Inside the lives of Nigerian women suffering vesicovaginal fistula (VVF)

Maryam Abubakar had been in labour for days. She had endured the pains but there was no childbirth facility in her neighbourhood.

The 26-year-old mother of two dreaded the interstate trip to a health facility because it would intensify her pain.

But as her condition became more desperate, she finally accepted to embark on the 70-kilometre trip from her hometown, Nguru in Yobe State, to Hadejia in Jigawa State.

Hours after she arrived at Jahun General Hospital in Jigawa, she had a stillbirth through cesarean section.

Doctors at the facility later told her that due to her prolonged labour, she had vesicovaginal fistula (VVF).

According to one of the oldest and globally recognised medical journals, Lancet, vesicovaginal fistula (VVF) is “a serious medical disorder characterised by an abnormal opening between the vagina and the bladder or rectum, which results in continuous leakage of urine or stool.”

Ms Abubakar said after she was admitted to the fistula section of the hospital managed by Médecins Sans Frontières (MSF), which translates to Doctors Without Borders, her husband divorced her.

“When I was told about my condition, I was terrified and cried like I had never done in my life. The doctors pleaded with me and gave me hope that they will treat me and return my life to normal. But I am disturbed because I am aware that women with VVF are stigmatised,” she said.

“While still being treated at the hospital, my husband called me and said he needs a new car, which is an idiom that he wanted to marry a new wife. This was days after he stopped visiting the hospital or calling to check on me.

“He said he could no longer eat the food I cook because of my condition,” she said crying.

After she was discharged, (by which time her husband had married another woman) she spent two months with her parents while she waited to be certified VVF-free. After she was certified as being completely healed following corrective surgery, she prepared to return to her husband.

Ms Abubakar said she wore decorative traditional henna on her legs and hands and was set to return to her husband when he called asking him to wait for a message. He subsequently sent her a message divorcing her.

She said her life took a difficult turn after her health challenge. She said she is now stigmatised in her community and would-be suitors stay away from her upon learning of her battle with VVF.

Prevalence of VVF in Nigeria

VVF is one of the most devastating maternal diseases in Nigeria. Approximately two million women were estimated to be living with unrepaired vesicovaginal fistula (VVF) and about half of the total from developing countries were from Nigeria.

It is considered one of the most serious and tragic childbirth injuries that often lead to depression, social isolation and deepening poverty. It is prevalent in Nigeria due to the existence of some cultural practices including child marriage, female genital mutilation and poor access to healthcare facilities.

According to the United Nations Children’s Fund (UNICEF), between 400,000 and 800,000 Nigerian women are living with VVF and between 50,000 and 100,000 new cases are added every year.

The United Nations agency said Nigeria has a prevalence of obstetric fistula, as VVF is also known, of 3.2 per 1000 births. It bemoans the slow rate of fistula repairs caused by inadequate fistula surgeons and the high rate of new cases.

1The agency estimated that it may take up to 83 years to clear the backlog of cases at the current rate of repair.

At the Jahun General Hospital where MSF renders free surgical repairs VVF in women from Northern Nigeria and the neighbouring Niger Republic, 532 women with the condition were treated in 2021 and 2022.

The MSF team at the facility also provided 33,917 women with antenatal care, assisted in 12,519 deliveries and another 1,626 deliveries through caesarean section.

More fistula patients recount ordeals

Shema’u Muhammed from Bauchi who got her fistula repaired in the Jahun hospital said the rupture was caused by prolonged labour and how she could not get a professional medical personnel to attend to her following a long strike by doctors.

“I could not get medical attention in my community because doctors were on strike. I started the labour one certain Sunday morning but because there were no doctors in the Darazo hospital, I was referred to Bauchi Teaching Hospital (in the state capital). I was attended by doctors on Tuesday, and I delivered through cesarean, unfortunately, I lost the baby.

“My complications worsened for about six days after the surgery, my stomach was swollen like a bubble. It later burst and there was water all over the ward. My bladder was infected. I was later referred to the Jahun hospital, where MSF treated me for free, and I am now okay, but life will no longer be the same,” she said.

She said after she had an obstetric fistula, she was stigmatised by community members, and her husband divorced her and married another wife.

“I have a child with my husband. He later married a new wife. After she delivered a baby, my husband was instructed to divorce me because his family believed that I could no longer conceive. The marriage has ended because of my health condition.

“I am now assisting women who found themselves in my conditions. I am travelling across northern states and even to the Niger Republic to counsel women facing stigmatisation due to obstetric fistula,” Mrs Muhammed told PREMIUM TIMES.

Underage marriage

According to a United Nations survey, 43 per cent of Nigerian girls are married before they are 18. The problem of early marriage is particularly endemic in the North-east and North-west regions of the country.

With more than 80 per cent of girls married before their 18th birthday, Jigawa State has one of the highest prevalences of child marriages in the country.

Under the Child’s Rights Act 2003, the minimum legal age of marriage is 18 years. The act covers vital aspects of the lives of children and adolescents. It is divided into survival rights, development rights, participation rights, and protection rights.

Jigawa is among the Nigerian states that have domesticated the legislation. It, however, expunged the section that regulates the age of marriage for children.

In the state’s version of the Child’s Rights Act, parents are allowed to decide the marriage age of their children. Thus, the law in Jigawa still does not protect girls from underage marriage.

Aishatu Suleiman-Jahun, the head of the Baba Azumi Foundation (BAF), a non-governmental human rights organisation, said in Jigawa State, violence against person prohibition law penalises female genital modulation – one factor responsible for the Obstetric Fistula in the state.

“A person who cut a female genital and a person that hires another to cut a female genital will be sent to prison for a minimum of six months or pay a fine of a minimum of N10,000 or both.

“A person that attempts to cut the genitals of a female and a person that assists or counsels another to cut the genitals of a female will be punished with community service,” Mrs Suleiman-Jahun, a barrister, said.

27-year-old Binta Manu, from Jahun Local Government Area of Jigawa State, who got married at 14, told our reporter how she got affected by the fistula in her eighth child delivery.

“I got an obstetric fistula when delivering my eighth child. Of all the children I gave birth to, this is the first time that I am coming to the hospital for delivery because of complications.

“I took a long period of labour, and the baby was removed through cesarean. Two days after I was discharged from the hospital, while at home, I noticed that my urine was uncontrollable. I returned to the hospital again, where I was diagnosed with fistula and was successfully treated by the MSF doctors,” she said.

READ ALSO: UNFPA trains 210 VVF survivors in Borno

Mrs Manu described her husband as a caring man who stood by her in trying times. She was, however, worried about the condition of her co-patients, whom she said were divorced due to their conditions.

“It’s a bad experience for many of us who have undergone the treatment. Some men are not patient enough to stand with their wives in trying times like this. I witnessed how at least five of my co-patients were divorced because of their condition, and their husbands married other women while they were undergoing treatment,” she added.

Dangers of traditional practices

Some women receiving treatment at the hospital have VVF after engaging in harmful traditional practices during home delivery.

Unskilled traditional birth attendants ruptured their bladders, said Halima Uba, a nurse who has been treating fistula patients for several years.

Mrs Uba, a focus of the Jigawa Ministry of Health at the hospital, said harmful traditional practices such as ‘Yankan Gishiri’ – a cut performed during labour by traditional birth attendants meant to expand the pelvic outlet to relieve obstructed labour and aid delivery also, aside from the long obstructed labour during the home delivery, often resulted to fistula.

“Traditionally, when a girl runs away from a forced marriage and her husband complains about difficult penetration during sex, her parents would think something was blocking their private part that needs to be removed. They get traditional barbers, locally called Wanzan, to open their vaginas. This usually affects her bladder, causing uncontrollable pouring of urine, and sometimes faeces,” Mrs Uba said.

She said though the hospital gets patients from across the north of the country and even from Niger Republic, the treatment process is slow.

“From 2008 to date, when the fistula department was handed over to MSF, we admitted over 4,000 patients across the states in the north. Some of the patients have both urine and faeces running down on them. We need to treat one at a time which usually causes prolonged stay in the health facility,” she said.

“Some of our patients are being stigmatised by their family and the larger community, some of them are being abandoned in the hospital by any caregiver from their relatives, and some got divorced while on admission in the hospital.

“They are being divorced while on treatment some of the patients got divorced after the successful surgery was repaired due to a belief that they will no longer conceive. Divorce is one of the major challenges we are facing while the patients are on admission,” Mrs Uba lamented.

A patient with repaired fistula can have normal sexual life- Expert

Obstetric fistula occurs mostly in girls whose pelvis are not mature for reproductive function. It is also common in girls who suffer from malnutrition and polio. They usually lack the strength to deliver by themselves unless through cesarean, said Na’ima Idris, a Kano-based reproductive health expert.

“It also occurs in adult women with illnesses such as diabetes. It’s prevalent in underserved communities with the dominance of low-income earners and where women are being marginalised – with poor medical accessibility, acceptability and affordability.

“Fistula is preventable, and when it occurs, there is going to be reconstructive surgery to repair the fistula. Afterwards, when it is treated, women can have a normal sexual life and deliver as many babies as they want.

“However, problems occur only when the fistula is left unrepaired – the patient will contract reoccurring infections, chronic incontinence and even infertility,” Mrs Idris said.

On underaged marriages, Mrs Idris said a girl’s maturity goes beyond the ages of puberty – their physical maturity must correspond with inner development – which gives them the strength to deliver a baby. The gynaecologist insisted that parents should evaluate the development of their children before allowing them to get married.

Efforts are being made to address the problem

The Head of field communication for the MSF in Nigeria, Abdulkareem Yakubu, told PREMIUM TIMES that the MSF’s medical team repaired 524 women across Nigeria using surgical procedures at the Jahun Hospital between 2021 and 2022.

Mr Yakubu said having completed their treatment, the women left the MSF’s care in Jahun and returned home after a colourful celebration ceremony last conducted in December last year.

“The ceremony is also an opportunity to promote the socio-economic integration of these women who have often been pushed aside. We give them spaghetti-making machine and flour to enable them to start a small business at home as a self-reliant activity”, Mr Yakubu quoted Jean-Clément Ishimwe, the MSF’s Field Coordinator in Jahun.

“Around 50 women who completed the fistula treatment will start a rehabilitation and skill acquisition training in January 2023, a programme that is supported by the Fistula Foundation and the Jigawa State Government.

“The international medical organisation, Médecins Sans Frontières/Doctors WithoutBorders (MSF), is calling for a concerted effort to help women affected reintegrate into their communities and prevent these devastating injuries from occurring in the first place by expanding access to quality maternal care.

“Since 2008, when MSF started its activities in Jahun, the organisation has been providing surgical repairs, physiotherapy, occupational therapy, and psychosocial support to women suffering from fistula. This condition often leads to shame, isolation and stigma, with husbands, families and communities excluding the women who suffer from it.

“Most of these women usually live in abject poverty, shunned or blamed by society which leads them to fall deeper into poverty and further despair. Many of the women who develop fistula lose their babies to stillbirth, which adds to their depression, pain and suffering,” the MSF said.

However, due to the corrective surgeries and reintegration programme by MSF doctors at Jahun General Hospital, many women, like Ms Abubakar, are getting their lives back. They are filled with hope for the future.

“Life is difficult. I only feel happy whenever I am at home with my parents, or I come to Jahun Hospital and meet the doctors from the Médecins Sans Frontières who treated me. They gave me hope and courage to live, and when I saw other women who are yet to be healed, I gave glory to God,” she said.