Closing the Gap Between Contraceptive Technology and Those Who Are in Need

	Learn about the benefits of family planning beyond better health. Check out our 3for1 video!

Birth Control Over Baldness, Nick Kristof’s op-ed column on September 26, calls for increased investments in contraceptive development, and touts promising new technologies, including a vaginal ring that offers up to one year of contraceptive protection. The ring is a product of our valued partner and sister organization, the Population Council, which has made significant and important contributions to contraceptive development during the past 50 years (including program support so that new products may be available to all women).

Below, EngenderHealth experts weigh in on what it will really take to forge the missing link in making contraceptive technologies – old and new alike – available to the 215 million women who don’t have access to a modern method of birth control:

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Innovation is Just Half the Equation

Family planning indeed has a direct link to alleviating poverty. Moreover, its cost effectiveness is irrefutable: In addition to saving lives, each dollar spent on voluntary family planning can save governments $31 in health care, water, education, housing, and more.

Developing new contraceptive options is critical. But no matter how many technologies come to market, a major challenge remains: ensuring that those who need contraceptives the most—poor women and couples often living in remote communities—can get them. Strengthening health care systems, including training local providers, must be part of the solution.

We’ve learned from our own experience on the ground that all the technology in the world won’t work without trained providers to offer counseling, information, and quality care for family planning and reproductive health. Innovation is just half the equation. Access and delivery is the other half. Only when you have both will new contraceptives break through.

— Pam Barnes, President and CEO

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“Software” v. “Hardware”
New technologies are important, but so many of the access issues in poorer countries relate to “software”. These include knowing about available methods and where to go to get them; human resources, such as the scarcity of trained providers; a competing disease burden (such as HIV and AIDS); and traditional gender norms and other sociocultural barriers. The “hardware” issues of not having sufficient technology to meet demand are still secondary in many places.

— Dr. Roy Jacobstein, Medical Director

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Interconnections

To make vaginal rings – or any contraceptive technology - available to those women who currently don’t have access to modern birth control methods is quite simply going to require more than the technology itself. There is a complex set of interconnections among what women and men need, the technologies that can address those needs, the services that can provide those technologies, and the resources available to sustain supply and services.

— Karen Beattie, Director, Fistula Care

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Investment, Policy, and Accountability

New contraceptive technology is only part of the solution. Training health providers at every level – community health workers, nurses, midwives, physician’s assistants, as well as doctors – and positive changes in health systems are needed. But more than that, donors need to invest more in finding innovative solutions. For instance, supplies like condoms, IUDs, and contraceptive pills, don’t always get to where they are needed when they are needed. Without solving what ought to be simple distribution problems (but are actually quite complicated), the vaginal ring will just be one more supply that is stuck in a warehouse and takes weeks if not months to get to rural clinics.

There needs to be local policy commitment, and investment of local resources and accountability. If we look at success stories, like Thailand, Mexico, and Colombia, where use of modern contraception has greatly expanded (and contraceptive prevalence rates are 70.9%, 71.5% and 78.2%, respectively), it’s because there was political support and investment in improving health systems and making contraceptives available.

— Terry Jezowski, Vice President, External Relations

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Technology and Stronger Health Systems – We Need Both

New contraceptive technologies always hold the promise of better options for women and couples. But options don’t de facto equal access. Addressing the health care worker crisis and improving commodity security (e.g. getting needed supplies to clinics and pharmacies so customers can get them when they want them) would go a long way towards helping women access modern family planning methods.

The cost-effectiveness of family planning is paramount. I was curious that Kristof reports Sino-Implant costs only $3, when the cost typically cited is $8. Both prices make it a less expensive option than Jadelle®, yet in the countries where women most need better access to modern methods, health ministries still don’t have (or allocate) enough money to procure commodities.

Nonetheless, there are some interesting additional contraceptive technologies on the horizon that Kristof did not mention:

• Essure is a form of non-surgical female sterilization that is tremendously quick and less invasive than tubal ligation.
• Mirena® is an IUD that also delivers a minuscule dose of progesterone, which reduces menstrual bleeding – a side effect that women in the U.S. and Europe have warmly welcomed!
• Sub-Q Depo has the potential of clients self-injecting at home.

Still, the fact remains that to make any of these viable options for women and men everywhere, we need strong health systems, staffed with well-trained workers and strong distribution networks.

— Erin McGinn, Senior Technical Advisor for Family Planning

Action Alert: Urge Congress to End Fistula

Today, EngenderHealth joined a broad coalition of organizations in applauding Rep. Carolyn Maloney (D-NY) and Rep. Michael Castle (R-DE) for introducing important legislation that will help transform the lives of millions of women worldwide. The Obstetric Fistula Prevention, Treatment, Hope and Dignity Restoration Act of 2010, H.R. 5441, would authorize funding to prevent obstetric fistula and treat women suffering from this debilitating condition. Read the joint press release here.

“We are thrilled to see that the bill recognizes the importance of partnering with national governments and institutions and strengthening local capacity as the way forward,” said Ana Langer, M.D., President of EngenderHealth. “We know this is the most sustainable approach to preventing and treating obstetric fistula. This captures the spirit and intent of the Obama Administration’s Global Health Initiative.”

H.R. 5441 was introduced just days before the start of Women Deliver, the largest-ever conference on maternal and reproductive health, convened in Washington, DC, from June 7–9, 2010. Download the full legislation here (PDF, 41KB).

Take a moment now to write to your representatives today and ask them to co-sponsor the bill.

Learn more about Fistula Care, which is bringing vital fistula prevention and treatment services to women in 11 countries, with support from the U.S. Agency for International Development.

Bringing Back Dignity: Fistula Survivors in Ethiopia

Three newly-posted videos tell the stories of Tihun, Yeserash, and Abebu -- three young women from Ethiopia who have survived obstetric fistula. The women and their family members give insight into the difficulties of life with fistula, the joys of being repaired, and the lessons learned from their experiences. These videos are excerpts from the film "Bringing Back Dignity," produced under the ACQUIRE Project funded by USAID.

Despite the double tragedy of losing her baby and developing a fistula, Tihun has been blessed with a supportive husband who did not leave her when she was ill. Her husband Aweke explains that everyone urged him to leave his wife with beliefs that he would contract her condition, but he would not do so. Both Tihun and Aweke have learned valuable lessons from Tihun's fistula. Aweke regrets not being careful to use protection that would prevent an early pregnancy. Tihun vows that if she ever has a daughter she will not marry her off, and instead will let her go to school and then choose her own husband.

Yeserash and her father, Simeneh, express the hardships of obstetric fistula as well as the lessons learned from their experience. Simeneh's father regrets marrying off his daughter at the young age of 12 or 13 and vows that he will not do the same with his other daughters. He wishes other people would learn from his "painful mistake", urging them not to arrange early marriages and to allow their daughters to consent to marriage. Yeserash is now fully recovered and has since had a health baby boy.

Abebu, a 20-year-old fistula survivor, describes the hardships of living with a fistula and how her life has been transformed by repair. Abebu was married at the age of 15 and developed her fistula after four days of prolonged labor. When her leaking began, her husband stole her property and threw her out and her parents shunned her. Now that she is cured, Abebu is glad to be able to mingle with friends and participate in community events.

These videos recount hardships and celebrate achievements related to the participant's daily struggles with pregnancy, loss, and relationships, as well as their search for safety, acceptance, and dignity. Our hope is that viewers will come away with greater compassion, as well as an understanding of what causes fistula, how women can be repaired, and why community members, the health sector, and policymakers all have critical roles to play in prevention.

EngenderHealth's Fistula Care Project Highlighted at the Huffington Post

Hanna Ingber Win, the World Editor of the Huffington Post, writes about obstetric fistula today as part of her series on mothers in Ethiopia. As part of her research, Hanna talked to Karen Beattie, project director of EngenderHealth's global Fistula Care Project (funded by USAID), who is featured in the column. Read the full column.

PBS's FRONTLINE/World and Obstetric Fistula in Sierra Leone

PBS's FRONTLINE/World recently published a video by Jenny Chu—Sierra Leone: Yeabu's Homecoming—about obstetric fistula in Sierra Leone, and listed EngenderHealth among organizations working on the issue (see the Links section). The 14-minute video focuses in part on Mercy Ships, one of the partners working with EngenderHealth on the global Fistula Care Project (managed by EngenderHealth).

For more information about this work, see the Sierra Leone country profiles at EngenderHealth.org and FistulaCare.org.

(Photo care of and copyrighted by WGBH/PBS.)

Video: Fistula Care Launches Activities at Fourth Guinean Hospital

(Video in French without subtitles.)

Every year, EngenderHealth organizes a national “Fistula Day” in Guinea to raise awareness of fistula among communities and key decision makers. Held this year on May 21, it marked the official launch of Fistula Care activities at a fourth site in Guinea, Labé Regional Hospital, the main hospital of the country’s central mountain region.

The opening ceremony, held at the amphitheater of the local training center, was well-attended by dignitaries from across the country, including the Governor and the Mayor of Labé, the Mayor of Kissidougou, officials from the Ministries of Health, Social Affairs, and Decentralization, and representatives of the U.S. Ambassador to Guinea and the Mission Director of the U.S. Agency for International Development (USAID), which supports Fistula Care. The Peace Corps, United Nations Population Fund, World Health Organization, OIC International, civil society organizations, the private sector, and the media were also represented.

To begin the proceedings, Labé Mayor El Hadj Amadou Thiam presented EngenderHealth with a key to the city. Accepting on behalf of the organization, the Vice President for Programs, Dr. Isaiah Ndong, later reflected that “this facility offers hope and the chance for a new life to women living with fistula throughout the Labé region.”

The Governor of Labé, the representative from USAID, and Ministry staff voiced their appreciation for the Fistula Care project. “One characteristic of the project is its big-picture consideration of all of fistula’s causes and its relevant strategy for sustainability, engaging technical departments from different partner Ministries and the community beneficiaries themselves,” said Dr. Cherif Sylla, General Secretary of the Ministry of Health and Public Hygiene.

A local youth group led a chant of the slogan “let’s fight together against fistula,” adding a spirited energy to the event. And three fistula survivors whose lives have been transformed by surgical repair shared emotional testimonies, including one who brought her infant, whom she gave birth to following a successful fistula repair.

Hundreds of peer educators invited the crowd to participate in a vibrant procession to the Labé Regional Hospital, where the General Secretary of the Ministry of Health and Dr. Ndong jointly cut the ribbon to celebrate the start of fistula repair services.

Fistula repairs at Labé began in early June. The hospital builds on the successful model Fistula Care developed at other sites in Guinea: Kissidougou District Hospital, Ignace Deen University Teaching Hospital, and Jean Paul II Hospital in Conakry. The Fistula Care project supports surgical repair, prevention, and reintegration into society for repaired women and creates partnerships between health facilities, communities, and local governments. Read more about Fistula Care’s activities in Guinea.

Reflections on Mother's Day and Obstetric Fistula

Carrie Ngongo is the Program Coordinator for the Fistula Care Project, which is managed by EngenderHealth.

This is my first Mother’s Day as a mother: I am blessed to have a delightful baby girl who is growing, learning, and thriving. Becoming a mother has certainly given me a great deal of appreciation for all mothers. I’ve also found myself thinking about women who have not been so fortunate on their road to motherhood and who instead have faced great difficulty and loss along the way.

In March I had the opportunity to meet a group of inspiring women in Niger who had all been through traumatic labors. Each of these women had been eager to bring a baby into the world. They felt the joy of kicking in their wombs, and they talked to their growing babies as they went about their days, just as I did. Yet while I was in the care of an experienced doctor and delivered at a hospital in a major city, most of these women were in rural areas without the help of a skilled health provider. They labored and labored, but something wasn’t right: Their babies were not passing through the birth canal. By the time they were brought to a hospital for emergency care, it was too late. Their babies were dead.

This would have been loss enough, yet it didn’t stop there: They soon discovered that they were leaking urine, the result of obstetric fistula. They couldn’t control the flow, even if they tried not to drink much or used cloth to soak up the mess.

For some, their husbands and family members stood by them in spite of their smell, but many experienced rejection and isolation from those closest to them. Not only had they lost their babies, but they’d lost their health and their personal relationships too.

Fortunately, each of these women had found out that there was hope for them. Fistula can be repaired in most cases, and the women heard that surgical repair is available at Lamordé Hospital in Niamey. Lamordé is one of the hospitals supported by the Fistula Care Project, which EngenderHealth leads with funding from the U.S. Agency for International Development.

	Fistula survivors in Niger

At Lamordé Hospital there were 17 women who were hoping for healing. Lamordé has a structure set aside for women awaiting fistula repair surgery. It’s a plain building jammed full of simple bed frames, without power for fans or air-conditioning in the sub-Saharan heat. There’s space just next to it for women to cook or find shade to rest. Some of the women have been here for more than a month, waiting to be hospitalized for the treatment.

At first glance, providing fistula repair surgery seems straightforward. A trained surgical team in an equipped hospital is all you need—but it’s not so simple. In much of Africa, there are too few doctors to serve large, dispersed populations. Motivated surgeons need time to be trained and to advance their skills, especially because of the complexity of repair and the reality that no two fistulas are the same. One fistula surgeon in a hospital is often not enough, because that doctor may be called away. Moreover, fistula repair is never an emergency, and understaffed and overburdened hospitals can easily prioritize a thousand other important things.

As I talked with the women, I was amazed by their patience and endurance. These women have already been through plenty. How can we reduce the time they wait for surgery?

This was one of the subjects I discussed with the hospital staff who make fistula repair possible, including social workers, nurses, record keepers, and surgeons. We agreed that the Fistula Care Project will continue to train surgical teams and equip the hospital, so that client backlogs diminish over time. Together, we’re working on innovative solutions like supporting field trips for trained surgeons to travel between hospitals in order to pool their efforts, and encouraging hospitals to improve communication and record keeping in order to improve the quality of their services.

All 17 women whom I met in Niger have now had their lives transformed by fistula repair surgery. They are recovering, looking forward to returning to their homes and rebuilding their lives. Many hope to try to have a child again. Thanks to fistula repair surgery, they too may be mothers celebrating healthy babies on a Mother’s Day in the future.

Ten Thousand Women with Fistula Receive Life-Changing Surgery

Dear colleagues and friends,

EngenderHealth and the U.S. Agency for International Development (USAID) today celebrate a milestone in global maternal health: A total of 10,000 women have received fistula repair surgery with U.S. support since 2005. Fistula, a devastating childbirth injury affecting millions of women in developing countries, can be surgically repaired up to 90% of the time, but most of those with the condition lack access to a skilled surgeon or health center, making treatment out of reach.

Four years ago, USAID launched a global effort to both treat and prevent fistula. To date, through initiatives such as the EngenderHealth-led Fistula Care Project, and in collaboration with local governments, regional health care organizations, and faith-based organizations, medical teams in 12 countries and 25 health facilities across Africa and Asia have been trained and equipped to provide surgery for fistula.

It is these trained medical professionals, as well as their supporting institutions, whose dedication has made it possible for 10,000 women to regain dignity and hope through fistula repair surgery. We honor the tireless efforts of the surgical teams as we mark this maternal health milestone.

Obstetric fistula is an injury caused by prolonged obstructed labor, when the head of the baby cannot pass safely through the woman's birth canal. The baby often dies as a result, and the woman is left with an abnormal opening in the birth canal and chronic incontinence. If left untreated, fistula can lead to skin ulcerations and infections, kidney disease, social isolation, and even death.

The hopeful part of the story is that in addition to most cases being reparable, fistula is almost entirely preventable. This is why the Fistula Care Project is working to improve access to emergency obstetric care and cesarean section for women who develop complications during delivery. Together with skilled attendance at all births and the availability of voluntary family planning, this could make fistula as rare in the developing world as it is in the industrialized world. The Fistula Care Project is working to engage all levels of society to raise awareness about fistula and its underlying causes, including early pregnancy, poverty, and a lack of education and empowerment for women and girls.

As the largest USAID-supported effort to both treat and prevent fistula, the Fistula Care Project will keep you apprised of our work to transform the lives of thousands more women and girls around the world--work that is possible thanks to your partnership. To learn more, please visit our web site at www.fistulacare.org.



Gratefully yours,

Karen J. Beattie
Project Director
Fistula Care Project





The Fistula Care Project is a five-year cooperative agreement funded by USAID and managed by EngenderHealth. The project works to address the enormous backlog of women awaiting life-altering fistula repair, ensuring that they receive timely and quality care from trained providers. At the same time, it works to remove barriers to emergency obstetric care that lead to fistula in the first place, so that women in labor get to the right place with the right services at the right time. The project is supporting a network of facilities offering a continuum of services, from emergency obstetric care, referrals, and family planning to complex fistula repairs and advanced surgical training. Visit www.fistulacare.org for more information or contact fistulacare@engenderhealth.org.

The American people, through USAID, have provided economic and humanitarian assistance worldwide for nearly 50 years. For more information about USAID and its programs, visit www.usaid.gov.

Fistula Care Launches New Web Site

The Fistula Care Project is pleased to announce the launch of its new web site: www.fistulacare.org. Supported by the U.S. Agency for International Development (USAID), Fistula Care is a global leader in building the capacity of developing countries to address fistula, a devastating vaginal injury that affects an estimated 2 million women and girls.

The Fistula Care web site is a comprehensive resource for anyone interested in or working on issues related to fistula and maternal health. Sharing program insights and technical expertise, the web site offers a host of resources and tools, including:

• Training guides and curricula
• Communications and social mobilization materials
• Journal articles and presentations
• Technical updates and program reports
• Country-specific updates on current activities

The web site also features stories of women whose lives have been transformed by fistula repair. Every day, Fistula Care helps prevent and treat fistula across 11 countries in Africa and Asia. More than 9,600 women received surgical repair between 2005 and 2008 through the support of USAID, the project, and its partners.

Additionally, detailed information about the project’s on-the-ground, country-specific activities is readily available and will be regularly updated.

The Fistula Care Project is a five-year cooperative agreement funded by USAID and managed by EngenderHealth. The project works to address the enormous backlog of women awaiting life-altering fistula repair, ensuring they receive timely and quality care from trained providers. At the same time, we work to remove barriers to emergency obstetric care that lead to fistula in the first place, so that women in labor get to the right place with the right services at the right time. The project is supporting a network of facilities offering a continuum of services, from emergency obstetric care, referrals, and family planning, to complex fistula repairs and advanced surgical training. Visit www.fistulacare.org for more information or contact us at fistulacare@engenderhealth.org.

Fistula Care lance un nouveau site Internet

Le projet Fistula Care (Soins de la Fistule) a l’honneur d’annoncer le lancement de son nouveau site Internet: www.fistulacare.org. Financé par l’Agence américaine du développement internationale (USAID), Fistula Care est un leader mondial dans le domaine du renforcement de capacité des pays en voie du développement en matière de prévention et traitement de la fistule, une blessure vaginale qui ravage à peu près 2 millions de femmes et filles.

Le site Internet Fistula Care est une ressource compréhensive pour ceux qui s’intéressent à la fistule et la santé maternelle. Ce site Internet servira comme une base d’échange d’information technique et programmatique, en offrant des outils et ressources tels que:

• Les guides et curricula de formation
• Les matériels de communication et mobilisation sociale
• Les publications et présentations
• Les rapports programmatiques et techniques
• Les mises-à-jour des activités dans les pays

Le site Internet contient aussi les témoignages de femmes dont les vies ont été transformées par la réparation de leurs fistules. Chaque jour, Fistula Care aide à prévenir et traiter la fistule dans 11 pays en Afrique et en Asie. Plus de 9,600 femmes ont été opérées entre 2005 et 2008 avec le soutien de l’USAID, le projet Fistula Care et ses partenaires.

Les informations détaillées des activités du projet Fistula Care sur le terrain ainsi que les activités spécifiques dans chaque pays sont disponibles et seront régulièrement mises-à- jour sur le site Internet.

NB : Actuellement le site Internet n’est pas complètement traduit en français. Cependant certains documents sont disponibles en français, par exemple les outils de formation et de prestation de services, et aussi toutes les présentations de la réunion des partenaires qui a eu lieu à Accra, Ghana en avril 2008.

Le projet Fistula Care est un agrément de coopération financé par l’USAID et géré par EngenderHealth. Le projet œuvre à pallier à une liste d’attente énorme de femmes qui ont besoin de la réparation vitale et transformante de fistule en assurant qu’elles reçoivent le soins de haute qualité à temps et par les agents de santé bien formés. En même temps, nous œuvrons à enlever les barrières aux soins obstétricales d’urgence qui causent la fistule en premier lieu, afin que les femmes, en période d’accouchement, arrivent à la meilleure place et reçoivent les meilleurs services au meilleur moment. Le projet soutient un réseau de structures offrant une gamme de services partant de soins obstétricaux d’urgence, la référence et la planification familiale à la prise en charge de cas de fistule compliquées et la formation avancée de chirurgiens. Pour plus d’information, veuillez visiter le site Internet www.fistulacare.org ou nous contacter à fistulacare@engenderhealth.org.

New York Times: A Preventable Trauma

The New York Times has published a letter from Karen J. Beattie, director of the Fistula Care Project (managed by EngenderHealth), in response to a recent story about obstetric fistula:

"While increasing access to fistula repair surgery restores hope and improves lives, there is no way to stem the rising backlog of fistula cases unless we prevent the injury from occurring in the first place.

"We know what works: increasing access to quality emergency obstetric services and meaningful prenatal care, ensuring the availability of contraception, delaying early marriage and childbirth, and improving education and nutrition to help girls grow and thrive. These actions, combined with stepped-up political will and community engagement, would improve countless lives."

Karen J. Beattie
New York