Fistula is a health condition that most conscionable humans will not even wish for their enemies, especially when the condition is almost entirely preventable. Suffered by hundreds of thousands of women in Nigeria, VICTOR OKEKE in this report writes on the culpability of some surgeons in this case.
The experiences of 20-year old Deborah Joshua from Vandeikya Local Government Area of Benue State, Nigeria, to that of 22 year-old Linda Ojini, from Bamanga in Cameroon Republic, attest to the culpability of medical doctors in widening the fistula burden.
Deborah Joshua narrated her story, “After I got married, I became pregnant and when I was due for delivery I went to the hospital. I stayed at the hospital for three days- from Friday to Monday and I couldn’t deliver by myself. It was then that the doctor carried out an operation on me to bring out the baby. After that, the baby died and I also developed this sickness.
She has been experiencing urine leakage for over one year and six months now after she had the C-section.
She said that the doctor at the Katsina-Ala hospital where she had the C-section attributed the leakage to the long period she went through labour of child delivery.
Joshua has since been abandoned by the boy that got her pregnant but thanks to Fistula Care Plus, she has been healed.
Also, Alice Ebagu from Gakem in Bekwarra LGA, Cross River State, told the story of how she got married four years ago, but was not able to put to bed on my own during pregnancy, then opted for a C-section and then developed a fistula afterward.
“I was there with the problem. I did not know what to do but luckily one of my sisters called me that there is solution to this problem at the Ogoja Hospital. I thank God and that was how I came here,” she said.
She said the C-section was conducted at a private clinic she called Dr Otobo Clinic in Bekwarra.
Elizabeth Ebok Ayam, who is at the post-operation ward, also had a similar experience.
According to her, when she was pregnant, her mother took her to Dr Benson’s hospital in Ikom, Cross River State where the doctor told her that the baby had died in her womb.
“At the hospital, the doctor said that my baby had died inside the womb and he operated on me to bring out the baby, that was how the doctor spoiled me.
He came and knelt down and was begging my mother to forgive him as he as ‘spoilt’ her daughter. That is why I’m passing through all these.”
Also, 22 -year-old Linda Ojini, from Bamanga in Cameroon Republic, said she dropped out of an Arabic school from class six following an incident of unwanted pregnancy worsened by an escapee boyfriend. “I got pregnant and when my labour started I went to the hospital to deliver the baby but the baby could not come out and later when my baby came out, urine started coming out also.”
She explained that it was her brother who took her to a hospital in Bamanga, Cameroon where her mother is staying but was met with an unsuccessful treatment.
She was later referred to the Fistula centre in Ogoja by her uncle who she said, spent N4,500 to get to Nigeria.
Most women in the developing world, including Nigeria, are experiencing “unimaginable suffering” due to lack of effective care during pregnancy and childbirth.
According to medical experts, non-fatal maternal childbirth injuries such as Vesico Vaginal Fistula (VVF) often have devastating psychological and social consequences with an impact greater than maternal death.
VVF is an abnormal communication between the urinary bladder and the vagina that results in the continuous involuntary discharge of urine.
In other cases, it is called obstetric fistula, which is a hole between the vagina and the rectum or bladder that is caused by prolonged obstructed labour, leaving a woman incontinent of urine or faeces or both.
This condition has tremendous psycho-social and health consequences on the affected women as the uncontrolled urine or faeces leakage causing unpleasant odour results in social stigma and consequent neglect.
Most women affected are living in shame and isolation, often abandoned by their husbands and excluded by their families and communities.
According to the United Nations Population Fund (UNFPA), in Sub-Saharan Africa alone, between 3,000 and 130,000 of women giving birth develop fistula each year.
However, in up to 90 per cent of cases, the fistula can be surgically repaired.
Through the Fistula Care Plus project, the largest U.S. government-funded effort to date dedicated to treating and preventing fistula, EngenderHealth works to restore dignity to women with fistula and to prevent other women from developing the condition.
Engender Health Nigeria Country Project Manager; Chief Iyeme Efem, says Nigeria currently has over 200,000 women living with fistula with 12,000 new cases occurring every year.
The prevalence of fistula is much lower in places that discourage early marriage, encourage and provide general education for women, and grant women access to family planning and skilled medical teams to assist during childbirth.
Hence the burden of fistula rests largely on the women in poor rural communities of Nigeria and its severe nature puts a serious toll on the lives of those affected.
Majority of the victims are very young and without the basic elementary education. Most of them find it difficult to engage in any economic activity, surviving the hardship is very complicated and pathetic as coping is done in isolation and loneliness.
Some of the studies were explained in a presentation by Prof Oladosu Ojenbgede, during a ‘hands-on training on VVF repair workshop’ at the 51st annual scientific conference of the Society of Gynaecology and Obstetrician of Nigeria (SOGON) held at the Usmanu Danfodiyo University Teaching Hospital (UDUTH) Sokoto this week.
Also, last week, as part of its activities in Nigeria, EngenderHealth gathered a pull of several expert fistula surgeons in Ogoja, Cross River State, the location of one out of the 13 fistula hospitals the charity operates in Nigeria, to carry out surgeries on over 25 women suffering from fistula.
Most of the patients narrate how they developed the fistula following caesarean section operations to get the baby out after a prolonged obstructed labour and in all the instances, their babies died.
Dr Sa’ad Idris, Lead Fistula Surgeon, former Commissioner for Health, Zamfara State, explained how increased access to cesarean sections without regard to quality of care is causing an increase in Iatrogenic fistulas, a form of fistula unintentionally caused by a health care provider.
Unfortunately, Idris said that the trend of fistula is now changing in that most incidents are caused by lack of medical expertise during surgery. “We are seeing more fistulas caused by the medical personnel during the caesarean section- operation to remove the baby-maybe because of a lack of expertise or some other conditions which we are trying to see if we can liaise with the Society of Obstetricians and Gynaecologists (SOGON).”
He said Fistula Care Plus is sponsoring many doctors for specialised training on fistula treatment and to have round-table discussions so that the issue can be addressed right from the university.
“You don’t have to be a specialist to do a caesarean section but you have to be doctor. Now a doctor even at the House Officer level should be trained to know that if you are going to conduct a C-section you have to reflect the bladder very otherwise, what we are seeing more now is what we are seeing more is fistula following a C-section operation which is technically very difficult to do,” Idris added.
Iatrogenic fistulas are sometimes caused by inexperienced clinicians who are thrown into situations with many patients. According to data from Fistula Care Plus, of nearly 6,000 fistula repair cases in 11 countries, approximately 13 per cent were caused by surgical errors performed by all types of clinicians.
According to Chief Iyeme Efem, there is a big challenge of expanding the curriculum of medical training and education in Nigeria.
He said that a clinician is not trained and graduated from the medical school knowing how to do fistula surgery. “Even when you specialize as a gynaecologist, you still do not have the expertise to do fistula surgery. You need additional training. We look for all opportunities to talk to them.
During doctors’ meetings, we also have opportunities to talk to them telling them that their doctors are doing a lot of harm and causing a lot of trauma to pregnant women.”
“It is challenging that when these women go to hospital for delivery (and we preach delivery under trained healthcare provider and attending antenatal) when they do all of these, then have a C-section and end up with fistula. That is not right,” Efem said.
He noted that fistula is just one component of the morbidity and a marker on the poor health system including the skills of the surgeons. “We are now working on a strategy we call unlocking potentials, potentials that exist in certain levels -tertiary institutions, which can be unlocked to be able to do fistula at that level.”
Efem said that the minister of Health, Professor Isaac Adewole has given his approval for the 49 teaching hospitals in Nigeria to begin a programme of free treatment of fistulas in order to tackle the mounting backlog of women living with fistula in the country.
“The minister said that the skills are resident in the teaching hospitals and he has signed a memo to all the teaching hospitals waiving the fees for fistula repairs. He has waived fees for registration, and bed space and so on. We will support them by providing consumables,” Efem said.
Medical experts are of the view that healthcare authorities must ensure that with the rapid expansion of surgical care in low- and middle-income countries comes high quality care.
They said if rates of Iatrogenic fistula continue on the current trajectory, the caseload for fistula will remain steady, even if fistula from prolonged and obstructed labour no longer occurs.
Taking swift action will help guard against normalising iatrogenic fistula.
Doctors working with EngenderHealth under the Fistula Care Plus programmes called for the following five actions to address iatrogenic fistula: Standardise aetiology definitions, signs and symptoms used to classify fistula. This will allow doctors to analyse trends and make valid comparisons between facilities and settings.
They said increase awareness of Iatrogenic fistula in the obstetrician-gynaecologist and surgical community to accelerate improvements in surgical workforce training as well as clinical environment.
Secondly, effective improvements in surgical and post-operative team training and work environment- this applies to all clinicians, not just lower-level providers.
Thirdly, improve decision-making regarding surgical obstetrician gynaecology procedures. Preventing unnecessary surgeries is crucial to preventing iatrogenic fistula.
Fourthly, implement routine monitoring and reporting of iatrogenic fistula in settings where surgical ob-gyn care is provided.
Fifthly, preventing the need for surgery in the first place—by preventing unwanted pregnancy through family planning and preventing unnecessary caesarean sections and hysterectomy surgeries through proper antenatal care and skilled obstetric care—is critical to preventing iatrogenic fistula.
When surgery is needed, however, standards, guidelines and accountability mechanisms will help ensure high quality and optimal outcomes for mothers and babies.