The mobile surgical outreach program for management of patients with genital fistula in the Democratic Republic of Congo

Abstract Objective To describe components of the mobile surgical outreach (MSO) program as a model of care delivery for women with genital fistula; present program results; and discuss operational strengths and challenges. Methods A retrospective observational study of routinely collected health data from women treated via the MSO program (2013–2018). The program was developed at Panzi Hospital in the Democratic Republic of Congo to meet the needs of women with fistula living in remote provinces, where travel is prohibited. It includes healthcare delivery, medico‐surgical training, and community sensitization components. Results The MSO team cared for 1517 women at 41 clinic sites across 18 provinces over the study period. Average age at presentation was 31 years (range, 1–81 years). Most women (n=1359, 89.6%) presented with vesicovaginal fistula. Most surgeries were successful, and few women reported residual incontinence postoperatively. Local teams were receptive and engaged in clinical skills training and public health education efforts. Conclusion The MSO program addresses the backlog of patients awaiting fistula surgery and provides a template for a national strategic plan to treat and ultimately end fistula in DRC. It offers a patient‐centered approach that brings medico‐surgical care and psychosocial support to women with fistula in their own communities.


| INTRODUCTION
Female genital fistula is often a direct result of inadequate obstetric health services for women with obstructed labor; congenital, iatrogenic, and genital trauma represent other less frequent causes. [1][2][3] Women with fistula suffer physical, socioeconomic, and psychological consequences and experience a high level of disability, which further limits their access to adequate health services and skilled surgical care. [4][5][6] The Democratic Republic of Congo (DRC) is a country characterized by weak maternal health indicators; the World Bank reports a fertility rate of 6 births per woman and a maternal mortality ratio of 550 per 100 000 live births. 7 Additionally, the vast size of the DRC, ongoing insecurity, extreme poverty, and poor infrastructure further compound barriers to health care. 8 Despite efforts to improve obstetric care, many women lack access to sufficient perinatal care and suffer complications from childbirth, including genital fistula. 7 It is difficult to estimate the incidence and prevalence of fistula in DRC as the majority of the country's 77 million people live in rural areas that are difficult to reach and significantly underdeveloped. 9 Political instability, conflict, and inadequate investment in health infrastructure further contribute to this lack of data. In 2018, the DRC's Ministry of Health reported 42 000 women with genital fistula are awaiting surgical care. 10 However, a national strategic policy for fistula prevention and treatment does not exist to address this significant burden. 3 As a result, women with fistula often suffer for years with the associated primary and secondary health consequences while waiting for surgical care. 5,11 The Panzi General Reference Hospital in eastern DRC was established in 1999 as a tertiary care facility with specialization in obstetrics and gynecology. Since its inception, thousands of women have received surgical care for repair of gynecologic injuries, including fistula. 12 In 2011, Panzi Hospital developed a surgical outreach program after receiving two women who had walked over 1000 km to receive care. Recognizing geographical barriers and persistent insecurity in much of the country, hospital staff worked to create mobile surgical teams to bring skilled health services to patients living in remote areas, so that other women might avoid making such an arduous and potentially life-threatening journey to reach the hospital.
The objectives of the present paper are to describe the components of the Panzi Hospital mobile surgical outreach (MSO) program as a model of care delivery for women with fistula; to present data highlighting the program's scope and clinical impact; and to discuss operational strengths and challenges to program sustainability and expansion.

| MATERIALS AND METHODS
This paper provides a retrospective descriptive study of programmatic information across MSO sites. The Ministry of Health and South Kivu Province Ethics Committee approved this program and publication of its description and results.

| A model for healthcare delivery for women with fistula
The Panzi Hospital MSO program organizes mobile teams, each consisting of two surgeons, one surgical assistant, one nurse, and one anesthetist. Outreach trips occur annually or biannually for most sites, depending on the volume of cases and available resources.
Site selection occurs in a two-step process: (1) identification of accessible hospitals in strategic locations; and (2) initial visit and site readiness assessment.

| Site selection and site readiness
Sites may be identified by Panzi Hospital staff by first considering regional health zones and then surveying general hospitals within each zone to determine the volume of fistula cases in that region, as well as whether the local hospital meets the necessary minimum requirements for site selection (Box 1). Alternatively, sites may contact Panzi Hospital to request the MSO team given the number of fistula cases presenting in a particular area. This may be initiated by the general hospital in the region or by community organizations, such as churches, civil society agencies, or women's networks, who express the need for fistula services. Once a site has been identified, a contractual agreement is signed, which commits the MSO team to provide skilled surgical care, including consultation, surgical supplies, medications, and a 3-month postoperative follow-up visit. Panzi Hospital also provides transportation and hygiene kits for each patient. The local reference hospital agrees to participate in community sensitization efforts, to support patient care, and to provide space, including operating theater and beds for women to recover for 2-4 weeks postoperatively.  Such training efforts aim to build local capacity to identify and treat women with fistula, as well as those with pelvic organ prolapse, and to encourage referral of complex cases appropriately to Panzi Hospital.

| Community outreach
Community outreach begins during the site selection process, as out-

| RESULTS
Records from 2013 to 2018 were available for review. Data available by site varies due to challenges with documentation and data storage, and some information was missing or inconsistent. Efforts were made to reconcile patient information by crosschecking Panzi Hospital and partner site records and addressing discrepancies with local health staff when possible. Results presented here provide a summary of patient characteristics and surgical outcomes. In addition to incontinence, associated symptoms were also reported. Forty-six percent of women presented with genital irritation due to chronic urine exposure, and 38% complained of sexual pain.  T A B L E 2 Type of fistula and surgical outcomes.

Gynecological and obstetric history
Age at first delivery, y n=1214 • Absence of a national support policy for prevention and treatment and for long-term monitoring of women with fistula