12,000 fistula cases occur annually in Nigeria— Dr. Zakariya

Dr. Suleiman Zakariya, is a fistula surgeon, public health physician and a clinical associate, for Engender Health Fistula Care Plus project; a USAID funded project that seeks to prevent, treat, reintegrate and rehabilitate obstetric fistula patients in Nigeria. In this interview with AJUMA EDWINA OGIRI, he speaks on high prevalence rate of obstetric fistula in the country, and the shortage of qualified surgeons to tackle it.

Burden of obstetric fistula in Nigeria
Globally, obstetric fistula is a public health concern. There over two million cases of obstetric fistula patients globally, with majority of them in sub-Saharan Africa and Asia.

In Nigeria we have about 120,000 to 150,000 cases of obstetric fistula, with about 12,000 new cases occurring annually in the country.

We only have the capacity; that is the combined efforts of all the partners in the country, to repair just about 5,000 cases. It means we always have a backlog of about 7,000 added to what already exists, in terms of the prevalence.
The number of new cases far outweighs the capacity to repair. So, we need to redouble our prevention strategy.

Causes of fistula
Obstetric fistula primarily is a result of prolonged obstructed labour, 80 per cent to 90 per cent of all fistula cases are as a result of prolonged obstructed labour.
We have other causes of fistula like, traumatic fistula; as in the case of violent rape, and iatrogenic fistula; which occurs as a result of inadvertent hospital procedures, chiefly caesarian operations.
The most common cause of obstetric fistula in the country is prolonged obstructed labour.

The social demographics of the categories of women that come down with these maternal morbidity and mortality issues are usually rural women, with no education and low socio-economic status. Absence of emergency obstetric care usually results in the formation of obstetric fistula.
When we have functional hospitals, like Primary Health Centres, within their catchment areas and we orient them culturally, they will seek expert care during pregnancy, labour and delivery.

But when these emergency services are absent, chances are high that these women will come down with obstetric fistula, especially during labour and delivery, if not supervised by a skilled birth attendant.

Common types of fistula
We have Vesico-Vaginal Fistula (VVF); this is as a result of an abnormal hole created between the urinary bladder and the vagina, leading to uncontrollable leakage of urine into the vagina vulva.
We also have the Recto-Vaginal Fistula (RVF), which is an abnormal hole between the vagina and the rectum, resulting to uncontrollable leakage of faeces into the vagina vulva.
These two conditions can co-exist or occur concurrently in a woman.
A woman can as well have VVF with no RVF component or RVF with no VVF component.

It depends on the point where the head of the baby is causing the necrosis, as against any of the pelvic bones. If the head of the baby is infringing on the urinary bladder against the pubic bone, that could result to VVF.

But, if the head is infringing on the rectum against the pubic bone, due to the necrosis of the tissue around there, a hole could result abnormally as a result of the dead tissue, between the rectum and the vagina, thereby leading to RVF. It is a very devastating childbirth injury.

How prolonged labour causes fistula
This is as a result of a mechanical obstruction; a disproportion between the head of the baby and the pelvic. This is what usually results in prolonged obstructed labour.

The labour will last longer than normal, and then the woman will not be able to deliver. She is going to need an emergency medical intervention in terms of caesarian operation, which if not available can lead to foetal death, and as well as the mother coming down with significant morbidity. That is if she is lucky not to lose her life during the process.

There are a lot of conditions that could make a labour to be prolonged, but not obstructed. It is only in a hospital with trained and skilled medical personnel that the progress of labour is accessed and monitored on a partograph; a graphical representation of how labour is progressing.

Hospital personnel are trained to record, read and take action depending on what the partograph indicates, and also based on clinical assessment of the patient. These are things that are carried out early by skilled and trained medical attendants.

Northern Nigeria, early marriage and fistula

Early marriage is not the major cause of fistula, as generally believed. It is chiefly as a result of prolonged obstructed labour, in the absence of skilled emergency medical interventions. It can happen to anybody.

Outside the country, 14-year-old girls give birth to babies without complications. This is because the eat the right nutritional foods to prepare them for delivery.

It is more in the North because that is where they don’t hide it. It is also in other parts of the country, as much as it is in the North, just that the people there hide it or do not talk much about it.

Shortage of fistula surgeons in Nigeria
Only few surgeons in the country have the interest and capacity to repair obstetric fistula cases. We are actually trying to clinically manage cases of obstetric fistula in Nigeria.

The challenge has been how to retain even the few doctors we have. Retention of fistula surgeons within the system has actually been a challenge. Most surgeons in Nigeria are not interested in fistula repair because it is not lucrative.
On Engender Health Fistula care plus project

Engender Health Fistula care is the only key player in Nigeria, when it comes to prevention, treatment, reintegration and rehabilitation of obstetric fistula clients.
We have other implementing partners like UNFPA and Fistula Foundation. UNFPA does fistula occasionally. Other people do it as a one-off thing.
MSF supports one centre in the North. Engender Health is the only one that has sustained the tempo through USAID to do fistula work.

If you add all the ones the other people are doing, maybe we will have about 4,000 repairs. It is not up to the number of new cases every year, let alone tackling the backlog.

We are in 13 states; Sokoto, Kebbi, Katsina, Ebonyi, Kano, Bauchi, Kwara, Cross River, Zamfara, Oyo, Kaduna and Osun. In all these states, we support the treatment of obstetric fistula, as well as prevention and integration through our community services.

Treated cases
Each year we have the capacity to repair between 2,000 to 2,500 cases of obstetric fistula surgically or conservatively, through the use of catheter.

We are actually doing a lot regarding prevention and the treatment of obstetric fistula in the country, in partnership with the Federal Ministry of Health and other implementing partners in the country.

We always double our efforts to see that we do more because of the ever-increasing number of backlogs that reoccur each year in the country.
We do this via a dual approach of supportive routine services as well as conducting free of charge fistula repairs.

The routine services we support are across health centres that have the required expertise and surgeons that are skilled to perform this operation.
Those centres that have the surgeons to do this operation, we always encourage them by retraining them, providing them with essential theatre consumables that are required for the operation.

The services, from admission to discharge, are free for the patient. Government has been really supportive in our partner states. We have a community mobilisation activity that we conduct towards creating awareness to these patients on the dangers of obstetric fistula. We focus on the rural areas because that is where the case is most prevalent.

The social demographics of the categories of women that come down with these maternal morbidity and mortality issues are usually rural women with no education and low socio-economic status.

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