CHAPTER ONE

INTRODUCTION

Background to the Study

Frajznygier, Ruminjo & Barone (2012), described vesico-vagina fistula (VVF) as an abnormal opening between the vagina and bladder, resulting from prolonged obstructed labour and resulting in urinary incontinence. At present, Africa has recorded approximately 3 million cases of vesico-vagina fistula (Maggi, Rogers, Scanlon, Koroma & Mends, 2011; Egender Health Organization and the United Nations Population Fund, 2013). Meanwhile, a research by the National Demographic Health Survey (2012) showed that no fewer than 12,000 women develop VVF in Nigeria yearly. The study further indicated that more than 150,000 registered patientswas recorded at present in Nigeria (The News Agency of Nigeria, 2013). However, many researchers consider these figures to be grossly underestimated as they are based on women seeking treatment, whereas the condition most widely and severely affects women who are unable to reach, seek or afford treatment (Donnay & Weil, 2004).

In the words of Sambo (2008), Nigeria has the highest prevalence rate of VVF in Africa, with wide regional variations. The regional variation is as a result of the difference in the distribution of risk factors like, unavailability or under-utilization of obstetric health facilities and other cultural practices inimical to safe motherhood. Such cultural practices include: Female Genital Cutting (FGM); early marriage, with consequent pregnancy when the pelvic muscles and bones are not matured; traditional type of episiotomy (cutting through the vagina to create a passage for the baby); home delivery and patronage of unskilled traditional birth attendants (TBAs) (Donnay & Weil, 2004). In addition, VVF could also occur due to urological and lower gastro- intestinal or pelvic surgeries (Yamin, Tayyaba, Naeem, Shafia & Hussain, 2009). During these surgeries, an accidental and unrecognized injury to the bladder causes urine to drain through

13

the vaginal cuff suture line. This results from pressure necrosis, hematoma formation and the occurrence of infection from incorrectly placed sutures between the vaginal cuff and posterior bladder wall, bringing about VVF (Garthwaite & Neil, 2010).

Gbola (2007) penned that, victims of VVF suffer from urinary incontinence, which makes them smell of urine at all times and expose them to infections such as; vaginitis, and excoriation of the vulva (injury to the surface of the skin or mucous membrane caused by physical abrasion, such as scratching). Also, they suffer vagina stricture, secondary amenorrhea, possible secondary infertility even after repair of VVF, and a low child survival rate.

VVF is considered one of the most dehumanizing conditions to afflict women, because patients also suffer devastating emotional and social challenges in addition to the medical sequels of the condition. The emotional challenges include shame, depression, loss of self esteem, discrimination and anxiety, while the social challenges include unemployment, divorce or separation, rejection, social isolation and abandonment by significant others (Munir-Deen, 2007). Other social problems associated with vesico- vagina fistula include secondary infertility and childlessness, as well as elective caesarean section in subsequent pregnancies. Wall (2007) opined that these emotional and social challenges are jointly termed psychosocial challenges and result from the offensive/pungent smell of urine. This is in line with Onwunali (2012) who stated that these challenges affect the femininity, intimate/social relationships and the daily life functioning of victims, thus leading many to early death by suicide. Moreso, it is the psychosocial challenges experienced by VVF patients that hinders them from reporting for treatment, thus making the assessment of VVF incidence, prevalence and magnitude difficult to assess in Nigeria (Taylor, 2011) .

In addition, Onwunali (2012) noted that vesico vagina fistula leaves the women and girls incapacitated for several months, years or for a lifetime. Consequently, these women live a life of 14

destitution and often end up on the streets begging for survival (Onwunali, 2012). However, the condition is a preventable one with the key measure being prevention of obstructed labor. Other measures include: poverty alleviation and improvement in socio-economic conditions; prevention of childhood malnutrition and consequent osteomalacia and pelvic bone mal-development (Munir-Deen, 2007). Furthermore, formal education and women empowerment can prevent early marriage. This is because, it will allow the women to better appreciate and utilizethe available health facilities for antenatal care, hospital delivery and family planning services. Incorporation of sex education into post-primary education curricula, to sensitize people on sexual health from an early age, is another preventive measure. However, it is pertinent to state that VVF prevention can only be achieved through comprehensive strategies and with the combined efforts of the government, health and community organizations (Munir-Deen, 2007).One of these strategies is assessing the psychosocial challenges that the victims of VVF have, as a means of strategizing and giving evidence based care. Therefore this study addressed the psycho-social challenges of women with vesico-vagina fistula.

Statement of Problem

VVF is a serious disability experienced by some women after childbirth. According to The News Agency of Nigeria (2013), there are more than 150,000 registered vesico- vagina fistula patients in Nigeria. This represents about 40 percent of the cases in the world (United States Agency for International Development, 2013).Vesico vagina fistula is an injury often secondary to an obstetric manipulation, gynaecologic surgery, radiation or invasive cancer of the cervix, and patients present with constant leakage of urine. This results in perineal wetness and excoriation, as well as ammoniacal urinary odour (Yola, 2012). In addition, VVF has been known to affect the activities of daily living of its victims (Onwunali, 2012).

15

Regardless of the etiopathology, the development of vesico-vagina fistula like any other chronic health condition has profound and devastating consequences on the patient’s physical, social and psychological health (Garthwaite & Neil, 2010). Moreover, previous studies and up-to-date information on VVF has often concentrated on the medical and surgical needs of these victims, leaving out the psychological and social challenges associated with this devastating condition, which has serious implications. Thus making it difficult to describe the psycho-social impact of Vesico-vagina fistula on its victims (Onwunali, 2012). Therefore, this study was selected by the researcher to assess the psycho-social challenges of women with VVF at the National Obstetric Fistula Centre, Abakaliki, Ebonyi State.

Purpose of the Study

The purpose of this study was to assess the psycho-social challenges experienced by patients with vesico-vaginal fistula (VVF) at the National Obstetric Fistula Centre (NOFIC), Abakaliki, Ebonyi State, and the effect of such challenges on their emotional and social health.

Objectives

Specifically, the objectives for this study were to assess;

v    How VVF affects the emotional health of patients at the National Obstetric Fistula Centre, Abakaliki.

v    How the attitude of significant others affect the social health of VVF patients at the National Obstetric Fistula Centre, Abakaliki.

v    The relationship between the psychological challenges and social health of VVF patients at the National Obstetric Fistula Centre, Abakaliki.

16

Research Questions

v    How does VVF affect the emotional health of patients at the National Obstetric Fistula Centre, Abakaliki?

v    How does the attitude of significant others affect the social health of VVF patients at the National Obstetric Fistula Centre, Abakaliki?

v    What is the relationship between the psychological challenges and social health of VVF patients at the National Obstetric Fistula Centre, Abakaliki?

Significance of the Study

The findings of this study would be relevant to VVF patients, healthcare providers, counselors, community health workers, philanthropists, non-governmental organizations, religious organizations, policy makers and researchers.

To VVF patients, it would help them to understand how VVF affects their emotional healthand how the attitude of significant others affect the social health. This would enable them gain insight to their psycho-social deficiency and thus seek, accept and appreciate psycho-social support programmes planned or provided for them.

To health care providers at different levels, it will help themto understand the psychological and social problems of VVF patients and thus plan holistic care that will address the social and psychological needs of VVF patients as much as their physical needs. This is important because often times, health care providers focus more on the physical aspects of the patients care with little or no concern about their psycho-social health.

To counselors, it would help them to design and organize counseling sections that aim at identifying and handling patients psycho-social needs.

17