Approximately, about 7 million women were affected from complication of pregnancy and child birth worldwide. Out of the estimates, 6.5million women are from the developing countries. (WHO Global burden of disease 1998).
According to the data from West African Journal of Medicine (WAJM 2004; 23 1) the prevalence of obstetric fistula in West Africa is around 1-3 per 1000 deliveries while, in other African region is 5-10 per 1000 deliveries.
Report shows that, maternal morbidity and mortality is among the major problem for women in Nigeria. Maternal mortality ratio of 800 deaths per 100,000 live births which is also rated among the highest in the world. The report further stated that for each death that occurred 20 or more women will be affected by childbirth injuries and most of this is obstetric fistula (UNFPA/Nigeria 2005).
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Obstetric fistula is one of the maternal morbidities and mortality problem in Nigeria which is an issue of concern to Public Health (WAJM 2010; 29 (5); 293-298. The situation is being more evidence in the Northern part of the country, prevalence estimation ranges from as low as 400,000 to as much as 800,000 cases, 5% of these cases are from the Northern region. There could probably be an incidence of 20,000 new cases a year, with approximately 2,000-4,000 fistula repair surgeries being carried out yearly. Also Nigeria count for 40% of the worldwide fistula prevalence (Country assessment UNFPA/Nigeria 2009). Life expectancy of female population at birth is 52 yrs, with a total of 5.5 fertility rate (Unicef 2010).
Statistic report from (UNFPA /Nigeria 2005) stated that, majority of fistula patient visited the Health centers are below 20 years. Nigeria is facing a great challenges of Health care providers, with an estimated of 58-39% trained skilled attendance for Ante-Natal and delivery (Midwives) attached to the Health facilities (NDHS 2008). Efforts by the Government to provide them remain unsuccessful.
In Nigeria, early marriages contribute 23% of the maternal death that are cause by severe hemorrhage, obstructed and prolong labor which may result to obstetric fistula and often time still birth. 69% of women in the rural areas face difficulties in accessing medical care that made them to have home deliveries by unskilled birth attendant. (Lindros and Lowkkainen 2004).
Kebbi State with an estimated population of 3.8million out of it 836,000 are women of child bearing age is located in the North West part of Nigeria. It has a particularly low socio -economic indicators. Maternal mortality rates for the region are estimated at 1,000/100,000 live births (NDHS 2008) Total fertility rate is 8 which are above the national average. According to Leadership News paper 19 April 2012, stated that, kebbi state rank among the highest rate of maternal death in the country. Most of the direct causes of maternal death are hemorrhage, sepsis, eclamsia and anemia. While long and obstructed labor has been responsible for both maternal morbidity and mortality such as vesico-vaginal fistula. According to a survey, the state faces serious maternal challenges.
Age at marriage in the state is 12-13 years and most of them became pregnant by 13-14 years. VVF victims can be found in all part of the state with prevalence rate of 5,000-8,000, Birnin Kebbi Local Government has the highest rate of 2,500 cases. (Khalid & Zango 1996). Factors accounts for high morbidity in women in the state include social, cultural, economic accessibility and health facility associated problems.
Obstetric fistula is can be treated but, poverty, ignorance and lack of information are the most contributing factor for women to seek for medical attention. These high prevalence shows negligence for the government to address the situation.
This study actually is going to look in to the Knowledge about the vesico vaginal fistula and the attitude towards it. The study will also be conducted among women with and without vesico vaginal fistula. The result will provide information as to knowledge level regarding vesico vaginal fistula and as to how the women without fistula look at vesico vaginal fistula as a disease and their attitude towards fistula women.
1.2. Research questions study
1.2.1 What is the prevalence of self reported cases of Vesico Vaginal Fistula among married women?
1.2.2. What are the knowledge, attitude and knowledge of preventive measures of women towards vesico vaginal fistula in Birnin -Kebbi LGA of Kebbi- State, Nigeria?
1.3. Research Hypothesis
Knowledge, attitude and preventive measures of women towards vesico vaginal fistula living in Birnin Kebbi Local Government of Kebbi State, Nigeria.
1.4.1. General Objective
To assess the knowledge and attitude towards vesico vaginal fistula in Birnin Kebbi LGA of Kebbi State, Nigeria.
1.4.2. Specific Objectives
To study the prevalence of vesico vaginal fistula in Birnin Kebbi LGA.
To assess the level of knowledge of married women on the contributing factors of vesico vaginal fistula.
To find out if married women knows about preventive measures of vesico vaginal fistula.
To determine the attitude towards women with vesico vaginal fistula.
To determine the possible risks factors related to status of vesico vaginal fistula.
To analyze the association of knowledge and attitude with the status of vesico vaginal fistula.
1.5. Conceptual Framework
Age of Marriage
Status of Vesico vaginal fistula
Access to health care:
Place of delivery
Knowledge about the
Risk factors, sign and symptoms and preventive measures of vesico vaginal fistula
Attitude of women towards vesico vaginal fistula and women with recto vaginal fistula
1.6. Operational Definitions:-
1.6. Operational Definitions:-
Age of Marriage: – refers to getting marriage below 18 yrs.
Poor birth practices: – Home delivery by un- skill attendant.
Parity: – Multiple birth with low spacing.
Patriarchy: – Head of the house decision is final.
Untrained birth attendants: – Untrained or self practice in delivery.
Knowledge: – Knowledge in this study regarding to sign and symptom of VVF.
Attitude: – In this study refers to the availability of health services and the barriers to seeking.
Preventive Measures: – Knowledge about steps to tackle the VVF.
Status of vesico vaginal fistula:- The status of vesico vaginal fistula in this study is women have obstetric fistula or vesico vaginal fistula
The chapter 11 deals with the:
History Vesico Vaginal Fistula
Global situation of vesico vaginal fistula
Situation of Fistula in Nigeria
Causes of vesico vaginal fistula
Social Consequences of vesico vaginal fistula
Treatment of vesico vaginal fistul
2.1. History of vesico vaginal fistula
Vesico vagianal fistula or obstetric fistula has been identified to be a major issue or women of child bearing age since decades. In 1935 professor Derry from Cairo stated that, the remains of Queen Henhenit (2050 BC) were the oldest to discover fistula. Around 1845 james marion sims was the first surgeon to successfully repair VVF from a 3 female slaves in Montgonery Albana. Later, in 1852 he established a VVF repair centre where many patients from America and Europe came for surgery (Robert F. Zacharin 2008).
A discovery during 1550 BC in the ancient Egypt, Aveicenna was a famous Arabian physician to differentiate VVF and obstetric (Derry DE 1935; 42:490). Another innovation came up in 1836 from Peter Mettnauer from Virginia who was identified to be the first surgeon to close fistula in United State (Aust N.Z.J. surg (2000) 70, 851-854.)
Study indicates that, during the 19th Century, women with fistula in United State and Europe were caused by dystocia (Russell). In the early 20th century, more experiments and techniques came up to improve the quality of VVF repair. Again, in 1942 Latzko published a new procedure in repairing post -hysterctomy of VVF which recorded 95-100% success (VVF MedScape).
Many historical innovations and advanced technique by surgeons has been recorded while, more researches and experiment are still ongoing for the improvement and better solution towards VVF.
2.2. Global Situation of Vesico Vaginal Fistula
Vesico Vaginal fistula (VVF) which is also called obstetric fistula is an abnormal opening between the urinary bladder and the vagina or between the vagina and the rectum (RVF).This is caused as a result of prolong labor where the child presses against the normal way thereby developing the hole between the vagina and the urinary bladder (WHO def).
Globally, 529,000 women were estimated to have died every year due to pregnancy and childbirth related complication. Almost 90 percent of this death is from Africa and Asia. Generally, 5 percent of this death is expected to have experience from obstructed labor (UNFPA/Nigeria 2005).
According to M.J Metro report in 2006 indicated as VVF is not new disease it has been in existence for decades. He further highlighted that, in the third world countries mostly in the west 90% of VVF cases are caused by bladder trauma during hysterectomy surgery. Nowadays, advanced technologies from developed countries such as Europe and part of North America have eliminated the disease (VVF) in there region (M.J.Metro 2006).
In the same report of metro 2006, he stated that, VVF is an uncomfortable disease the victims should be more serious towards their personal hygiene.
In a WHO report of 2006 indicates that, about 2 million women living with untreated VVF, while 50,000 to 100,000 new cases are reported every year (WHO 2006).The increase on figures could be due to stigma that associated with the situation. Also in another report from WHO study on global burden of disease, stated that, if 2% of the obstructed labor are caused by VVF, then 130,000 women are going to be affected with the condition (WHO 1998 243-66).
A study report published from UK indicated that, out of 166 cases treated within 18 year, only 21 cases are caused by obstetric complications. Another report from Nigeria stated that, out of 377 cases of VVF 369 cases are caused by childbirth (Lawson J. 1998, 83; 454-456).
2.3. Situation of vesico vaginal fistula in Nigeria
The millennium Development Goals (MDGs) targeted at reducing the proportion of women dying in childbirth by three quarter by 2015 become unrealistic in Nigeria. (Adeyemi Ezekiel). The reason behind it is that, the country has made less progress in reducing maternal and mortality than any other sub-Saharan African countries. The maternal mortality rate in Nigeria estimated as 800nto 1,500 per 100,000 live birth (WHO 2006).
The Northern part of the country has generally worse indicators with an estimated maternal mortality rate of 1,500/100,000 live birth. The high maternal mortality rate affects the basic health services in the country (NDHS 2003).
According to UNFPA report, Nigeria approximately to have an estimate of 400,000 and 800,000 women affected with VVF condition while, 20,000 new cases are recorded every year. Most of these patients are from the northern part that lives in the rural areas where they find it difficulties in accessing proper medical care. (UNFPA/Fistula Nigeria 2005). Also statistics shows that, most of the VVF victims are below 20years.
The underlying cause of VVF in Nigeria is due to prolong obstructed labor and mostly the young ages are at risk due to early marriage and early childbirth where there body is still in the stage of developing (WHO2006). In 2002, a multi-sectorial committee was setup by the Federal Ministry of Health to find the solution to the problem. At the same time the committee identifies Engender Health along with UNFPA/Nigeria to conduct a nationwide needs assessment in order to develop a framework and action plan for the elimination of fistula in Nigeria.
Although Nigeria has been taking measure to address reproductive health and maternal health problems, the implemented interventions have not reach optimum coverage to obtain the desired impact. (NDHS 2008).
2.4 TYPES OF FISTULA
Many surgeons have described fistula according to their experience during repair. In 1852 Sims also classified fistula by its location in the vagina. According to (Cater, Palumbo et al. 1952) stated that, it is difficult to describe the reported cases of fistula but, the standard method is to identify it during the actual operation and the result.
Mayor clinic doctor has briefly classified six types of vaginal fistula
Vesico vaginal fistula- is abnormal opening between the vagina and urinary bladder
Ureterovaginal fistula- is abnormal opening that connect the vagina and the ducts which carry the urine from the kidney to the bladder.
Urethrovaginal fistula- is an opening between the vagina and the tube that carries the urine out.
Rectovaginal fistula- an opening between the vagin and the opening anus.
Colovaginal fistula- the opening between the vagina and the large intestine.
Enterovaginal fistula- an opening between the small intestine and the vagina.
2.5. CAUSES OF VVF
Many publications and journals have their different versions on the causes of vesico vaginal fistula. According to medicine for African journal classified the factors that contributed to the cause of vesico vaginal fistula as: – (MfA- VVF)
Childbirth: – 8% of the VVF cases are prolong and obstructed labor where the deliveries are conducted by untrained skilled birth attendant or as a result of malpresentation of baby in the uterus which cause a lot of damage to the woman’s urinary tract.
Hysterectomy or other gynecological problem:- This can be caused by accidental surgery that occur within the pelvic and may result to VVF.
Gishiri cut or Salt cut:- It is a traditional way of treatment by a traditional healers mostly practice in Nigeria and some part of west Africa. When a woman present Gishiri disease symptoms such as vulva itching, absence of menstruation, infertility or obstructed labor. As a result of these symptoms a local surgical cut in the anterior vagina wall of a woman was done for total cure.
During removal of clitoris in a process of female Genital mutilation or female circumcision the vaginal tissues and its surrounding will be scrapped thereby causes VVF.
Sexual transmission disease or previous pelvic inflammatory disease.
Bladder stone or retain foreign body within the vagina
2.5.3. Socio-cultural causes
The most underlying socio-cultural causes in Nigeria are: – Early marriage; harmful traditional birth practices; poverty and illiteracy.
2.5.4. Early marriage
Early marriage can be define as being marriage at the age of 15-24 years when the reproductive organs are not fully matured for taking responsibility as done by the adult. This will result t damage of the birth canal that will lead to vaginal fistula (John Zang). According to WHO/UNICEF, the recommended age of marriage is 25 to 26 years.
In article 16, of the convention on the elimination of all forms of discrimination against women, specified the right to protect child marriage.
I n a publication from unicef research centre on early marriage 2001 stated the guidelines on changing attitudes of families and societies towards child marriage.
According to global assessment of child marriage it is estimated that, South Asia and Africa has the highest number of young women/young girls who are given out into marriage at the age of 15-24years. These will affect their nutritional status which will lead to so many pregnancy- related complications and most of the time she has no say in making decision for herself.
Also in another report from WHO 2006 indicate that: more than 25% of women with fistula from Ethiopia and Nigeria are pregnant before the age of 15years while over 80% of them also become pregnant at 18years of age.
2.6. SOCIAL CONSEQUENCES OF VVF
Almost all the report from the medical professional indicates the psychological consequences of women with VVF that bears. This is attributed due to lacj of support from the families and societies as a whole. Majority of these women faces great challenges in the society because of the odour from the incontinence of urine.
According to WHO report indicate that, women with VVF are facing difficulties to manage the urinary incontinence that causes odour from urine. The report also highlighted that, due to injury to the vaginal wall many complications may arise even after obstetric repair of the VVF. These complications are narrowing of the vagina, secondary amenorrhea inability to carry the child.
However, (Murphy 1981 and Harrison 1983) stated that, the most traumatic aspect of VVF resulting to urinary incontinence and lost of child who sometime may lead to marital separation/divorce and also social excommunication.
In another report from (WHO 2006), VVF patients are to be sympathized due to the lower social status of women in Nigeria. The most disheartening is that, they are abandoning by their husband and they have limited role within the family.
Women with fistula face a lot of challenges which most of the time find difficult to disclose their situation. The only solution for their survivor is surgery and personal hygiene.
A statement from WHO Maternal Health and Safe Motherhood program indicate that, the endemic VVF area should focus prevention aspect through effective social changes that will improve the status of women.
3.1. Research Design
Cross- sectional survey study among the married women of reproductive age in Birnin Kebbi LGA in Kebbi State, Nigeria.
Focus group approach to assess the knowledge and attitude towards vesico vaginal fistula among people who live in Birnin Kebbi LGA, in Kebbi State, Nigeria.
3.2 Study Area
Birnin- Kebbi LGA which lies in the centre of Kebbi State of Nigeria. A total of 45 wards :- Nasarawa 1, Nasarawa 11, Dangaldima, Marafa, Gwadangwaji, Zauro, Ambursa, Gulumbe, Ujario, Kardi, Gawasu, ,Makera, Kola, Tarasa, Fadama,
3.3. Study Population
The study will be among the married women of reproductive age 15-49yrs of age.
3.4. Sample Technique
Selection of Sample sites: – Systematic Randomly sampling will be done for the collection of data in 45 settlements from 15 wards
3.4.1 Exclusion criteria are
The sample who are not Birnin Kebbi cases
The samples have never followed up doctor or refilled medical attention during 3 months prior to study
The sample who are unable to communicate verbally and orally to interviewer appropriately
3.5. Sample size
Yamane sample size Formula
n= (1.96)2 X 0.22 (1-0.22) = 264
n = sample size
p = proportion of women of reproductive age in B/Kebbi LGA that are expected to have knowledge about vesico viginal fistula.
e = Marginal error or accepted error
z = Standard value of 95% confidence interval of 1.96
Sample size is 264 + 10% to add up in case of any missing value/data, the total sample size will be 264 + 26.4 (10%)= 290
3.6. Measuring Tools
Survey questionnaires are to be admitted on knowledge and attitude of married women towards vesico vaginal fistula.
Face to Face interview will be carried out during the focus group discussion
3.7. Validity and Reliability test
3 Expert validity are to be selected from B/K LGA.
Questionnaire will be checked and reviewed by these 3 experts.
Questionnaire will be pr-tested by the respondents who are comparable to the targeted respondents. The reliability of questionnaire will be statistically tested with the Crobach’s Alpha, which its acceptable coefficient is more than
3.8. Data Collection
Constructed questionnaires to be used on the followings:–
General and household information,
Knowledge towards the sign and symptom of Vesico Vaginal Fistula.
Attitude towards the
Preventive Measures on the vesico vaginal fistula
Access to the health facility- information and service.
Focus group discussion – women with and without VVF
3.9. Data Analysis (Statistics)
Questionnaire will be coded before entering into the computer.
SPSS version 17 will be used
Descriptive statistic is to be used to analyze data which will describe the frequency, percentage, mean and standard deviation
3.10. Ethical Consideration
Under the guidance of College of Public Health Sciences, and local authorities
Interviewees will be informed and explained
Informed signed consent
Have freedom to withdrawal
Can access to final report or results
Not use for other purpose
The study will not represent the general population of Birnin Kebbi LGA.
Different socio-demographic group may have different practice
The study will not represent for other types.
Margaret Murphy (1981). Social Consequences of Vesico-Vaginal Fistula in Northern Nigeria. Journal of Biosocial Science, 13 , pp 139-150 doi:10.1017/S0021932000013304
Vesicovaginal fistula. Retrieved from the web
Wall, L. L (1988) “Dead Mothers and injured wives: The Social Context of
maternal morbidity and mortality among the Hausa of Northern Nigeria.” Studies in family planning 29: 341-359
WHO (2006) Obstetric Fistula: Guiding principles for clinical management and programme development. WHP Press: Geneva Zacharin, R F. 1998. Obstetric Fistula. New York: Springer-Verlag Wien.
COMPASS 2006 – FMOH partnership works to achieve Millennium Development Goal of improving maternal health care Abuja, Nigeria September http://www.compassnigeria.org/site/PageServer?pagename=News_200609_FMoH_Partnership
Haddad S, Fourier P: “Quality, Cost and Utilization of Health Services in Developing Countries: A Longitudinal Study in Zaire”. Soc Science Medicine 1995, 40: 743-753.
Metro (2006) Modification of O’Connor’s technique for the treatment of VVF
Abu- Zahr C. Prolonged and obstructed labour, In: Murray C. Lopez A. Ed
Health dimensions of sex and reproduction: the global burden of sextually transmitted diseases, HIV, maternal conditions, perinatal disorders and congenital anomalities, Cambridge: Havard University Press for WHO. 1998; 243-66
Ijaiya MA, Aboyeji PA. Obstetric urogenital fistula: the Ilorin experience, Nigeria. West Afr J Med 2004; 23(1):7-9.
Article Source: http://EzineArticles.com/1016812
Lawson J. Vesico -Vaginal fistula y’ a tropical disease. Trans R Soc. Trop. Med Hyg 1998; 83: 454-456
11. MfA – VVF – Vesicovaginal Fistula
12. About Vaginal Fistulas – Mayo Clinic
Preparation and paper review
Detail and tool development
Research tool try out
– test validity and reliability
Revise the tool
Recruitment of interviewer team
Field work and data collection
Report writing and Presentation
-Souvenir for respondent
Total Thesis document process
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