Abiye Maternal and Child International Foundation recently at its office in Maryland, Lagos received  seven modern mobile ultrasound systems donated by GE Health care West Africa, to help increase access to quality maternal and child medical services especially in rural areas in Lagos.

Speaking at the acceptance ceremony, the Founder and Chief Executive

Officer of AMCH, Prof. Elizabeth Disu expressed her gratitude to GE West Africa for donating the medical equipment to AMCH and promised that it would be used to  improve medical services rendered to pregnant women especially in the rural areas in Lagos State and Nigeria in general. She said AMCH had collaborated with other partners to execute several training programs such as Essential Care for the Newborn which comprise of Helping Babies Breathe, Essential Newborn Care, Essential Care for Every Baby and Essential Care for Small Babies, Newborn Resuscitation Training (NRT), to mention a few.

According to Prof Disu, the organization recently partnered with Rotary Club International, California, USA to train health workers in Epe and Ibeju-Lekki communities in Lagos State on Essential Newborn Care Course (ENCC). The ultrasound system donated by GE, would enable them add obstetric care trainings in these rural communities.

Prof. (Mrs) Aba Sagoe, and AMCH’s patron, in her remark, equally expressed her gratitude to GE for the donation. “We appreciate this and we believe this will improve quality of care. We assure you that you are going to see positive results very soon. Thank you GE, she added.

The representative of the Federal Ministry of Health Head of Newborn, Family Health Department, Dr. John Ovuoraye, in his address, commended GE for their contributions to the development of the health sector in Nigeria and for donating the equipment to AMCH, a reputable NGO whose commitment to maternal and child health is widely recognised. He said, “On behalf of Federal Ministry of Health, I wish to thank GE for the company’s commitment to improving access to medical services in various communities in Nigeria. We have had collaborative trainings with AMCH and its founder, Prof. Elizabeth Disu, a pillar and a worthy person in the health sector, especially on maternal and childcare services. The equipment that I am seeing here will help in no small measure to improve quality services to pregnant women in Nigeria. The machine is technologically driven, simple, handy and mobile. It works amazingly well with a soft touch, gives accurate analysis, and has durable battery life. Once again, I want to thank GE for this donation.”

Prof. Adeniyi Adewumi, the director of training at AMCH and a consultant at Lagos State University Teaching Hospital, Ikeja opined that the ultrasound equipment would help monitor the number of babies a pregnant woman is carrying, baby’s position and growth of pregnancy amongst many other factors associated with improved quality care.

In his goodwill message, the Permanent Secretary, Primary Health Care Board (PHCB), Lagos State, Dr. Ibrahim Mustafa, also expressed gratitude to the donor and said that ultrasound equipment would help achieve focus on antenatal with its special features for obstetrics examination and quantification and could not have come at a better time than this.

The GE team was led by Mr. Abdulrahman Alabi, Manager, Ultra Sound, GE West Africa, accompanied by Mr. Gospel Johnson, Clinical Application Specialist, GE West Africa, and Mrs. Modupe Shittu, Lead, Life Care Solution Business, West Africa. Mr. Alabi said, GE did background research on NGOs and found AMCH worthy to receive the donation of ultrasound equipment to help improve quality services in maternal and child care access of many pregnant women in Nigeria.

Other dignitaries present at the acceptance ceremony were; Mrs. Ekhaiyeme Taiwo (rtd), Clinical Volunteer (AMCH), Retired Chief Matron Mrs Oluwatoyin Odukoya, and Miss Funmilola Oremakinde, an administrative officer with AMCH.

World Breastfeeding Week is celebrated every year from 1st to 7th August to encourage breastfeeding and improve the health of babies around the world.

This year’s theme by the World Alliance for Breastfeeding Action (WABA) was “Support Breastfeeding for a Healthier Planet”. In line with this theme, WHO and UNICEF called for governments to protect and promote women’s access to skilled breastfeeding counselling to optimize support for breastfeeding. The national vision and sub-theme was “Start Strong; zero water exclusive breastfeeding for a better future”.

Inspite of the COVID 19 pandemic, AMCH collaborated with Lagos State Ministry of Health to commemorate this year’s world breasting week with four main activities which included:

• Public enlightenment on breastfeeding through a radio talk 

Prof. Elizabeth Disu, Executive Director of AMCH, along with Dr Akinyinka of the Community Health and Primary Health Care Department of LASUTH were on the Radio 96.1 FM in Lagos talking about breastfeeding, its importance to the survival of the baby, benefits to the baby, mother and its role in sustaining our planet. On Saturday, a similar talk by the AMCH director featured on LTV 8, a local channel with emphasis on breastfeeding and child development. 

• Public enlightenment on social media

Pictures and clips of our activities for the week were covered on our social media platforms; Facebook, Instagram and also on our website for interested parties to see and be encouraged and supported to do exclusive breastfeeding.

• Sensitization talks to mothers and care-givers  

This took place at the Immunization Clinics of ten public health facilities in Lagos State which included Lagos State University Teaching Hospital (LASUTH), Ifako-Ijaiye General Hospital, Ajeromi General Hospital, Kola PHC, Agbara Paediatric Centre Ikorodu, Ifako PHC, Isolo General Hospital, Ibeju-Lekki General Hospital and Eti-Osa Mother and Child Centre. These talks were done throughout the week starting on Tuesday 4th August and culminating on Friday 13th August. 

There were breastfeeding talks, counselling and demonstrations on when and how to initiate breastfeeding, positioning of the baby, the rewards of exclusive breastfeeding for 6 months with zero tolerance for water and any formulas, continuing to 2 years and how it helps maintain a healthier planet. The psychosocial aspect of dealing with the bond created between the baby and the mother was also emphasized.

• A Webinar for Health Care Workers on Breastfeeding 

Abiye Maternal and Child Health International Foundation and her partners, Lagos State Ministry of Health and Lagos State University Teaching Hospital held a webinar for health care workers. The theme was “support breastfeeding for a healthier planet” in line with WHO and UNICEF’s call to “promote, protect and support breastfeeding in the Covid 19 era”.

Prof Disu anchored the programme. Lagos State Ministry of Health was represented by Mrs. Olubunmi Braheem, the State Nutritionist Officer, Directorate of Family Health and Nutrition and LASUTH was represented by the Director, Clinical Services and Training LASUTH, Dr Ibrahim Mustapha.

There were goodwill messages from President of Society of Gynecologists and Obstetrics of Nigeria (SOGON), Dr Ireti Akinola, The President of Paediatric Association of Nigeria (PAN), Prof. Edward Alikor and AMCH’s Patron, Prof. Aba Sagoe, a retired Professor of Haematology. There were over a hundred attendees and six speakers talked on different topics with PowerPoint presentations.

The first speaker was Dr Zainab Imam a Consultant Paediatrician/Neonatologist at the Department of Paediatrics, LASUTH. 

Topic: Overview of the World Breastfeeding Week 2020 theme.

The second speaker was Mrs. Olubukola Olawuyi, Deputy Director and the Coordinator Paediatric Nursing Programme in Lagos University Teaching Hospital, (LUTH), Idi-Araba.

Topic: Zero Water Initiative of Starting Strong with Exclusive Breastfeeding.

The third speaker was Dr Florence Funmilola Folami-Adeoye who is the Founder and the President of Cross of Christ Hospital and the CEO of Lactation Literacy in the United States (www.lactationliteracy.com). 

Topic: Challenges, Benefits and Support for the Breastfeeding Mother (International Perspective)

The fourth speaker was Dr Opeyemi Oluwabiyi, a consultant paediatrician/neonatologist at Ifako-Ijaiye General Hospital.

Topic: Challenges, Benefits and Support for the Nigerian Breastfeeding Mother

The fifth speaker, Dr Peter Ubuane, a Consultant Paediatrician/neonatologist at the Department of Paediatrics, LASUTH

Topic: Breastfeeding in the context of Covid 19.

The sixth and last speaker was Mrs. Olubunmi Braheem, Lagos State representative and the State Nutritionist Officer, Directorate of Family Health and Nutrition

Topic: Updated Ten Steps to Successful Breastfeeding 2018 Nigerian Adaptation

There were questions and answers and shared information on breastfeeding for the health workers on this platform.

Conclusion

Inspite of the pandemic, AMCH celebrated World Breastfeeding week effectively, sensitizing and educating the public and also the health care workers on the significance of breastfeeding in helping to reduce the mortality rate of neonates, benefits on the mother and child, its support for a healthier planet and its sustainability.

Be an advocate for change!

Introduction

What is Obstetric Fistula? 

Obstetric fistula is one of the most devastating medical conditions that affect women following childbirth. It is characterized by an abnormal hole connecting the vaginal to the bladder (vesico-vaginal fistula), the rectum (recto-vaginal fistula) or the ureter (uretero- vagina fistula) or a combination of these which leads to uncontrollable passage of urine or faeces or both through the vagina. 

Most cases occur when labour becomes prolonged, obstructed and is not relieved promptly. Obstructed labour is usually relieved by caesarean delivery, a surgical operation, carried out by appropriately trained personnel in adequately equipped health care facility. 

Prolonged pressure of the bony foetal head against the maternal pelvic bone results in the destruction (necrosis) of the soft vaginal, bladder or rectal tissue that is sandwiched between the two opposing boney surfaces. The dead tissue disintegrates after a few days creating the hole.

Who is affected?

Obstetric fistula now cuts across all age groups; affecting any woman or girl of childbearing age whose labour becomes unduly prolonged and is not promptly relieved.  Such women may have been in active labour with strong uterine contractions (labour pains) and progressive cervical dilatation for typically 12 to 16 hours, or even days. Teenage mothers are more vulnerable. Their incompletely developed pelvis result in small-sized birth canals that prevent the easy passage of average-sized babies. Adult women with adequate birth canal may have prolonged labour if their babies are bigger than usual or the baby’s head is abnormally positioned to present a larger than normal diameter. Even older women who have had many deliveries are not left out.

Where does Obstetric fistula occur?

Obstetric fistula occurs in settings with a high maternal mortality ratio.1 Women in low and middle income countries of sub-Saharan Africa and South Asia are disproportionately affected 2 with Nigeria perceived to bear a heavy burden of obstetric fistula.3 Other sub-Saharan African countries with high incidences are Ethiopia, recently reported as having the largest number of women with fistula symptoms, 4Uganda and Sudan. 

The burden and impact of obstetric fistula

Reliable estimates of the occurrence of obstetric fistula are lacking because majority of women affected never seek medical help due to their location in remote rural communities or due to fear of stigmatization. 5  Worldwide, about one to two women per 1000 deliveries develop obstetric fistula; 50,000–100,000 fresh cases are reported per annum6 and approximately 2 to 3.5 million women are living with untreated obstetric fistula, almost all entirely in sub-Saharan Africa and south Asia. 2

According to the 2019 Federal Ministry of Health’s National Strategic Framework for the Elimination of Obstetric Fistula in Nigeria, 7  12,000 fresh cases occur per annum while a backlog of 150,000 fistulae await repair. Nigeria thus remains a significant hub for the burden of obstetric fistula. The bulk of these cases arise from prolonged obstructed labour.  Though obstetric fistula is more prevalent in Northern Nigeria because of determinants like child marriage and early pregnancy, fistula cases exist in all parts of the country.7 At the current rate of surgical repair, it will take almost nine decades to clear the existing backlog in Nigeria.7

What do fistula patients experience?

Women living with fistula experience continuous leakage of urine, feaces or both. Prolonged contact of urine with the genital skin causes rashes and itchiness around the vulva. In some cases, other injuries encountered from the effect of prolonged labour complicate the situation. These may include the inability to walk properly, bed sores, urinary tract infections and general ill-health. 

Some of these women suffer the “double tragedy”  of losing their babies who are born dead (stillborn) or die soon after birth due to the distress suffered in the womb from prolonged labour.  The risk of stillbirth is documented to be 99 times greater when women develop fistula than if they have a normal uncomplicated delivery.9 The quality of such women’s lives is tragically affected in all domains of life.

Why do women develop fistula?

Though, the direct cause of obstetric fistula, in most cases is prolonged obstructed labour.  Lack of awareness of causes of fistula; poverty and low level of education which affect health-seeking behaviours; poor infrastructures, scarcity of skilled birth attendants and inadequate emergency obstetric services contribute to the occurrence.

A common scenario is that of a woman undergoing labour at home.  When her labour becomes prolonged, she delays in seeking expert care at the health facility; eventually, when she gets to such a facility after some transport delay, she is not promptly attended to, due to many other patients waiting to have a caesarean delivery. The labour gets more prolonged, the baby dies and the mother develops obstetric fistula.

 Impact of Obstetric fistula 

Obstetric fistula affects the individual, family, community and the nation at large. Fistula causes severe psychosocial, physical and economic distress; 8, 9 and has been classed as a violation of internationally recognized human rights.10 Women affected are often abandoned by their husbands and families, and ostracized by their communities as a result of their constant smell. Social consequences can be overwhelming and include stigma and social isolation, infertility, divorce, and depression.

Such women lose their economic power, become dependent on sympathetic family members, adding to the national economic burden of surgical repair and societal re-integration.

Efforts towards the elimination of obstetric fistula 

Obstetric fistula is completely preventable when timely comprehensive emergency obstetric care, including caesarean section, is accessible to all women. Obstetric fistula has been long eradicated in high- income countries due to universal access to emergency obstetric care. The continued occurrence of obstetric fistula in some communities indicates a disparity between accesses to safe obstetric care. 

Globally, the agenda for obstetric fistula is to strengthen each country’s fistula program and support national ownership, sustainability, and accountability for obstetric fistula policy development and problem solving toward 2030. 

In 2012, the United Nations muted the idea of the ‘’International Day to End Obstetric Fistula’’ (IDEOF) and this has been observed by member countries since 2013. IDEOF is celebrated every 23rd of May to increase awareness and strengthen advocacy for obstetric fistula.  

The Nigerian situation

As part of her initial efforts towards eradicating obstetric fistula, Nigeria has developed two National Strategic Frameworks for Eradication of Fistula (NSFEOF). Strategies included collaboration with non-governmental organizations and developmental partners; training of more fistula surgeons; provision of funding to support free fistula repairs; incorporating community screening for obstetric fistula into the Nigeria Demographic and Health survey; establishing more fistula treatment centres; strengthening fistula prevention by dealing with the underlying determinants of obstetric fistula and increasing access to treatment and rehabilitation services.  UNFPA, Fistula Foundation, and USAID-supported Fistula Care Project have impacted substantially on the number of surgeons trained and fistula repair surgeries carried out.

Though the number of repairs has increased, fresh cases continue to occur, obscuring the impact of increased repairs.  It is evident that our fistula response is not commensurate to the burden posed by obstetric fistula.  

A major challenge to scaling up fistula repairs is women’s and families’ ability to cover costs of fistula care. The collective cost of transportation, surgical repair, feeding, medications, companion expenses, rehabilitation and re-integration are often limiting and are not borne uniformly by treatment centres.

Way forward

Prevention is crucial.  Strategies need to be scaled up to avert new cases. These will include universal access to quality emergency obstetric and other reproductive health services.  Such facilities should be efficient in monitoring labour progress, prompt in the recognition of prolonged labour and be able to provide high-quality caesarean deliveries.  Efficient referral systems should be established to enable women access timely interventions.  

Educating communities on the need for women to have hospital deliveries; empowering the girl child through education; discouraging child marriage and early childbearing; training health workers to conduct safe caesarean delivery without causing iatrogenic fistula are important in preventing new cases of fistula.

 Women living with fistula need to be reached wherever they are in the community.  There is a need to raise awareness, encourage community participation in finding solution and strengthen advocacy by engaging fistula survivors.     

The Federal Government of Nigeria, in her response to the call in 2018 by United Nations General Assembly, for an end to fistula within a decade, has developed another ‘National Strategic Framework for the Elimination of Obstetric Fistula in Nigeria 2019 – 2023’. The framework consists of seven well -costed priority thematic areas with defined interventions. 7 Though the cost implication is enormous, we can no longer rely entirely on donor funding.

With strong political and financial commitments; implementation of every component of this strategic framework; provision of adequate infrastructures such as good transportation and communication systems; and health-care services with efficient operative services, eliminating obstetric fistula is within our reach and can become a thing of the past in Nigeria.

Be an ambassador 

What are your roles as an advocate for fistula elimination?   What can you do? Do you want to transform lives? You can start by doing one or all of the following;

1. Engage women and girls of reproductive age about preventive measures for obstetric fistula in your community, at work and on your social networks.
2. Encourage women with fistula to seek care.
3. Provide support to women in labour by facilitation their transportation to health facilities.
4. Educate the girl child.
5. Establish a partnership with your local government to reduce obstetric fistula.

The time is now! 

Dr. Fatimat Akinlusi is an Obstetrician/ Gynaecologist at the Lagos State University College of Medicine, Nigeria with special interest in Obstetric fistula.

References 

1. De Ridder D, Badlani GH, Browning A, et al. Fistulas in the developing world. In: Abrams PCL, Khoury S, Wein A, eds.  Incontinence, 4 edn. Paris: Health Publications Ltd. UK; 2009:1419–1458
2. Tunçalp Ö, Tripathi V, Landry E, Stanton CK, Ahmed S. Measuring the incidence and prevalence of obstetric fistula. Bull World Health Organ. 2015; 93(1):60–2.
3. Fistula Care. Urinary Catheterization for Primary and Secondary Prevention of Obstetric Fistula: Report of a Consultative Meeting to Review and Standardize Current Guidelines and Practices; 2013. p. 6-26. 
4. Maheu-Giroux M Fillipi V Samadoulougou S et al. Prevalence of vaginal fistula symptoms in 19 sub-Saharan African countries: a meta-analysis of national household survey data. Lancet Glob Health. 2015; 3: e271-e278
5. Murk W. Experiences with obstetric fistula in rural Uganda. Yale J Biol Med. 2009; 82: 79-82
6. World Health Organization. 10 Facts on obstetric fistula. Updated January 2018. https://www.who.int/features/factfiles/obstetric_ fistula/en/.
7. Federal Ministry of Health, Nigeria.  National Strategic Framework for the Elimination of Obstetric Fistula in Nigeria, 2019 – 2023. 2019
8. Wall L. L. (2012). Obstetric fistula is a “neglected tropical disease”. PLoS neglected tropical diseases, 6(8), e1769. https://doi.org/10.1371/journal.pntd.0001769
9. Saifuddin Ahmed, Erin Anastasi, Laura Laski. Double burden of tragedy: stillbirth and obstetric fistula. The Lancet Global Health. Volume 4, Issue 2, February 2016.
10. Donnay F, Weil L. Obstetric fistula: The international response. Lancet. 2004;363:71–72.

The World Prematurity Day (WPD) is a day set aside to raise awareness of preterm deliveries and discuss issues surrounding the management of these vulnerable children.

Training of health care workers involved in pre and post natal care of the mother and her infant and especially on courses such as Emergency Obstetric Care, Helping Babies Breathe, Essential Newborn Care and Kangaroo Mother Care.