curriculum.

Travelling to Liberia during the rainy season was a much different experience than what I had previously experienced. The rain comes down in sheets, not at all like the constant mist of my current hometown of Seattle. Much of the country is inaccessible during this time given the condition of the roads, which made my goal of seeing multiple clinical sites, some of which were far off the main road, unrealistic. Instead I focused on the hospitals near Phebe along the main highway, CB Dunbar and Ganta. CB Dunbar is a Ministry of Health hospital run by Dr. Obed Dolo; the facility specializes in obstetrics and women’s health. Dr. Dolo was very receptive to our ideas and it seems as though the nurse anesthetists will be able to rotate through CB Dunbar soon. This will allow them more exposure to OB anesthesia, a specialty that is sorely lacking in Liberia, as well as give them more gynecologic cases to add to their overall case mix. I also was able to visit Ganta Hospital, which is located near the Guinea border. There I had a very productive meeting with the director of the hospital and made plans to work on the collaboration, the biggest logistical hurdle being housing.

Through out this time, I continued to work with the nurse anesthetist students as a clinical mentor. The nurse anesthetist program is based in Phebe, and they have struggled with inconsistent NGO support and a lack of resources. Mr. Wilmot Fassah, an amazing gentleman who has basically kept the anesthetist program afloat during the difficult periods of the civil war and Ebola, is my primary contact there. He has been working diligently with Mary O’Sullivan, a nurse anesthetist stationed at Phebe, through a program with the Peace Corps designed to adapting the curriculum to fit the needs of the Liberian students and population. It was amazing to work with such dedicated people, and the students are the reason I stay so involved as they have sacrificed a great deal to continue their training in spite of a lack of recognition by the Ministry of Health as nurse anesthetists. . Progress is slow but steady; I am hopeful that in time there will be a robust anesthesia program that can safely serve the people of Liberia.

Overall, I had an excellent trip and look forward to returning to Liberia in continuing this work. I really appreciate the support of IMR and hope that we can continue this fruitful collaboration.

2016 Update

2016 has been a fulfilling year for IMR as we continue to commit to improving the lives of those in underserved areas of the world by educating and collaborating with local healthcare professionals.

This summer, Ambereen traveled with a Haitian medical group, NOAH-NY, and Howard University School of Medicine to participate in a 2 day health educational seminar for medical students, doctors and nurses in Cap Haitian, Haiti. She spoke about pelvic floor disorders in Haitian women, a wide-spread problem that many had not heard of. In August, she and other experts in the fieldpresented a workshop on complex surgical repair of Obstetric Fistula at the International Urogynecological Association's annual conference (iuga.org) in Cape Town, South Africa. Through her lecture series, Dr. Sleemi continues to strengthen the dialogue about obstetric fistulas and pelvic floor disorders and help equip those who care for patients who suffer from these conditions. 

We also continued our work in in Liberia on the Liberian Fistula Project with trips both in April and September. Almost 50 women were treated for obstetric fistula with surgery. Local doctors in training were trained in a static this for repairs as part of an ongoing commitment with the Ministry of Health and United Nations Population Fund (UNFPA) to train Liberian doctors in this surgery. Additionally, IMR supported the staff with donations to cover food and essentials during the campaigns as all days require overtime and extra hospital staff.

We hope 2017 will be another productive year for IMR and that you will help us continue our work!

Treating fistulas in Liberia

This past April, I returned to Liberia for the third obstetric fistula campaign in 9 months. Each visit builds on the previous trip, on the surgical skills taught to the Ob/Gyn residents in Phebe and the care given to our fistula patients, many whom need multiple surgeries to repair pelvic damage due to obstructed labor and fistula formation.

This last trip was funded in part by WAHA International and I am very grateful for their support. WAHA is an amazing organization that is committed to helping women and children worldwide. Our work was also supported by the hospital staff and the Liberian College of Physicians and Surgeons as well as the Ministry of Health. On the ground, in addition to wonderful staff, nothing could have been done with out the help and coordination of Dr. Lise Rehwaldt, an Ob/Gyn and attending in Phebe and the senior Liberian Ob/Gyn residents, Drs. Wheesah, Massaquoi, Geha and Karbah.

The Phebe Hospital and School of Nursing is in Bong County, Liberia, over 100 miles from the capital, Monrovia. It was opened in 1965 with the support of various churches and the Liberian Government . It currently relies heavily on donor assistance. Major departments include medicine, Pediatrics, Surgery nad Ob/Gyn. It was established as a 62 bed hospital with rudimentary Intensive and Critical Care units. It is also a school of nursing in collaboration with nearby Cuttington University.

Phebe has 2 operating rooms and has a dedicated generator. Running water is occasionally present, however, my experience was more with stored water in large plastic containers. There are full-time Nurse Anesthetists and NA students who are highly capable, helpful and always available. The senior Ob/Gyn residents spend the year in at Phebe and and a local Maternity Hospital.

A structured and MOH-approved VVF curriculum allows for a resident to scrub on every fistula case and also for a structured series of lectures based on FIGO’s VVF Training Manual.

After arriving late in the evening into Monrovia, I was met by a driver from the Liberian College of Physicians and Surgeons. I spent the night in Monrovia and left for Phebe, a 3 hour drive, early in the AM. Upon arrival, I settled into a room on the Phebe Hospital grounds spent the day pre-operatively evaluating the women who may need surgery. With Dr. Rehwaldt, and Ob/Gyn based in Phebe and senior Ob/Gyn residents, women were interviewed, examined and scheduled for surgery if deemed candidates for an operation. Lectures that are part of the residents’ fistula training curriculum were given during 2 afternoon sessions.

We are grateful to these Liberian women for trusting us with their care and thankful that IMR can continue to work with Phebe Hospital to train the next generation of Ob/Gyns in Liberia in vaginal surgery and obstetric fistula repairs.

Together with our partners who support us and those on the ground, we can make strides to end fistula in Liberia! Our next trip is planned for fall of 2016. We would love your support to continue our work!

Ambereen Sleemi

Haiti Update: Pelvic Reconstruction Surgical Trip

IMR continued our work for the Haitian Women’s Collaborative project in May by working side by side with the Department of Obstetrics and Gynecology at the National hospital in Port au Prince. The Dept. is led by Dr. Viala and supporting attending physicians including Dr. Batsch Jean-Jemeau are partners in our educational pursuits. With support from the operating room team, anesthesia and nursing, we were able to focus on teaching pre-operative evaluation of surgery patients, review laboratory testing and develop further guidelines on patient safety. Ensuring all complex cased of pelvic reconstruction were performed with senior resident, hands on training, mentorship and didactics remain the cornerstone of our work.

Cases of vaginal prolapse and maternal birth trauma were cared for and preventive strategies were discussed. Pre- and post-operative surgical care was discussed with trainees and students.  We were happy to have Dr. William Meyer, a urogynecologist from the University of Arizona, Tucson, join us and share his surgical expertise with the residents.

Effectiveness of Charitable Programs in Global Surgeries

Approximately 28 % of the global burden of disease is surgical, many of which are concentrated in resource poor countries. In many of these countries, the gap in services are rapidly being filled by international aid organizations in the form of short-term missions to specialized hospitals. Learn more about the effectiveness of such programs in this systematic review co-authored by IMR co-founder Dr. Ambereen Sleemi. It also just happens to be the most downloaded article from World Journal of Surgery in 2015! 

Emergency Medicine training for Haitian nurses begins!

Earlier this year, we began hearing stories from Port-Au-Prince's Haitian National Hospital (HUEH) that there was a dire need for practitioners who specialized in Emergency Medicine. HUEH is Haiti's national government run hospital, yet currently there are no EM-trained practitioners on staff.  To address this crucial need, we conducted the first of our training sessions for the ER nursing staff of HUEH, which consisted of approximately 25 participants.

Lectures were given in a small group format based with discussion facilitated by IMR's Dr. Schiller, translated by IMR volunteers. We also brought Dr. Cameron Kyle-Sidell from University Hospital, a hospital built by Partners in Health in Mirabalais, to provide lectures in an effort to coordinate between the two hospitals more closely. The seminar was very well received by participants and we hope for this project to continue over the next year, with expansion to include interns and residents.

Updates from the Haitian Women's Collaborative Project

By: Ambereen Sleemi

We traveled to Port-Au-Prince in February to continue our work in the National Hospital.

The team consisted of myself and gynecologic surgeon Dr. Lise Rehwaldt. I was thrilled to have Lise join me and contribute her vast experience working in resource-poor areas, gynecologic surgery and resident education.  Cervix cancer screening was performed, and didactic training was given.  This was the 1st time we had the capability of performing screening and hope to continue to build on this initiative. One of our patients had advanced cervix cancer and her referral to a facility for further treatment was secured. 

IMR’s focus on surgical training continued with major operations performed in the hospital’s ORs, focusing on using what is readily available and creating feasible alternatives to other needs.  Residents actively participated in all cases, which consisted of major pelvic reconstructive surgery for pelvic organ prolapse and genito-urinary fistulas (obstetric and iatrogenic).

The feedback from attendings and residents was again overwhelmingly positive as we seek to build on the relationships formed with the Ob/Gyn department and the hospital.   We traveled to the newly built hospital in Mirebalais and met with the head of Ob/Gyn to discuss possible collaboration in the future.

Our work was supported in part by generous donations of medical supplies from Direct Relief International and surgical supplies from MAP International’s GEMS program  in partnership with Ethicon/J and J.

In the Land of a Thousand Hills

Hills of Butare

By: Mayano Ochi and Josh Schiller

We’ve just wrapped up a week-long project in the southern city of Butare. This was our first trip to Rwanda, and we focused on the implementation of a pilot program teaching primary healthcare providers at Rango Health Center located on the outskirts of the city.  Rango is a very busy clinic serving the local community 24 hours a day staffed primarily by nurses and midwives.  Their patients suffer from things like trauma, difficult infections--such as tuberculosis, malaria, or HIV-related illnesses--as well as general adult and pediatric disease.  In addition, Rango provides prenatal care and is a safe place for women to deliver their babies.

We chose Rango as a site for our project through a collaborative effort with AIGINET, a non-profit organization run by Rwandan native Claire Umubyeyi, which focuses on community building in Butare.  Since the genocide in 1994, Rwanda has made significant advances in providing healthcare to its citizens, but like many other sub-Saharan African countries, the country still struggles with basic preventable and treatable conditions.

Rango Health Center

Our mission for this trip was two-fold: first, to identify the needs of the health center; and secondly, to supplement their knowledge and skills in recognizing and treating emergent patient conditions. We began the workshop going over how to take a thorough history on the patient and conducting physical exams with an emphasis on “red flag” exam findings. We then discussed abdominal and respiratory conditions that require prompt recognition and intervention and about emergencies that may arise during childbirth such as postpartum hemorrhage and an unresponsive newborn. By the end of our presentations, the participants were able to more accurately estimate postpartum blood loss, identify which patients required prompt transfer to the district hospital, describe management steps to treat severe diarrhea and dehydration, and utilize correct technique for resuscitating a newborn.

The participants were active in describing their clinical practice as well as asking questions; as a result, much of our time was spent in small group discussion. Through our exchange, we learned that these folks demonstrated amazing abilities to be resourceful to compensate for lack of resources.  For example, Rango had new pulse oximeters but were nonfunctional due to faulty wiring, yet the nurses could easily list signs and symptoms of respiratory distress and decreased oxygenation.  Rwanda is one of the few African countries where substantial gains in health indices have been made and that was evident by the amount of pride and care that the practitioners took in their care of the community.  It was no surprise that they took a similar approach towards our curriculum.  As a result, the training was intense but by the end, a feeling of genuine accomplishment was felt by instructors and students alike. 

We have gotten excellent feedback so far, and are in preliminary discussions with the director of the area hospital--who had attended our first day--about expanding our curriculum to multiple clinics district-wide.  In addition, there has been interest among several groups in the area for IMR to serve in a supportive role for medical and psychiatric evaluations of Rwandan widows and orphans. It was apparent that the locals are heavily invested and committed to bettering their community and this inspires us to support them in the best way we can.

We hope to continue building partnerships in Butare to help this community and we appreciate your continued support for these important projects!

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IMR in Rwanda

IMR is officially heading out to Rwanda in August to lead a workshop on Emergency Medicine and Maternal/Child care at Rango Health Center in Butare! Thank you to Claire at AIGINET for this opportunity and we can't wait to report back to you about this project.