Brain shift leaves poor women with fistula desperate

Folake Abdulrazak felt raw pain-a long, hard labour to give birth to her third child.
She was booked in a clinic and no surgery was on her charts, she remembers. “I later gave birth, but it took a long time.”
Her baby’s head got stuck in her pelvis, and the pressure burnt a hole between her vagina and bladder. The result: urine constantly leaking straight into her vagina.
She became a 27-year-old who constantly wet herself. But the stench was too much for a woman who dealt in baby wear.
When she left hospital, the “problem was still there,” Folake says. “I came home and started drying as if I wanted to die. People see me and run away.”
She had fistula. A simple repair to fix the hole could have changed her life. Five years on, she still can’t get a surgery to fix it: the doctors aren’t available.
Obstetric fistula is virtually unknown in developed countries, where better health care access for pregnant women have reduced chances of prolonged labours, but is recondite in developing countries where not many doctors know how to deal with it.
Up to 150,000 women have fistula, and 5,000 more develop it each year, according to the National Demographic Health Survey.
Medical training is short on it. “Fistula is only taught in hospitals,” says Dr Hassan Wara, one of Nigeria’s few fistula surgeons. Newer universities spread knowledge, “but the extent to which they have the experience may differ,” he says.
A former head of clinical services at Federal Medical Centre in Kebbi State, Wara got training on fistula from 2005 when the National Council for Women’s Societies raised an alarm about it.
The council’s 2005 Fistula Fortnight was the start of training for doctors about a condition that locks women in despair and misery.
A separate project, Fistula Care Plus, funded by the US government has trained 32 doctors and 74 nurses since 2007. Their patient load is 8,648 women repaired since then.
But only 35% of those trained-for full time, part-time or newly trained-are available to do the work needed, according to Dr Habib Sadauki, country manager for Engender Health, which implements Fistula Care Plus in Nigeria.
Nearly 70 of them have been sucked away by what’s being termed a brain shift-move to administrative work and transfer from hospitals to ministries.
Upward mobility in career path for doctors cost poor women the doctors they need.
Dr Steven Arigidi trained in fistula surgery and headed Kwara State Specialist Hospital in Sobi where he repaired women. This year, a transfer moved him to the state health ministry in the capital to head the fistula desk.
Dr Mansur Dada headed a facility in Ningi, but he has since been transferred to the capital to work in Bauchi State health ministry.
Dr Sa’ad Idris had a sister-in-law with fistula while growing up. “She was a very neat woman, but her room smelled,” he remembers. In medical school years later, he got passionate about dealing with fistula and trained to become a trainer of doctors.
He was on the Mercy Ship when he got the call to take up appointment as a health commissioner for Zamfara State. But he still finds time to do fistula work under a “pool effort”-a programme to bring fistula surgeons to women in need in select hospitals with support from the Fistula Care Plus project.
Up to 12 hospitals are part of the pool effort, which also trains any health worker with a passion for women living with fistula.
“We do train many doctors,” says Idris, who now consults for the project. “Out of the ones we have trained, we think just about 10% are in the field now.”
Fistula is curable, but doctors’ attention is turning elsewhere for some reason.
With a pregnant woman, a gynaecologist can do a caesarean section and get a live baby and a happy woman, says Idris.
“In VVF [vesico-vaginal fistula] you see only a miserable woman coming alone. She may not even have transport fare to get to the facility. She will be treated free. She even needs assistance to go back home after she is closed and dry.”
Myths about fistulas still ring true even among medical personnel. “Sometimes you find some not very conversant with the situation,” says Dr Idris, adding: “They say that’s just another end of the spectrum. If you have the passion, you can turn a miserable woman into a smiling woman.”
Few are smiling. Pool efforts facilitates repair for some 5,000 women across Nigeria, but 12,000 new cases crop up each year.
A backlog is building and could take up to 300 years to clear, according to some estimates.
“We want people to come and learn the procedure, so they can do it,” says Wara.
“Actually VVF is not an area for making money. You have to know that from the beginning, it is a sacrifice.”
“The most important thing is to have people who work with interest,” adds Sadauki.
The surgery is not well remunerated and only a handful of the thousands of women currently living with fistula can afford up to N100, 000 for surgery in a teaching hospital.
The lure to fistula surgery is weak. A certification in fistula surgery may count in continuing medical education, but it hardly counts as additional qualification for promotion.
Teaching hospitals, with the most consultants in gynaecology, are a good bet for brains.
“The potential for you to have some knowledge is higher,” says Sadauki. “But unfortunately, they may not have the exposure because the patients may not be there.”
But Drs Halima Bello and Shukura Okesina have gone where the patients are-to start training in repairing fistula, alongside Wara and Idris.
“I have always been with women,” says consultant gynaecologist Bello. “I have pity on them when I see them suffering stigma, trying to get themselves [to be] like other women. It makes me feel bad. I really want to be a part of it, so I can assist as many women as I can.”
Folake lost her spot for surgery at University College Hospital, Ibadan, after her family couldn’t afford her medical bills. “I decided, if that is the case, God is my saviour,” she said
But she is among some 40 women lined up for the latest pool effort in Ilorin where Bello has started her training in fistula surgery. She’s been watching patients in line ahead of her being wheeled into surgery.
“They are coming back successfully, so my mind is at rest,” she says. “I thank God. I wish to be among those going in and come out successful.”