Asiya Abubakar’s dream took her beyond her little village in Dawakin Kudu , in one of the 44 local government areas that make up Kano State. She loved western education and always wanted to speak the English language and one day become a teacher or some other professional. But her parents had their own dreams too. They wanted to see their favourite daughter get married and bear children and live a responsible life in her husband’s house.  But neither Asiya nor her parents are living their dreams today.

Asiya was given out in marriage immediately after her first menstruation at the age of 14. She had just completed primary two  when she was married off by her parents to a man who sells firewood at the village market. She had her first pregnancy at 15 and never went for any antenatal care.

When the labour pangs started, her mother became the midwife that was to oversee her delivery. But for two days, the poor girl was in painful labour and the baby refused to come out. On the third day, she was rushed to the Murtala Mohammed Specialist Hospital in Kano,a driving distance of about one hour. By the time she was delivered of the baby, she had developed Vesicovaginal fistula (VVF) and had started leaking urine. Of course, she had a still birth.

When ICIR met her at the specialists’ hospital on April 10, Asiya, now 20 years, was in the hospital for her second delivery, and another fistula surgery. She had gone back home after her first surgery five years ago, but took in again last year. This time she went for ante natal care in the Primary Healthcare Centre in Dawakin Kudu up till her due date.

“But my parents and husband asked me to deliver at home and hired a traditional birth attendant in the community,” she explained while sitting on the hospital bed, with a rubber tube(catheter) extending from her virginal area into a urine bag tucked inside a bowl  under the bed.

As with the first pregnancy, she went through a prolonged labour for more than 24 hours before she was brought to the hospital where doctors again found she had developed another fistula and had a still birth too. She had a successful operation and was awaiting discharge when ICIR met her.

Amiru Imam, the Surgeon who operated on her, told the reporter that Asiya could have been saved from another VVF if she had been brought to the hospital earlier. “She could have been delivered through a caesarean section and mother and child could have been ok,” he lamented.

Murja Mohammed, 35, presents a different but locally familiar face of VVF. A Kano based NGO known as Voice of Widows Association of Nigeria (VOWAN) had arranged the meeting with her in an office on Maiduguri Road Kano. She travelled from her village at Rehaza in Tudun Wada Local Government Area of Kano. As she stepped into the office, flies swarmed around her and the nose could perceive a stench. She seemed accustomed to the company of flies as she settles down for the interview without a bother.

“What are these flies doing here,” the reporter asked innocently in Hausa. “It’s because of my sickness,” she explains with a little dry smile on her face. She had a VVF operation at 15, also a year after marriage due to prolonged labour at home. Since then she has been in and out of hospital for the past 20 years.

She suffered several complications during delivery which led to both VVF and RVF (Recto virginal Fistula} – an abnormal connection between the lower portion of the large intestine and the vagina. The RVF allows bowel contents to leak, allowing gas or stool to pass through the vagina.

For the past 20 years she has had to wear a small folded towel before putting on an underwear, because she can’t afford pampers to soak the urine and little drops of faeces. Every few hours, she has to remove the towel, wash and dry it before wearing it again. That takes its toll on her, financially as she has to find money to buy soap and other hygiene items every day.

Her husband left her after her first surgery due to the local myth that women who had a VVF operation would no longer be able to get pregnant. She has not been married again since then and has to take care of her health by herself. She is a tailor in the village but said nothing much comes in as revenue. So she has to rely on begging for alms. Sometimes on her “lucky” day, she gets a male admirer willing to part with some cash.

“I want to get married, but I want to take care of my health first,” she said with little conviction.

In Sokoto, at the Maryam Abacha Women and Children Hospital, four women were waiting for VVF surgery when the reporter visited on April 13. Maryam Baba, 20, had her own surgery three days earlier and was waiting to be discharged after  being certified ‘dry’ enough to go back home.

She was married at 15 and had her first child without any problem. But the second pregnancy came with some challenges. She lived in a village without any primary healthcare facility. The nearest health facility to her village is located in Salame, Gwadabawa Local Government, which is a distance of about seven kilometres. So, going to the hospital was not an option for her and her family, and for many other families in the village.

“I was in painful labour at home for two days and the baby refused to come,” she recounted in her Hausa dialect. “After two days everybody attending to me gave up and someone suggested they should bring me here.”

She was delivered at the hospital but the obstructed labour had damaged her bladder and she had developed VVF.

These women are part of the estimated 400,000 to 800,000 women and girls living with VVF in Nigeria. The World Health Organisation, WHO, and the United Nations Children Fund, UNICEF, rank Nigeria as the country with the highest prevalence of Obstetric Fistula in the world with over 20,000 new cases reported annually.

In recent years, the Nigerian Government has awakened to the reality that VVF has become an embarrassing condition, not only for those living with it and those that would develop it, but also for the government which is confronted with these damning statistics

That is why under previous administrations there were attempts to address the problem. There was a National Strategic Framework for the Elimination of Obstetric Fistula in Nigeria 2011- 2015. It was the first real coordinated attempt to tackle the problem. But it turned out there was nothing strategic about it as new cases continue to emerge.

The current administration under President Muhammadu Buhari appeared to have set a 10-year target for the elimination of the VVF. Isaac Adewole, Minister of Health, said the federal government was determined to eradicate obstetric fistula from Nigeria in the next 10 years. But this target, as ICIR investigations revealed, is unrealistic and unattainable as things stand now in the country’s health sector.

The government has focused more on building fistula centres and offering free surgeries to victims than attacking the factors responsible for this condition for majority of girls and women in the country.

MORE FITSULA CENTRES, MORE VVF

By 1987 when the Kano Chapter of the National Council of Women Societies (NCWS) built and donated the VVF Centre at the Murtala Muhammed Specialists Hospital, there were less than three fistula centres in the country, and only one foreign fistula surgeon, Dr Kees Waaldijik.

But nearly three decades after, the country now has more than 12 surgical repair centres across the states, including three zonal centres. The zonal centres owned by the Federal Government are located in Katsina, Ningi, Bauchi State and Abakaliki in Ebonyi State.

There are also not less than 24 Nigerian fistula surgeons, all working in different centres across the country. There is also a government funded Nigeria National Fistula Programme to support free surgeries, surgeon training, and equipment upgrades since 2011.

In the last 16 years, many states have all also declared free maternity services which reduces the burden of ceasarian section and other delivery costs.

But in spite of these interventions, more cases of obstetric fistula continue to come up.There are said to be 20,000 new cases every year while the existing centres can only handle less than 4,000 cases annually.

Lawal Bello, the Chief Medical Director of the Sokoto centre, who spoke to ICIR said it would be wrong for anyone to claim that VVF cases are on the decline. Relying on his record, he said when he resumed at the hospital some five years ago, the centre was registering  about 100 cases per year.But that number had now gone to not less than 200.

“By the population census, the number of young women is rising and that means number of women that would carry pregnancy will increase.As more women get pregnant, possibilities of VVF are high because it is associated with prolonged labour,” he stated. The 1991 Census puts Nigeria’s female population at 44,462,612. But the number had risen to 69,086,302 by 2006.

Between October 2016 and September 2017, the Sokoto centre operated 227 patients but only 186 was successful. Bello revealed some of the cases were so bad that they were deemed inoperatable. These are patients with severe conditions due to the extent of damage they suffered during labour. Some of the patients had completely damaged bladder while in some it is the private part. Such women require advanced reconstruction surgery to become normal again. In 2016 four women benefited from this surgery at the hospital and six in 2017.

At the National Obstetric Fistula Centre, Abakaliki, Ebonyi State, the trend has remained the same in the last 10 years. Daniyan Babafemi, the Acting Medical Director of the centre was unavailable when ICIR visited the hospital. But a senior doctor at the centre who did not want to be quoted because he’s not authorised to speak to the Press, disclosed that the hospital has continued to record nearly similar figures since it became a zonal centre for the South East 10 years ago.

The centre still does two to three surgeries per day and all within the age range of 20-35. He also revealed that most of the patients come from the rural areas, but a few come from big cities such as Portharcourt, Owerri, Lagos, Abuja and outside the country from Cameroon.

This website learnt that the Abakaliki centre sees more complicated cases of VVF because most of the patients developed it after the third or fourth birth. The reason for this, according to the doctor, is that babies expand with each pregnancy and most mothers do not eat right in preparation for delivery. The result of unhealthy eating habits is that the babies become too big for the mother to push during labour.

The problem is complicated because most of the women would insist on delivering their babies through the natural way because of the belief that a real woman must be able to deliver her baby herself. “Thus, by the time the patients get here, she has suffered severe damages,” he explained.

The Kano centre still does an average of 10-15 surgeries in a week and about 300 every year. Amiru Imam, a surgeon and head of the VVF theatre at the Murtala Muhammed Specialist Hospital Kano, said the only reduction in the cases of VVF is “not in terms of real reduction, but reduction in the suffering, stigmatisation, divorce and so on”. And this is due to the establishment of more fistula centres and creation of more awareness by the government.

EARLY MARRIAGE SYNDROME

A visit to any VVF centre in the country would show that most patients of the disease are victims of child marriage who developed it in the process of childbirth (obstetric fistula).Most of the patients interviewed had their first VVF surgery at 14 or 15 years of age, following their first pregnancy. Health experts say early child bearing makes the adolescent girls particularly susceptible to obstructed labour because their pelvises are not fully developed. The girl may also develop other complications such as eclampsia, anaemia, heavy bleeding and infection.

According to the document: National Strategic Framework for the Elimination of Obstetric Fistula in Nigeria: 2011-2015, Nigeria alone accounts for a staggering 40% of global obstetric fistula prevalence. It also accounts for 40% of child marriages with two in every five girls getting married before the age of 18.

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 17%  and in the South East, 10%.

This is why some concerned leaders, especially in the North, are spearheading the campaign against early marriage among adolescent girls. The Emir of Kano, Lamido Sanusi, has been unrelenting in his campaign against child marriage in his domain, using the media, especially radio to propagate his messages. He has also recruited the district heads in the Kano Emirate and religious leaders to reach out to the rural populace. But the practice has endured for long and it may take more than elite persuasion to stem the tide.

FAILURE OF PRIMARY HEALTHCARE

On a Wednesday morning at about 10.00 am, a man was in deep slumber, lying on a bench at the entrance of the Primary Health Centre at Tambagarka, in Gwadabawa Local Government Area of Sokoto State. There seemed to be no other person within the premises orinside the centre. The reporter feigned a cough and the sleeping man gently pulled himself up, wiping his face and the saliva dropping from a corner of his mouth.  He was the “gateman” of the centre.

The reporter introduced himself and asked if there was no one else at the centre. Then he pointed at a house beside the centre and said the head of the clinic lived there. He went in to inform him there was a visitor. It took him nearly 12 minutes to come out. Obviously he too was also asleep.

He told the reporter there was no patient at the clinic and that the other staff had gone out. He confirmed that patients do come to the centre once in a while and that they also go on medical outreaches to the village and surrounding communities. But the reporter found no evidence of any of these.

There were cobwebs at the entrance of the centre and inside the ward. The chairs, tables and some of the beds in the ward were dusty and showed signs no one has used them in a while. Outside the centre in a corner is an ambulance that still looked new but has been parked probably for weeks or months. No driver, nurse or community health worker was in sight. It’s either the centre had no staff or the staff had gone on their own business.

The centre is one of the evidence of the failure of primary health care in the country. Facilities without staff or equipment cannot encourage reluctant rural dwellers to come to the hospital. In many cases where facilities have some level of equipment and minimal staffing, they are located either too far away from the people they are meant to serve or inaccessible due to lack of motorable roads.

Dr Imam is of the view that lack of functional and accessible primary healthcare facilities, especially for rural dwellers, is a major reason for the prevalence of VVF.

“Poor and inaccessible primary healthcare facilities and lack of education are the foundational bedrock for VVF prevalence,” he told this reporter in his office a few minutes after coming out of the theatre room.

In Sokoto, where 350 women were operated and treated successfully in the last one year, a register of VVF and RVF patients seen at the Maryam Abacha Women and Children Hospital show that out of the 103 cases treated in 2016, only five were from Sokoto metropolis, three from Sokoto North and two from Sokoto South Local Government Areas. The remaining 98 came from the rural areas, with Wammako LGA leading with 14 cases, followed by Denge Shuni with 10. Others with high numbers include Kware 10, Silame 7, Shagari 4 and Tambuwal 4.

The centre also treated 16 patients from Zamfara, 13 from Kebbi and 8 from Niger States – all from the rural areas.

In 2017, the number of those treated from Sokoto State increased to 119, with Bingi Local Government recording 17 patients-the highest-followed by Wammako 10 and Kware 9. In the same year, 15 came from Zamfara, 12 from Kebbi and 10 from Niger States Out of the 15 from Zamfara only one came from Gusau, the state capital. In Kebbi  and Niger States, none came from the capital-all from remote villages.

Majority of those admitted for fistula repairs in Kano, according to Imam, come from the rural areas of the state where there is still poor health education and strong reluctance to visit the hospital. Primary healthcare facilities meant to serve them are in most cases not functional, and at best, mere dispensaries.

The distance of health facilities to several communities they are meant to serve is also a hindrance. Besides many who are willing to take advantage of the centres may find them too far away from their communities.

Fago is a rural community in Minjibir Local Government of Kano State. It’s about five kilometres to Minjibir, the local government headquarters where the nearest health facility is located. There are not less than five other communities surrounding Fago and all would have to depend on the facility at Minjibir. The centre had only one nurse and one community health officer.

According to 2006 Census figures, Minjibir has a population of 213,794, but has only 28 primary healthcare centres and one general hospital. But only three of the PHCs are equipped to deliver pregnant women. The three are located in Kunya, Gandirwawa and Zabainarwa. That means any woman who falls into labour would have to be referred to one of those three facilities, aside the general hospital. And if the labour is obstructed, she has to be referred to The Murtala Mohammed Specialist Hospital in Kano, about 40 kilometres away.

But there are other challenges too. Minjibir got 12 ambulances from the state government in 2015 to help convey pregnant women to the nearest health facility to avoid prolonged labour, which is the major cause of VVF. Less than three years after, not one of the ambulances is on the road. A staff of the local government told this reporter some of the vehicles were parked due to engine problem; some tyre issues, and some because the LG can’t fuel them.

According to Aliyu Lawan, the Primary Healthcare Coordinator for Minjibir, the local government now relied on tricycle ambulances in all the 12 wards to transport pregnant women from their homes to a health facility nearest to them. But even this intervention could not be sustained. Many of the tricycles have packed up and are rusting at the LG secretariat. The women are left to their own devices in the absence of any feasible and convenience means of transportation.

Ige Hashim is the Maternal and Child Health Coordinator at the Kware LG Secretariat in Sokoto State. She told ICIR that the state primary healthcare facilities were short of skilled workers. “When you have just one person in a facility, once she’s tired, she’ll leave the place and there won’t be anyone to attend to patients,” she lamented.

From the statistics seen by ICIR, Kware is one of the LGs with the highest incidence of VVF, and the reasons became obvious when the reporter visited on Wednesday April 11 at about 10; 30 am. There was no single official at the secretariat and most of the offices were under lock. Only Hashim and a handful of female community health workers receiving training on a project supported by PLAN International were around.

Asked where all the local government staff had gone, one of the health workers said: “It’s middle of the month and there’s no money, so they don’t come to the office.” The reporter was told that a similar scenario plays out in other remote local governments of the state.

MORE WOMEN STILL DELIVER AT HOME

Majority of women in the rural areas of the country are still at the mercy of unskilled traditional birth attendants who deliver them of their babies at home. Because of the challenges associated with health facilities in the rural areas, poverty and general ignorance about healthcare, many pregnant women do not attend ante natal care and still deliver at home.

According to statistics from the World Bank and the WHO, 49.8 percent of Nigerians live in rural areas and 70 percent of the population live in poverty.

In Salame, a rural community of about 2,000 people in Sokoto-mostly farmers, only a dispensary built since 1984 is still in use. The dispensary also serves surrounding villages. It has a nurse and one community health worker. Tuesday of every week is the antenatal day but only few pregnant women attend, mostly from Salame town.

Talatu Haruna, the community health worker who takes the ante natal lessons, told ICIR that majority of the women do not come to the clinic for ante natal and delivery. “Most of them still deliver at home and it is when they have obstructed labour that they come to us and we refer them to Sokoto,” she disclosed, while showing the reporter around the labour room of the dispensary which looked more like a scrap store that had not been opened for a while.

Although antenatal care and delivery have been declared free in government hospitals in the state, Haruna said the dispensary had no supply of medical items needed for delivery so women who come for delivery have to buy them. She admitted this could also be a turnoff for many poor rural women.

Haruna was recruited along with others under the Midwives’ Service Scheme two years ago and posted to serve in Salame. She and the others received salaries until December 2017. “We have not received any salary this year,” she told ICIR, adding that she depended on whatever patients give her after treatment.

Dalhatu Buhari, the traditional ruler of Salame, said the community required a general hospital, and urged the state government to complete the general hospital that had been abandoned for eight years. The hospital was started by the Aliyu Magatakarda administration and taken up to the roof level, but was since abandoned.

According to Dr Imam, 90 percent of fistula cases are as a result of obstructed and prolonged labour. He said labour time for a woman carrying her first pregnancy should not exceed 12-18 hours, while for a woman carrying third or fourth pregnancy should not exceed six hours.

But many women, especially in the rural areas are not aware of this. And because they deliver at home, the women usually suffer severe damages before they get to the hospital, leading to either VVF or RFV or both.

“Those living in the cities and are educated know how and when to go to the hospital. But those in the rural areas have so many hindrances, obstacles like decision, right from the family unit. The decision to go to the hospital, decision to deliver in the hospital, who gives the permission? Who decides on what to do and not to do? And when they come out of the house, then the transportation to the hospital, how do they transport themselves? For how long would they transport themselves? The cost of transportation is also an issue,” Imam explained.

HARMFUL CULTURAL PRACTICES THAT CAUSE VVF

In all parts of the country, some traditional practices have endured till today. One of these is female genital mutilation (FGM) also known as female circumcision. It is common in most parts of the country, especially in the South East and South West. And they are done, especially in the rural areas by unskilled local people who cut in so deep sometimes that the urethral wall is damaged. Fistula surgeons say a woman who suffers this condition is likely to develop VVF.

In the Northern part of the country, especially the North West where local barbers still engage in what is called “Yanka Gishiri.” It refers to the cutting of a growth around the female vagina (Guria) that prevents women from having sex. In the process of cutting it, they cut other vital organs of the woman. Some of the cases of VVF seen in the North West zone were as a result of this practice.

To get around some of these challenges, some states with support from international partners such as UNICEF, USAID and PLAN International are investing in training of traditional birth attendants and providing them delivery kits. In some states, there are also Volunteer Community Mobilizers to track pregnant women in rural areas and bring them to the hospital.

But as health experts  have stated, nothing else can take the place of a fully functional primary healthcare system and sustained effort to discourage girl-child marriage and promote health education .