Wednesday, 18 November 2009

As Stubborn VVF Scourge Stays with Us...

It is estimated that about 800, 000 women are caught in the web of
Vesico-Vaginal Fistula (VVF) in Nigeria. The figure is reflective of the dismal
health indices of the country as experts lament that the weak healthcare
delivery system has combined with the moribund cultural practice of betrothal to
decapitate the womenfolk. Of the sundry health challenges the nation is facing,
investigations show that VVF is a scourge Nigeria can do without. GODWIN HARUNA

They look pale and sickly as a result of weeks of hospitalization. The first is
25 year-old woman, Mrs. Hauwa Umar, who was cornered at the Vesico-Vagina
Fistula (VVF) centre in Zaria, Kaduna State. Hauwa got married after her primary
school education. Married for about a decade now, she has been hospitalized at
the centre for more than a month, but her VVF condition started years ago.
She told THISDAY in an interview that she has never given birth in a hospital
but had visited it sometimes for antenatal care. In her words: "Three years ago
when I was in labour, the child refused to come out. We tried everything, but my
situation was getting worse and so I was brought to a hospital in Kaduna where I
gave birth later to a child that died immediately. Later, I started noticing
urine coming out from my body, which I couldn't stop. After so many different
kinds of traditional treatments without success, I was told about the center in
Zaria and I was brought here."
She said she didn't want to come initially because was scared of the fees but
somebody who had come to the hospital, who told her it was free, encouraged her.
Hauwa was lucky in her own case because she did not suffer rejection, as her
husband has been standing by her in her worst moments. Several other women
suffering the condition are not as lucky as family and friends have abandoned
THISDAY also spoke to 26 year-old Monica Garba at the Zaria centre. Married for
11 years with two children, Monica had spent about three weeks at the centre.
She said she went to a hospital when she had a difficult labour and after
delivery, she was diagnosed with VVF. She too, has the support of the husband,
who was present at the hospital, but declined interview.
Experts say there are two types of obstetric fistula, which are Vesico-Vaginal
Fistula (VVF) and Recto-Vaginal Fistula (RVF). They say VVF occurs when blood
supply to the tissues of the vagina and the bladder are restricted during
prolonged obstructed labour leading to the death of the tissues between these
organs forming holes through which urine can pass uncontrollably while
Recto-Vaginal Fistula (RVF) occurs in a similar way to VVF when the holes form
between the tissues of the vagina and the rectum and leads to uncontrollable
leakage of faeces.
Several women, who are not up to childbearing age, but forced into marriage and
others who could not access hospital care on time are tied down with this
condition in Nigeria. Dr. Clara Ladi Ojembe, a consultant community physician
with the Department of Community Medicine, Ahmadu Bello University (ABU) Zaria,
and the Secretary of the National Foundation of VVF, said Nigeria has the
highest number of VVF in the world. Ojembe said it is estimated that there are
about 800,000 cases of VVF in Nigeria out of a global estimate of 2 million.
"It is a major maternal issue. The bottom line is that anywhere a woman is
allowed to labour for days at home without seeking medical attention; she may
come down with VVF. We know the health situation in Nigeria, so anywhere you
look for VVF in Nigeria, you will find it. But unfortunately, the northern part
of Nigeria has the highest burden, and I think available data tends to suggest
that; as many as between 60 – 70 of the total VVF in Nigeria is found in the
core northern part of Nigeria.
We have done some work and we have found out that the incident of VVF is about 1
per 1000 deliveries and that compares with the same study that was done by Dr.
Kees in Katsina. He covers Katsina, Sokoto and many of the northern centers of
VVF. The same study also found the rate to be 2 per 1000 deliveries. So for
every 2 out of a 1000 deliveries a woman has VVF, according to his study in
Katsina and ours," Ojembe told THISDAY in an interview.
Dr. Ado Zakari Mohammed, former Chief Medical Director of the hospital and
currently the officer-in-charge of VVF surgery at the Gambo Sawaba General
Hospital, Zaria said VVF has been a major maternal problem in the north. "You
know it is part of the morbidity that women experience in the process of birth,
so in every woman that die about 10 others have complications in the process of
birth. One of the complications is the VVF, so as much as we have high number of
women dying in Nigeria, we will continue to have a high number of women with
VVF," Mohammed said.
He said there are five major centers in the northern part of the country where
those with the condition are looked after. These include Katsina as the
headquarters, Kano, Zaria, Sokoto and Kebbi. He said the activities of the
National VVF Project are in these five centers in the north under a Dutch
surgeon known as Dr Kees, who is the head of the whole project. He added that
Krees trained all of them in these centers.
Ojembe sees VVF as more of a social problem than medical. She says even though
they look at it as a medical condition, the major determinants are social, and
also, people that have VVF are the ones that have been able to escape maternal
death. "They had the problem but luckily they did not end up dead but ended up
with VVF. If you look at the statistics of maternal mortality in Nigeria, the
rate in the north-west is 6 times the rate of the south-west, the rate in the
north-east is 9 times higher the rate of south-west. So when you look at it,
what is the problem? Why should we have higher rates in the north than in the
south? Then you need to look at what the causes of maternal mortality are
because they are the same.
"You have the immediate ones that you know cause it, but beyond that, are lot of
factors that include the environment, social condition and the state of
development of a country's health care system. And one of the determinants of
VVF is the reproductive behavior of women, and one of the reproductive behaviors
is early onset of child bearing. Once you marry early and you start bearing
children early, it is like the case of a baby getting married and attempting to
give birth to another baby.
The pelvis is not sufficiently mature and so if the pelvis is small, when you
want to give birth, the head of the baby cannot pass through the birth canal.
The head of the baby gets stuck in the birth canal and if the thing remains here
for a long time it just crushes the tissue around. The bladder is in front, the
rectum where the faeces come out at the back, nerves at the sides, and if the
head gets impacted for a long time, it just cut off the blood supply and the
tissues die, so a woman will now end up with a hole connecting her bladder or
urethra to her vagina or connecting her rectum to her vagina or destroying her
nerves. So if the thing continues and you are not able to get the woman to a
hospital on time so that they can carry out an operation to remove the baby,
then the tissues will just die because the blood supply has been cut off, and so
obstruction can happen. But if the woman is taken to a hospital on time,
something could be done. So if you are too young and your pelvis is not
sufficiently big enough and you want to give birth, then you have a very high
chance of getting VVF than somebody that is mature," the consultant physician
She said early marriage was a problem in the north. According to her about 80
per cent of girls in the north begin to give birth before they are 18 years old;
adding: "Around Zaria where I work, the medium age of marriage is 13 – 14 years
and it has remained like that for more than 20 years that I have been living in
this area because I keep doing surveys with medical students. When you marry at
13 you are still a child who has gone to start servicing a man and having
children. So early marriage is a major problem which is one of the reproductive
behaviors of women."
Ojembe said the other cause of VVF has to do with health services-related
factors. She said if there are healthcare services that are fully equipped with
qualified health personnel and women attend anti-natal care and there is a
problem with birth, it could be adequately handled and the women can even go for
cesarean operation. "Even if you don't go, but you are able to be quickly rushed
to the hospital in good time, an operation can be done on you and the baby
quickly removed. But where are the hospitals in the north? They are nowhere.
You have all sorts of health clinics and all sorts of nonsense called health
facilities. You don't have the doctors, theatres or anything and you may have to
ride on an animal to get to the road before you can get a bus, and then get to
the hospital. When you get to the hospital, you are told to go and bring money.
The man has to go and sell his animal before coming back with the money. By that
time the woman would have died, if she doesn't die she will get VVF. So these
are issues relating to availability and qualities of services of obstetrics
services to deal with complications," she added.
She also located another cause in the fact that most of the deliveries are done
at home adding that 9 out of 10 are at home and it is often late before they
recognize that there is a problem. She said they must have tried Koranic
reciting, herbal treatment, which include salt cut by a local barber, before
finally deciding to come to the hospital. She stressed that the delay at home is
due to ignorance and traditional practices that are inimical to health. The high
rate of poverty, which is higher in the north is a major barrier to getting
quality health care; adding: "How many people in rural Nigeria can afford
N40,000 – N50,000 to pay for caesarian section, because that is the only way
they can bring out the child, except if the baby is dead then you crush the head
and pull it out. Poverty is a major limitation."
She stated that the issues of infrastructure, which are in deplorable condition
in a country with a huge population, also contribute to the problem. She said
attempts to make maternal health free via legislative framework have remained a
mirage as many state governments are paying lip service to the issue.
"Marginalization in decision making is also an issue. The status of women is bad
in the north. Much of them lack education, they are secluded and can't even go
out. Most don't even know what is going on in the outside world. They can't go
to the hospital without the express permission of their husbands. They can't
take decision as even when they have complications during pregnancy, they have
to wait for their husbands to come and give them direction about going to the
hospital and if he had traveled, then the woman may be sitting in front of the
hospital and die waiting for her husband to tell her what to do. Lack of
autonomy in decision making even about their health, limitation of movement,
lack of knowledge about any other happening outside their homes and all sorts of
problems which include lack of education, economic dependence on their husbands
for everything are all vices that are worst in the north, and consequently, you
tend to find out that maternal mortality and cases of VVF are much worse in the
northern part of the country," Ojembe stated.
However, Mr. Iyeme Efem, Project Manager, USAID ACQUIRE-Fistula Care Project
(Engender Health), Abuja, said the Problem of Fistula (VVF/RVF) is generalized
around the country. He noted that it is more prevalent in states where the
health indices are much poorer, adding that the failure of the health system is
reflected by the existence and indeed increase in fistula cases. He said in the
north, the condition is much more prevalent in all the geo-political zones.
"We do not have clear statistics of those with the condition. However, there is
the general belief that there are between 800,000 and 1,000,000 women with the
condition currently in Nigeria. Globally, there are 2,000,000 women with the
condition. Hopefully, with the recent DHS conducted, we are hoping that we will
have data of the prevalence rate in Nigeria," Efem said.
He said cultural practices are generally implicated as contributors to women
developing this condition. He added that female genital cutting is one of them
as it damages the environment and either makes women susceptible during
childbirth or even during the cutting itself. "Also, the practice of early
marriage which does not allow the girl child to develop fully thus creating the
opportunity for obstructed labour is another. Prevention of the discussions on
family planning which does not allow the women to obtain services that will
prolong the period before pregnancy thereby allowing their bodies heal well is
also a major culprit. Practice of insisting that women should have their first
baby at home as a sign of strength is also very bad. Refusal to have Caesarian
Section done on women because it shows sign of weakness is also another factor.
All these, including the delay in making a decision to take the woman to
hospital, delay in finding vehicle to move the pregnant woman to a suitable
facility and delay in finding a trained health care provider to take immediate
action are major culprits in the cause of obstetric fistula," Efem added.
The situation at the Kwalli VVF hostel, Kano where the people with the condition
are kept, is deplorable. When THISDAY visited the hostel recently, the place is
in dire need of government attention because of the unhygienic condition of the
hostel. The patients, numbering over 200, are living under terrible condition,
because of the inability of the government to provide basic facilities.
THISDAY observed that patients at the Kwalli VVF hostel are crying out, saying
enough medical and rehabilitative attention are not being given to them even as
the state government disclosed that it would build N1billion VVF centre in the
Mr. Suleiman Ilyasu, husband of a VVF patient, Mallama Zulaihatu Suleiman, said
if government would honour its pledge and commit such a huge amount of money on
VVF, the sufferings of the patients would reduce. According to him, "my wife
spent six years receiving the treatment after she became the victim of VVF. It
took a lot of resources from me to ensure that the surgery is done for her. She
is now normal as if nothing happened to her, but the bad condition of the Kwalli
hostel is terrible."
However, medical experts in the state observe that keeping control of VVF goes
beyond the confines of the hospital. Experts spoken to in Kano think government
should adopt a robust enlightenment campaign about the side effects of early
marriage and also, empower women so as to douse the effects of excruciating
poverty in the rural areas.
Kano State Commissioner for Health, Mallama Aishatu Isyaku Kiru, said as part of
government's effort to control VVF, it provides rehabilitation centres where the
patients are kept for three months before their discharge. She added that
government also schedules the patients' spouses and gives them seminars on
reproductive health-related issues.
18 year-old Mallama Aminatu Abdussalami Kunya, a VVF patient, told THISDAY that
she encountered the condition after she became pregnant at the age of 16.
Aminatu said her husband divorced her when he saw her in that condition and
lamented that her parents are taking care of her, adding that her former husband
is nowhere to be found.
She also lamented that, even her relatives also ran away from her when the
problems manifested, but managed to say with some cheer: "As you can see now,
my condition has improved and I am expecting to be discharged anytime from now.
I have recovered from the successful surgical treatment, many thanks to the
state government because the government is providing three square meals for us."
Dr. Amiru Imam, a consultant surgeon with Kano State Ministry of Health, said
many issues compound the case of VVF. He said apart from low literacy, poverty
and poor access to medication, the dearth of medical personnel in the state is
detrimental to maternal health as it relates to VVF. Dr Imam, who performs
surgery on VVF patients said prolonged and obstructed labour is the major cause
of the ailment. Other complications associated with this obstetric fistula, he
said, are psychological and neurological conditions where the women come up
limping, adding that notwithstanding all the joint efforts, the incidence are on
the increase. Imam noted that, at least, 15 new cases are operated upon every
week and the number is still increasing. According to him, "One should question
why things are not moving. Why are we still stagnant?"
Ojembe said although VVF cases are on the increase, but the area of success is
that in the past, when a woman has VVF, she is treated like an outcaste in the
society, nobody wants to stay close to her because she is smelling and passing
out urine. "Sometimes they have both VVF and RFV. Then, the chances of treatment
were slim. Even the Dutch surgeon that is in charge of the VVF programme only
developed interest in it. He was not a gynecologist but a different surgeon,
but seeing the cases of VVF occurring in Katsina, he decided to take an interest
in it, and so he started operating on it, and later developed the skill with
which he presently operates on the women. Fortunately for Nigeria, because of
the fact that the doctor is ready to pass his skills to any doctor in Nigeria
that wants to operate on the women, he started training us. We now have a lot
of indigenous doctors that can operate VVF successfully. At least we have about
300 doctors now and all were trained by Dr. Kees," she said.
Mohammed expressed the optimism that their work is attracting help from outside
government. He said Rotary International came into it by assisting them just
like Family Care (a Japanese NGO) that has started rehabilitating the patients
after their operations. "They are the ones that bought the sewing and knitting
machines that are given to the women after their training. They also give the
soft loan of N20,000 to the women to start something which is to be repaid in
two years. They are also the ones that employ the teacher that teaches the women
adult literacy. Family Care is also the ones that built the new wards we now
have, which includes the kitchen, store, toilets and the training center,"
Mohammed said further.
On his part, Efem said: "From ACQUIRE Fistula Care Project, we work to prevent
occurrence through community education and family planning, repairs of those
that have occurred through support to the fistula centers like provision of
operating tables, theatre consumables, training of more surgeons and nurses,
refurbishing of the facilities; rehabilitating those that have been repaired and
reintegrating them into their communities of families."


The writer is a grantee under 2009 Investigative Report for Maternal, Newborn and Child Health in Nigeria, moderated by Development Communications Network under the Ford Foundation supported projects in Nigeria.

No comments: