Fourteen-year-old Suwaiba is laid out on the operating table. She has received an epidural anaesthetic to numb the pain. Meanwhile, three doctors are busy assessing the extent of the trauma and preparing to operate. Her vagina is badly torn, her sphincter is in shreds and a double fistula, the result of an impossibly difficult birth, connects her vagina, bladder and back passage. Urine and faeces trickle through the opening, as the young girl lies helpless: she no longer has control of her bodily functions.
In the north of Nigeria (the most densely-populated country in Africa), Suwaiba’s condition is common-place. Here in Kano, under the scorching sun of the hospital courtyard, dozens of women swathed in brightly-coloured veils await their turn for the operation which will restore their lost dignity. A thin trickle of urine runs down their legs and into the dust, visible proof of their discomfort.
Like theirs, Suwaiba’s fate is an unlucky one. Married before puberty (as are the majority of Fulani and Hausa peasant girls) she followed custom and returned to her parents’ home for the birth of her first child. Doctors believe this time-honoured tradition may have arisen out of the high incidence of maternal deaths associated with a first delivery. Sadly, Suwaiba’s pelvis was too narrow for the baby’s head to pass through. For three days, she suffered in silent agony, modestly stifling her cries as Hausa custom demands. When at last her mother became aware that something was wrong, it was already too late to take her to the hospital. In this part of the country, hospitals require 24 hours’ notice to prepare for a costly and complicated operation such as a Caesarean section.
The only person who could help Suwaiba was the unguzuma or traditional midwife. Her method, similar to that used in the past by local midwives in Europe, was to pull as hard as she could on what she could reach of the child’s body. Suwaiba’s own body was badly torn in the process; and the baby girl was born dead. Her mother, who was too young to give birth, was in scarcely better state.
Suwaiba already knew that her husband would now reject her. In the Muslim culture, with its emphasis on ritual ablutions before prayer, women like her are thought to be in a permanent state of uncleanliness and are cast out by their own families.
The older women survive through begging or what odd jobs they can pick up. The younger ones are frequently drawn into prostitution. Suwaiba could have sought shelter, as many others do, in one of the gidajen mata (a Hausa word meaning houses for women, also sometimes pejoratively called gidajen pisari or houses of piss), which, in the large Muslim cities of northern Nigeria, offer shelter to thousands of such divorcees who find themselves forced into prostitution (1). Across the courtyards of these wretched asylums, cloths can be seen hanging out to dry; these have been washed again and again to get rid of the lingering stench of urine.
Soon after Suwaiba gave birth, she heard on Nigerian radio of the great doctor: a Dutch surgeon, who has become a sort of legend in the northern savannah. Kees Waaldijk came into contact with the problem of vagino-vesicular fistulae (2) in 1983, when he came to the city of Katsina to work amongst lepers. A large number of his female patients suffered from this condition which, though it has long disappeared in the West, is probably as old as human-kind itself and, like leprosy, is synonymous with social exclusion.
Fistulae caused by childbirth have afflicted women in all countries and from all sections of society. Traces of the condition were discovered on the mummified body of the Egyptian princess Hehenit, who died in childbirth nearly four thousand years ago. It is also known that the court of Louis XIV used to make fun of the King’s young mistress, Louise de la Vallière, who suffered from this embarrassing affliction. The condition was so widespread among the early American pioneers that a specialist hospital was set up in New York in the 1840s to offer surgical treatment, using a procedure invented by a doctor from Alabama.
Since the medical revolution of the 20th century, fistulae have disappeared from the Western world. These days, if labour continues beyond the normal length of time, a Caesarean section is performed, explains Dr Waaldijk. But out in the bush, young women in this situation simply die and, in 90% of cases, so does the child. It is estimated that, out of every thousand women who survive childbirth, two are left with a fistula. This is caused by pressure from the child’s head, which can block the circulation in that area, giving rise to necrosis of the tissue at a particularly vulnerable point. Often the perianal nerve is also damaged, as a result of which some of these women are left limping for the rest of their lives.
An operation to patch the damaged wall of the urethra can be performed, using a muscle from the inside of the thigh which is normally removed subcutaneously. This technique was first developed by a medical couple, Reginald and Catherine Hamlin, who devoted their lives to these women, and it has since been successfully adopted in Nigeria. With an experienced surgeon, complete recovery occurs in 80% of cases. The women regain full control over their bodily functions and are accepted back into society, usually going on to remarry.
Two million suffer in silence
How many sufferers are there in the world today? Specialists suggest a figure of two million. We know at least that the majority of sufferers live in Africa: in Sierra Leone, Mauritania, Niger, Mali, Tanzania, Ethiopia, Somalia and in Sudan, where many women suffering from the condition go on to commit suicide. It is also present in Haiti, India, Pakistan and Bangladesh. Wherever, as a result of war, peoples are displaced and there is disruption to an already fragile public health infrastructure, there is a return or an increase in the number of cases of childbirth-related fistulae. In Afghanistan, the regressive policy of the Taliban’s new Islamist regime is likely to increase the number of cases by restricting women’s access to surgical care.
In Nigeria alone, which has a population of 100 million, there are thought to be 200,000 sufferers, 70% of whom are concentrated in the north. According to Professor Bandipo, a medical director in Zaria, There’s no other country in Africa where this public health problem is so acute: one in every 25 women in Nigeria dies as a result of complications in childbirth. That is 400 times more than in the West. And for every mother who dies, 15 to 20 others go on to survive with some sort of permanent physical damage. These figures, no doubt linked to the neglected and often rapidly deteriorating public health services (in which the government invested heavily in the 1970s and 1980s), stand in stark contrast to the substantial oil revenue enjoyed by this African giant(3).
A number of cultural factors also come into play, but these are less straightforward to address. The tradition of child-brides is still very much alive in the vast savannah region of northern Nigeria, with its Muslim majority. Even in urban areas, parents tend to marry their daughters at a very young age as a way of safeguarding family honour in an environment characterised by violent social relations (4). In addition, the custom of yankan gishiri, which involves making an razor-blade incision in the young bride’s vagina if the marriage road has proved too narrow, carries a relatively high risk of damage to the bladder.
The mainly Christian south is unhappily influenced by evangelical sects who discourage women from giving birth in hospital. In order to bolster their own status, pastors tell women that God is present in the Church, not in the hospital. They encourage pregnant women to fast and stay up all night to pray, and the women become exhausted, explains Dr Ann Ward, an Irish nun. She runs a health centre for the treatment and rehabilitation of fistula sufferers in the city of Uyo, in south-eastern Nigeria (5).
The problem is further compounded by male indifference and poor transport facilities. The medical files kept by Dr Ward and her colleagues contain countless heart-rending examples. There are cases of mothers begging the few local men with motorised transport to fetch help for their daughters, and being refused. In one case, a dying woman, her baby’s half-decayed arm protruding from her body, was taken to hospital on a board attached across a moped. There are husbands who refuse to donate blood to save their wives from haemorrhaging to death.
Thanks to the commitment of a growing number of doctors and to Amina Sambo (a militant feminist in Kano who is currently president of the Nigerian Women’s Union), genuine efforts have been made over the last decade towards putting an end to this unnecessary suffering. Radio programmes broadcast in local languages, television documentaries and newspaper articles have succeeded in bringing to public attention the suffering (hitherto unnoticed) of the thousands of women converging on health centres for treatment.
But, as in other countries afflicted by poverty or war, the number of these female pariahs in Nigeria increases steadily as the population expands. Meanwhile, very few doctors choose to specialise in what is essentially a poor people’s blight; and those who are trained to treat the condition are too few to deal with the enormity of the task which faces them.
Reviewed by Utrop Sør-Trondelag
