Obstetric Fistula
Janet Ogundepo
Annually, about 50,000-100,000 women sustain obstetric fistula in the act of birthing new lives, and this condition subjects most to misery and stigmatisation.
The condition, according to the United Nations Population Fund, is the most devastating of all pregnancy-related disabilities and Nigeria accounts for 40 per cent of fistula cases worldwide.
As the world commemorates the International Day to End Obstetric Fistula on May 23, senior obstetricians and gynaecologists have called on the government to provide free maternal care, delivery and caesarean section for all pregnant women in the country.
They made the call amid Nigeria’s 12,000 new cases of obstetric fistula annually and the 2030 target to end the preventable and treatable condition.
fistula
The International Day to End Obstetric Fistula is set aside by the United Nations to raise awareness and support for affected women.
According to the World Health Organisation, OF is an abnormal opening between a woman’s vagina and bladder and or rectum, which allows the continual and uncontrollable leakage of urine or faeces.
WHO
This is caused by long and obstructed labour, whereby the baby’s head pressed against the pelvis reduces the flow of blood to the soft tissues surrounding the bladder, vagina and rectum.
The WHO further noted that OF is caused by a lack of unskilled care, early marriage and childbirth, poverty, harmful traditional practices, and lack of family planning and birth spacing.
However, in rare cases, a fistula can be caused unintentionally by a healthcare provider during CS.
This type is called iatrogenic fistula, according to a health blog.
The WHO states that about 50,000 to 100,000 women globally are affected by obstetric fistula.
A 2016 report from the Federal Ministry of Health notes that about 150,000 Nigerian women lived with OF, while 12,000 new cases occur annually.
To further reduce the disease burden, the FMoH drafted a National Strategic Framework for the Elimination of Obstetric Fistula, 2019-2023, and devoted N18bn within the given year to implement the strategic plan by priority areas.
Currently, Nigeria has 11 specialist fistula centres in the six geo-political zones of the federation, while treatment is subsidised in teaching hospitals.
A reliable source at the Federal National Obstetric Fistula Centre told PUNCH Healthwise that cases are promptly attended to and surgeries are free.
The source further confirms that 12,000 new cases are recorded annually, nationwide, with facilities handling hundreds of repairs and treatments each year.
Speaking on the burden of condition, the former president, Society of Gynaecology and Obstetrics of Nigeria, Professor Rotimi Akinola, attributed the high rate of fistula to inadequate obstetric care and services.
Professor Oluwarotimi Akinola
He noted that the primary cause of obstetric fistula is pressure necrosis, a condition where the baby’s head presses on the bladder or rectum for a long time, causing the tissue to die.
The don explains, “What makes the baby’s head lie there for a very long time is because the labour is obstructed. A labour that is not well supervised can get obstructed and when that happens, it puts pressure on the bladder or rectum.
“Ordinarily, doctors and midwives won’t allow it to get to that extent. We will relieve it by probably doing a caesarean section or something.
“In developing countries, the CS rate is low; it should be something between 10–15 per cent. This low rate means that more people are pushing through when they should not and one of the side effects is pressure necrosis and this results in obstetric fistula.”
He further noted that fistula cases are prevalent in the northern part of the country due to early child marriage and the paucity of skilled healthcare providers.
Akinola decried the lack of awareness about the prevention and treatment of fistula, noting that it further contributes to its prevalence in the country.
The former SOGON president said despite the presence of specialised fistula centres in the country, teaching hospitals in each state perform the surgery.
Addressing the feasibility of Nigeria meeting the 2030 goal to end fistula, the don emphasised the need for improved obstetric care, reducing teenage pregnancy and addressing existing cases.
The gynaecologist advised pregnant women to seek care and medical attention from skilled birth attendants, doctors and midwives to prevent the risk of vesicovaginal fistula.
Akinola also urged the government to raise the marriage age by enforcing Universal Basic Education for girls to prevent early childhood marriages and reduce the incidence of obstructed labour.
Speaking also, a Professor of Obstetrics and Gynaecology at the Usmanu Danfodiyo University, Sokoto State, Abubakar Panti, said clinically, there is a reduction in existing fistula cases.
Prof Panti
He attributed this development to the intervention of the Federal Government and Non-Governmental Organisations that helped to clear pre-existing cases of obstetric fistula.
However, he noted that new cases of obstetric fistula continue to emerge, primarily due to obstructed and prolonged labour.
“What we see clinically is that because of continuous enlightenment, the number of fistula cases has greatly improved. In the past, when NGOs came to carry out free fistula surgeries, you will see lots of women lined up but the cases have reduced. It is not as before.
“Fistula cases are still there because the causative factors have not changed and they include poverty, malnutrition, lack of education, high prevalence of child marriage and early childbirth, and inaccessibility of healthcare due to the inability to afford it,” Panti said.
The don noted that the continued practice of female genital mutilation, specifically the Gishiri cut, further contributes to the occurrence of fistula.
He added, “FGM that contributes to obstetric fistula is not the type where the clitoris is removed. This type of FGM is when the woman is in labour and the baby’s head can’t come out, and the traditional birth attendant, instead of giving episiotomy (a surgical incision made in the tissue between the vaginal opening and the anus during childbirth) to enlarge the uterus, gives a cut along the line of the urethra, which is called ‘Gishiri cut’.
“This can cause vesicovaginal fistula, which is the continuous leakage of urine. The TBAs can also cut along the line of the rectum, which can cause rectovaginal fistula, a continuous leakage of faeces. That is why we link it to obstetric fistula.
“The tradition is dying now as we don’t see many cases as such. The ones we see now are those caused by obstructed labour.”
Need for improved care
Speaking on the 2030 goal to end fistula in Nigeria, Panti said the only way to achieve this is by making maternal delivery and caesarean sections free.
Making maternal delivery free
He asserted that if these services were free, the cultural and religious factors contributing to the problem would no longer be significant.
The gynaecologist noted that developed countries like Saudi Arabia, which share similar religious factors with Nigeria, have no record of fistula because maternal healthcare, including deliveries and caesarean sections, is free.
He warned that the increasing costs of accessing maternal services in hospitals would lead to a rise in fistula cases.
However, the fertility specialist debunked claims that many women with fistula remain untreated, noting that specialist fistula centres have adequate facilities and personnel to attend to all cases and that these services are provided for free.
“Right now in Sokoto, we have a fistula centre and sometimes when you go there, there is no fistula surgery ongoing, not because the personnel are not there but because patients have been mopped up gradually. I don’t think we have that much number of fistula cases that remain untreated.
“I am not saying that the VVF prevalence has changed but saying that we have this much number of women living without treatment is untrue. Though new fistula cases are occurring daily, the centres are free and those who can’t wait for the free ones have those in the teaching hospitals done at a subsided rate,” the gynaecologist said.
Panti further noted that recent innovations have enabled the immediate repair of fistulas, thus, eliminating the previous three-month observation period women had to endure.
The don advised pregnant women to prioritise antenatal care and regular visits to hospitals with trained gynaecologists and midwives who can detect abnormalities during labour and provide appropriate care.
“Where women present with already obstructed labour, the catheter should be left there for some time so that the place would rest and some of these fistula can be prevented. Urethra catheterisation is key in the prevention of obstetric fistula and sometimes it is used as a conservative treatment and that is a gateway in mitigating the scourge of obstetric fistula,” Panti said.
‘Patronage of TBAs, unsafe abortion’
On his part, a Consultant Obstetrician & Gynaecologist at the Obafemi Awolowo University, Ile-Ife, Osun State, Professor Ernest Orji, identified the high patronage of TBAs and unskilled birth attendants as the main causes of obstetric fistula.
Prof Ernest Orji
He further noted that harmful traditional practices and the insecurity that has displaced many women into IDP camps have exacerbated the issue.
Although obstetric fistula is prevalent in the Northern part of the country, Orji noted that there is an increase in iatrogenic fistula cases in the South.
He affirmed that this is caused by the “carelessness and mistake made by some care providers during vaginal delivery or caesarean section.”
The don further mentioned that unskilled birth providers performing illegal abortions cause injuries to the bladder and rectum, also leading to fistula formation.
“Because abortion is illegal, some women go to the wrong people and places, resulting in these bladder and rectal injuries and fistulas,” he explained.
The women’s health specialist asserted that while many patients cannot afford hospital treatment, specialised fistula hospitals offer free care.
“But also, lack of funds for treatment is another major issue here. Poor surgical techniques leading to increased iatrogenic cases can also be blamed. Also, fewer trained fistula surgeons are in Nigeria,” he noted.
The researcher on Reproductive and Feto-maternal Health said he is optimistic that the 2030 goal to end obstetric fistula is achievable but difficult, and called for increased government intervention.
Decrying the increased cases of traumatic fistula caused by unsafe abortion and FGM despite existing laws, he said, “There are ongoing attempts at improving care of fistula patients in Nigeria to better their outcomes. There is a body funded by UNFPA saddled with this responsibility. The body is working closely with FMoH.
“Our government must be ready to prioritise women’s health and equip our health facilities with adequate resources.”
He urged pregnant women to prioritise antenatal care in the hospitals and present early during labour before complications set in.
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