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Fistula: Some doctors mess up pregnant women – Iyeme Efem, USAID Country Project Manager

By Chioma Obinna

Engender Health Nigeria, Country Project Manager for the USAID-funded Fistula Care Plus, Chief Iyeme Efem, says Nigeria is lagging behind in efforts to preventing new cases of fistual while cases of backlogs abound.   


Is Nigeria on track in the campaign to end Fistula?

I cannot say that we are on track. We have a backlog of over 200,000 women living with fistula and we have new 12,000 cases occurring every year. Meanwhile, the total number of repairs Engender Health does is 2,000.   And Engender Health is actually the only organization that does fistula as a programme. Other people do it as a one off thing. And MSF supports one centre in the North. UNFPA does fistula occasionally. 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 have about 4,000 repairs. It is not up to the number of new cases every year let alone tackling the backlog. A lot needs to be done but we are not doing enough to address it. One strategy we introduced to the Minister of Health, Prof Isaac Adewole, which he has agreed to assign to us, is that we should expand the number of centres that are conducting fistula repairs. He agreed that the skills are resident in the teaching hospitals and he has sent a memo to all the teaching hospitals to waive the fees for fistula registration and bed space and so on. We will support them by providing consumables.   For example, there are 49 teaching hospitals across Nigeria; if each of them does 15 repairs every month, then we are looking at 735 repairs done in a month. Doing that from just teaching hospitals alone, we would have done 8,830 repairs in one year. If you add that 8,830 repairs in a year to the 2,000 Engender Health is doing, we would have 10,000 repairs and that takes us to over 12,000 repairs. What that means is that we have at least removed the 12,000 new cases out of the number we have. So the minister is very excited and he has signed. Now, we are going to be sitting with CMDs and decide how do we roll this out?   We don’t want it to wait too long. We were hoping to start in December but we will start by January 2018.

A possible free fistula generation

Fistula is only a marker to show that the health system is poor. Achieving a free fistula generation is not a one person or one organization thing. It is all hands on deck, the federal and state governments; ministries of health specifically; agencies such as the National Primary Healthcare Development Agency and the international donor community.

Fistula is also a marker to show that pregnant women are not having adequate support. It also shows that pregnant women are not ensuring better healthcare for themselves.

First of all, what does it take to prevent fistula? To prevent fistula, the person must attend antenatal care.   The World Health Organisation, WHO, came up with a new regulation that pregnant women require at least eight antenatal care visits before delivery. A pregnant woman must deliver under a trained healthcare provider. The healthcare provider must use pantograph to ensure and monitor progression. But about 65 per cent of pregnant women attend at least three antenatal care visits, is that enough? No. Do they deliver under a trained healthcare provider? Only 35 per cent of pregnant women do that according to the National Demographic Health Survey. And who is supporting the pregnant women? Do their husbands, cousins, etc. support them? That is another challenge.

Then, the trained nurses, do they follow through with the pictograph?   And for a pregnant woman who needs a CS, is the person doing the CS a trained gynaecologist   and trained surgeon that he does not have to cause additional trauma just by treating one?   So, it is not one organisation that will address that.

The Society of Obstetric and Gynaecologists of Nigeria, SOGON, has a responsibility to sanction doctors who messe that place up. It is a challenge when you tell a woman to go and deliver in hospital so that she doesn’t have fistula and the woman goes and comes back with fistula. How do you address that?   The regulatory bodies must address this injustice.

We also need to look at the nurses and ask ourselves, why is it that people are not attending antenatal clinic or repairs in hospitals?   The reasons are not far -fetched. This is because nurses talk to them anyhow; they don’t treat them well. Some of them thus believe it is better to go traditional birth attendants who respect them.

There are other implementing partners who focus on so many things. Family planning is another major thing we are working on. Women should have healthy timing and spacing so that they can recover from one child birth effectively and then have time to breast feed and then go through another birth process.   You should also decide on what is the right number of children you want to have to be sure you can feed and take care of them and not just have them and send them out on the street. We also need to look at the facilities. Because sometimes you have people coming in for surgeries and there are no facilities. Sometimes there is no mere anaesthesia machine that will monitor progression and help you make a decision. It is a broad range of things. So when you asked for a fistula free generation, it is by working with all this group of people together and channelling a direction. If you work in sync, then everything will work well.

Fistula is in all corners

If Nigeria can prove that any section, or geopolitical zones in Nigeria has the best healthcare system comparable to the UK or US or anywhere, then that zone can claim that they do not have fistula. But if the governor of that state can say that when he falls sick he goes back to the hospital in his zone and gets treated, then one will say maybe there is no fistula.   But that is impossible. If a governor falls ill, the first place they go is out of the country.   If that is the case, our healthcare is indicted.   It is very poor.   Yes, it is more in the North, because that is what they display them. In the South, people hide them.   In the South, a woman with fistula on the street is a disgrace to the family. In the North, a woman with fistula you find on the street is a disgrace to womanhood. In the South, the family will rather hide the person so that she will not bring disgrace to them, that is why people don’t see them in the South but they are there.

In Osun, the state government said there was no fistula, we did announcement and the place was flooded more than the bed space.

Message to rural women

Women should go for antenatal when they are pregnant and also deliver under a trained healthcare provider. You cannot miss those two. For the healthcare providers, once labour is more than a certain number of hours, between 12 to 18 hours, they should refer to the next level of care so that they take care of that woman. Remember, fistula is as a result of prolonged obstructed labour.


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