I was greeted by the hum of sewing machines in the livelihood training hall at the Centre for Comprehensive Promotion of Reproductive Health (CCPRH) in Maiduguri, Borno, where women learn and practice their sewing skills. While activities went on, some of the women appeared partially detached from the crowd. A closer inspection revealed that these were women affected by Vesicovaginal Fistula (VVF).
VVF is a condition where an abnormal opening forms between the bladder and the vagina, allowing urine to leak out. One of the root causes of this condition is prolonged or obstructed labour, however, it is partially linked to the practice of Female Genital Mutilation (FGM). Yet, thousands of women still suffer in silence.
In a groundbreaking move to alleviate the burden of VVF on affected individuals, Professor Muhammad Ali Pate, Minister of Health and Social Welfare, has announced that 154 healthcare facilities nationwide will offer free VVF repair surgery. Although this initiative is a positive step, its impact is limited in Borno, where only one hospital -- the University of Maiduguri Teaching Hospital -- currently offers these vital services.
Every year, approximately 12,000 new cases of VVF are recorded. The situation is worse in the northeast due to the prolonged effects of the Boko Haram insurgency. In 2022 alone, about 626 women in Borno were abandoned by their families due to the condition.
The majority of VVF survivors come from low-income families or rural areas where healthcare facilities are not equipped to carry out corrective surgeries or manage the condition. This highlights the urgent need for additional centres to provide comprehensive and free VVF care in Borno.
Making a case for Borno
Decades of conflict have severely crippled Borno's healthcare system. During the heat of the crisis, up to 40% of healthcare facilities were destroyed. 48 healthcare workers were killed, and 250 more were injured. Many health workers also fled the state, leaving a wide gap in healthcare delivery.
This devastation led to the compromise of maternal care and sexual and reproductive health services, forcing many women to seek care from untrained traditional birth attendants (TBAs). Furthermore, the crisis has exacerbated underlying socioeconomic factors contributing to VVF, including the prevalence of early marriages.
Although the Borno State government has made significant strides in revitalising primary healthcare centres and introducing the Borno State Contributory Healthcare Management Agency (BOSCHMA) since 2022, more needs to be done to ensure that VVF services are accessible and affordable for all, regardless of location.
Beyond free corrective surgeries
In addition to surgical interventions, comprehensive counselling services are essential to support VVF survivors in overcoming the emotional and psychological trauma associated with their condition. I spoke with eight VVF survivors at the centre, and from their stories, I learned that some of them developed VVF at age 12. Some developed it at 14, 16, and 18 years old, where it manifested during their first childbirth. Others experienced it during their sixth, seventh, or tenth birth.
Some of the survivors had already undergone multiple surgical repairs, enduring pains, stress, anxiety, low self-esteem, and shame. In addition to their harrowing experiences, they also face being disowned by their family and divorced by their husbands because they are seen as an unwanted financial burden.
In Borno State, many VVF survivors who do not have access to treatment are forced to rely on inadequate local coping methods, such as using rags to absorb urine -- which often prove insufficient, lasting barely an hour. This leads to humiliating situations where urine frequently leaks out, worsening their emotional distress.
Clearly, the situation takes a mental toll on them, but none of them can openly admit to being mentally burdened.
Impact on reproductive health
A lesser-known consequence of VVF is the profound mental stress it inflicts, which can have a ripple effect on survivors' reproductive health and menstrual cycles. One of the survivors I spoke to shared that she began experiencing irregular menstrual cycle. Concerned, I sought expert advice on the matter.
According to Dr Mdurvwa Ijari Solomon, a VVF surgeon at Borno State Specialist Hospital, "Psychological stress caused by the condition can lead to disturbances. When a woman is under the stress of leaking urine, the hormone balance, particularly the estrogen, can be affected. As a result, her menstrual cycle may be disrupted."
Efforts made across the state
From October 2024 to November 2024, CCPRH offered free surgery to about a hundred VVF survivors across the Borno, Adamawa and Yobe states. The Organisation also empowered them with life-saving skills like sewing and bead making and gave them starter packs.
Although they have been provided with relevant skills and starter materials to start petty businesses, one major challenge they face is low patronage from their community due to social segregation.
In addition to CCPRH's intervention, Borno State Government; the World Health Organisation (WHO); Korea International Cooperation Agency (KOICA); and other non-governmental organisations (NGOs) have been offering free surgical repair to VVF survivors.
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Prevention is better
It is pertinent to note that since VVF is preventable, there should be an increased effort in educating men on women's reproductive health and rights, improving the quality of maternal care, encouraging family planning, and improving the socioeconomic conditions of women. The National Strategy for the Elimination of Obstetric Fistula in Nigeria 2019-2023 prioritises prevention through a multifaceted approach. Central to this is enhancing access to quality maternal healthcare, particularly emergency obstetric care, to manage obstructed labour effectively.
Simultaneously, the strategy addresses the root causes of fistula by tackling socioeconomic disparities, including poverty, lack of education, and gender inequality, with a focus on ending child marriage and gender-based violence. There must be concerted efforts in community outreach and advocacy, raising awareness about fistula causes, prevention, and treatment, alongside strengthening health systems to provide adequate resources and trained personnel. Furthermore, ensuring that pregnant women access and attend antenatal care visits and are educated on signs of obstructed labour is a key preventative measure.
