●How lack of hospitals, child marriages, others promote obstetric fistula
●Desperate locals construct ‘Cowrollas’ to convey pregnant women to distant clinics
By Cosmas Omegoh
As Dr. Sunday Lengmang spoke, his voice was crisp and clear, his words ringing out with authority. They vividly reminded everyone that “knowledge is power.”
He held everyone spellbound while discussing the monster called obstetric fistula and its nightmare, drawing applause from the audience.
Obstetric fistula is a hole, which develops in women between the vagina and rectum or bladder as a result of prolonged obstructed labour.
Then at some point, Dr. Lengmang changed gear, digressing to give a regrettable account of how women, who go into labour in some parts of the country spend long hours on their way to the nearest healthcare facilities. He said those journeys were made in wheel barrows and carts, on bicycles, cows or donkeys’ backs. He said sometimes those handy means of transportation get bogged down in sinking sand or impeded by rocky or marshy terrains, thus adding to the women’s miseries. He regretted that even in areas where there seemed to be fairly good roads, there are often no vehicles to take persons, needing urgent medical attention to the nearest clinic. He said it’s at such point that the ingenuity of the people come to play.
“They fashion out a craft by yanking the carriage of a disused truck, which they mount on a pair of used tyres and fasten the contraption to the horns of a few fully-grown cows and then edge them on. An improvised vehicle is on the move. The name of this vehicle is New Cowrolla!”
With this, the presentation, which had the character of a review, turned to a comedy, forcing the audience to erupt into wild laughter.
The whole episode mirrored the startling reality of the lot of women in some remote parts of the country, who suddenly go into labour and what it takes to get them to hospital.
The venue was Bolton White Hotel, Abuja and the occasion was the health tribunal organised Christian Health Association of Nigeria (CHAN). Once every year, representatives of managers of Christian faith-based hospitals and health facilities in the country, believed to be in the region of 5,550 gather to review their activities and share ideas on how to provide quality healthcare services to rural communities across the country. They also seek ways of working with the Federal Government and donor agencies to keep their health facilities going good.
On this occasion, it was the turn of Dr. Lengmang and his institution, and the specialist family medicine practitioner, with training in Obstetrics and Fistula Surgery, was in command. He is the Project Director of Bingham University Teaching Hospital VVF Centre, Jos, an institution promoted by the Evangelical Church of West Africa (ECWA).
Many of his listeners were medical experts, representing various medical schools run by Christian faith universities. Others were clergymen and women managing Christian health facilities in various states. Officials of the Federal Ministry of Health, Abuja, were present too. Everyone listened to Dr. Lengmang, as he reviewed his organisation’s long effort at helping women suffering from obstetric fistula, aka VVF.
“Obstetric fistula is a problem afflicting women and girls. It results from prolonged obstructed labour. This occurs when there is a disproportion between the head of the baby and the passage of the woman. When the head of the baby is bigger than the passage, it will not be able to pass through during delivery and that leads to the problem between the bladder and the vagina or between the rectum and the vagina, leading to a 24-hour continuous leakage of the urine and faeces by the woman.
“We are having a researched estimate that in Nigeria, we have about 150,000 women living with fistula and awaiting surgery. And every year, we have about 12,000 new cases being added to that number.”
He said although this phenomenon was largely believed to be the nemesis of most women, living in the northern part of the country, women in the South too were being afflicted by fistula.
“VVF exists in virtually all the states of the country,” he said. “But it is most prevalent in the north western and north eastern parts, followed by the north central part. It usually occurs less in the South; but the South-south region is now increasingly experiencing the condition, followed by the South-east and then the South-west. In the South-east, it is being recorded in Ebonyi State where a national VVF hospital has been established. In the South-south, Akwa Ibom State is in the lead, with traces of fistula reported in Cross River State.
“The phenomenon occurs far more in the rural than the urban areas because it afflicts poor people, living far away from healthcare centres. So, it is mostly a problem of the rural areas.”
As for the cause of the condition, he said: “Different things lead to this, but the main one is prolonged obstructed labour. This occurs because of different reasons. In the South-south, for instance, some people neglect going to the hospital when they are pregnant. They prefer going for delivery in churches because of traditional beliefs in evil spirits’ influence on delivery. So, when we have delivery occurring in places where there are no trained hands, prolonged labour is sure to occur.
“In the North-west and North-east, there is the prevalence of early marriage and early pregnancy. During such delivery, the head of the baby is usually bigger that the passage of the mother because the mother has not completed her growth before becoming pregnant.
“But the worrisome development now is that we are beginning to see more women that are delivered normally, who come down with fistula in subsequent deliveries because of mismanaged surgical procedures in the hospital. This is beginning to occur in the places where quacks and poorly-trained doctors are operating; so their patients are having fistula.”
Dr. Lengmang, who is now a national consultant on fistula, sounded an alarm bell, warning that something drastic needed to be done to halt the march of the monster.
“There has to be a lot health education; there has to be a lot of community effort to make people aware of the danger of this condition; people have to be educated at the community level.
“At the individual level, people have to be aware of the prevalence of this condition and its dangers.
“Women should not be allowed to labour up to one day. The maximum length of time a woman delivering for the first time has to spend in labour is 18 hours. After the first delivery, no woman should last beyond 16 hours in labour. Any woman, who has laboured up to 16 hours should be taken straight to the hospital immediately where there can be caesarean section intervention to overcome the challenge. Once this is not done, the woman can develop fistula. So, it is important for women to develop the culture of going to be delivered in the hospital and to stay away from traditional beliefs that encourage fistula to occur.
“Sometimes, this happens because of lack of money to go to the hospital. So, people have to be educated to know that once they get pregnant, they should start saving to be able to go to the hospital because they can never tell if they will deliver via caesarean section or not.
“Besides, bad cultural practices like the female genital mutilation in the South and some parts of the North can result in fistula. This is a direct cut done traditionally, which can also lead to the condition. We need to discourage that practice in order to keep out fistula.
“Since fistula can be caused be quacks or poorly trained doctors, government needs to ensure that quacks are not allowed to practise and young doctors are properly trained to do the procedures they are undertaking. If this is not done, people will continue to struggle with fistula, not minding whether they patronise hospitals for delivery or not.”
According to him, surgery was the only solution to fistula. He said: “If a woman has fistula that has lasted up to one month and it has not closed, chances are that it will remain for life unless it is surgically corrected. Up to 80 per cent of women can be treated of fistula and they get dry. In 10-20 per cent of women, the fistula might close but the woman might remain incontinent because her continence mechanism has been destroyed. There are other surgeries that can be done to take care of fistula. In some conditions, the fistula might not close at all. So, there are bigger surgeries that can be done to divert the urine from the urine system to another place so that the woman can achieve continence.”
He, however, informed that all hope wasn’t lost. “Government has done enough in the past years to stop fistula through the establishment of VVF centres across the country. Now we have 15 of such centres in the country to complement the few numbers that existed. The Federal Ministry of Health had started three new VVF centres – one each in Abakiliki in Ebonyi, Katsina in Katsina State and Ningi in Bauchi State. So, they have stepped up action against fistula, targeting prevention, treatmentand rehabilitation. But the burden is still large and a lot still needs to be done to curb the menace of fistula in the country.”