Late Wednesday October 24, 2018, Dr Amina Abubakar Bello, an obstetrician and the First Lady of Niger state in Nigeria, shared several posts on Twitter through which she announced the successful completion of surgeries aimed at correcting a hole that develops between the vagina and the bladder, resulting in uncontrollable leaking of urine through the vagina. This condition is called vesicovaginal fistula, VVF.
The well received posts became controversial when Bello stated that VVF is not caused by early marriage but by obstructed labour and refusal to deliver in hospitals to enable medical professionals take the deliveries to detect complications.
“VVF is not caused by early marriage but by obstructed Labour and refusal to deliver in Hospitals to enable medical professionals take the deliveries to detect complications,” Bello stated.
This claim was vastly rejected health care practitioners on social media.
“How is it possible to say this? Against years of evidence and literature. I love how she uses her role to push for health but this is like giving alms to beggars without dismantling the system that produces them.” a doctor responded.
Bello was widely accused of misinforming Nigerians by ignoring the strong connection between underage marriage and VVF.
Some outrages
@AdugbaDavid said: Early Marriage-➡️Early Conception at young Age➡️Term Pregnancy before Full Pelvic growth➡️ Cephalopelvic Disproportion➡️ Obstructed Labor ➡️ VVF (wch is a common complication) . Ma with all due respect they are all connected,pls don’t misinform the public.thank you.
@nkaechi responded: “Good job but child marriages, pregnancies and child rape greatly predisposes girls to VVF… VVF ravaging girls in northern nigerian is a wide case study but ofcourse you’d disclaim and obscure the truth to encourage pedophilia in your region, how ethical.”
@avidmaverick added: “Early marriage predisposes girls to VVF though. This is like saying smoking doesn’t cause lung cancer.”
@iszabel_lah contributed: “You must think everyone is a cow by saying early marriage is not responsible for vvf. Why don’t other parts of the country that don’t support early marriage record high numbers of vvf patients?”
@LordTyrion4 also added: “Hey hajiya. There is something called Root Cause Analysis. It can help you here. Children’s pelvis are not developed enough to handle birth. Why are the majority of VVF sufferers young mothers? Please don’t mislead people.”
Her erratum
The following day, Dr. Bello attempted to walk back the controversial aspect of her post when she shared a tweet that was aimed at clarifying the earlier message.
She said: “…what I meant was VVF is not necessarily caused by only early marriage but also by obstructed Labour and refusal to deliver in Hospitals by women of any age where medical professionals take the deliveries to when there are complications. As a trained obstetrician, I am aware that one of the most common cause of VVF is early age of childbirth and marriage. The average age of occurrence of VVF in Nigeria is 11 years to 15 years of age.”
What science says about VVF
A review published in the leading science journal Lancet described VVF as a devastating injury in which an abnormal opening forms between a woman’s bladder and vagina, resulting in urinary incontinence. This condition is rare in developed countries, but in developing countries it is a common complication of childbirth resulting from prolonged obstructed labour.
Estimates suggest that at least 3 million women in poor countries have unrepaired vesicovaginal fistulas, and that 30 000–130 000 new cases develop each year in Africa alone.
So, Bello was technically right about the cause of VVF and why it is happening – prolonged obstructed labor due to delayed access to care.
Here’s where underage marriage gets involved
But, like the comments showed, the questions remains “why is fistula so prevalent in developing countries?” According to researchers, the answer lies in a complex interplay of biological, social, and economic forces
Obstructed labour and subsequent fistula formation are most common in young women that are not yet of childbearing age. This is a well documented fact. This is further complicated by African women’s relatively narrow architecture of their pelvis when compared with Europeans.
Additionally, many African girls are married at a very early age. The likelihood of obstructed labour is increased in areas where early marriage and childbearing are common, because although growth in height stops or slows with the onset of menstruation, the capacity of the bony pelvis normally continues to expand. These problems are worsened if girls have been undernourished throughout childhood and adolescence – as is the case in the poverty-ridden parts of Nigeria.
In other words, although girls are capable of becoming pregnant at a relatively early age, their pelves do not develop their full capacity to accommodate childbearing until much later, and many will have their lives destroyed by obstetric injury before they have even crossed the threshold into true adulthood.
In most case series, the average age of a fistula patient is younger than 25 years, and many are as young as 13 or 14 years.
…but again
Although the risk of obstructed labour is greatest in younger mothers, any woman can develop the condition if the right combination of obstetric factors converge: large fetal size, malpresentation, intervening disease or malnutrition, etc. A distribution of fistulas shows it is more common in underage mothers, and among women who have had four or more pregnancies—a reflection, perhaps, of the tendency of birthweights to increase with subsequent gestations.
Vaginal fistulas can also result from particularly violent cases of rape, especially those involving multiple rapists and/or foreign objects.
Some health centers in countries such as the Democratic Republic of Congo have begun to specialize in the surgical repair of vaginal fistulas. It can also be associated with hysterectomy, cancer operations, radiation therapy and cone biopsy.
Poverty is at the core of VVF
Poverty has been described as the breeding-ground where obstetric fistulas thrive. Early marriage, low social status for women, malnutrition, and inadequately developed social and economic infrastructures are all more common in poor areas.
Most importantly, lack of access to emergency obstetric services is ubiquitous in the poor areas of the world.
Fistulas are most prevalent where maternal mortality is high. Most maternal deaths are due to preventable causes: haemorrhage, infection, hypertensive disorders of pregnancy (pre-eclampsia and eclampsia), unsafe abortion, and obstructed labour.
Although the prevention of maternal death from these causes requires skilled medical and surgical care, none of these interventions requires high-technology resources. The essential elements of emergency obstetric care are intravenous fluids, antibiotics, blood transfusion, oxytocic drugs, and basic surgical services (which can usually be provided under spinal anaesthesia).
Tackling VVF
Virtually all obstetric fistulas could be prevented by adequate intrapartum care that would detect the abnormal progression of labour and would allow timely intervention before labour became obstructed.
Simple graphic analysis of the progress of labour (the partograph) used by trained birth attendants reduces maternal deaths, prevents prolonged labour, and even results in a decrease in operative intervention (by allowing normal labour to proceed without unnecessary interference).
On the other hand, the backlog of unrepaired fistulas continues to increase throughout these impoverished countries.
Since fistulas by themselves are not fatal, the millions of women thus afflicted continue to live lives of unremitting misery, while tens of thousands more are added to their ranks every year.
It is worthy to note that the basic techniques needed for fistula repair have been known for more than 150 years.
Furthermore, fistulas are severely stigmatising. In many African countries, difficult labour is believed to be a punishment sent by God or the ancestors for adultery on the part of the woman, loading a moral stigma on top of a physically offensive condition.
One major global trend in combating VVF is the establishment of specialised centers dedicated exclusively to the care of women with VVF. As at 2006, the Addis Ababa Fistula Hospital, the outstanding model of this kind, has treated more than 25,000 fistula patients.
Not only does this focused factory approach allow maximum efficiency of patient care, but it also allows for the development of a uniquely supportive sisterhood of suffering among these women that is a key component in healing their psychosocial wounds.
Much of the nursing care in such a hospital can actually be provided by current or former fistula patients, which further strengthens the sense of community among these women.
Verdict
While Dr. Bello was factually right about early marriage not being the cause of VVF, her initial statement was misleading since early marriage has been indicated as a major risk factor.
It was high commendable that she issued a correction.
For members of the society that do not have access to information regarding the connection between underage marriage and VVF, the earlier message could be taken to embolden their resolve to continue to engage in underage marriages.
“She did not have to mention early marriage if she was not sure nor comfortable with blaming the popular practice in the northern part of the country. It is just like saying unprotected sex does not cause HIV infection. No it doesn’t, it only significantly increases the risk,” a medical doctor told healthnews.africa
