Kelina is nine and has used diapers all her life. She was born with a congenital abnormality that left her without an anus. (Names of minors in this report have been changed to protect their identity).
The nine-year-old is among dozens of women who appeared for a pool repair of fistula at the Vesico-Vaginal Fistula Centre at the Ogoja General Hospital in Cross River State early November.
Without a normal anal opening, Kelina has had to pass both urine and faeces through her vagina. It is a rare condition called congenital fistula: an unopened anus or vagina.
“Imagine what she and her parents have been going through,” says Dr. Sa’ad Idris, lead surgeon on the fistula repair team.
“All the time, her vagina is packed with faeces. The nurses in the clinic have been having a real very difficult time with her, cleaning her up and dressing her with diapers because she cannot control stool.”
Two previous surgeries in Abuja were unsuccessful, and her parents: a catechist father and a farmer mother from Amana in Obanliku area of Cross River State, got tired of buying drugs and injections.
“They felt there was nowhere else they could go,” said Peter Njagu, who heads the VVF unit.
The Idris team worked for several hours to create an anal canal for Kelina. They then diverted her bowel movement through the canal.
Kelina is the third girl since August on who surgeons have had to create anus for at the centre.
The second is Linda. She lay almost lifeless as the team worked on her. It took hours to get the diversion right.
Beside Kelina and Linda more than 500 women have undergone surgical repair for fistula at the centre alone.
Fistulas are abnormal holes formed in the vagina during prolonged and obstructed labour at childbirth. The basics are simple: the head of a foetus presses against portions of the birth canal during childbirth. In prolonged labour the pressure is sustained.
Some women have been known to labour for up to 72 hours.
The pressure ruptures the vaginal wall and can also rupture nearby tissues: the bladder or the rectum, causing the contents of either or both to leak into the vagina.
Women with rectovaginal fistula leak pass faeces through the vagina. Those with vesicovaginal fistulas leak urine uncontrollably due to ruptured bladder.
The stench is ground for much stigma and discrimination. Some are even totally abandoned by their families.
Ekaette Bassey was dumped and abandoned at the VVF clinic in Ogoja by a man (believed to be a pastor two months ago).
She is from a family of six out of which four are dead. Her only surviving sister and relative couldn’t tolerate living with her and so left her.
“I stayed with my sister in Akankpa but later on she abandoned me. I couldn’t see her or anybody. I kept begging people on the streets to help me because I was very sick and I needed money to feed,” she recalled.
The race is on for a fistula-free generation, but a backlog and emerging cases of the condition are overwhelming efforts to stem it.
“I cannot say that we are on track,” said Iyeme Efem, Country Manager for Engender Health, which implements a US-funded project, Fistula Care Plus, to prevent, treat and rehabilitate women and girls living with fistula.
“We have a backlog of over 200,000 women living with fistula and we have new cases occurring every year,” she added.
Engender Health routinely gets volunteer surgeons to offer their skills and gets surgical centres across states to offer space and personnel. It is the “pooled effort” in which Kelina, Linda and Ekaette underwent repairs.
The pool is able to do around 2,000 repairs a year. Ad hoc repairs at teaching hospitals and pet projects run by governors’ wives also add to the trickle of repairs, sometimes doubling it a year to 4,000.
“It is not up to the number of new occurrences every year let alone attacking the backlog,” said Efem.
“It is like telling me that Nigeria is on track when the tap is still running and the bucket of water is overflowing and what we are using is tea spoon to try to empty the bucket of water.”
Minister of Health, Isaac Adewole, this year, announced free fistula care services in tertiary hospitals nationwide in efforts to expand access. Projections show tertiary hospitals stepping in may help mop up the backlog: 49 teaching hospitals each doing 15 repairs a month total 735 cases, in addition to the current 4,000.
However, not all teaching hospitals and not all gynaecologists take on fistula repair. And some gynaecologists do cause fistula in attempts to perform caesarean section (CS).
Engender Health has plans to liaise with the Society of Obstetricians and Gynecologists of Nigeria (SOGN) to put modules to teach surgeons fistula repair right from the university.
“A lot of fistulas are formed by us the medical personnel, probably because of lack of expertise or something else. If you look at it, the commonest site where you would have seen fistula is the junction between the bladder and the urethra,” said Idris, a former commissioner for health in Zamfara State.
“The main thing is to restore her continence, for her to be closed and dried and then her sexuality. After then she will become a complete woman again,” Idris said concerning fistula patients.
With more than 500 repairs at the centre, it is a testimony that awareness is growing about the condition a signal on where to get help.
Cross River State government, through the Commisioner for Health, Inyang Asibong, said it was willing to provide “additional support” to help combat fistula in the state.
The wife of the governor donated food and financial support to support the repaired patients through their stay at the centre.
However, the centre’s coordinator, Njagu, said the centre still faced challenges with personnel and transportation of the patients.
Another major problem is liaising with family members, because reintegration is always difficult.
Many of the women are divorcees, rejected by their spouses and communities, or sent out of their homes on account of their condition, most claiming it is the result of a curse or witchcraft. The cycle increases the stigma and trauma.
Reintegration is essential but there is no mapped out plans for it and the way forward requires all partners to unify in rehabilitation and sensitisation of these patients, said Njagu.
“Repairing VVF is not only about closing the hole, but a holistic situation where they get their womanhood back,” he added.
A day after her surgery, Kelina is wide awake and without a diaper. Her mother cannot believe it. She still wonders whether her daughter’s new anus really works. However, she is waiting and watching to be sure.
“I don’t know yet. Maybe, in a week or two, if she doesn’t need diapers, it would be good,” she said.
