What is VVF?
An obstetric fistula is the breakdown of tissue in the vaginal wall communicating into the bladder (vesico-vaginal fistula - VVF) or the rectum (recto-vaginal fistula - RVF) or both. It is one of the most degrading morbidities resulting from pregnancy and childbirth. Maternal morbidity as a result of VVF or RVF is particularly high in Northern Nigeria. Out of an estimated 150,00 cases of VVF in Nigeria 70% occur in the North.
Causes of VVF
Approximately 80% of VVF cases reported in Nigeria are due to unrelieved obstructed labour during childbirth. Obstructing labour is directly related to the custom of early marriage in Nigeria (frequently below the age of 18 and sometimes before the onset of menstruation, as early as 11 years old). Early marriage invariably leads to early sexual contact and subsequent pregnancy at a time when a young girl is not adequately physically developed to permit the passage of a baby with relative ease. This can lead to a prolonged and obstructed labour and damage leading to VVF. The same phenomenon also occurs in women whose growth has been stunted as a result of poor nutrition or malnourishment.
About 15% of VVF cases are caused by the harmful practice of female genital mutilation. The 'gishiri' cut, a form of female genital mutilation, is commonly practised in Nigeria amongst the Hausa people. This traditional practice, performed by untrained traditional birth attendants, is used in the treatment of a wide variety of gynaecological ills and is commonly employed during pregnancy and labour. A cut is made in the anterior wall of the vagina with an unsterilised sharp instrument, if the cut is made too deep, a hole is created between the bladder and the vagina resulting in VVF. The rationale for the 'gishiri' cut defies scientific explanation, but belief in its effectiveness persists.
The immediate physical consequences of VVF are urinary incontinence and / or faecal incontinence (due to RVF) and related conditions, such as dermatitis. If nerves to the lower limbs are damaged, women may suffer from paralysis of the lower half of the body.
The social consequences for those who suffer from VVF are severe. Many victims of obstructed labour, in which the fistulae subsequently occur, will also have given birth to a stillborn baby, thus leaving the woman childless. In some areas,a high percentage of fistulae occur during the first pregnancy. In a society where childbearing is so highly valued this gravely affects the woman's future. If the fistula is not repaired, and the woman remains incontinent and childless, she is likely to be abandoned by her husband, on whom she is economically dependent. In addition, she may be ostracised by society as being considered to have brought shame on her family. Victims, therefore, become social outcasts.
VVF leaves such women physically, emotionally and socially traumatised. With no education, no vocational training, no gainful employment or visible means of livelihood, they travel a long road of rejection and pain.
Approaches towards eliminating VVF
Research and observations have shown that patients with fistulae are a particularly disadvantaged group in relation to both socio-economic status and education. The majority of patients are from rural areas, low in literacy levels and lacking in physical and economic access to medical care. Since many do not attend antenatal clinics, high risk conditions and medical and obstetric complications endangering the life or impairing the health of the expectant mother and baby will not be detected early enough to adopt precautionary measures. Many women in rural communities are taken to hospital only when the situation is hopeless and often too late.
In the short term, better use of existing obstetric services and increased provision of effective health services in rural areas will lower the incidence of VVF. However, in the longer term there is a need for an holistic approach to address both the direct and indirect causes of VVF and other maternal morbidities. Ultimately, improving the education and economic empowerment of young women will remove the conditions that lead to the occurrence of VVF. Such improvements would lead women to seek safer obstetric practices, including the use of family planning, delay childbearing, and seek prenatal and antenatal care during pregnancy. It has been found that women with a formal education have a maternal mortality rate one fourth that of women with no formal education