An obstetric fistula (OF) is an “abnormal opening between a woman’s vagina and bladder and/or rectum through which urine (vesico-vaginal fistula) and/or faeces (recto-vaginal fistula) continually leak”. An obstetric fistula can also occur between the urethra and the vagina (urethrovaginal fistula), between the ureter and the vagina (ureterovaginal fistula) and rarely, between the bladder and the uterus (vesicouterine fistula). Vesicovaginal fistula is the most common type (in Nigeria). This condition has terrible effects on a woman’s life and remains a source of public health concern to the United Nations and its member states.
According to the World Health Organisation (WHO), 50,000 to 100,000 women are affected annually worldwide and women who experience this suffer constant incontinence, shame, social segregation and health problems. It is also estimated that over 2 million young women in Asia and Sub-Saharan Africa have untreated obstetric fistula. In developing countries like Nigeria, over 1 million women are affected by this condition.
Obstetric fistula can be prevented by raising the age of the first pregnancy or by delaying the age of the first pregnancy, eliminating hazardous traditional behaviours, and improving access to obstetric care. However, in Nigeria, there is a backlog of OF treatment as it remains persistent due to a lack of awareness and delay in eradication.
In Nigeria, the prevalence of obstetric fistula is 3.2 per 1000 births, with an estimated 13,000 new cases per year indicating that the backlog of unrepaired cases might take up to 83 years to clear at current repair rates. According to the United Nations International Children’s Emergency Fund (UNICEF), there are around 400,000 to 800,000 Nigerian women living with OF, with a further 50,000 to 100,000 cases recorded each year.
The increased burden could be attributed to a lack of reliable data on prevalence and incidence, inaccurate maternal morbidity statistics, inadequate human resources to address the backlog, poor funding and the lack of modern technology. OF is a severe and tragic birth injury that can lead to depression, social isolation, chronic medical issues, and increased poverty.
Some factors have led to an increased incidence of OF in Nigeria.
Socioeconomic factors
Socioeconomic characteristics of women significantly impact the risk of obstetric fistula (OF), particularly among underprivileged women. OF is more prevalent among women with low economic status and living in rural areas and remote areas, where health infrastructure is marginalised. For instance, in Northern Nigeria, low socioeconomic status, transportation difficulties, and rural residence are risk factors for OF.
Nutrition
Malnutrition, primarily due to insufficient calcium and vitamin D, can lead to pelvic deformities or underdeveloped pelvis which predisposes women to cephalo-pelvic disproportion with resultant prolonged obstructed labour (POL) if state of emergency obstetric care (EmOC) is not initiated on time. In Nigeria, 12% of women of reproductive age (15-49) are underweight, with a body mass index below 18.5. This contributes to a higher risk of developing OF from POL due to inadequate pelvis and poor health-seeking behaviour. Many women and girls living with fistula find themselves trapped in poverty and, in most cases, further malnutrition because they are isolated from community life, denied livelihood prospects, and abandoned by their husbands and family. Improving women’s socio-economic conditions can help eradicate malnutrition and improve their nutritional status.
Education/Literacy
Education is crucial in eradicating obstetric fistula (OF) and empowering women, which can alleviate poverty and contribute to the reduction of obstetric fistula risk factors. In Nigeria, educated females tend to marry later than uneducated ones, and less than a quarter of girls would have completed secondary school by ages 15-19. UNICEF estimated that Nigeria has the largest number of dropouts from school, with one in every five of the world’s out-of-school children, and around 16 million children, particularly girls aged 5-14 years, being out of school. Maternal education has been reported to be a protective factor against OF. Literate women make better use of antenatal care, family planning information, and reproductive health services. Increased female education in Nigeria can enhance empowerment, improve access to quality antenatal care, and prevent POL, the main cause of obstetric fistula.
Early marriage/childbearing
Early marriage is linked to maternal and infant morbidity, as women are unprepared to care for a family. Nigeria has the highest child bride population in the world, with 23 million girls and women married as children. These young brides become pregnant at an early age, leading to higher rates of obstetric fistula and death. Over the last three decades, Nigeria has seen a slight decline in child marriage per year, but the total number of child brides is expected to double by 2050. In 2018, 43% of women married before 18 years, and 19% of adolescent women aged 15-19 years were already mothers or pregnant with their first child. The highest number of young mothers was reported in the northwestern zone, where obstetric fistula is also high. In Northeastern Nigeria, 83.8% of women with obstructed labour developed it before the age of 15 years, and 93.7% had obstructed labour with an average age at marriage of 14 years. These young women are disempowered and denied the right to make decisions on when to give birth, how many children to give birth to, and how to give birth. Early marriage is not only peculiar to Nigeria but also occurs in most African societies as a cultural norm. However, there is reform and attention in Nigeria on reducing early marriage through the enactment\minimum marriage age. These regulations have been adopted, but they fail to prevent forced or arranged marriages of girls under the legal age with parental approval, indicating that the execution of such legislation is still far behind.
Harmful traditional/cultural practices
Harmful traditional practices in Africa, such as female genital mutilation (FGM), early/child marriage, and son preference, have severe and adverse effects on girls’ health and well-being. Efforts to modify or eradicate these practices are often met with distrust or hostility from the communities practising them. FGM can result in fistulas or impaired female genital tract, endangering the mother during childbirth. In northern Nigeria, FGM accounts for 2-13% of vesicovaginal fistulas. Female education is crucial in preventing FGM and associated morbidities, as educated women are more likely to avoid such practices. Lack of autonomy also impacts the time frame for seeking care, as women need permission from their spouse or in-laws to go to a hospital.
Women living with obstetric fistula (OF) face significant psychosocial challenges, including low self-esteem, feelings of rejection, stress, anxiety, mental health dysfunctions, post-traumatic stress disorders, loss of dignity and self-worth, loss of sexual pleasure, depression, and suicidal thoughts. Incontinence often results in extensive social stigma and mental health issues, leading to marginalization by households and communities. Women often feel unfit to live with family members and isolate themselves, leading to divorce. Social exclusion and lack of recognition during the fistula period can lead to a diminished sense of self-worth. Many women with OF live apart without economic support from their husbands or families, and the demise of their babies can further exacerbate psychological distress.
Governments and non-governmental organizations should focus on reducing the incidence of obstetric fistula (OF) through stakeholder engagement, innovative family planning strategies, and policy support. Improved access to family planning can prevent pregnancy and reduce the risk of developing OF. Strengthening the healthcare system and ensuring quality maternal health services, including state of emergency obstetric care (EmOC), is crucial. Monitoring women seeking fistula care is essential to track the need for surgical repair and maternity-care facilities should offer diagnosis and surgical repairs, particularly simple fistula, to reduce backlogs. Training providers on prevention and diagnosis, early identification and treatment of iatrogenic fistula, and prompt referral systems are also essential with emphasis placed on outreach and prevention services for rural and malnourished women.
In conclusion, obstetric fistula is a terrible and preventable condition that affects many women in Nigeria. It’s caused by a combination of poverty, poor nutrition, lack of education, child marriage, and harmful traditions. These things make it hard for women to get the healthcare they need, especially during childbirth. To solve this public health burden, Nigeria needs a call to action. This means making healthcare better, especially for pregnant women and new mothers. It also means helping girls stay in school, creating awareness of OF, avoiding child marriage and changing harmful traditions. If we can achieve these things, we can stop obstetric fistula and help the women who are suffering from it.
