women play in the family and society at large. One of the major reproductive health challenges facing women in sub Saharan Africa is obstetric fistula (Stanton et al, 2007). In developed countries obstetric fistula is almost nonexistent due to the improvement in emergency obstetric care facilities (Creanga and Genadry, 2007). In contrast, women in developing countries are still suffering from the scourge of this medical condition (Tinuola and Okau, 2009). This view was supported by Tebeu et al, 2009 who revealed that obstetric fistula is common in low resource countries while it is rare in high resource countries. The entire burden of this disease is mainly confined to the “fistula belt” which extends across the northern half of sub Saharan Africa to the south of Asia (WHO, 2006). Consequently the global morbidity and mortality from obstetric fistula has been on the increase over the years (Mohammad, 2007). It has been estimated that 50,000 to 100,000 women worldwide develop obstetric fistula annually adding to the pool of women who are living with the disease (Shittu et al, 2007). However, the figures have been reported to be have been underestimated this is because most women with obstetric fistula live in isolation and fear of rejection and hence do not seek medical care resulting in a vast majority of unreported cases (Tsui et al, 2007). Ahmed and Holtz, 2007 estimated that close to half of the total burden of obstetric fistula is recorded in Nigeria alone. The country remains at the centre of the international resolve to tackle this disease due to its large population and its poor maternal mortality rates (Zheng and Anderson, 2009). The World Health Organisation (WHO) stated that one out of every nine maternal deaths occurs in Nigeria with obstetric fistula as the major threat to women’s reproductive health (WHO, 2006). Ahmed and Holz (2007) divided the effects of obstetric fistula into physical consequences, social and economic effects. The physical consequences includes: skin problem (this resulting from direct and constant irritation by urine), amenorrhoea, vaginal stenosis, bladder infection, neurological injury leading to foot drop, intra uterine scarring and hypothalamic dysfunction (Ahmed and Holz, 2007). The social and economic effects enumerated includes: divorce, disturbed sexual life, poor quality of life, weight loss and stigmatisation (Wegner et al, 2007). Across Africa and Asia treatment of obstetric fistula is through a variety of setting such as the specialist fistula centres, fistula units in general and specialist hospitals and at times treatment can be accessed through gynaecology and urological departments and fistula camps in rural and remote areas (Donnay and Ramsey, 2006). Small fistulas close without surgery through continuous bladder drainage although this is only possible if the woman presents within three months of child birth (Donnay and Ramsey, 2006). Donnay and Ramsey, 2006 added that a surgical technique for the closure of obstetric fistula was first described by J. Marion Sims in the mid eighteen hundreds and that these techniques involve the surgical closure of the fistula with the use of tissue grafts.
However the dynamic nature of this medical problem requires a skilled professional that has a sound knowledge of this condition (Cook et al, 2004). The number of women with unrepaired obstetric fistula in Nigeria is between 800,000 to 100,000 while the average cost of treatment in Nigeria is USD $300 which is beyond what the average woman can afford due to extremely poverty that exist in the country as 75% of its inhabitants live below USD $1 per day (UNICEF, 2009). In 2001 the United Nations Population Fund (UNFPA) brought together brought together potential partners in London in order to launch an initiative which aims to address obstetric fistula especially in developing countries by gathering data and provide funding towards prevention and treatment (Wegner et al, 2007). The stakeholders involved are: the Addis Ababa fistula hospital, Columbia hospital, Averty Maternal Deaths and Disability Program (AMDD), the International Federation of Gynaecology and Obstetrics (FIGO) and the World Health Organisation (WHO) (UNICEF, 2009). This lead to the inauguration of the Foundation for Women’s Health Research and Development (FORWARD) in Nigeria to improve the socio-economic status and health of women who have either been treated or those who require intervention for obstetric fistula (Shittu et al, 2007). This project located in Kano state (northern Nigeria) is been funded by the United Kingdom Department for International Development (DFID) and the international partners listed above (Shittu et al, 2007). This has lead to increase awareness of obstetric fistula in Nigeria however; a lot needs to be done in order to reverse the increasing trend of this condition (WHO, 2006). Stigmatisation which women with obstetric fistula suffer remains a major concern for public health programmes committed to addressing this medical condition (Donnay and Ramsey, 2006).
1.2 PROBLEM STATEMENT
The importance of tackling obstetric fistula in Nigeria cannot be overemphasised as it poses a major setback to the reproductive health of young girls and women in this West African country (WHO, 2006). A six month assessment of nine African countries conducted by the United Nations Population Fund in 2002 revealed that an estimated one million women are suffering from the burden of obstetric fistula in Nigeria and that this trend is on the increase (Wall, 2007). As the country’s population approaches the 200million mark the number of women with obstetric fistula may be tripled if the pertinent issues on this medical condition are not addressed (UNICEF, 2009). This view was supported by the World Health Organisation (WHO) findings that stated that forty percent of the global burden of obstetric fistula is recorded in Nigeria and at the current rate of management it will take three hundred years to clear the backlog of women who needs surgical intervention if no new cases is recorded (Shittu et al, 2007). This has reflected in increase in Nigeria’s maternal mortality rate as one out of every maternal death occurs in this country and most women who survive the ordeal of child birth are faced with compromised health status with obstetric fistula being the foremost (UNICEF, 2009). Galadachi et al 2007, reiterated this fact by stating that maternal mortality rate in Nigeria is one of the highest in the world accounting for 948 maternal deaths per 100,000 live births and further more for each maternal death that occur 15 to 20 other women suffer from either long and short term maternal morbidities among this is obstetric fistula. The stench of urine and faeces associated with obstetric fistula makes affected women vulnerable to domestic violence and suicidal adhesions among others (Mohammad, 2007). For this reason the World Health Organisation emphasised that management women with obstetric fistula require a holistic approach that does not only see this disease as a medical problem but also addresses the psycho-social impact it has on their lives and families (WHO, 2006). In rural communities in Nigeria the women with this disease are often blamed for their condition and are seen as a failure to motherhood this has contributed to being ostracised from their communities (Kelly and Winter, 2009). The increasing incidence of obstetric fistula posses a major threat to the attainment of the UNICEF fifth millennium development goal which aims to reduce maternal mortality between 1990 and the year 2015 and also to achieve a universal access to reproductive health by the same year (Galadachi et al, 2007). Hence, the impact of obstetric fistula on women, their families, health care, public health and clinical research is enormous and requires urgent attention (Kelly and Winter, 2009). For this to be addressed, a sound knowledge of the risk factors that predispose women in Nigeria to developing obstetric fistula needs an indebt understanding and this is the premise of this research study.
1.3 STUDY QUESTION
What are the risk factors that are associated with obstetric fistula among women in Nigeria?
1.4 AIM OF STUDY
The principal aim of this study is to explicitly explore the risk factors that predispose women in Nigeria to obstetric fistula.
To critically explore the risk factors associated with obstetric fistula in Nigeria.
To shed more understanding on the difficulties faced by women living with this disease.
To proofer recommendations and how these risk factors can be fully addressed in order to improve the reproductive health of women in Nigeria.
1.6 STUDY JUSTIFICATION
On a global scale the continued increase in the incidence of obstetric fistula in low resource countries is one of the most visible indicators of the enormous gap that exist in the maternal health care services between the developed and developing world (WHO, 2006). This view was further reiterated by Cook et al, 2004 who stated that the high prevalence of obstetric fistula not only shows the level of injustice and violation of basic human rights and disparities in the quality of life but further encompasses disparities between younger and mature women and between developing and developed Nations. Despite interventions from a number of international organisations no concerted effort has brought this medical condition into global consciousness until recently hence most of the studies done on obstetric fistula only concentrates on the medical causes of the disease without addressing the interplay of socio cultural factors as key determinants. (Donnay and Ramsey, 2006). Although obstetric fistula has ravaged a lot of women not only in Nigeria but in Africa it remains a preventable disease if high basic and comprehensive maternal health services are made available. Hence interventions to tackle obstetric fistula must embrace prevention as an important step in reducing the incidence of this disease for this to be done effectively more relevant studies on obstetric fistula is needed (Stanton et al, 2007). Accordingly, this research study will unveil not only the medical risk factors that predispose women to developing obstetric fistula but will also include the socio cultural determinants that affect this risk group. Both qualitative and quantitative studies will be explored to give a thorough understanding of these factors and how they interplay. This will go a long way in addressing the increasing incidence and prevalence of the disease. This will also add to the pool of knowledge on obstetric fistula as it remains a disease that has been given little attention.
1.7 PROFILE OF NIGERIA
Nigeria accounts for forty-seven percent of the total population of West Africa (UNICEF, 2009). It presently inhabits 148 million citizens with 36 states and four geographic zones and remains the biggest oil exporter in Africa with a vast reserve of human and natural resources (UNICEF, 2009). It occupies 923,768 square kilometres and has Niger, Chad, Cameroon, and Benin as it borders (World Bank, 2010). The country has over 350 ethnic and linguistic groups with a vast array of social groups (UNICEF, 2009). Majority of the population reside in the rural areas while approximately thirty six percent reside in the urban areas (UNICEF, 2009). Nigeria’s natural reserve reached US $ 42.4 billion at the end of 2009 and both foreign and domestic debts have remained low (UNICEF, 2009). Internationally, Nigeria remains a leading player in the African Union (AU), Economic Community of West African States (ECOWAS) and the New Partnership for Africa’s Development (NEPAD) (World Bank, 2010). However, the country continues to face a rising rate of unemployment and also in spite of the successful initiatives in human development the country is presently facing challenges concerning the millennium development goals especially in the northern part of the country (World Bank, 2010).
1.8 STRUCTURE OF THE STUDY
Chapter one comprises of the introduction and overview of the study topic. This chapter includes background of obstetric fistula, aims and objectives of the study, the problem statement, study justification and a brief profile of Nigeria.
Chapter two presents the literature review on the factors associated with obstetric fistula.
Chapter three presents the methodology section which analyses the process of literature review. This chapter also includes the methods section which explains the process used by the authors in the search of relevant studies and health models.
Chapter four comprises of the analysis of the studies selected and the review of findings.
Chapter five presents the discussion on the result obtained.
Chapter six this chapter presents recommendations, conclusions, limitation and a general reflection on the study.
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