AN ASSESSMENT INTO THE CULTURAL PRACTICES AND THEIR INFLUENCE ON THE INCIDENCE OF OBSTETRIC FISTULA IN NORTHERN REGION OF NIGERIA

CHAPTER ONE

INTRODUCTION

Background of the study

Obstetric fistula is a serious maternal health disorder caused by extended and blocked labour, usually seen in areas with little healthcare facilities. A vesicovaginal fistula is an anomalous connection between the birth canal and either the bladder or the rectum, resulting in persistent urine or faecal leakage (WHO, 2020). The aforementioned disorders are especially widespread in sub-Saharan Africa and some regions of South Asia, where there is limited availability of prompt and proficient maternal healthcare, and cultural elements often hinder the successful handling of birthing difficulties (Tebeu et al., 2022). In Nigeria, the Northern area has a disproportionate incidence of obstetric fistula, mostly attributed to distinct cultural traditions and socio-economic prevailing circumstances (Wall, 2022). In Northern Nigeria, there is a significant prevalence of obstetric fistula, which is associated with one of the highest rates of maternal death globally (Adamu et al., 2019). According to the World Health Organisation (WHO), the yearly global incidence of obstetric fistula affects around 50,000 to 100,000 women. A considerable number of these cases are concentrated in Nigeria, particularly in the Northern area (WHO, 2020). The research conducted by Johnson and colleagues (2018) revealed that almost 80% of obstetric fistula cases in Nigeria are concentrated in the Northern area. This may be attributed mainly to factors such as early marriage, insufficient availability of trained birth attendants, and restricted access to emergency obstetric treatment. 

Cultural practices have a substantial influence on the development of maternal health outcomes, especially in rural and semi-urban regions of Northern Nigeria. The high incidence of obstetric fistula is largely attributed to the widespread cultural practice of early marriage. Across some communities in Northern Nigeria, females are often wedded at a tender age, perhaps as little as 13 years old (Musa et al., 2021). The association between early marriage and early pregnancy is associated with an elevated likelihood of obstetric problems, such as fistula, due to the underdeveloped state of young girls' bodies during delivery (Browning, 2004). Evidence indicates that young women are more prone to experiencing difficulties such as obstructed labour, which may result in obstetric fistula (Ahmed et al., 2020). Furthermore, cultural conventions in Northern Nigeria often dissuade women from seeking medical aid during delivery, instead endorsing traditional birth attendants (TBAs) or home deliveries. According to Ibrahim et al. (2020), a significant number of women living in rural areas hold the belief that delivery is an inherent phenomenon that does not need medical intervention until difficulties develop. Regrettably, this conviction can rise to delayed reactions to difficulties such as extended labour, resulting in increased occurrences of obstetric fistula. Moreover, in Northern Nigeria, poverty compoundes the problem. Approximately half of the women affected reside in rural regions with restricted availability of healthcare services, which leads to elevated rates of maternal death and morbidity (Fistula Foundation, 2019). A significant number of families lack the financial means to cover the expenses related to hospital deliveries or emergency obstetric care. Consequently, this economic constraint compels many women to give birth at home or in inadequately equipped facilities. In such settings, problems such as obstructed labour often remain untreated for extended durations (Bello et al., 2017). The convergence of poverty, limited access to education, and cultural conventions fosters a conducive setting for the proliferation of obstetric fistula. However, the healthcare system in Northern Nigeria is confronted with notable obstacles such as insufficient infrastructure, a scarcity of highly trained healthcare practitioners, and restricted availability of emergency obstetric services (Wall, 2022). The United Nations Population Fund (UNFPA) reports that a significant number of women living in rural regions are located at a considerable distance from the closest healthcare institution equipped to carry out caesarean sections or handle complicated births. This poses a crucial challenge in the prevention of obstetric fistulas (UNFPA, 2021). The scarcity of well educated healthcare professionals, along with deficiencies in infrastructure, delays in receiving medical attention, and insufficient postnatal care, exacerbate the susceptibility to fistula. Furthermore, the level of knowledge about obstetric fistula is somewhat limited in Northern Nigeria, and women afflicted with this ailment often encounter social disapproval and marginalisation within their communities (Amosu et al., 2018). The presence of societal stigma deters several women from seeking therapy, therefore intensifying the issue. Patients with fistula often experience prolonged periods of social isolation, psychological anguish, and financial difficulties as a result of their inability to regulate their urine or faeces (Muleta, 2015). Thus, attempts to tackle obstetric fistula in Nigeria have been continuous, with substantial involvement from both governmental and non-governmental organisations. Programs devised by organisations like the Fistula Foundation and UNFPA target the provision of free surgical repair treatments to women suffering by fistulas and the promotion of knowledge about the disease (Fistula Foundation, 2019). Furthermore, efforts have been made to provide training for healthcare professionals and equip health facilities in Northern Nigeria with the aim of enhancing maternal healthcare services and decreasing the occurrence of obstetric fistula. Notwithstanding these efforts, the enduring presence of cultural customs such as early marriage and the dependence on traditional birth attendants still impedes advancement. Therefore, the researcher sought to assess the cultural practices and their influence on the incidence of obstetric Fistula in Northern region of Nigeria.

1.2 Statement of the problem

Obstetric fistula is a severe postpartum injury that mostly impacts women in resource-limited environments, particularly in the Northern area of Nigeria, where cultural customs have a substantial impact on maternal health status. The yearly incidence of obstetric fistula in Nigeria is expected to reach up to 2,000 instances, with the Northern area being responsible for a substantial fraction of these cases (Nwogu et al., 2020). The considerable prevalence of obstetric fistula may be attributed to cultural beliefs and practices, including early marriage, a preference for home deliveries, and insufficient maternal healthcare (Adetayo et al., 2018; Olufunke et al., 2019). 

In several communities in Northern Nigeria, early marriage and childbirth are widespread, typically influenced by cultural norms that emphasise female compliance and family prestige. The risk of obstetric difficulties is increased for women who marry at a young age because of their physical immaturity, which results in extended labour and the subsequent development of fistulas (Musa et al., 2021). Moreover, conventional birth methods, which often include individuals without proper training as birth attendants, increase the likelihood of difficulties during childbirth (Ibrahim et al., 2020). Moreover, the cultural stigma associated with obstetric fistula discourages women from seeking medical help, therefore sustaining a cycle of neglect and isolation (Giwa et al., 2022). Gaining insight into the convergence of cultural practices and the prevalence of obstetric fistula is essential for devising efficacious strategies to tackle this significant public health concern. Hence, the study assess the cultural practices and their influence on the incidence of obstetric Fistula in Northern region of Nigeria.

1.3 Objective of the study

The broad objective of the study is to assess the cultural practices and their influence on the incidence of obstetric Fistula in Northern region of Nigeria. The specific objectives is as follows

To examine the prevalence of obstetric fistula in the Northern region of Nigeria

To analyze whether early marriage contributes to the increasing risk of obstetric fistula among women in Northern Nigeria.

To assess whether traditional birth practices contributes to maternal health outcomes and the incidence of obstetric fistula among women in Northern Nigeria.

To identify challenges of women in accessing skilled maternal healthcare services in Northern Nigeria.

1.4 Research questions

The following questions have been prepared to guide the study

What is the prevalence of obstetric fistula in the Northern region of Nigeria?

Does early marriage contributes to the increasing risk of obstetric fistula among women in Northern Nigeria?

Do traditional birth practices contributes to maternal health outcomes and the incidence of obstetric fistula among women in Northern Nigeria?

What are the challenges of women in accessing skilled maternal healthcare services in Northern Nigeria?

1.5 Significance of the study

Finddings of the study will be significant to the ministry of health as it will provide evidence-based recommendations for improving maternal health services in the Northern region. The results will help health practitioners and organizations tailor maternal healthcare interventions to the cultural realities of Northern Nigeria, promoting more effective and culturally sensitive healthcare delivery.

Furthermore, findings of this research will be valuable to government agencies and non-governmental organizations working in maternal health, as they seek to design policies and programs that address the root causes of obstetric fistula. The study will inform the creation of laws and policies to discourage harmful practices such as early marriage and support the promotion of skilled birth attendance. In addition, the study will be significant to the academic community as it will contribute to the existing body of knowledge and also serve as a guide to future researchers.

1.6 Scope of the study

The study focus on the cultural practices and their influence on the incidence of obstetric Fistula in Northern region of Nigeria. Empirically, the study will examine the prevalence of obstetric fistula in the Northern region of Nigeria, analyze whether early marriage contributes to the increasing risk of obstetric fistula among women in Northern Nigeria, assess whether traditional birth practices contributes to maternal health outcomes and the incidence of obstetric fistula among women in Northern Nigeria and identify challenges of women in accessing skilled maternal healthcare services in Northern Nigeria.

Geographically, the study will be delimited to Dawakin Tofa LGA, Kano State.

1.7 Limitation of the study

Like in every human endeavour, the researchers encountered slight constraints while carrying out the study. The significant constraints are: 

Time: The researcher encountered time constraint as the researcher had to carry out this research alongside other academic activities such as attending lectures and other educational activities required of her.

Finance: The researcher incurred more financial expenses in carrying out this study such as typesetting, printing, sourcing for relevant materials, literature, or information and in the data collection process.

Availability of Materials: The researcher encountered challenges in sourcing for literature in this study. The scarcity of literature on the subject due to the nature of the discourse was a limitation to this study

1.8 Definition of terms

Obstetric Fistula: A medical condition characterized by an abnormal opening between a woman’s genital tract and the bladder or rectum, caused by prolonged obstructed labor, resulting in continuous leakage of urine or feces.

Cultural Practices: The customs, beliefs, and behaviors shared by a particular group of people that influence their way of life. In this study, it refers to practices such as early marriage, traditional birthing methods, and reliance on untrained birth attendants in Northern Nigeria.

Early Marriage: The practice of marrying at a young age, often before the age of 18, which is common in certain parts of Northern Nigeria. Early marriage is associated with early childbearing and an increased risk of complications during childbirth.

Traditional Birth Attendants (TBAs): Individuals, often women, who assist in childbirth based on experience and cultural knowledge rather than formal medical training. They are commonly used in rural and remote areas of Northern Nigeria, where access to skilled health personnel is limited.

Maternal Healthcare: The health services provided to women during pregnancy, childbirth, and the postpartum period to ensure the health of both mother and child. This includes services such as antenatal care, skilled birth attendance, and emergency obstetric care.

Prolonged Obstructed Labor: A labor complication that occurs when the baby cannot pass through the birth canal due to physical or physiological barriers, leading to prolonged delivery. Without timely medical intervention, this can result in obstetric fistula.

Socio-Economic Factors: The social and economic conditions that influence individuals’ or communities’ access to healthcare services. In this study, socio-economic factors include poverty, education level, and access to healthcare facilities, which affect the risk of obstetric fistula.

Stigma: A negative social label associated with a particular condition or characteristic. In the case of obstetric fistula, women often face social isolation and discrimination due to the incontinence and other physical effects of the condition.

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