It was about 11am in Sokoto. It had just stopped raining and the skies were still somewhat cloudy. A middle-aged woman dressed in a white, long hijab, walked swiftly into the well-lit room and sat on an empty bed beside the window, all ready to share her story. With a calm smile on her face, while taking a glance around the room, she said, “my name is Mariam Mani and I have been leaking urine for 34 years”.

Mariam Mani

Fifty-year-old Mariam was born in Hulanji, a village in Silame LGA, Sokoto state. The eldest in a family of six, she had no form of education. At just 13, when her peers in bigger cities were enjoying their childhood, she was married off to a much older man. She did not resist the idea of marriage as it did not matter if it was her desire to get married or not. 

“It was my parent’s decision that mattered and they made the decision for me,” Mariam said.

Mariam got pregnant about three years into her marriage when she was around 16 years old. She did not attend any antenatal classes because it’s not a common thing in their village.

Months later, on a Saturday afternoon, she began to feel labour pains. According to the middle-aged woman, the thought of going to a medical centre did not occur to her as it was normal in her village to give birth at home and she believed she would do the same. Unfortunately for Mariam, she laboured at home for seven days and there was no sign the baby would come out.

“There was no plan to take me to the hospital at first until they found out that I was weak and might not be able to give birth on my own. So they rushed me to the nearest hospital in the village,” she said.

The decision to move her to a hospital was swift and the best at that moment, but it was many days too late. Mariam had a stillbirth at the hospital. The pain of losing a child wasn’t the only problem she faced in this situation. Days later, she noticed she had started leaking urine and was subsequently diagnosed with a vesicovaginal fistula (VVF).

NEGLECTED AND ABANDONED 

With the smile slowly fading from her face, Mariam said the most painful thing that happened to her as a result of VVF was that her husband divorced her. He could not live with a woman that was constantly leaking urine. To add insult to injury, her family members also deserted her.

Mariam

“I had no one to take care of me. I have faced a lot of challenges with this problem. There are a lot of places I would like to go but I cannot. I don’t want people to laugh at me,” she said.

In order to douse the smell from the urine and hide her condition, Mariam resorts to using perfumes when going out.

In 2012, Mariam felt a glimmer of hope after she got a free fistula repair surgery at Maryam Abacha Hospital in the state, courtesy of the Fistula Foundation Nigeria (FFN). Unfortunately, the surgery failed to completely curb the flow of urine. The 50-year-old had two more surgeries after that, both of which still failed to completely cure her. She was told her case was “very complicated”.

She is, however, hoping to have another surgery soon — one she hopes will bring an end to her troubles.

Maryam Abacha Hospital, Sokoto

“I was told there is a surgeon from an Arab country that will come. Hopefully, if he comes, I’ll undergo another fistula repair and I hope that this time it will be a positive result,” she said.

In the meantime, Mariam, who now lives in a hostel within the Maryam Abacha Women’s hospital with other fistula patients awaiting surgery, uses special reusable absorbent panties given to her by the Fistula Foundation Nigeria (FFN).

A hostel in Maryam Abacha Hospital, Sokoto, where Mariam lives with older fistula patients

Mariam can possibly be described as unique because even with her condition and all she has been through, she refuses to sit down and wallow in sadness. To make a living for herself, she does some petty trading. Mariam proudly said she makes local hand fans and sells them for N250 each.

“Even with my condition, I do everything available because I want to fend for myself and survive,” she said.

For Mariam, if she could turn back the hands of time, she would not get married at that age. 

“Right now, I’m a fistula advocate and I tell every pregnant woman to deliver in the hospital,” she said.

VVF, EARLY MARRIAGE 

According to health experts, VVF is an abnormal opening between the bladder and the vagina that results in continuous and uncontrollable urination. 

Goke Akinrogunde, the principal associate at GTAKHEALTH Communication and Allied Services, told TheCable that the small size of a pelvis increases the likelihood of developing VVF. “The pelvis has potential to grow bigger before a girl gets to adulthood. This means it’s actually smaller for those children — imagine a 12-year-old or 14-year-old. When the pelvis is small, the baby will find it more difficult to come out, if it comes out at all,” he said. “VVF is a situation whereby the womb gets pressed on the bladder. So if you don’t have enough space for the womb expansion, the potential to press on the bladder is more. “We all know that generally for first-timers, the womb does not get open easily so we usually expect a longer time for labour. So the longer the labour, the higher the chances of the bladder being pressed and leading to an opening from the bladder towards the lower part of the womb. And that is what you see that causes the dripping through the vagina.”

According to Statista, between 2012 and 2018, 18 per cent of females in Nigeria were married before the age of 15, whereas 44 per cent of girls were before the age of 18. Only three per cent of the men were married before 18 years old.

Incontinence underwear, a reusable undergarment designed to absorb urine

In some cultures in Nigeria, early marriage of girls is seen as a tradition, despite the trauma the children go through when they are married so early.

A 2021 report by Save the Children noted that if a girl is out of school, her chances of poor health outcomes are increased.

“If a girl is out of school, the likelihood of getting married at an early age is very high. She has an increased risk of poor health outcomes, having children at a younger age, dropping out of school, experiencing ongoing violence in the home, being restricted in her mobility, being left with limited decision-making ability, and earning less over her lifetime. Girls in Nigeria are more impacted by inequality and discrimination than boys, and their rights to survive, learn and be protected are unfulfilled and blatantly ignored,” the report reads.

ANNUAL FISTULA SURGERY RATE IS LESS THAN 40%

Musa Isa, director of the Fistula Foundation Nigeria (FFN), said despite the number of organisations and institutions across Nigeria dedicated to providing care for women with obstetric fistula, an estimated 150,000 women of reproductive age suffer from complications resulting from untreated fistula. 

“The annual surgery rate in Nigeria is less than 40% of the new cases leaving a huge backlog of vulnerable women without viable means of cure, thus more additional efforts are needed to bring down the long-neglected condition,” he told TheCable.

He added that the pattern of presentation of the obstetric fistula patient in Nigeria is obstructed labour which is not relieved in time.

Fistula Foundation Nigeria showing older VVF patients how to use incontinence underwear.

“This is because the stereotype fistula patient of a young, sick, stigmatised, rejected and divorced fistula patient accompanied by an old poor relative from the rural areas are now the exception in most of the fistula centres,” he said.

“VILLAGERS PREFER TRADITIONAL AT-HOME BIRTH” 

Twenty-year-old Fatimah Abdulahi from Zamfara state was one of many young women seated outside a ward in Maryam Abacha hospital, waiting for their turn to get a free fistula repair. 

The young woman, who was wearing a long green hijab over her dress, wore a tired look that held many stories. As she bowed her head to prevent eye contact with anyone in the room, Fatimah began to tell a sad tale in small bits.

Fatimah

Fatimah travelled from Zamfara to Sokoto after a family member told her about a free fistula repair she heard of on the radio.

She said she has been living with a fistula for two years and three months. Recalling how she developed VVF, Fatimah said she was in labour for a whole day at home but was unable to give birth. She was then taken to a hospital to deliver. 

“In my village, we don’t go to the hospital when we are pregnant. We prefer to deliver at home. We have women who come to help us during delivery. But if the labour is difficult, maybe after two days, we go to the hospital,” she said.

Fatimah never attended antenatal classes and only discovered their importance upon her arrival at the hospital.

Young girls/women waiting their turn for a free fistula repair at Maryam Abacha Hospital

Like many young girls who suffer prolonged obstructed labour, Fatimah had a stillbirth. Four days after the delivery, she discovered that she was leaking urine. 

Now looking intently at the cement floor, Fatimah said when she went back home, she was divorced by her husband.

“In my community, I no longer have friends, so I stayed in my room almost all the time. I used to hear about people that had fistula but I had never met anyone that had it. I did not really understand what it was until I also had it,” she said.

“I DID NOT WANT TO GET MARRIED” 

Umaima Aliyu said she was only 14 years old when she got married to her husband as his first wife. According to Umaima, she did not desire to get married at that time but was made to do so by her parents. 

The now 15-year-old Umaima took in shortly after her marriage and just like many girls in her circumstance, did not attend any form of antenatal.

Umaima

Her labour took three days and occurred entirely at home with the help of a traditional birth attendant. She said despite the difficulties, her husband insisted she must give birth at home.

Umaima lost her baby during delivery.

“After I delivered the baby, I discovered that I was leaking urine. I felt bad for not being given adequate care because my mother is late and I was left with my father’s younger sister to take care of me,” she said.

Umaima, who looked quite timid, said she does not really understand why this happened to her.

“I was just told I have fistula,” she said.

The story is not much different for 15-year-old Sadiya Mohammed from Dange Shuni, Sokoto.

The teenager, who was married off at 12 to her farmer husband, said she has had VVF for the past seven months.

Her labour had taken a day at home with the help of a birth attendant and it resulted in a stillbirth.

Sadiya Mohammed from Dange Shuni LGA, Sokoto

“In my community, we prefer to deliver at home. I grew up like that; we don’t go to the hospital to deliver in my community. And my parents believe in delivering a baby at home,” Sadiya said. 

Days after the delivery, she started leaking urine.

“I felt ashamed of myself when I saw that I was leaking urine. I was humiliated in my community. I isolated myself a lot and my friends started distancing themselves from me,” she said.

“I had never heard about fistula until I had it. When I found out I had fistula, I told my father about it and he brought me to the hospital. When I got to the hospital, they said I was not strong for surgery so I was told to come back. I heard from one of the fistula survivors that there would be free surgery here, so I came here.”

Sadiya said she considers her condition as her destiny and would want to go back to her husband’s house after her surgery. 

DESPERATION FOR REPAIR SURGERY

Inside the operating room at Maryam Abacha hospital where free fistula repairs were being done, a young woman in her early 20s lay sprawled on the operating table.

She looked around the room and watched the movement of the medical practitioners.

Examining the patient’s fistula, the surgeon said, “I think she had an operation done but she still cannot hold the urine”. 

“Instead of the urine to come out from here (urethral opening), it is leaking from here (vagina).”

The surgery was done and the patient was wheeled out of the theatre. This kind of surgery, when successful, is rewarding for both the patient and the surgeon.

Ongoing free VVF repair surgery at Maryam Abacha Hospital

According to Sa’ad Idris, a fistula repair surgeon with the United Nations Population Fund (UNFPA), VVF can cause death if infection sets in. He, however, added that deaths due to VVF are “very rare”.

“In women who have had several fistula repairs, it’s possible the actual problem was not detected. Complexity and expertise are very important. This is a field where there are not many surgeons over the world and we’re just getting advanced. There used to be cases that were deemed inoperable. There are cases where some surgeons attempt and fail and then if a better hand is not gotten, they keep attempting and attempting,” he said.

Idris added that “if we have good obstetrics, we can do a safe cesarean on the mother, even in a 10-year-old.”

“But we can say a much younger woman is more vulnerable to the problem,” he said.

Friya Bulus, director of gender affairs at the ministry of women affairs, told TheCable that the institution in collaboration with the ministry of health has carried out a lot of interventions amongst survivors of VVF.

“The minister in collaboration with other stakeholders has engaged in aggressive advocacy for the girl child enrollment, retention and completion of school. This has yielded positive results with community leaders signing to ensure the girl child is educated,” she said.

“We have an aggressive campaign on girl child school enrichment, retention and completion. The campaign includes that even if the girl child gets pregnant, she must be made to complete her studies after delivery.”

But one thing stands out. Although some of the young girls have had their lives disrupted by fistula, the surgical repairs are giving them a new lease on life.

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