1. Obstetric Fistula overview in Afghanistan at CURE International Hospital, Kabul Dr. Yousuf Khan MD Deputy Medical Director CURE International Hospital, Kabul IOFWG meeting 2012, Dhaka- Bangladesh

2. Outline of presentation Introduction of Afghanistan Health care structure review Pregnancy related mortality ratios and other maternal health indicators Overview of obstetric fistula at CURE International hospital, Afghanistan Outreach effort by CURE hospital

3. Introduction Afghanistan is land locked country located in south central Asia Population: 29.7 million Total land area of the country: 652,690 Square Km Annual population growth rate: 2.6% Around 85% of the population lived in the rural areas 34 Administrative division (provinces) About 36% population is un employed and lives bellow poverty threshold

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5. Health care structure Information Health post (hp): 10277 Health sub centre (HSC): 468 Basic health centre (BHC): 807 Comprehensive health centre (CHC): 388 District hospital (DH): 67 Provincial hospital (PH): 29 Regional hospital (RH): 5 National Hospital (NH): 24

6. Pregnancy Related Mortality Ratios and associated maternal health indicators Pregnancy related mortality ratio, AMS 2010 Percentage of women receiving ANC from skilled provider Percentage of births delivered by SBA Percentage of births delivered in a health facility Percentage of ever married women age 15-49 with no education 327 60 34 32 88

7. Overview of obstetric fistula work at CURE Hospital, Kabul In 2006 obstetric fistula repair launched by an expatriate surgeon In 2007 CURE hospital sent two local obstetrician/ gynecologist to Hamlin fistula hospital in Addis Ababa for initial training Later on both doctors received an advance training in Hamlin hospital

8. Overview… In 2011,3 rd Obstetrician/gynecologist received initial training in Hamlin hospital During this time 3 nurses and one OF coordinator received training in Hamlin hospital One Anesthesia technician received training in abroad as well since the program launched there is always visiting fistula surgeons support is available to help these doctors in repair of extensive fistula cases Construction of Fistula hostel in CURE hospital compound

9. All birth injury seen at CIH since program inception

10. Outreach efforts Obstetrical Fistula coordinator trips to provinces 20 minute power point explaining what OF is, how it is detected, how it can be prevented and how it can be treated for free at CIH Letter of introduction from MOPH essential Each trip lasts 2 to 4 weeks involving 15 to 25 training sessions at as many different health care facilities as possible

11. 4784 health care workers at 329 different health care facilities in 16 provinces 11

12. Outreach con… Clinical clerkships at CURE CURE was hosting 20 trainees per month from 20 different provinces to offer clinical refresher training in their fields. (OBGYN, PEDS, GEN SURG, INT MED, Nurses, Midwives, Anesthetist, lab technicians) We took some time during their orientation to explain about our free OF program and provided them with brochures in the local languages.

13. Over 700 healthcare providers from 20 provinces trained at CURE 13

14. Outreach con… OF training of provincial healthcare providers 2009 12 trainees came to CURE for 4 to 6 weeks – 1 surgeon – 4 anesthetists – 5 nurses – 2 midwives Provinces – 5 from Herat – 3 from Badakshan – 4 from Kabul 14

15. Outreach con… Orientation of Midwives In sep 2012 totally 21 midwives were invited for two days OF orientation workshop from 21 different provincial hospitals Those midwives who came for training will act as focal points for OF referral in their respected hospitals and provinces An incentive plan were considered for each OF referral

16. Outreach con… Mass Media TV Radio OF printed brochures

17. Mass media advertising March to October 2011

18. Way forward Prevention - CURE Hospital has plans to continue its OB/GYN and family medicine training programs, In addition, CURE would like to augment this effort by expanding midwifery training at both its hospital and clinic - we recognizes that these programs are having not only impact in decreasing maternal and infant mortality in Afghanistan, but also helping to prevent OF

19. Way forward Expansion of treatment capacity: CURE’s goal is to perform 160 repairs in 2012 alone and to be capable of repairing 200 annually by 2014 Expansion of outreach activities

20. Thanks Women Hope International (WHI) Fistula Foundation (FF) Ministry of Public Health (MOPH), Afghanistan