Obstetric Fistula is a condition arising from obstructed or prolonged labour which results in a hole or opening in the birth canal. It remains a plague in nations with high rates of child marriages, and Nigeria with 40% of child marriages accounts for 40% global prevalence rate of Obstetric Fistula. In Northern Nigeria, some victims have lived with VVF for up to 20 years and have learnt to deal with it. The number of fresh cases however dim hopes that Nigeria would ever achieve zero incidence of Fistula. Damilola Oyedele in this report, after a visit to Kano and Katsina states, writes that the situation would remain pathetic unless drastic measures are taken to protect girls in child marriages.

She tried to put up a cheery face as she introduced herself, but her countenance gradually changed as she told her story. It is a tale of pain and despair, yet she has to latch onto the little shred of hope she had left after years of suffering psychological agony and trauma, after years of constantly checking herself to make sure she has not soiled herself with urine like a helpless toddler.

At 14, Nafisah Ahmed (all names have been changed to protect the victims) was married off and she soon became pregnant. She went into labour and after two days of continuous intense pain, her husband decided to take her to the health facility. She laboured for another two days at the health facility and eventually lost the baby. But her troubles were just beginning as due to the prolonged labour, she had developed Vesico Vaginal Fistula (VVF).

VVF occurs when the blood supply to the tissues between the vagina and bladder is restricted due to prolonged obstructed labour, leading the tissues to necrotize and then forming holes through which urine passes uncontrollable. Some patients also develop Recto-Vaginal Fistula (RVF) where the holes form between the tissues of the vagina and the rectum leading to uncontrollable leaking of faeces.

20 years later, Nafisah has had 11 surgeries to attempt to repair the VVF and is preparing for her 12^th in a few days. The leaking of urine has not stopped and so she carries around a catheter inserted into a plastic bag or uses re-usable pads whenever she summons the courage to go visiting friends and family members.

Struggling to hold her tears, she narrated (in Hausa language) the kind of stigmatisation she has had to cope with.

“I am very unhappy every single day . I cannot go for all the gatherings that women go for such as weddings parties, child naming ceremonies, visitations, and others because of the constantly leaking urine unless I use something to absorb it,” she lamented.

“Even with that I cannot travel overnight. If I travel overnight at all, I would not exceed a day, and I have to be careful. When the rags (re-usable pads)  get wet, I have to remove them, wash and spread to dry  and then people there would start looking at me, and would know what I am are hiding. That would be shameful. Now I am scheduled to have another surgery. May God let this one work,” she said with a sigh as she pulled herself together.

The story of Aisha Awwal is even more pathetic.  Married at 14, she developed VVF and RVF after prolonged labour for three days.  During labour, the baby’s head came out but got stuck and the other parts of its body would not come out. Even in that life threatening state, her husband, just 20 years old, and his parents did not think it was necessary to take her to the hospital. After all, his own mother has had nine deliveries at home.

A Good Samaritan from her community secretly went to tell her parents who reside in a different community. They came to take their daughter to the hospital so she could be given proper care but her husband’s parents initially resisted. However, after much argument with the in laws, they succeeded in taking her to a health facility, but she lost the baby. While still at the facility, her husband sent a letter of divorce apparently on the instructions of his parents, because she had been taken to the hospital without their consent.

She tells her story, her face burrowing into a painful frown as if reliving the horrible experience: “I went into labour around 4pm. I am from Wudil, but my husband is from another community. They did not take me to the hospital. My water broke early the following morning, and the baby’s head came out and got stuck, with the body inside me, and still they did not take me to the hospital. The dead baby started to decay and smell, but his parents insisted the local midwife can handle it. My parents came to take me to the hospital where the doctor forcefully pulled out the dead baby.”

She then goes philosophical:  “I felt a lot of pain, I got VVF and RVF, my husband divorced me and left the problem for my parents. They did not pay a dime out of what my parents spent for my recovery. I have resigned myself to fate, I have accepted it as the will of God and whatever he brings you whether good or bad, you have to accept it as a good Muslim.”

“What can I do if I do not accept my fate?” she queried, her voice full of pain.

Asides still leaking urine after three repair attempts, Aisha developed a blocked vagina, called ‘ba hanya (no road) as result of the extent of the injuries sustained from the prolonged labour. The implication is that she cannot have any sexual relations, even if she remarries, unless she has vaginal reconstruction surgery. The surgery for the RVF however worked at the first repair attempt.

Fifteen year old Lauratu Abdullahi’s case is new. She also developed VVF from prolonged labour less than a month ago. While Aisha and Nafisah have come to terms with their condition and learnt to live with it, Lauratu is still in disbelief. Just two months ago, she was a young wife awaiting the birth of her first child. Now she is a scarred young girl who does not understand what has befallen her and is uncertain about the future. Her sorrow was heightened when immediately she started leaking urine, her husband moved her back to her parents’ home in Gabasawa LGA, Kano State, supposedly to be properly taken care of. She has heard tales that this is the first step of abandonment and is already expecting that he may divorce her.

“I was taken to the hospital when I started labour, at the hospital, they left me to labour for four days, and because of this, I lost the baby and had eclampsia (toxic condition which causes convulsions after pregnancy). I am also just soiling my clothes with urine, I cannot control it and now I don’t want to come outside my mother’s room because I do not want anyone to see me,” she said with her face down.

A local herbalist has already extorted N3000 from Lauratu and her parents claiming he would be able to cure her condition.  Her mother, Hadiza told this writer that the herbalist demanded for N15,000.

“Where would we get that kind of money? We sold some farm produce and other things and have raised N3000 which we gave him. We are struggling to raise the rest of the money. He has given her some concoction, but the urine is still leaking. I look up to God for help, Lauratu is my only child, and I was very happy when she got married because she would give me grandchildren,” the mother said.

Hadiza continued, “She lost the baby, but we still have to do the ‘dogonyaro” (neem leaves) bathe that is done after childbirth to help her body heal. She cries each time because the leaves are dipped into hot water and used on her body. But what can I do? Sometimes I cry with her because of her troubles.”

These cases are just a few out of at least 40 women with different stories encountered by our reporter in several communities in Kano and Katsina states.

According to data obtained from the Laure VVF Centre in Kano, 553 new cases of VVF patients were recorded in 2013 with 26 fresh RVF cases. Ten patients had a combination of VVF and RVF while 782 follow up (which are at various stages of treatment) cases were recorded.  Some 462 patients were successfully repaired and discharged. By the end of August 2014, 304 fresh cases had already been recorded at the same centre with 32 new RVF cases. There have been 661 follow up cases with 350 successfully repaired and discharged.

According to the Minister of Health, Prof. Onyebuchi Chukwu, between 400,000 to 800,000 women are living with fistula with about 20,000 fresh cases reported annually. In his foreword for the document: National Strategic Framework for the Elimination of Obstetric Fistula in Nigeria: 2011-2015, Chukwu said all 12 currently existing surgical repair centres in Nigeria can only handle less than 4000 cases annually.

Nigeria alone accounts for a staggering 40% prevalence of global obstetric fistula prevalence, according to the document, and health experts have linked obstetric fistula to prevalence of child marriage/teenage mothers. Nigeria also accounts for 40% of child marriages with two in every five girls getting married before the age of 18.

The document further explains that the link between obstetric fistula and child marriage is not early marriage per se, but early childbearing.

“Adolescent girls are particularly susceptible to obstructed labour, because their pelvises are not fully developed,” it read.

According to the Demographic and Health Surveys (DHS) 2008, child marriage is highest in the North West with 76% of adolescent girls in marriages. It is followed by the North East with 68% and the North Central with 35%. Prevalence of child marriage in the South-South was put at 18%, in the South West at 17% and 10% recorded in the South East.

According to the DHS 2013, Jigawa state topped the list with 78% closely followed by Katsina with 72% and Zamfara at 70%. Others are Bauchi (66%), Sokoto (56%), Gombe (55%) Kebbi (51%), Borno (51%) Yobe (49%), Kano (38%) and Kaduna (38%). Most of these were recorded in rural areas with higher levels of poverty and minimum education.

Most patients of VVF and RVF are victims of child marriage who developed it in the process of childbirth (obstetric fistula). One of the major causes is that at such age, the girl’s body is not fully developed to effectively handle the strain of childbirth, resulting in obstructed labour and other complications such as eclampsia, anaemia, heavy bleeding and infection. Too many attempts at childbirths can also result in obstetric fistula, which is why some women develop it later in their childbearing age.

While good prenatal care reduces the risk of fistula and other complications, these young girls are at a higher risk because they are usually in marriages where they do not really have freedom of movement or of decision making. They usually do not access health care services because of the need to take permission from their spouse or in-laws, distance to the health facilities and cost of healthcare services.

VVF can also be caused by rape or any forceful sexual activity. This reporter encountered a six year old girl at the centre who had developed VVF as a result of rape.

Three repair options are currently available for sufferers in Nigeria. The first is a catheter treatment using the rubber tube and bag, where the fistula heals without requiring surgery. This method works in mild cases and the fistula could heal up in two weeks depending on its size and location. In cases where the fistula is not obvious but the bladder has been weakened so much it cannot contract to control the release or non-release of urine, a bladder drill is used to re-stimulate the bladder. The patient is admitted to be monitored and instructed to consume a lot of water and deliberately pass urine at very short intervals.

The last option is the surgery where the fistula has to be closed surgically. In many cases, the fistula is successfully closed and healed. But in cases that some experts have now termed ‘incurable’ the damage is so extensive that there is not enough tissue to mobilize and close the fistula as the tissue around the bladder and urethra are very delicate. This is why women like Nafisah and some others continue to leak urine after several surgeries and for several years.

RVF is, however, easy to repair as the tissues around the rectum are stronger and usually closes successfully after the first attempt.

In most cases, the most immediate consequence of developing VVF and or RVF is that the husband sends the victim back to her parents supposedly so her mother can care for her. After some time, he divorces her. This explains why there is at least a 90% divorce rate among VVF/RVF victims.

However, an even more traumatising effect of this ailment is the stigmatisation of a sufferer. As her parents struggle to cope with her affliction (which some consider a curse), she is kept away from visitors, her invitations to gatherings decline and seize completely, and she is ostracized by the community and members of her household because of the stench.

Meanwhile , because of the constant leaking of urine and/or faeces, she also suffers dermatitis and erosion of the skin. This results in unimaginable psychological trauma for the victim.

Some relocate to communities where they are not known and engage in street begging to meet their basic needs. There have also been reports where some turned to prostitution in their new communities thereby increasing their chances of contracting other diseases, including the deadly HIV/AIDS.

However, some get respite at the rehabilitation centres usually established by the state governments. At the time of filing this report, the state owned Kwalli Fistula Rehabilitation Centre in Kano was closed for renovation and repairs. Some of the women try to stay within the premises of the Laure VVF centre located within the State General Hospital, but they are not allowed to stay within the premises of the hospital because it is just a treatment centre.

A hospital attendant told THISDAY that the victims are chased away because “they spoil this place with their rags which always smell, and attracting a lot of flies.”

This reporter visited the National Obstetric Fistula Centre in Babbar Ruga, Katsina but was denied access to the facilities on grounds that the Chief Medical Director, Dr. Mohammed Aliyu El-Ladan was away and would be for a week. Requests for his email or mobile phone number were declined after the Chief Nursing officer, Baratu Suleiman spoke with him on the telephone.

However in a casual conversation, a woman told our reporter that she came to enquire about bringing her daughter to the centre. Her daughter, she said, had developed VVF and RVF after prolonged labour at the health facility where she was taken to.

“We have heard that we should go to the hospital immediately labour starts. Her husband did just that, but at the hospital, they left her and laboured for three days, without referring her to a better equipped facility. She lost the baby, and now she is leaking urine and faeces. We heard she can get cured here, so I have come to know how much it would cost,” she said and gave her name as Mariam.

But the stories get more heart-wrenching.

The Founder/Chief Executive of the Fistula Foundation Nigeria, Mallam Musa Isa narrated some of his experiences while in the field. He told of a man whose two wives developed fistula: one as a result of prolonged labour, the other as a result of having too many babies. He also narrated how a VVF patient on admission at the hospital developed a stroke and died after her daughter who was married for just a year was also brought in having developed fistula. The daughter has since developed mental problems, he told this writer.

Isa said that the Fistula Foundation in collaboration with the local chapter of the International Federation of Women Lawyers, FIDA has had to work with the police to get some victims evacuated from the homes to the centres, due to resistance from the husbands.

“The issue of obstetric fistula is on the increase because almost every week you find a patient coming with a fresh fistula case of seven days, ten days, two weeks, five weeks. We keep an up to date data, so we realise it is on the increase because of the number of fresh cases,” Isa said.

He explained that the rate of obstetric fistula cannot be measured by the number of successful repairs or follow up cases, rather by the number of fresh cases that continue to show up daily.

The foundation, supported by the UNFPA, is involved in creating awareness in rural communities on danger signs in pregnancy. It also involves religious and traditional leaders in its campaign due to their influence in their communities.

The VVF state co-ordinator, Kano State, Dr. Amiru Imam Yola explained that the state government, working with development partners, bears the cost of treatment with each surgery costing between N35,000 and N40,000.

Yola, who is also a VVF surgeon, said patients who have had successful repairs can still go ahead to have more children, but have to opt for elective caesarean section. He further explained that the success of the repairs also depends on the health condition of the patient, which is why some cases can be termed incurable or inoperable.

“Nobody has really defined what this is, but in simple terms when one says inoperable, that means the extent of the damage the woman sustained within the birth canal is so extensive that she does not have any tissue that can be used to close the fistula. It also depends on the location of the damage, it can be just by the urethra region, or it can extend to the bladder section. It may involve the Urethro-Vesico junction. There are three points, the Urethra, the urethro-Vesico junction and the Vesica which is the bladder. Any of the three can be involved, and sometimes there is a massive destruction which even where you have to mobilize whatever tissue is remaining there, you may not attain a very good closure,” he explained.

Yola, however, clarified that a case deemed incurable by one surgeon may be curable to another.

The state, he added, is making efforts to reduce the incidents of fresh fistula cases by embarking on community education for people to understand the risk factors that lead to maternal deaths and obstetrics fistula. Radio jingles and community outreaches almost on a weekly basis in partnership with development partners, he said, have served to be useful as it has been discovered that some of the men are still so ignorant they prefer to use the services of Traditional Birth Attendants (TBA), therefore denying their wives access to hospitals during delivery. In these areas, he noted that the husbands now support their wives to access antenatal and post natal care following hospital delivery.

But for Musa Isa, whose foundation works directly in the local communities, even in the hard to reach areas, some of the problems occur in the health facilities, where even though a pregnant woman arrives at the onset of labour, she still suffers delayed labour.

“So there is need to build the capacity of health workers themselves to know how to handle emergency cases of labour and childbirth. Some of the facilities are not well equipped, some of the health workers are not aware of when to refer or how to refer to better equipped facilities. I know they are trained and they think they are trying to do their best for the patient but that delay is the issue that can create fistula” he said.

A couple of the women interviewed for this report had been subjected to prolonged labour at the health facilities, and some had developed the VVF through the actions or inaction of unskilled hospital workers.

FIDA is therefore considering instituting legal action against such facilities and workers whose negligence cause pregnant women to contract VVF or other complications.

The Kano State Chairperson of FIDA, Barrister Huseina Aliyu in an email said although the association is yet to prosecute anyone on these issues, it has been instructed by its national body to institute legal action against any husbands or relatives who prevent their pregnant women to seek medical care.

It is clear, however that a lot more needs to be done to prevent fresh obstetric fistula cases in Nigeria relevant stakeholders cannot afford to continue to shy away from the truth of the primary contributor to this scourge; child marriage/ early child bearing. According to damming statistic from the UNFPA 4,615,000 of the young girls born between 2005 and 2012 will be married before age 18 by 2030.

*All names have been changed     *All interviews with victims were conducted in Hausa language

*This report was supported by Ford Foundation and the International Centre for Investigative Reporting