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A young VVF patient after
surgery.
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01 April 2001
My first and last encounter with a
victim of vesico-vaginal fistula, better known by its
acronym VVF, was almost 40 years ago. She was a constant
visitor to my uncle's house in my old neighbourhood in
Maiduguri, Northern Nigeria. A mere teenager, she had
fallen victim to VVF after a protracted labour that
resulted in a stillbirth. Her husband had also died.
Because of her condition, her dresses were always soiled
with urine and faecal matter. Her fate was one shared by
many women worldwide, but one that is particularly acute
in parts of Africa.
VVF and its sister ailment,
vesico-rectal fistula, occur when, as a result of
prolonged unrelieved obstructed labour, the baby's head
tears through the orifice of the mother, creating an
opening between the bladder and the vagina, and
sometimes, between the vagina and the rectum. This
condition is most often associated with childbirth by
young girls or small-statured women when the pelvis is
small and the baby is large. In other cases, the baby
may not be in the correct position when labour begins or
other complications can arise. Where the woman can be
taken to hospital quickly, doctors are usually able to
aid the birth. But in remote communities with limited
access to standard medical facilities, the woman can
spend days in fruitless labour. In such cases, the baby
is almost always stillborn and the woman, if she
survives, falls victim to VVF. The VVF sufferer loses
control over her bodily functions and as a result, has
urine, and sometimes faecal matter, constantly trickling
down her legs.
Perhaps more damaging than the
physical effects of VVF is the social isolation that
follows in many instances. Because of the offensiveness
of the injury, many sufferers find them-selves abandoned
by their husbands and families and shunned by their
former friends. Those families that try to care for
their relatives with VVF injuries often do so from a
distance. In many cases, the few sufferers who are able
to find their way to hospitals usually face a long wait
before they can receive adequate medical attention,
because of the general inadequacy of medical services.
Not surprisingly, many sufferers become destitute and
turn to begging.
It is estimated that there are more
than two million VVF sufferers worldwide, with a
considerable proportion in sub-Saharan Africa. According
to Dr. Mulu Muleta of the Addis Ababa Fistula Hospital,
a large number is also to be found in poor areas of Asia
and South America where health facilities are
inadequate, transportation systems are poor or absent,
harmful traditions exist and women are accorded poor
socio-economic status.
Not much reliable data is available as
to the exact number of sufferers in Nigeria. What is
certain, however, is that they can be found across the
length and breadth of the country but appear to be
concentrated most in the Northern, South Eastern and
Middle Belt regions of the country. The current figures
in use by the health authorities are estimates based on
information gathered from those victims who come to seek
care in established medical facilities. The reality,
however, is that most sufferers, either because of
distance or cost, never get to any formal medical
establishment to seek care.
When the time came to write this
report, I immediately decided to seek out the woman I
had met 40 years earlier. Alas, enquiry in our old
neighbourhood revealed that she had died long ago. She
too became a statistic - one more of the estimated
600,000 who die every year in developing countries as a
result of pregnancy and child bearing-related causes.
The Nigerian Government estimates that
there could be as many as 400,000 cases of VVF in the
country. According to the Ministry of Health, the number
is between 200,000 and 400,000 with up to 10,000 new
cases occurring annually and with an incidence of two
per 1,000 deliveries. The prevalence rate is said be
higher in rural areas, because of inadequacy of
facilities for pre and post-natal care. In such areas,
long distances combine with high cost of care, ignorance
and poor nutrition to make women more vulnerable to VVF.
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| Dr. Ann Ward is one of
the top VVF repair surgeons in Nigeria. She runs
a care centre in Uyo, southeastern
Nigeria. | |
Accusing
fingers have been pointed at religion for the prevalence
of this situation. Specifically, religious, traditional
and cultural beliefs that seem to encourage early
marriage and lead to early pregnancy are seen as the
principal culprits. Because their pelvises are not fully
developed, young girls who become pregnant often have
obstructed labour, thereby dramatically increasing their
chances of developing VVF. Early marriage is prevalent
in some northern Muslim communities in Nigeria where
many see the practice as a religious injunction. But
leading religious leaders have made it clear that the
practice is not an Islamic injunction. They accuse the
practitioners of ignorance of Islam and of using the
religion as a cover for their selfish activities.
They point out that no section of the
Qur'an or the Haddith sanctions early marriage or
specifies an age for marriage. Instead, reference is
only made to age of marriage as the age of "sound
judgement" and "maturity", both physical and mental. In
fact, marriage is not encouraged unless a man can cater
for the wives' and children's health, religious,
educational and socio-economic needs. Islam is
emphatically against early marriage or marriage without
the mutual consent of the partners.
Notable Islamic scholars, including
those from the British Muslim Parliament, have
emphasised that, "marriages without the consent of both
partners are not valid under Islamic law, so sex within
forced marriage is rape and parents and religious
leaders who force couples to wed are abetting sex
crimes". According to them, early marriage is only
permissible where it is done to protect the life of the
young girl and on the condition that the husband accepts
to be responsible for the girl's education. Such a
husband also agrees to permit the girl to mature before
the consummation of the marriage.
The good news about VVF, though, is
that it is treatable. According to the Ethiopia-based
Addis Ababa Fistula Hospital, the operation to close a
fistula is often a simple one. In its annual report for
the period October 1999 to September 2000, the hospital
said that following such an operation, many patients are
completely cured. They are able to return to normal life
and to bear children again.
Although Nigeria is yet to develop a
national strategy on VVF, the Government, both at the
national and state levels, has put in place legislations
and measures aimed at protecting the welfare of women
and promoting safe motherhood. Many of those actions,
though not specific to VVF, can impact positively to
ameliorate the suffering of VVF patients. Since the
International Conference on Population and Development
(Cairo, 1994) and the Fourth World Conference on Women
held in Beijing in 1995, the Government has acknowledged
the importance of women's and children's health to
national development. Attempts have been made to address
critical issues pertaining to population and development
with particular emphasis on the urgent need to reduce
maternal mortality and morbidity, eliminate harmful
practices that affect women and make reproductive health
a right for all, including adolescents.
The Ministry of Women Affairs and
Youth Development has spearheaded a multi-pronged effort
in this respect, including the establishment of
girl-child education units in all state ministries of
education and at the federal level in 1996, enactment of
state legislations to prohibit the withdrawal of girls
from schools, enactment of legislation against early
pregnancy, establishment of support and cure for VVF
sufferers in 1995, and production of a video
documentation and drama on the dangers of early marriage
in 1999. In addition, the ministry has conducted a
survey of harmful traditional practices with the aim of
putting in place a policy and legal framework to address
the issues involved. Last year, the government adopted a
policy on women to give additional boost to the
emancipation of women.
Perhaps, reflecting the absence of a
national strategy, interest in the plight of VVF
patients has come mostly from philanthropic
organisations, largely foreign ones, public-spirited
individuals and international agencies. Recently,
however, local non-governmental organisations (NGOs),
notably the National Council of Women's Societies (NCWS)
and Women in Nigeria (WIN), have taken a more aggressive
stance to bring the VVF problem into the national
agenda. A National Foundation for VVF, comprising
surgeons involved in VVF surgery and women's health
activists who coordinate, enlighten and advocate the
cause of VVF sufferers, has been formed as a non-profit
NGO. Publicity campaigns have also been launched to
attack the root causes of VVF and to sensitise people to
the harm that sufferers are forced to live through.
Additionally, the number of VVF
centres in the northern part of Nigeria has increased
from two in 1992 to seven today and state hospitals in
many of the affected areas now have special VVF wards
with anything between eight and 250 beds. The relatively
high cost of treatment, however, remains a major
stumbling block. Recognising that only very few
sufferers can afford the 10,000 Naira to 40,000 Naira
(100 Naira = $1) required for treatment, state
governments generally subsidise such treatment heavily
or provide it free. Voluntary agencies also complement
government efforts in training, treatment and
rehabilitation. Among these are the Annua Family Life
Centre, Akwa Ibom, led by Dr. Ann Ward, and the Evangel
Hospital, Jos, which provide heavily subsidised
treatment. The Foundation for Women, Health Research and
Development (FORWARD), an international NGO, has also
set up a rehabilitation centre for VVF patients in Kano.
The Ahmadu Bello University Teaching
Hospital (ABUTH), Zaria, has also distinguished itself
as a pacesetter in VVF reconstruction and surgery.
Unfortunately, many sufferers find the recovery fees
charged by the hospital to be beyond their means. As a
result, postgraduate resident doctors at the hospital
are not getting adequate expo-sure and training on VVF.
For the time being, nationwide training for VVF
treatment is limited to a one-month course for nurses in
post-operative care, a three-month training for doctors
and a three-week training for senior registrars in
obstetrics and gynaecology wards. Training for nurses is
also available at the Annua Centres in Kano and Katsina.
Dr. Adenike Adeyemi, Deputy Director
in the Federal Ministry of Health and Social Services,
believes that a final onslaught on the ailment will come
when the ministry begins the implementation of a new
plan of action that it is currently being finalised. The
plan of action anticipates a detailed assessment of the
VVF situation in the country, followed by the
introduction of measures to prevent future cases.
According to her, the international
community can play a role by helping to improve the
capacity of Nigerian doctors and other medical staff to
deal with VVF cases, both in terms of training and in
the provision of equipment. Opportunities for
international support also exist in the area of
provision of non-formal training to help former VVF
patients to become economically independent.
By Hajia Kindin Yolah
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