Overcoming Obstetric Fistula Burden

Obstetric Fistula remains one of Nigeria’s most devastating yet neglected maternal health crises. The childbirth injury, caused by prolonged obstructed labour without timely medical care, leaves women leaking urine or facing stigma, isolation, and poverty, writes Catherine Egwuom

When 17-year-old Fatima Ibrahim went into labour in her home in Kano with no antenatal records and a skilled birth attendant present, her pelvis was too small for the baby.

Six days of obstructed labour ended with a stillborn child and a devastating injury: Obstetric Fistula.

“I felt the pressure for so long, then suddenly nothing. Now, urine leaks constantly. My husband left me. I live in shame,” Fatima said.

Fatima’s story illustrates three of the interconnected causes of obstetric fistula affecting an estimated 2 million women in Asia and sub-Saharan Africa, according to the World Health Organisation.

A fistula is an abnormal connection or hole between two organs or vessels that should not be connected. Among such is Obstetric Fistula, which occurs between the vagina and bladder (vesicovaginal fistula) or rectum (rectovaginal fistula), also known as Vesico-Vaginal Fistula (VVF).

Fatima was a victim of three of the interconnected causes of obstetric fistula -obstructed labour, adolescent pregnancy, and not having access to antenatal care/healthcare.

According to the World Health Organisation (WHO), the development of obstetric fistula is directly linked to one of the major causes of maternal mortality, which is obstructed labour.

“When obstructed labour is unrelieved, the presenting fetal part is impacted against the soft tissues of the pelvis and widespread ischemic vascular injury develops that results in tissue necrosis and subsequent fistula formation,” WHO explains.

Prolonged pressure cuts off blood flow to tissues between the bladder and vagina, causing them to die and create a hole. Urine leaks continuously through this opening.

Also, as a risk multiplier, adolescent pregnancy increases fistula risk.

In Nigeria, 19 per cent of girls aged 15-19 have begun having children, with rates hitting 32 per cent in rural areas, according to a 2024 fact sheet on Nigeria’s teenage pregnancy burden.

“Cephalopelvic disproportion often complicates deliveries in young, primiparous women of low gynecologic age,” said the UNFPA global fistula campaign, noting that young girls’ pelvises haven’t fully developed, making obstructed labour far more likely.

Escalating the incidence, lack of antenatal care removes the critical opportunity to identify high-risk pregnancies before labour begins.

A 2020 study on obstetric fistula prevalence and risk factors found that inadequate antenatal care significantly increases the risk of fistula.

It is estimated that globally, no fewer than two million women “are living with untreated obstetric fistula, while between 50,000 and 100,000 new cases occur annually.”

In Nigeria alone, between 100,000 and one million women may be living with an untreated fistula.

WHO emphasises that fistula can largely be avoided by “delaying the age of first pregnancy and timely access to quality obstetric care,” including early access to antenatal care.

While obstetric fistula contributes significantly to maternal mortality, it can be prevented.

Outlining prevention strategies, Dr Aisha Adamu Buba, a Consultant Gynaecologist at Yobe State University Teaching Hospital, said: “Obstetric fistula is a heartbreaking consequence of neglected maternal healthcare.

“It’s preventable through family planning, early identification of high-risk pregnancies, skilled birth attendants, and emergency obstetric services.

“The key to obstetric fistula prevention is competent obstetrical care delivered respectfully, promptly, and at affordable cost.

“Healing begins with awareness,” Buba emphasises.

Dr Mohammed-Ado Zakari, Chief Surgeon at Hajiya Gambo Sawaba General Hospital (HGSGH) Fistula Centre, Zaria, noted that the condition remains a major public health and social problem, particularly among rural women with poor access to quality maternal healthcare.

He describes an obstetric fistula as an abnormal opening between the vagina and the bladder or rectum, caused mainly by prolonged obstructed labour, resulting in continuous leakage of urine or stool.

He also identifies early marriage, home delivery, shortage of skilled birth attendants, poverty, and prolonged obstructed labour as major causes of the condition.

He raises concerns over increasing cases linked to medical quackery and poor surgical practices, noting that many fistula patients have become victims of such unqualified medical personnel undergoing fistula repairs.

However, he says the centre, established through collaborative efforts of the Kaduna State Government, Rotary International, and Waaldijk to address the growing burden of obstetric fistula in northern Nigeria, has been doing successful fistula repair procedures.

He notes that the centre has successfully repaired over 2,000 obstetric fistula cases since its establishment in 1999, performing an average of 150 repairs annually, with a success rate of over 70 per cent.

According to him, five doctors and several nurses have also been trained at the centre under the mentorship of Dutch Fistula Surgeon, Dr Kees Waaldijk.

“I am retired and own a private hospital, but I know that the priority of some private clinics is money, not patient-centred services,” he says.

The surgeon, however, commended the Federal Government for interventions through the Basic Health Care Provision Fund (BHCPF) and the Comprehensive Emergency Obstetric and Newborn Care (CEmONC) initiatives.

Dr Hassan Adamu, the hospital’s Medical Director, reiterates the hospital’s commitment to providing robust health services to VVF patients.

He calls for increased investment by governments, development partners, and philanthropists to strengthen maternal healthcare services and eliminate fistula and childbirth injuries.

He also stressed the need for relevant authorities to take action against illegal operators.

Indeed, for obstetric fistula, early professional help is associated with a high repair success rate.

Dr Moriamo Shaibu, Medical Director of Gwarinpa General Hospital, said the centre has recorded more than 90 per cent success in fistula repairs, serving women from across the country, including Zamfara and Cross River States.

Dr Halima Bello, Head of the Fistula Centre, explains that the centre even offers comprehensive care beyond free surgeries.

“We provide holistic care, post-operative rehabilitation, counselling, and follow-up support to ensure full recovery and reintegration into society,” Bello says.

Also at the National Obstetric Fistula Centre (NOFIC) in Abakaliki, free surgical repairs are often offered, and they have been successful.

Mrs Egoyibo Adama, an obstetrics fistula survivor, recounts her successful fistula repair surgery and how the condition almost made her take her life, expressing that the condition is uncomfortable and embarrassing.

“One cannot even explain the severity except one has experienced it.

“It is not what I wish any woman to go through.

“You smell, you stink, you will be stigmatised, and you will be very unhappy.

“I felt like taking my life.

“I am happy to have gone through the surgery, and it was successful.

“I thank GOD and everyone who made it happen. I am grateful”.

To fistula survivors, Dr Henry Jumbo, Head of the Vesico Vaginal Fistula Unit, Federal Ministry of Health, urges survivors to reintegrate freely into their communities, noting that they are no longer victims but survivors and advocates.

Similarly, the Gombe State Commissioner for Health, Dr Habu Dahiru, advises fistula survivors to prioritise their physical and psychological healing before entering into new marriages.

Dahiru said that this holistic recovery process is crucial for long-term well-being and successful relationships.

He also cautions survivors of reproductive age to wait at least two years before remarrying, to allow the surgical repairs to heal properly.

According to him, remarrying or becoming pregnant too soon after surgery can lead to complications and possibly damage the repaired area.

“If you remarry immediately, there is every possibility that the repair will be damaged,” he warns.

The commissioner further advises survivors who eventually conceive to ensure regular antenatal visits and to inform healthcare workers about their previous condition.

According to him, this will enable medical personnel to provide appropriate care and prevent a recurrence of the problem.

Recognising the helpless conditions of those with fistula, governments and partners have continued to scale up free surgeries to end fistula.

The Federal Government is also lending its weight to ending obstetric fistula through a federal initiative that provides  Governmen is also lending its weight to ending obstetric fistula through a federal initiative that provides is also lending its weight to end obstetric fistula through a federal initiative aimed at providing free surgeries, rehabilitation, and health insurance coverage for women with obstetric fistula.

Under the National Health Insurance Authority (NHIA) Fistula-Free Programme (FFP) initiative of the Federal Government, no fewer than 1600 women with obstetric fistula have undergone surgeries to resolve the conditions.

Dr Saka Agboola, Head, Standards and Quality Assurance Unit of the National Health Insurance Authority (NHIA), said: “The government realises that the number of Fistula centres in the country was very few, hence the need to increase it to 18 nationwide.

“With this initiative, over 1600 cases of fistula have been resolved,” he says.

Agboola notes that Nigeria is on a mission to improve the health status of 400,000 Nigerian women with obstetric fistula in the country by reducing the maternal and neonatal mortality.

Agboola highlights that developing countries bear a higher burden of the disease, with about 1 million cases.

He adds that, through the programme, patients are saved from financial and physical pain, with feeding, transportation, and stipends covered.

“The National Health Insurance Authority (NHIA) has reiterated its commitment to quality healthcare, transparency, and accountability in service delivery.

`This renewed focus is exemplified in its support for the Fistula-Free Programme (FFP), which provides care for women affected by obstetric fistula.

Nevertheless, the Director-General of NHIA, Dr Kelechi Ohiri, stresses the importance of credibility, accurate data entry, and proper validation of claims as key factors in the programme’s success.

“The FFP is an innovative financing mechanism for poor and vulnerable women suffering from obstetric fistula.

“The use of third-party administrators for claims verification has improved accountability and ensured efficient resource utilisation,” he said.

Ohiri notes that the NHIA is playing a strategic role in expanding access to quality fistula care through sustainable financing and partnerships with accredited centres.

He adds that with strengthened data systems and community-based approaches, the Authority is not only delivering healthcare but also restoring dignity, hope, and a future to thousands of Nigerian women.

For the First Lady, Sen. Oluremi Tinubu, no woman or girl should suffer from obstetric fistula, because the condition is both preventable and treatable.

Egwuom writes for the News Agency of Nigeria