According to the Federal Ministry of Health, between 500,000 and 1,000,000 women and girls in Nigeria are living with Vesicular Vaginal Fistula (VVF), with about 12,000 fresh cases reported each year. This figure alarmingly is the highest rate worldwide, thereby contributing grossly also to an equally disturbing high rate of maternal/infant mortality ratio. PharmaTimes Editor, MORGAN NWANGUMA in this write-up reveals the reasons for this – being mainly socio-cultural as well as ethno-religious, but still needlessly avoidable.
For many years running Nigeria has been battling with the issue of Vesicular Vaginal Fistula. The stigmatising health condition which is seen mainly among (young) women and girls is mainly concentrated in two major locations – a highly prevalent situation spread across the far north, and a pocket of sufferers in the southern part of the country. Contrasted with the north, a few locations in the southern areas have been bedevilled with this health problem, with Ebonyi State standing out with the singular largest concentration of VVF cases in the country. The state alone sees about 3,000 new cases arising each year.
What is Vesicular Vaginal Fistula?
VVF is an occurrence of an abnormal hole between the bladder or rectum and the vagina, characterised by continuous and uncontrollable leakage of urine and even faeces. And today even as most parts of the world have successfully prevented or found ways to grapple with Vesicular Vaginal Fistula, Nigeria has instead assumed the unenviable position of having the highest prevalence rate of women suffering from the condition in the world! According to a VVF surgeon, Dr. Ahmed Yola, about as many as 12,000 women develop Vesico Viginal Fistula every year in the country, and of course and a majority of them remain untreated.
The rampant nature of VVF stems from the backdrop of various obnoxious cultural and even religious practices of the endemic localities; the practices are mainly child marriages and female circumcision. Even when these practices are being proscribed by international law, they tend to continue unabatedly thereby denying many young girls of their childhood, as well as a bright future, with increased risks of ill health like VVF, and a short life span.
It is a known fact that VVF is easily preventable, yet its wide occurrence in certain locations is mostly as a result of increased poverty, illiteracy, ignorance and inefficient use of the very scarce medical facilities available in the poor hinterlands. Most of the women in these places rely on traditional birth attendants who are usually not knowledgeable enough and would simply cut through the vagina to create passage for the baby, and that is just enough to cause VVF experts say.
Prevalence of VVF in Nigeria
Research has shown so far that VVF is most prevalent in communities where there is a high rate of ignorance, poverty and little or no access to modern health facilities. It affects mainly teenage and short girls, as well as young women who are trying to have their first baby, and even older women or elderly women residing in very backward and remote villages. A cursory look at the situation easily suggests that both the extreme north of the country and the extreme southern parts are more involved in VVF cases, but more rampant in the north according to the latest demographic health studies on the issue.
According to a health awareness group, Community Partners for Development (CPD), “more than 800,000 Nigerian women nationwide are living with VVF.” This was made public after an awareness programme that was conducted in Uyo, Akwa-Ibom State. When this figure is juxtaposed with the total number of sufferers worldwide i.e. 2.5 million (made up mainly of people from Asia and Sub-Saharan Africa), then you begin to realise the magnitude of the problem on our hands, and how embarrassing the realities on ground are.
Buttressing this point, a professor of obstetrics and gynaecology at the University of Ibadan, and also the president of International Society of Obstetric Fistula Surgeons, Professor Oladosu Ojengbede, recently declared that the majority of the over two million women living with obstetric fistula globally reside in Nigeria. “We expect that someone who is skilled attend to a pregnant woman in labour. But in Nigeria, only about a third of women ever get attended to by someone who is skilled” he said.
The aetiology of the disease widely suggests that about 90 percent of VVF cases are as a result of prolonged unattended obstructed labour. Other major causes include harmful traditional practices such as female organ circumcision otherwise referred to as female genital mutilation (FGM). There is also the case of religious beliefs and practices whereby in the core Muslim north, girls as young as 11 to 15 years are frequently and forcefully given out in marriage, and therefore compelled to become pregnant when they are not physiologically ready.
Aside ignorance, etc, a vexed issue in the VVF pandemic is that it is exacerbated sometimes by powerful people who ought to know better, but hide under the cloak of religion to abuse innocent little girls in the name of ‘Islamic marriage’ like we have in the northern parts of the country. According to a health expert in Sokoto State, Dr. Bello Lawal, another strong factor leading to the rising cases of fistula in the state is the activities of Traditional Barbers popularly known in Hausa Community as Wanzan. The traditional practice known as “Gyaran Gurya has in no small measure contributed to the problem of VVF in that region.
Lawal noted that “The Traditional Barbers’ activities are particularly causing a lot of iatrogenic fistula in the process of trying to remove a supposed growth in the vagina of the woman. In an attempt to remove the supposed growth, the traditional barber will injure the vagina and the woman will end up with fistula. Again, the same traditional barbers are also invited to help women with obstructed labour at home; in the process of trying to expand the size of the uterus, inadvertently they will injure the bladder or the rectum and the patient will end up with VVF or Rectum Fistula.”
In as much as the causes may be that complex and due to a myriad of social and economic issues, there is a reason the condition is so much prevalent in some parts of the country than others. When under-aged girls are given out in marriage, they begin to engage in sex and start having babies long before they are ‘mature’ enough to start having children, this is what we get. But unlike in the north, studies show that the major causes of obstetric fistula in the southern parts of Nigeria – Prof. Ojenbgede says, are issues stemming mainly “from poor obstetric services, especially in women who undergo surgery for other conditions like fibroid, prolapse and other gynaecological conditions as well as caesarean section.”
Control and treatment of the disease
The stigma and the odium that is associated with the deplorable living conditions of most of the women living with this disease easily results in their becoming social outcasts. According to a publication in the Ebonyi Medical Journal (Vol 8, no1, 2009), titled ‘Vesico vaginal fistula (VVF): a shift in epidemiology in north-eastern Nigeria’, “Vesico vaginal fistula is not only a medical disorder, but a serious social calamity.
“It reflects the state of health system failing to meet the basic needs of a growing population.” The victims of this medical condition go through a nightmarish experience; they are not cared for, they are stigmatised, and live a lonely life usually for no fault of theirs. And unfortunately, this condition is responsible for about 75 percent of death of children especially during birth, and even as much as 55 to 60 percent of divorce rates in places in the country where it is more widespread. Data collected from the research which was carried out using some eighty VVF patients over a period of 10 years showed as follows:
“VVF Constituted 1.4%, of the total Gynaecological admissions during the period. About 76 % were over 20 years, with a peak-age specific prevalence rate of 33.8% at the 20-24 years age group. Teenagers accounted for 23.8%. Most (51.3%) sustained the VVF during their first childbirth; by the second delivery 78.8% were involved. All the teenagers had only one delivery. Majority had no supervised antenatal care and had their deliveries at home under TBAs. Prolonged obstructed labour was the leading cause in 90%, and most were in social class IV and V (using standard occupational classification, OPCS).”
Very disheartening is the fact that the rate of morbidity continues to soar as Nigeria has not only insufficient but also an unbalanced distribution of VVF experts among women living with the condition. As a result it behoves the authorities to ensure that training is intensified for the right calibre of doctors, surgeons and nurses equipped to deal with the accumulated number of VVF cases in the country. Hence it is highly unacceptable that only thirteen VVF centres are available in the country to take care of the surgical operations for the numerous numbers of women with VVF cases that emerge each year.
Even though VVF is one health and social calamity too many according to experts, the disease remains preventable and certainly curable as well. In the cited study above, 75 percent had successful repair, while about 50 percent were either divorced or neglected by their husbands. The situation therefore urgently calls for concerted efforts by individuals, governmental, non-governmental and faith-based organisations to join the campaign to eradicate this dehumanising condition.
The government in conjunction with the various NGOs and other organisations must put in place rehabilitation measures as well as re-integration and capacity building initiatives for women especially in the rural areas of every state in the federation.
Unfortunately in Nigeria reports have it that about 90 per cent of the cases remain untreated, yet the disease is not contagious and can be easily prevented. Education therefore becomes a key factor in the quest to prevent and also eradicate this scourge from our society. All we need do is ensure to eliminate any situations leading to obstructed labour through improved obstetric care, and also preventing under-aged females going into child bearing. Education and enlightenment from all levels of society is very crucial and cannot be over-emphasised.
Over the years the Federal Ministry of Health has managed some inroads towards improving maternal and child health delivery, but more effort is needed to ensure safer delivery, and more children-friendly health services especially at the rural areas where government presence is urgently and most required. The Ministry must intensify efforts at the grassroots to make sure that more resources are channeled towards the strengthening of the nation’s primary health care centres which is critical to putting an end to this embarrassing health problem.