The secret scourge of African women


Le Monde Diplomatique, July 1997


Childbirth remains an untold risk throughout the developing world, bringing death and permanent disability to the world's poor. Two million women suffer from fistulae, a degrading condition which makes them outcasts in their own society – and which could be treated... In Nigeria the situation is particularly grim, with 1 in 25 dying of childbirth complications

                                                By Joelle Stolz and Philippe Le Faure



                              Fourteen-year-old Suwaiba is laid out on the operating table. She has

                              received an epidural anaesthetic to numb the pain. Meanwhile, three doctors

                              are busy assessing the extent of the trauma and preparing to operate. Her

                              vagina is badly torn, her sphincter is in shreds and a double fistula, the result

                              of an impossibly difficult birth, connects her vagina, bladder and back

                              passage. Urine and faeces trickle through the opening, as the young girl lies

                              helpless: she no longer has control of her bodily functions.


                              In the north of Nigeria (the most densely-populated country in Africa),

                              Suwaiba's condition is common-place. Here in Kano, under the scorching sun

                              of the hospital courtyard, dozens of women swathed in brightly-coloured veils

                              await their turn for the operation which will restore their lost dignity. A thin

                              trickle of urine runs down their legs and into the dust, visible proof of their



                              Like theirs, Suwaiba's fate is an unlucky one. Married before puberty (as are

                              the majority of Fulani and Hausa peasant girls) she followed custom and

                              returned to her parents' home for the birth of her first child. Doctors believe

                              this time-honoured tradition may have arisen out of the high incidence of

                              maternal deaths associated with a first delivery. Sadly, Suwaiba's pelvis was

                              too narrow for the baby's head to pass through. For three days, she suffered

                              in silent agony, modestly stifling her cries as Hausa custom demands. When at

                              last her mother became aware that something was wrong, it was already too

                              late to take her to the hospital. In this part of the country, hospitals require 24

                              hours' notice to prepare for a costly and complicated operation such as a

                              Caesarean section.


                              The only person who could help Suwaiba was the unguzuma or traditional

                              midwife. Her method, similar to that used in the past by local midwives in

                              Europe, was to pull as hard as she could on what she could reach of the

                              child's body. Suwaiba's own body was badly torn in the process; and the

                              baby girl was born dead. Her mother, who was too young to give birth, was

                              in scarcely better state.


                              Suwaiba already knew that her husband would now reject her. In the Muslim

                              culture, with its emphasis on ritual ablutions before prayer, women like her are

                              thought to be in a permanent state of uncleanliness and are cast out by their

                              own families.


                              The older women survive through begging or what odd jobs they can pick up.

                              The younger ones are frequently drawn into prostitution. Suwaiba could have

                              sought shelter, as many others do, in one of the gidajen mata (a Hausa word

                              meaning houses for women, also sometimes pejoratively called gidajen pisari

                              or houses of piss), which, in the large Muslim cities of northern Nigeria, offer

                              shelter to thousands of such divorcees who find themselves forced into

                              prostitution (1). Across the courtyards of these wretched asylums, cloths can

                              be seen hanging out to dry; these have been washed again and again to get rid

                              of the lingering stench of urine.


                              Soon after Suwaiba gave birth, she heard on Nigerian radio of the “great

                              doctor”: a Dutch surgeon, who has become a sort of legend in the northern

                              savannah. Kees Waaldijk came into contact with the problem of

                              vagino-vesicular fistulae (2) in 1983, when he came to the city of Katsina to

                              work amongst lepers. A large number of his female patients suffered from this

                              condition which, though it has long disappeared in the West, is probably as

                              old as human-kind itself and, like leprosy, is synonymous with social



                              Fistulae caused by childbirth have afflicted women in all countries and from all

                              sections of society. Traces of the condition were discovered on the

                              mummified body of the Egyptian princess Hehenit, who died in childbirth

                              nearly four thousand years ago. It is also known that the court of Louis XIV

                              used to make fun of the King's young mistress, Louise de la Vallière, who

                              suffered from this embarrassing affliction. The condition was so widespread

                              among the early American pioneers that a specialist hospital was set up in

                              New York in the 1840s to offer surgical treatment, using a procedure

                              invented by a doctor from Alabama.


                              Since the “medical revolution” of the 20th century, fistulae have disappeared

                              from the Western world. “These days, if labour continues beyond the normal

                              length of time, a Caesarean section is performed”, explains Dr Waaldijk. “But

                              out in the bush, young women in this situation simply die and, in 90% of cases,

                              so does the child”. It is estimated that, out of every thousand women who

                              survive childbirth, two are left with a fistula. This is caused by pressure from

                              the child's head, which can block the circulation in that area, giving rise to

                              necrosis of the tissue at a particularly vulnerable point. Often the perianal

                              nerve is also damaged, as a result of which some of these women are left

                              limping for the rest of their lives.


                              An operation to patch the damaged wall of the urethra can be performed,

                              using a muscle from the inside of the thigh which is normally removed

                              subcutaneously. This technique was first developed by a medical couple,

                              Reginald and Catherine Hamlin, who devoted their lives to these women, and

                              it has since been successfully adopted in Nigeria. With an experienced

                              surgeon, complete recovery occurs in 80% of cases. The women regain full

                              control over their bodily functions and are accepted back into society, usually

                              going on to remarry.


                                               Two million suffer in silence



                              How many sufferers are there in the world today? Specialists suggest a figure

                              of two million. We know at least that the majority of sufferers live in Africa: in

                              Sierra Leone, Mauritania, Niger, Mali, Tanzania, Ethiopia, Somalia and in

                              Sudan, where many women suffering from the condition go on to commit

                              suicide. It is also present in Haiti, India, Pakistan and Bangladesh. Wherever,

                              as a result of war, peoples are displaced and there is disruption to an already

                              fragile public health infrastructure, there is a return or an increase in the

                              number of cases of childbirth-related fistulae. In Afghanistan, the regressive

                              policy of the Taliban's new Islamist regime is likely to increase the number of

                              cases by restricting women's access to surgical care.


                              In Nigeria alone, which has a population of 100 million, there are thought to

                              be 200,000 sufferers, 70% of whom are concentrated in the north. According

                              to Professor Bandipo, a medical director in Zaria, “There's no other country

                              in Africa where this public health problem is so acute: one in every 25 women

                              in Nigeria dies as a result of complications in childbirth. That is 400 times

                              more than in the West. And for every mother who dies, 15 to 20 others go on

                              to survive with some sort of permanent physical damage”. These figures, no

                              doubt linked to the neglected and often rapidly deteriorating public health

                              services (in which the government invested heavily in the 1970s and 1980s),

                              stand in stark contrast to the substantial oil revenue enjoyed by this African



                              A number of cultural factors also come into play, but these are less

                              straightforward to address. The tradition of child-brides is still very much alive

                              in the vast savannah region of northern Nigeria, with its Muslim majority. Even

                              in urban areas, parents tend to marry their daughters at a very young age as a

                              way of safeguarding family honour in an environment characterised by violent

                              social relations (4). In addition, the custom of yankan gishiri, which involves

                              making an razor-blade incision in the young bride's vagina if the “marriage

                              road” has proved too narrow, carries a relatively high risk of damage to the



                              The mainly Christian south is unhappily influenced by evangelical sects who

                              discourage women from giving birth in hospital. “In order to bolster their own

                              status, pastors tell women that God is present in the Church, not in the

                              hospital. They encourage pregnant women to fast and stay up all night to pray,

                              and the women become exhausted”, explains Dr Ann Ward, an Irish nun. She

                              runs a health centre for the treatment and rehabilitation of fistula sufferers in

                              the city of Uyo, in south-eastern Nigeria (5).


                              The problem is further compounded by male indifference and poor transport

                              facilities. The medical files kept by Dr Ward and her colleagues contain

                              countless heart-rending examples. There are cases of mothers begging the few

                              local men with motorised transport to fetch help for their daughters, and being

                              refused. In one case, a dying woman, her baby's half-decayed arm protruding

                              from her body, was taken to hospital on a board attached across a moped.

                              There are husbands who refuse to donate blood to save their wives from

                              haemorrhaging to death.


                              Thanks to the commitment of a growing number of doctors and to Amina

                              Sambo (a militant feminist in Kano who is currently president of the Nigerian

                              Women's Union), genuine efforts have been made over the last decade

                              towards putting an end to this unnecessary suffering. Radio programmes

                              broadcast in local languages, television documentaries and newspaper articles

                              have succeeded in bringing to public attention the suffering (hitherto

                              unnoticed) of the thousands of women converging on health centres for



                              But, as in other countries afflicted by poverty or war, the number of these

                              female “pariahs” in Nigeria increases steadily as the population expands.

                              Meanwhile, very few doctors choose to specialise in what is essentially a poor

                              people's blight; and those who are trained to treat the condition are too few to

                              deal with the enormity of the task which faces them.



                              * Respectively, journalist and television producer.


                              (1) A study carried out in the early 1970s identified 123 “houses for women” in the city

                              of Katsina alone, which was nevertheless known for the strength of its Muslim



                              (2) The vagino-vesicular fistula (VVF), between the bladder and the vagina, is more

                              common than the recto-vaginal fistula (RVF), between the back passage and the vagina.


                              (3) Official statistics in Nigeria record a maternal mortality rate of 1,000 in every 100,000

                              live births (this figure is higher than that for any other country in sub-Saharan Africa),

                              compared to 1,800 in Sierra Leone, 1,700 in Afghanistan, 15 in France and 7 in Norway.

                              In northern Nigeria, only 25% of women give birth in the presence of medically qualified



                              (4) See Albert Olawale, “Women and Urban Violence in Kano”, Institut Français de

                              Recherche en Afrique (IFRA), Ibadan, 1996.


                              (5) The principal centres are located in the cities of Kano, Ibadan, Uyo and particularly

                              Katsina, where the Babbar Ruga hospital has 200 beds allocated for the treatment of

                              fistula sufferers.



                                                              Translated by Karen Wilkin


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