Why Fistula is prevalent in the North – Dr. El-Ladan

In Nigeria, there are about 120,000 to 150,000 cases of obstetric fistula each year, with about 12,000 new cases occurring annually. In this interview with AJUMA EDWINA OGIRI, the chief consultant, obstetrician gynaecologist and Medical Director of the National Obstetric Fistula Centre (NOFIC), Babbar Ruga, Katsina, Dr. Aliyu Mohammed El-Ladan, talks about the causes of fistula, solutions to ending it, as well as the high prevalence in Northern Nigeria.

Causes of obstetric fistula
Fistula is not caused by young or old age, it is caused by failure to intervene in labour. When a woman is in labour, there is what we call active labour; that is when you have labour pains in association with the neck of the womb which is the cervix, opening up for the baby to come out. When that process begins, it should not last more than eight hours.

But when you find a woman being in labour for four to five days at home before coming to the hospital, there will be prolongation of labour, and this will lead to the compression of the bladder against the burning pelvis by the head of the baby, thereby causing the tissue to die in between.

The tissues are deprived of oxygen by compression. The burning head compresses the soft tissue against the burning pelvis and the area that is compressed is deprived of blood supply and therefore oxygen supply, so the tissue dies. This will cause the woman to have Vesico-Vaginal Fistula, otherwise known as VVF.

VVF can be prevented in anybody, young or old, if labour obstruction is realised early, and intervention to deliver through caesarian section is instituted on time.

If you have obstructed labour and you are operated within three hours of the obstruction, you will not have VVF because the tissue would not have had time to die.

But if you are thinking about factors associated with VVF, you can say young age. This is because the young woman has a smaller pelvis and may not be ready. Even if she is not ready, but realised to be in obstruction in time and intervention is instituted she will not have VVF.

Fistula repair in NOFIC
What distinguishes us from most of the other fistula centres is that we do routine repair every day; every day we are in the theatre. We do four to six repair surgeries each day on a regular basis.
The work we do, the success we record and the patients we manage, are the ones who advertise us to the public.

The success story they tell is what brings women who have been hiding to come to us for repair. Patients who have also had failed surgeries elsewhere, will also hear these stories and come to us.

But when we have pool repairs, it is the Non-Governmental Organisation, like Engenderhealth, that help us through their community based workers to go into local governments, villages and towns, to bring patients.

They also do advertisement through radio and television, which also tends to bring out more patients.

The last pool effort, we had about 70 patients, and we repaired about 50 of them that week.

So, we had to manage the remaining the week after. By the time we finished managing the remaining ones, they looked at the success recorded and requested for a second round of pool effort before the year ran out, that is why we had a second one.

We are making more efforts to do more of this pool repairs to clear the backlog, because of the call to end fistula by the year 2020. We are also trying to prevent the development of new fistula cases by establishing proper antenatal care, labour and delivery supervision.

Why VVF is prevalent in the North
VVF is more common in the northern part of Nigeria because our culture is a little bit different. In the South people are more enlightened in terms of a woman knowing the need to go to the hospital.

In this place, the mother-in-law and daughter-in-law relationship is a little bit different; your mother-in-law is like a demigod to you. If she says don’t go to the hospital, your husband is not likely to counter his mother’s decision.

So, if she says ‘I delivered 20 times and I didn’t go to the hospital, therefore my grandchild will not be delivered in the hospital,’ that will cause delay in the decision to go to the hospital for care. The more you delay, the more the danger or possibility of having obstructed labour and therefore VVF.

Secondly, we tend to have women given out for marriage at a very young age. The younger she is, the less likely she knows she is a woman. She just knows she has breast, she can menstruate and can have sexual relationships.

What that entails, she is yet to come to grasp with it. She does not know that she should take direct responsibility for her health, she just surrenders to whatever the family decides for her and that is the danger. She is the one who will suffer, but somebody else is the one taking the decision as to when she will go to seek for help.

In other parts of the country, the women tend to marry much later. Even if they don’t go to school, they don’t get married before 25 or 30 years old. Here in the North, most of the girls get married maximum 17 or 18, and the next thing they are getting pregnant and having babies.

Ending fistula
The solution to fistula is that people, parents, husbands and even the women themselves need to understand that although pregnancy is a normal and life-giving event, it can become complicated.
The best thing any woman can do for herself or a family that has a pregnant woman, is to go to a hospital for antenatal care. And when it is time for her delivery, they should have access to a good hospital where she can labour and deliver under supervision.

If she succeeds and delivers on time, fine, but if the labour is delayed or obstructed, before it becomes dangerous to the woman or baby, an intervention can be done medically or surgically.

So, unless the community takes care of their women in pregnancy, we will not get anywhere. This is why the communities has to understand that healthcare is in their hands.
We have more Primary Healthcare Centres than even WHO recommendation, but the problem is manpower. Healthcare is not cheap, the pay package for doctors, nurses and most healthcare workers are a little bit on the high side, so a lot of them run away from employing good staff.

The local government has to take that responsibility, and the state governments have to provide a general hospital cloned around five or six primary healthcare facilities, so that they will have a secondary facility where they can all refer their women for caesarian section if there is any problem within that locality. The key to fistula is good ante-natal care, supervised labour and delivery and a good caesarian section.

What we are doing now is just emptying the bowl; the tap is flowing, the bowl is full, we empty it and put it back under the tap otherwise the whole room will be flooded. The tap can only be stopped if we can have good ante-natal care, supervised labour and delivery services and caesarian section when necessary. If we can do this we can eliminate fistula.

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