Godwin Haruna
11 November 2009
analysis
It is estimated that about 800, 000 women are caught in the web of Vesico-Vaginal Fistula (VVF) in Nigeria. The figure is reflective of the dismal health indices of the country as experts lament that the weak healthcare delivery system has combined with the moribund cultural practice of betrothal to decapitate the womenfolk. Of the sundry health challenges the nation is facing, investigations show that VVF is a scourge Nigeria can do without.
They look pale and sickly as a result of weeks of hospitalization. The first is 25 year-old woman, Mrs. Hauwa Umar, who was cornered at the Vesico-Vagina Fistula (VVF) centre in Zaria, Kaduna State. Hauwa got married after her primary school education. Married for about a decade now, she has been hospitalized at the centre for more than a month, but her VVF condition started years ago.
She told THISDAY in an interview that she has never given birth in a hospital but had visited it sometimes for antenatal care. In her words: "Three years ago when I was in labour, the child refused to come out. We tried everything, but my situation was getting worse and so I was brought to a hospital in Kaduna where I gave birth later to a child that died immediately. Later, I started noticing urine coming out from my body, which I couldn't stop. After so many different kinds of traditional treatments without success, I was told about the center in Zaria and I was brought here."
She said she didn't want to come initially because was scared of the fees but somebody who had come to the hospital, who told her it was free, encouraged her. Hauwa was lucky in her own case because she did not suffer rejection, as her husband has been standing by her in her worst moments. Several other women suffering the condition are not as lucky as family and friends have abandoned them.
THISDAY also spoke to 26 year-old Monica Garba at the Zaria centre. Married for 11 years with two children, Monica had spent about three weeks at the centre. She said she went to a hospital when she had a difficult labour and after delivery, she was diagnosed with VVF. She too, has the support of the husband, who was present at the hospital, but declined interview.
Experts say there are two types of obstetric fistula, which are Vesico-Vaginal Fistula (VVF) and Recto-Vaginal Fistula (RVF). They say VVF occurs when blood supply to the tissues of the vagina and the bladder are restricted during prolonged obstructed labour leading to the death of the tissues between these organs forming holes through which urine can pass uncontrollably while Recto-Vaginal Fistula (RVF) occurs in a similar way to VVF when the holes form between the tissues of the vagina and the rectum and leads to uncontrollable leakage of faeces.
Several women, who are not up to childbearing age, but forced into marriage and others who could not access hospital care on time are tied down with this condition in Nigeria. Dr. Clara Ladi Ojembe, a consultant community physician with the Department of Community Medicine, Ahmadu Bello University (ABU) Zaria, and the Secretary of the National Foundation of VVF, said Nigeria has the highest number of VVF in the world. Ojembe said it is estimated that there are about 800,000 cases of VVF in Nigeria out of a global estimate of 2 million.
"It is a major maternal issue. The bottom line is that anywhere a woman is allowed to labour for days at home without seeking medical attention; she may come down with VVF. We know the health situation in Nigeria, so anywhere you look for VVF in Nigeria, you will find it. But unfortunately, the northern part of Nigeria has the highest burden, and I think available data tends to suggest that; as many as between 60 - 70 of the total VVF in Nigeria is found in the core northern part of Nigeria.
We have done some work and we have found out that the incident of VVF is about 1 per 1000 deliveries and that compares with the same study that was done by Dr. Kees in Katsina. He covers Katsina, Sokoto and many of the northern centers of VVF. The same study also found the rate to be 2 per 1000 deliveries. So for every 2 out of a 1000 deliveries a woman has VVF, according to his study in Katsina and ours," Ojembe told THISDAY in an interview.
Dr. Ado Zakari Mohammed, former Chief Medical Director of the hospital and currently the officer-in-charge of VVF surgery at the Gambo Sawaba General Hospital, Zaria said VVF has been a major maternal problem in the north. "You know it is part of the morbidity that women experience in the process of birth, so in every woman that die about 10 others have complications in the process of birth. One of the complications is the VVF, so as much as we have high number of women dying in Nigeria, we will continue to have a high number of women with VVF," Mohammed said.
He said there are five major centers in the northern part of the country where those with the condition are looked after. These include Katsina as the headquarters, Kano, Zaria, Sokoto and Kebbi. He said the activities of the National VVF Project are in these five centers in the north under a Dutch surgeon known as Dr Kees, who is the head of the whole project. He added that Krees trained all of them in these centers.
Ojembe sees VVF as more of a social problem than medical. She says even though they look at it as a medical condition, the major determinants are social, and also, people that have VVF are the ones that have been able to escape maternal death. "They had the problem but luckily they did not end up dead but ended up with VVF. If you look at the statistics of maternal mortality in Nigeria, the rate in the north-west is 6 times the rate of the south-west, the rate in the north-east is 9 times higher the rate of south-west. So when you look at it, what is the problem? Why should we have higher rates in the north than in the south? Then you need to look at what the causes of maternal mortality are because they are the same.
"You have the immediate ones that you know cause it, but beyond that, are lot of factors that include the environment, social condition and the state of development of a country's health care system. And one of the determinants of VVF is the reproductive behavior of women, and one of the reproductive behaviors is early onset of child bearing. Once you marry early and you start bearing children early, it is like the case of a baby getting married and attempting to give birth to another baby.
The pelvis is not sufficiently mature and so if the pelvis is small, when you want to give birth, the head of the baby cannot pass through the birth canal. The head of the baby gets stuck in the birth canal and if the thing remains here for a long time it just crushes the tissue around. The bladder is in front, the rectum where the faeces come out at the back, nerves at the sides, and if the head gets impacted for a long time, it just cut off the blood supply and the tissues die, so a woman will now end up with a hole connecting her bladder or urethra to her vagina or connecting her rectum to her vagina or destroying her nerves. So if the thing continues and you are not able to get the woman to a hospital on time so that they can carry out an operation to remove the baby, then the tissues will just die because the blood supply has been cut off, and so obstruction can happen. But if the woman is taken to a hospital on time, something could be done. So if you are too young and your pelvis is not sufficiently big enough and you want to give birth, then you have a very high chance of getting VVF than somebody that is mature," the consultant physician said.
She said early marriage was a problem in the north. According to her about 80 per cent of girls in the north begin to give birth before they are 18 years old; adding: "Around Zaria where I work, the medium age of marriage is 13 - 14 years and it has remained like that for more than 20 years that I have been living in this area because I keep doing surveys with medical students. When you marry at 13 you are still a child who has gone to start servicing a man and having children. So early marriage is a major problem which is one of the reproductive behaviors of women."
Ojembe said the other cause of VVF has to do with health services-related factors. She said if there are healthcare services that are fully equipped with qualified health personnel and women attend anti-natal care and there is a problem with birth, it could be adequately handled and the women can even go for cesarean operation. "Even if you don't go, but you are able to be quickly rushed to the hospital in good time, an operation can be done on you and the baby quickly removed. But where are the hospitals in the north? They are nowhere. You have all sorts of health clinics and all sorts of nonsense called health facilities. You don't have the doctors, theatres or anything and you may have to ride on an animal to get to the road before you can get a bus, and then get to the hospital. When you get to the hospital, you are told to go and bring money. The man has to go and sell his animal before coming back with the money. By that time the woman would have died, if she doesn't die she will get VVF. So these are issues relating to availability and qualities of services of obstetrics services to deal with complications," she added.
She also located another cause in the fact that most of the deliveries are done at home adding that 9 out of 10 are at home and it is often late before they recognize that there is a problem. She said they must have tried Koranic reciting, herbal treatment, which include salt cut by a local barber, before finally deciding to come to the hospital. She stressed that the delay at home is due to ignorance and traditional practices that are inimical to health. The high rate of poverty, which is higher in the north is a major barrier to getting quality health care; adding: "How many people in rural Nigeria can afford N40,000 - N50,000 to pay for caesarian section, because that is the only way they can bring out the child, except if the baby is dead then you crush the head and pull it out. Poverty is a major limitation."
She stated that the issues of infrastructure, which are in deplorable condition in a country with a huge population, also contribute to the problem. She said attempts to make maternal health free via legislative framework have remained a mirage as many state governments are paying lip service to the issue.
"Marginalization in decision making is also an issue. The status of women is bad in the north. Much of them lack education, they are secluded and can't even go out. Most don't even know what is going on in the outside world. They can't go to the hospital without the express permission of their husbands. They can't take decision as even when they have complications during pregnancy, they have to wait for their husbands to come and give them direction about going to the hospital and if he had traveled, then the woman may be sitting in front of the hospital and die waiting for her husband to tell her what to do. Lack of autonomy in decision making even about their health, limitation of movement, lack of knowledge about any other happening outside their homes and all sorts of problems which include lack of education, economic dependence on their husbands for everything are all vices that are worst in the north, and consequently, you tend to find out that maternal mortality and cases of VVF are much worse in the northern part of the country," Ojembe stated.
However, Mr. Iyeme Efem, Project Manager, USAID ACQUIRE-Fistula Care Project (Engender Health), Abuja, said the Problem of Fistula (VVF/RVF) is generalized around the country. He noted that it is more prevalent in states where the health indices are much poorer, adding that the failure of the health system is reflected by the existence and indeed increase in fistula cases. He said in the north, the condition is much more prevalent in all the geo-political zones.
"We do not have clear statistics of those with the condition. However, there is the general belief that there are between 800,000 and 1,000,000 women with the condition currently in Nigeria. Globally, there are 2,000,000 women with the condition. Hopefully, with the recent DHS conducted, we are hoping that we will have data of the prevalence rate in Nigeria," Efem said.
He said cultural practices are generally implicated as contributors to women developing this condition. He added that female genital cutting is one of them as it damages the environment and either makes women susceptible during childbirth or even during the cutting itself. "Also, the practice of early marriage which does not allow the girl child to develop fully thus creating the opportunity for obstructed labour is another. Prevention of the discussions on family planning which does not allow the women to obtain services that will prolong the period before pregnancy thereby allowing their bodies heal well is also a major culprit. Practice of insisting that women should have their first baby at home as a sign of strength is also very bad. Refusal to have Caesarian Section done on women because it shows sign of weakness is also another factor. All these, including the delay in making a decision to take the woman to hospital, delay in finding vehicle to move the pregnant woman to a suitable facility and delay in finding a trained health care provider to take immediate action are major culprits in the cause of obstetric fistula," Efem added.
The situation at the Kwalli VVF hostel, Kano where the people with the condition are kept, is deplorable. When THISDAY visited the hostel recently, the place is in dire need of government attention because of the unhygienic condition of the hostel. The patients, numbering over 200, are living under terrible condition, because of the inability of the government to provide basic facilities.
THISDAY observed that patients at the Kwalli VVF hostel are crying out, saying enough medical and rehabilitative attention are not being given to them even as the state government disclosed that it would build N1billion VVF centre in the state.
Mr. Suleiman Ilyasu, husband of a VVF patient, Mallama Zulaihatu Suleiman, said if government would honour its pledge and commit such a huge amount of money on VVF, the sufferings of the patients would reduce. According to him, "my wife spent six years receiving the treatment after she became the victim of VVF. It took a lot of resources from me to ensure that the surgery is done for her. She is now normal as if nothing happened to her, but the bad condition of the Kwalli hostel is terrible."
However, medical experts in the state observe that keeping control of VVF goes beyond the confines of the hospital. Experts spoken to in Kano think government should adopt a robust enlightenment campaign about the side effects of early marriage and also, empower women so as to douse the effects of excruciating poverty in the rural areas.
Kano State Commissioner for Health, Mallama Aishatu Isyaku Kiru, said as part of government's effort to control VVF, it provides rehabilitation centres where the patients are kept for three months before their discharge. She added that government also schedules the patients' spouses and gives them seminars on reproductive health-related issues.
18 year-old Mallama Aminatu Abdussalami Kunya, a VVF patient, told THISDAY that she encountered the condition after she became pregnant at the age of 16. Aminatu said her husband divorced her when he saw her in that condition and lamented that her parents are taking care of her, adding that her former husband is nowhere to be found.
She also lamented that, even her relatives also ran away from her when the problems manifested, but managed to say with some cheer: "As you can see now, my condition has improved and I am expecting to be discharged anytime from now. I have recovered from the successful surgical treatment, many thanks to the state government because the government is providing three square meals for us."
Dr. Amiru Imam, a consultant surgeon with Kano State Ministry of Health, said many issues compound the case of VVF. He said apart from low literacy, poverty and poor access to medication, the dearth of medical personnel in the state is detrimental to maternal health as it relates to VVF. Dr Imam, who performs surgery on VVF patients said prolonged and obstructed labour is the major cause of the ailment. Other complications associated with this obstetric fistula, he said, are psychological and neurological conditions where the women come up limping, adding that notwithstanding all the joint efforts, the incidence are on the increase. Imam noted that, at least, 15 new cases are operated upon every week and the number is still increasing. According to him, "One should question why things are not moving. Why are we still stagnant?"
Ojembe said although VVF cases are on the increase, but the area of success is that in the past, when a woman has VVF, she is treated like an outcaste in the society, nobody wants to stay close to her because she is smelling and passing out urine. "Sometimes they have both VVF and RFV. Then, the chances of treatment were slim. Even the Dutch surgeon that is in charge of the VVF programme only developed interest in it. He was not a gynecologist but a different surgeon, but seeing the cases of VVF occurring in Katsina, he decided to take an interest in it, and so he started operating on it, and later developed the skill with which he presently operates on the women. Fortunately for Nigeria, because of the fact that the doctor is ready to pass his skills to any doctor in Nigeria that wants to operate on the women, he started training us. We now have a lot of indigenous doctors that can operate VVF successfully. At least we have about 300 doctors now and all were trained by Dr. Kees," she said.
Mohammed expressed the optimism that their work is attracting help from outside government. He said Rotary International came into it by assisting them just like Family Care (a Japanese NGO) that has started rehabilitating the patients after their operations. "They are the ones that bought the sewing and knitting machines that are given to the women after their training. They also give the soft loan of N20,000 to the women to start something which is to be repaid in two years. They are also the ones that employ the teacher that teaches the women adult literacy. Family Care is also the ones that built the new wards we now have, which includes the kitchen, store, toilets and the training center," Mohammed said further.
On his part, Efem said: "From ACQUIRE Fistula Care Project, we work to prevent occurrence through community education and family planning, repairs of those that have occurred through support to the fistula centers like provision of operating tables, theatre consumables, training of more surgeons and nurses, refurbishing of the facilities; rehabilitating those that have been repaired and reintegrating them into their communities of families."
Be the first to Write a Comment!
Copyright © 2009 This Day. All rights reserved. Distributed by AllAfrica Global Media (allAfrica.com). To contact the copyright holder directly for corrections — or for permission to republish or make other authorized use of this material, click here.
AllAfrica aggregates and indexes content from over 125 African news organizations, plus more than 200 other sources, who are responsible for their own reporting and views. Articles and commentaries that identify allAfrica.com as the publisher are produced or commissioned by AllAfrica.
