By Hamzat Ibrahim Abaga

In this report, Hamzat Ibrahim Abaga tells the story of how women living with vesicovaginal fistula (VVF) and obstetric fistula (OF) in Bauchi State are being neglected by their families amid stigmatization by the public.

After 15 unsuccessful operations in Plateau and Bauchi states, Fatima Hassan, 70, would eventually get rid of her fistula at the National Obstetric Fistula Centre (NOFIC) in Ningi, Bauchi State.

The septuagenarian told Xchange Hama Media she was 25 years old when she had prolonged child labour leading to the disease, a stigma she lived with for about three decades.

Fatima was told she had obstetrics fistula when she couldn’t stop passing urine after delivery. Sadly, the baby later passed away.

After getting rid of the stigma, Fatima was rehabilitated at NOFIC where she was serving as a cook. Cooking and serving other victims of vesicovaginal fistula (VVF) and obstetric fistula (OF) is what she does for a living. Fatima does this, happily, she told Xchange Hama Media.

“When some of these victims come to pick their foods here in the kitchen, some said they are tired and willing to let go of their lives after two to three operations, but I will tell them my story of being operated on 16 times and advise them that the suffering will definitely end,” she said.

What is obstetric fitula?

According to the National Library of Medicine, obstetric fistula is an “abnormal opening between a woman’s vagina and bladder and/or rectum through which urine (vesicovaginal fistula) and/or faeces (recto-vaginal fistula) continually leak.” It is a medical condition in which a hole develops in the birth canal in the course of prolonged childbirth.

It was reported that in March 2022, over 50 women living with VVF in Bauchi State communities were successfully treated in the Gamawa and Ningi local government councils.

Contrary to the wild belief, child marriage is not the only cause of the disease, according to medical experts. A woman could contact fistula during child labour; in some cases, after several successful childbirths. Other causes are barbaric cultural beliefs/practices like genital mutilation.

The disease could be treated through surgery and medications.

Hafsat, Halima as VVF victims, symbols of neglect

Unlike Fatima, who could be considered a little bit lucky, Hafsat Musa, 19, and Halima Mohammed, 16, who both got married at the age of 12 and 14, respectively, developed fistula during their first childbearing. Although they live many kilometres apart, they share a lot in common. They both gave birth to dead babies, suffered excruciating pains, and ended up suffering from obstetric fistula. Hafsat narrated how neglect by her husband worsened her condition.

Aside from constant urine leakage, she also suffers shame, social segregation and much more.

“When the problem of fistula first started, I was taken to a nearby healthcare centre in Tauya, Darazo local government area. Afterwards, I was operated on, and after several operations within the period of five days, the situation kept retrogressing,” she said.

Musa, Hafsat’s husband, had visited her only once. “He only came once and gave me N2,500,” she mumbled. “He neither calls to check on me.”

Fatima, on the other hand, had a much more terrible ordeal. “My husband completely abandoned me. Not only did he abandon me, I was also told that he was planning to marry a second wife,” she said as tears rolled down her cheeks.

Fatima said that apart from the pains and disgust associated with obstetric fistula, the constant thought of discrimination and social segregation by her husband and his relatives is another inconceivable pain she lives with.

“For me, the neglect I suffer from people that ought to be of help to me is more painful than the ailment that struck me. The most horrible condition any living being will suffer on earth is neglect by close relatives and people you love most. Everything in this world revolves around love and affection. When you don’t have it, that is the end of the world for you,” she narrated as she constantly wept.

Fatima and Hafsat’s toxic experiences are a symbolic posture of how women suffering from VVF are treated in Bauchi – and beyond. They suffer endless discrimination and lack of proper medical attention, and are inflicted with lifetime psychological trauma. Many of them perish in the process.

Several research findings suggest VVF remains a major nightmare for women in Nigeria. For instance, the Pan African Medical Journal states that the prevalence of obstetric fistula is 3.2 per 1000 births, and it was estimated that about 13,000 new cases occur annually. The data indicates that the backlog of unrepaired cases may take about 83 years to clear at such a present rate of repair.

Additionally, the United Nations Children’s Fund (UNICEF) reported that the number of Nigerian women currently living with VVF ranges from 400,000 to 800,000, Annually, an additional 50,000 to 100,000 new cases occur in Nigeria.

Figures suggest that 3.2 persons per 1,000 of the country’s population are faced with fistula annually, with, at least, 33,000 of these found in sub-Saharan Africa.

A baby could be born with fistula

A three-year-old girl (name withheld) was still breastfeeding when her family noticed her abnormal urine leakage. But they felt it was normal.

“She was three years old,” said her grandmother, “when we noticed unusual urination from her since she was little. But we overlooked it, thinking it was a minor case, which would stop very soon. Now we have to find our way to the hospital for a remedy.”

Opkara Edward Olanrewaju, the Acting Head of Clinicals, NOFIC Ningi, said there are scenarios that could endanger a newborn with a fistula.

He explained, “It might be congenital, which occurs during childbirth when a baby could accidentally be born due to the condition of the baby’s mother’s private part.

“There are also other causes like trauma, where a baby might fall and sustain injuries in her private part or the baby while playing might step on a sharp object and get her fistula damage.

“It could be as a result of the female genital mutilation through traditional delivery where the child’s bladder can be mistakenly damaged in the process.”

Olanrewaju said there are mainly two types of treatments: conservative and definitive.

He described the conservative as a cardiac treatment, a process when the VVF is treated by catching the fistula young. It passes through what is called cativa, and is in open treatment for some weeks to allow the fistula to heal.

He said, “In the conservative treatment, there is a 75 per cent assurance that the patient would be healed. Definitive treatment is when treatment of VVF is done through surgical intervention. Also, In this process when a patient works in the hospital, she gets admitted, doctors do the necessary check-ups and the patient undergoes surgery.”

The Managing Director, NOFIC Ningi,  Halima Mukaddas, said in an interview with Xchange Hama Media that the centre only has three mandates: training, research, and treatment/rehabilitation of fistula patients.

Mukaddas described fistula as a “terrible condition”, caused by childbirth and obstructed labour, child marriage, immature pregnancy, and genital mutilations.

“In a time of prevention, parents must allow their female child to grow very well before getting married. And when she is married and pregnant, the husband must prioritize proper nutrition for his wife,” she said.

She added that qualified personnel must be allowed to monitor or attend to women during childbirth to prevent unforeseen circumstances that might damage her bladder and lead to fistula.

“Access to hospital facilities and poor hospital facilities can as well cause obstructed labour, which might lead to developing fistula. So, at all times, the government must make available the necessary and needed resources at our hospitals to prevent such kinds of issues,” she stated.

The Bauchi case 

The NOFIC in Bauchi repairs between 400 and 500 fistula cases annually, with some done on routine bases, while others are gathered in groups of about 100 at a time. About 2,000 people are currently living with the VVF disease in Bauchi State.

The Bauchi case is a replica of the situation nationwide. Although there is no exact data on the incidence or prevalence of fistula in Bauchi, the state does host the NOFIC through the USAID Fistula Care Plus initiative and provides education, outreach, and free fistula repairs in the state.

Findings suggest the hospital has four surgeons trained in fistula repair and carried out 187 surgical repairs in 2016.

The majority of fistula patients in Bauchi State and North Eastern Nigeria in that year had no formal education (81.3 per cent), were mostly housewives (80 per cent), and lived in rural areas (77.3 per cent). About half of the studied population were teenagers and are not living with their husbands anymore as a result of the infection.

The majority of fistula patients in Bauchi State and North Eastern Nigeria in that year had no formal education (81.3 per cent), were mostly housewives (80 per cent), and lived in rural areas (77.3 per cent). About half of the studied population were teenagers and are not living with their husbands anymore as a result of the infection.

The existence of such a high number of obstetric fistula victims has highlighted the failure of health systems to provide high quality maternal health care, including skilled medical attention and timely emergency obstetric care. It is also a reflection of the socio-economic, regional and gender-based inequities, as well as the patriarchal nature of African societies that hinder women from accessing high-quality services.

The Bauchi case is compounded by years of system failure, inadequate budgetary allocations, and late releases of the allocations to treat patients, as well as lack of information flow that should create the necessary behaviour change communication to dissuade people and the larger society from discriminating against VVF patients.

Findings by Xchange Hama Media also indicated that apart from the location of the VVF facility provided by the Bauchi State government in Ningi, there is no intervention by the state government for patients living with the ailment. Symbolic help comes often from the office of the first lady of the state, although, sometimes it is negligible, .

The consequences of obstetric fistula among women

VVF is a life-threatening ailment for many women. Tellingly, it could quickly and prematurely terminate its victim’s life, or leave her with trauma till the end.

Professor of Radiology and Director, University of Nigeria Centre for Clinical Trials (UNNCECT) & Founder/Co-Chair, African Clinical Trial Consortium, Ifeoma Okoye, said that fistula has a very high tendency to cause suicide among its victims.

She said lack of proper information and access to quality medical care to repair and bring back the victims to society could prematurely end their lives or subject them to lifetime symbols of public discrimination and pity. Okoye also argued that neglected fistula victims will always be a significant burden on society.

“Of course, we know that without information and access to the medical care that is available to repair and reestablish them (fistula victims) back to normal life, they will remain abandoned and, with time, they either die or become beggars,” she said.

A glimpse of hope

Mukaddas said although the situation in Bauchi State is quite worrisome, a glimpse of hope for the victims is evident, looking at the series of interventions and attention the centre is getting.

She said the federal government has made it an annual routine to organise training and retraining of the medical and non-medical staff with the required knowledge for the smooth running of activities at the centre.

She added that other medical and non-medical staff outside the state also benefit from the training and retraining programmes.

Also, the federal government, in collaboration with the state government, has trained their staff about fistula to enable them perform simple operations of fistula cases. The training also houses counselling, which she says will help reduce the psychological effects of OF.

Mukaddas called on the Bauchi State government to further strengthen its collaboration with the centre because 70 to 80 per cent of fistula cases recorded at the centre are residents of Bauchi State.

“Our major challenge at the centre is funding. Going around the facility, someone will notice that there are uncompleted structures which, if completed, will boost the operations of the centre. Let both federal and state governments help in completing the structure so that the facility can operate optimally.

“Developing and implementing guidelines on the management of obstructed labour and the management of women who present themselves with obstetric fistula immediately after birth or with an established fistula requiring repairs is necessary. This, and many more, would help in achieving a great result in the fight against fistula,” Mukaddas said.

The social welfare unit of the NOFIC in Ningi also explains the steps the centre is taking to help victims of OF.

Sani Mohammed, the Unit Head of the Social Welfare Service, NOFIC, confirmed that more awareness creation was done across local government areas that were identified as flashpoints.

“The team of the Social Welfare Service often took to the local governments to identify the hotspots of the fistula patients to create more awareness and educate the locals, including the village heads of the affected community, on some practices considered as the major causes of their predicaments.

There was a case of a 17 years old lady who was abandoned because of a fistula. After four years when she was treated and confirmed dry, the husband returned to reclaim her as his wife. The social welfare service unit stood for her until she got her justice.

In another case, the unit in 2017 stood up for a 20 years old lady who was thrown out of her husband’s house after continuous family pressure from his family because she was unable to conceive after four years of marriage.

Luckily, she remarried and conceived immediately. Unfortunately, in the process of childbirth, she got infected with a fistula and was divorced again.

A few days after she got dried, the husband returned to claim her as his wife. “The social welfare stood for her and she got justice and she is now in her third marriage leaving happily,” Muhammed said.

This publication, republished from Xchange Hama Media is produced with support from the Wole Soyinka Centre for Investigative Journalism (WSCIJ) under the Collaborative Media Engagement for Development Inclusivity and Accountability Project (CMEDIA) funded by the MacArthur Foundation.