AT 13, Hafsat Auwalu was married. At 14, she became pregnant. When it was time for her to be delivered of her baby, Hafsat was taken to the nearby primary healthcare facility where she laboured for hours, but the baby would not come out.
There was a problem. Hafsat is frail in stature with a small pelvis. Her pelvis was too narrow for the head of the baby to pass through. She pushed and pushed, but the baby’s head was lodged in the narrow birth canal. The pain was excruciating.
There was nothing the birth attendants could do. There was no doctor on call and no one in attendance had the skill or the equipment to perform an emergency Caesarean Section. They only urged her to push harder. To worsen her plight the unskilled birth attendants simply cut through the birth canal to create passage for the baby.
Pressure against pelvis
As she pushed, the pressure against her pelvis gradually cut off blood to the surrounding tissue. Eventually, the tissue around her birth canal and bladder died off, creating a fistula, or hole. When the baby finally emerged, it was stillbirth.
The worst had happened. The would-be mother began to stink, urine trickling out of her unabated. Days passed and nothing changed. Hafsat had suffered an obstetric accident known as Vesico-Vaginal Fistula, VVF – one of the worst and most dreaded complications of childbirth. She is one of the millions of girls aged 11-18 in the country who become mothers early or through accidental pregnancy as a result of unprotected sexual intercourse.
Demeaning and degrading, the disorder is typified by continuous and uncontrollable leakage of urine from a woman’s bladder. A variant that occurs when there is uncontrolled passage of faeces is referred to as Recto-Vaginal Fistula, RVF.
No thanks to the practice of early marriage, obstetric fistula, a serious medical condition eradicated in North America and Europe over a Century ago, is still around as thousands continue to live with it in countries such as Nigeria where at least 100,000 new cases occur every year.
Treatment at gynaecology clinics
According to the United Nations Population Fund, UNFPA, in sub-Saharan Africa, where one in 10 girls becomes a mother by age 16, scores of girls and women suffering from one or both forms of fistulae are condemned to carry the brand of social outcasts and even though there is treatment at gynaecology clinics nationwide, most healthcare personnel are ill prepared to deal with the malady.
Dr. Ejike Orji, Country Representative, Ipas Nigeria. describes obstetric fistula as one of the most telling forms of maternal morbidity. “It usually occurs when a girl who is too young to get pregnant in the first place, suffers prolonged labour without timely access to emergency Caesarean Section. It is a debilitating condition that continues to leave hundreds of thousands of girls and women incontinent, suffering in solitude and shame.
Orji, a gynaecologist and obstetrician, points out that the key to ending complications of childbirth such as obstetric fistula is to prevent them from happening in the first place.
“Early marriage puts girls at great risk for premature child-bearing, disability and death. When a girl is under-aged and is pregnant, the birth canal is not well developed. It is narrow and unable to carry the head of the baby. If the baby is forced to pass through the birth canal, two things can happen.
“The girl, who is a baby herself and has no business having babies, would either rupture her uterus, and both the girl and the baby will die. The other thing that can happen is that even if the girl succeeds in delivering the baby after several hours of labour, she will end up with VVF, or if it is in the rural area where there is no skilled attendants, she will develop RVF. VVF occurs as she is pushing; she is stressing the tissues of the birth canal, because the head of baby is bigger than the birth canal.”
Presenting a graphic illustration of VVF, also known as an ‘obstetric disaster’ in medical circles, Orji explained that with continuous pushing, the baby’s head presses between the pubic bone and the urethra which takes urine from the bladder.
“When it presses for a long time usually 4-5 hours, the blood supply to that urethra will stop and that place will have what is called ischaemic death and fall off. So passage of urine will now be interrupted between the bladder and birth canal. The girl will no longer be able to hold or control urine anymore.
Immediately urine comes in from the kidney, it pours into the birth canal. And what happens is that the husband will reject her because she will be smelling of urine and will be sent back to her parents. The final thing is that she will hate herself. This is a big issue,” he remarked.
Orji stated that there was a time Nigeria contributed 10 percent of all maternal deaths in the world, and though the Midwifery Service Scheme enabled the nation to reduce the maternal mortality incidence almost by 50 per cent, the contribution of Nigeria to global maternal mortality has actually increased by 15 percent.
“Six years ago, a study was conducted to find out which women were actually dying in terms of age that was why when it was painfully realised that 70 percent of maternal deaths are young girls of 18 and below. What is happening is that other countries’ maternal mortality control method is working faster.
One of the key areas is that we keep making our young girls pregnant. If we eliminate teenage pregnancy, we will eliminate almost 50 percent of maternal deaths. If you look at abortion related deaths, 50-60 percent of theses deaths are among adolescents aged 10-24, the proportion that suffers that burden.
“If you marry a girl who is under 18, and start having sex with the girl and you say you will keep her till 18 before she gets pregnant, the girl will not die, but the consequences is that she would be out of school, and she would never, never get to her highest potential.
It is only in rare cases that you see such girls reach their life potential. We do know that in a girl that is well educated the outcome of the baby is better.” Findings show that complications during pregnancy and childbirth are leading causes of death among adolescent girls aged 15-19 resulting in thousands of deaths each year in low-resource and middle-income countries such as Nigeria.
Data from the UNFPA and Guttmacher Institute reveal that the risk of maternal mortality is higher for adolescent girls, especially those aged 15 and below, compared to older women. “Adolescent pregnancy brings detrimental social and economic consequences for a girl, her family, her community and her nation. Elimination of child marriage and meeting adolescents sexual and reproductive health needs would protect their rights and help prevent girls from having too many children too early in life.
“Adolescent pregnancies put newborns at risk. The risk of death during the first month of life is 50 percent higher among babies born to adolescent mothers. The younger the mother is, the higher the risk for the baby, says the WHO.”
A 2011 Report from the UN General Assembly titled “The Girl Child – Report of The Secretary General” affirms that: “The younger a girl is when she becomes pregnant, whether she is married or not, the greater the risk to her health. Girls under the age of 15 are at more risk of dying in childbirth than women in their 20s,” the Report concludes.
Findings from the UNICEF State of the World’s Children’s Report 2011 show that young women make up 64 percent of all new infections among people worldwide. “This is not just because they are more physiologically susceptible but because they are also at higher risk for sexual violence and rape, both inside and outside of marriage. In a marriage, adolescent girls often have limited control over contraceptive use or whether sex takes place or not.”