Dr. Suleiman Zakariya is a public health physician and a Clinical Associate for Engender Health Fistula Care Plus project, a five-year USAID funded project that seeks to prevent, treat, reintegrate and rehabilitate obstetric fistula patients in Nigeria. In this interview with AJUMA EDWINA OGIRI, he speaks on prevalence of obstetric fistula in the country and measures being taken to curtail it. Excerpts.
Overview of Obstetric fistula in Nigeria
Globally Obstetric fistula has been a public health concern. We have over two million cases of obstetric fistula patients globally, with majority of them in sub-Saharan Africa and Asia. In Nigeria we have about 120,000 to 150,000 cases of obstetric fistula, with about 12,000 new cases occurring annually in the country.
Burden situation in Nigeria
We have about 12,000 new cases reoccurring, and at any given time, the prevalence is 120,000 to 150,000 cases. We only have the capacity; that is the combined efforts of all the partners in the country, to repair just about 5,000 cases. It means we always have a backlog of about 7,000 added to what already exists, in terms of the prevalence. The number of new cases far outweighs the capacity to repair. So we need to redouble our prevention strategy.
Causes of fistula
Obstetric fistula primarily is a result of prolonged obstructed labour. 80 percent to 90 percent of all fistula cases are as a result of prolonged obstructed labour. We have other causes of fistula like, traumatic fistula, iatrogenic fistula, which occurs as a result of inadvertent hospital procedures, chiefly caesarian operations.
The most common important cause of obstetric fistula in the country is prolonged obstructed labour.
The social demographics of the categories of women that come down with these maternal morbidity and mortality issues are usually rural women with no education and low socio-economic status. Absence of emergency obstetric care usually results in the formation of obstetric fistula.
When we have functional hospitals, like primary health centres, within the catchment areas and we orient them culturally, they will seek expert care during pregnancy, labour and delivery. But when these emergency services are absent, chances are high that these women will come down with obstetric fistula, especially during labour and delivery, if not supervised by a skilled birth attendant.
Number of fistula surgeons in the country
Only few surgeons in the country have the interest and capacity to repair obstetric fistula cases. We are actually trying to clinically manage cases of obstetric fistula in Nigeria. Even the few doctors we have, the challenge has been how to retain them with the new system. Retention of fistula surgeons within the system has actually been a challenge because of a number of factors.
How prolonged obstructed labour causes fistula
This is as a result of a mechanical obstruction; a disproportion between the head of the baby and the pelvics. This is what usually results in prolonged obstructed labour. The labour will last longer than normal, and then the woman will not be able to deliver. She is going to need an emergency medical intervention in terms of caesarian operation, which if not available can lead to foetal death and as well as the mother coming down significant morbidity. That is if she is lucky not to loose her life during the process.
There are a lot of conditions that could make a labour to be prolonged, but not obstructed. It is only in a hospital with trained and skilled medical personnel that the progress of labour is accessed and monitored on a partograph – a graphical representation of how labour is progressing. Hospitals personnel are trained to record, read and take action depending on what the partograph indicates, and also based on clinical assessment of the patient. These are things that are carried out early by skilled and trained medical attendants.
Early marriage and fistula
Early marriage is not a cause fistula, as generally believed. It is chiefly as a results of prolonged obstructed labour. It can happen to anybody, in the absence of skilled emergency medical interventions.
Common types of fistula
We have Vesico-Vaginal Fistula (VVF); This is as a result of an abnormal hole created between the urinary bladder the vagina, leading to uncontrollable leakage of urine into the vagina vulva.
We also have the Recto-Vaginal Fistula (RVF), which is an abnormal hole between the vagina and the rectum, resulting to uncontrollable leakage of faeces into the vagina vulva.
These two conditions can coexist or occur concurrently in a woman.
A woman can as well have VVF with no RVF component or RVF with no VVF component. It depends on the point where the head of the baby is causing the necrosis, as against any of the pelvic bones. if the head of the baby is infringing on the urinary bladder against the pubic bone, that could result to VVF. But, if the head is infringing on the rectum against the pubic bone, due to the necrosis of the tissue around there, a hole could result abnormally as a result of the dead issue, between the rectum and the vagina leading to RVF. It is a very devastating childbirth injury.
On Engender Health Fistula care plus project
Engender Health fistula care is the only key player in Nigeria, when it comes to prevention, treatment, reintegration and rehabilitation of obstetric fistula clients. We have other implementing partners like UNFPA and Fistula Foundation. What Engender Health is a country-wide-programme. We are in about 13 states now. In all these states, we support the treatment obstetric fistula, as well as prevention and integration through our community services.
Each year we have the capacity to repair between 2,000 to 2,500 cases of obstetric fistula surgically or conservatively through the use of catheter. We are actually doing a lot regarding prevention and the treatment of obstetric fistula in the country, in partnership with the Federal Ministry of Health and other implementing partners in the country.
Numbers of fistula clients repaired
Like I said earlier, we repair between 2,000 to 2,500 cases annually. We always double our efforts to see that we do more because of the ever increasing number of backlogs that reoccur each year in the country. We do this via a dual approach of supportive routine services as well as conducting free of charge fistula repairs. The routine services we support are across health centres that have the required expertise and surgeons that are skilled to perform this operation.
Those centres that have the surgeons to do this operation, we always encourage them by retraining them, providing them with essential theatre consumables that are required for the operation.
We also make high level advocacy to government at different levels to increase funding or make budget for items for obstetric fistula in their states.
The services, from admission to discharge, are free for the patient. Government has been really supportive in our partner states.
We have a community mobilisation activity that we conduct towards creating awareness to these patients on the dangers of obstetric fistula. We focus on the rural areas because that is where the case is most prevalent.
The social demographics of the categories of women that come down with these maternal morbidity and mortality issues are usually rural women with no education and low socio-economic status.
