October 2013

Columbia Nursing Alumni Reception Highlights Global Effort to Prevent and Treat Obstetric Fistula



DNANjoki Ng'ang'a, PhD 13, spoke of educating nurses in Niger at Columbia Nursing's student-alumni reception

Njoki Ng’ang’a began her career with one goal – to help improve the health of underserved women. When she arrived in Niger in 2006 amid a severe famine brought on by an infestation of locusts, women lacked access to proper obstetric care and the few doctors there worked mostly in Niamey, the capital city. To achieve her goal, she quickly realized nurses would have to become partners in the treatment of obstetric fistula, one of the most devastating health problems faced by women in the region.

Ng’ang’a told her story this month at a reception sponsored by the Columbia Nursing Alumni Association, Office of Global Initiatives and Center for Children and Families, an event co-sponsored by Friends of the United Nations Population Fund. She was joined by two reproductive health providers honored this month at Friends of UNFPA’s annual gala: Liberian surgeon John K. Mulbah, MD and Anzaira Roxas, a nurse and midwife in the Philippines.

"There were five times more nurses than doctors,’’ said Ng’ang’a, PhD `13, a founding member of the Center for Children and Families, said of her time in Niger. “For most patients, all they were ever going to see in their lifetime was a nurse. That got me thinking how we can empower these non-physician providers to really make a change.”

Ng’ang’a, a founding member of the Center for Children and Families, worked in Niger caring for patients diagnosed with obstetric fistula, a devastating but preventable and treatable condition that afflicts at least 2 million women worldwide.  Fistula occurs when a pregnant woman endures a long labor without timely access to necessary medical interventions, such as a Caesarean section. The women least able to seek help are also the most vulnerable to fistula – teen mothers often have hips too small for a baby’s head to pass through the birth canal and the poorest pregnant women can have narrow pelvises due to malnutrition.

An obstetric fistula is a hole that develops during obstructed labor when the sustained pressure of the baby’s head on the mother’s pelvic bone damages soft tissue, creating a hole between the vagina and the bladder or rectum. Left untreated, obstetric fistula leaves women leaking urine and feces, often shunned by their husbands and communities and left to care for themselves and their children without any means of financial support.

While fistula was largely eradicated in the U.S. and Europe a century ago with improved obstetric care and the use of C-sections, the condition remains prevalent in sub-Saharan Africa and Asia. As many as 100,000 women develop obstetric fistula each year. Due to extremely limited medical resources, only a fraction of these women receive treatment.

In Niger, Ng’ang’a worked alongside nurses who said they wanted to help but didn’t know how. “They didn’t have the knowledge to manage fistula and care for these patients,” Ng’ang’a said.

Nurses in Niger felt isolated because they spoke French, while the doctors from outside the country communicated and the international doctors worked in English. Ng’ang’a asked surgeons to take extra time to use interpreters to explain the procedures. Nurses, once included in the conversation, began taking on more responsibility in the operating rooms and playing a much bigger role in patient care.  The experience working with nurses in Niger brought Ng’ang’a to Columbia, where her doctoral research examined the health workforce issues in low-income countries that affect the delivery of maternal health services.

Mulbah, is one of just four obstetricians in the war-torn West African nation of Liberia, and he also spoke at the reception about the urgent need for nurses and midwives to prevent and treat fistula. All too often, he encounters women who are so stigmatized by fistula that they attempt suicide. As program manager and lead surgeon at the Liberia Fistula Project, he doesn’t just repair physical wounds. He also works to restore dignity to his patients, with rehabilitation centers and job training to help women become self-sufficient. While international doctors can help with surgery, their brief stays still leave many women stranded, he said.

He recalled a time when women walked for days to reach a clinic, “only to be told that the doctor has left and nothing can be done for them.”

“They shouldn’t have to walk such distances to be told there’s no help for them,” Mulbah said. “Obstetrics isn’t just the affair of the obstetricians. Midwives reduce the incidence of fistula. Nurses and assistants are critical.”

Roxas grew up in the Philippines, where there has long been a surplus of nurses, and she said at the reception that she once dreamed of becoming a doctor. Volunteering for the International Planned Parenthood Association convinced her to train instead as a nurse and midwife and devote her career to reproductive health.

“Despite having two degrees, it’s difficult to earn money in the Philippines, but I stay because my country needs health care providers,” Roxas said at the reception. “With my work, it can impact a lot of women and young people.”

Among other things, Roxas gives pregnant women what she calls dignity kits - pails filled with simple toiletries such as a combs, nail clippers, and shampoo.

 “For the pregnant woman and mother of a new baby, this dignity is a big deal,” Roxas said. “If you are a nurse or midwife, you think nothing of working a 12 or 16 hours straight. It’s about touching the lives of women and girls every day.”