Introduction

Globally, about half a million women die annually from causes related to pregnancy and delivery and for each maternal death, about 10-15 other women sustain serious morbidity due to pregnancy including obstetric fistula [1, 2, 3]. Obstetric fistula (OF) has been described as an abnormal communication between a woman’s vagina and bladder and/or rectum through which urine and/or faeces continually leak [4, 5, 6]. This abnormal communication can be caused by physical situations like prolonged obstructed labour which is responsible for majority of the cases. Also implicated is sexual abuse and rape, complications arising from unsafe abortions, surgical trauma as a result of injury to the bladder at caesarean section, gynaecological cancers and radiotherapy [1, 7 , 8] .This is made worse by lack of access to maternal health services and delay in seeking medical care [9, 10] . Obstetric fistula also have underlying social causes which include poverty, illiteracy, early marriage and childbirth, inadequate family planning, low status of women in the community, harmful traditional practices such as female genital mutilation and other factors affecting women in the community [11, 12].

Historical knowledge of obstetric fistula dates back to 1872, through the Ebers papyrus which was discovered in a mummy from the Theban acropolis. The gynaecological reference in this papyrus addresses uterine prolapse, it seems to talk about vesico-vaginal fistula where it incorrectly warned the physician against trying to cure it saying, “prescription for a woman whose urine is in an irksome place: if the urine keeps coming and she distinguishes it, she will be like this forever” [1, 13, 14]. However, due to significant medical advances, including safer caesarean deliveries and the development of obstetrics into a scientific specialty, by the mid-1900s Obstetric fistula practically disappeared in the industrialized world but has remained in developing nations [15, 16]. Obstetric fistula is considered to be the most devastating morbidity that affects women following childbirth [17, 18].

The Nigeria Demographic Health Survey [19] indicated that about 31% of women have heard of obstetric fistula symptoms. The knowledge of obstetric fistula was seen to be higher among rural women (33%) than women residing in urban areas (27%). There was also a substantial variation in knowledge by age as 20% of women age 15-19 years have heard of obstetric fistula, compared with 37% of women age 40-44 years. It was interesting to note that knowledge of obstetric fistula was highest among women living in the North West and North East (66% and 50%, respectively), among those with no education (47%), among women currently in union (36%), and among women in the poorest households (41%). This level of knowledge was the lowest in the south east and south west regions (with about 8% in each). Twenty per cent (20 %) of those with secondary or higher education had knowledge of  obstetric fistula, 16% of those who were never in union and 21% of those from  a wealthy household had knowledge of obstetric fistula [19]. These findings may be the result of the many awareness creation activities relating to of that have been undertaken over the years in the North West and North East regions where prevalence is highest.

Studies have shown that the awareness of vesicovaginal fistula was 57.8% [17]. This shows that despite the problems associated with obstetric fistula, many women are not aware of the disease entity, making it difficult to control. Out of the 204 women of reproductive age used, 52.9% thought it was due to obstructed labour, 27.9% thought it was due to instrumental vaginal delivery, 12.7% thought it was due to caesarean section, and 6.4% thought it was due to short statue [17]. In a study done in Burkina Faso among young women, 36.4% of respondents were aware of obstetric fistula [20]. Only 25% of respondents could correctly identify that pregnant women are mostly at risk of vesicovaginal fistula. In developing countries, vesicovaginal fistula remains obstetric related [21, 22]. Female genital mutilation is another contributing factor that may be striking. Knowledge about Obstetric fistula amongst women of reproductive age, especially in low-income areas and the risk factors appear inadequate [23]. Important factors affecting awareness of obstetric fistula are prevalence, socioeconomic status, presence of adequate maternal health care facilities, educational status and affectation of a relative or friend by obstetric fistula [23].

Knowledge and attitude towards the danger signs of obstetric complications is the essential first step in the appropriate and timely referral to obstetric care [24]. Sadly, most fistula patients do not present at the standard hospital facilities with adequate antenatal care services, because the condition usually affects the most marginalized group, that is, the poor, young women who are often illiterates and who live in rural areas [25]. Because of poverty and the stigma associated with their condition, most women living with fistulas do not have adequate knowledge and obstetric features of obstetric fistula. They remain invisible to policy makers both in their own countries and abroad.

There are a few misconceptions about obstetric fistula, a study [26] showed that most healthy females believed that obstetric vesicovaginal fistula was a punishment from the gods to the affected person for their infidelity while the majority of women with obstetric fistula in that study believed that their condition either resulted from the effect of a poison from the skull bone of their dead macerated foetus or from manipulations by the traditional birth attendant while trying to deliver the dead foetus [26] In developing countries, causes of obstetric fistula could be attributed to factors like evil spirits, bad luck, culturally unacceptable acts committed by women, etc. [23] This is due to the widespread of poverty and lack of education

Throughout the world, but mainly in parts of sub-Saharan Africa and Asia, it is conservatively estimated that more than 2 million young women live with untreated OF. It has also been estimated that between 50 000 and 100 000 new women are affected each year[13, 27]. It is probable these figures are underestimates but it has been impossible to determine the true burden of suffering to date. Not only has there been generally a lack of commitment in addressing and resolving this problem, but also these young girls or women tend to live with their fear and stigmatization in silence and isolation, unknown to the health-care system [28]. According to the 2008 National Demographic Health Survey (NDHS), the prevalence of obstetric fistula is 0.4%. Fistula prevalence is higher in zones in Northern Nigeria than in Southern Nigerian zones. For instance, the prevalence of fistula in North Central Nigeria is 0.8%, followed by 0.5% in the North East and 0.3% in North West Nigeria. In contrast, the highest prevalence in the Southern zones was found in South Nigeria (0.5%), followed by South East Nigeria (0.3%) and South West Nigeria (0.2%). The prevalence for all Northern zones combined is 0.5%, compared to 0.3% for the Southern zones [19]. Almost one-third of women surveyed (30.7%) had heard of fistula symptoms, with knowledge considerably higher in the North East and North West zones (49.6% and 66.2%, respectively) than in other zones of the country [19].

Obstetric fistulae can be repaired surgically unless the fistulae are too large or there is associated damage to other tissues which makes repair impossible and complicated [1]. Fistulae can often be prevented by the insertion of an in-dwelling catheter (for 4 to 6 weeks) to relieve pressure on the bladder following prolonged obstructed labour [29, 30].

This study of women with obstetric fistula will provide data on knowledge of obstetric fistula and obstetric features of women with obstetric fistula at the Obstetric Fistula centre in Bingham University Teaching Hospital, Jos. Nigeria. Specifically, it looks at the type of fistula, source of awareness of treatment, duration before treatment and reasons for waiting before seeking treatment. This study also looks at pregnancy and labour characteristics of Obstetric fistula patients and delivery features of obstetric fistula patients.

Methodology

The study was conducted in the Fistula Centre of Bingham University Teaching Hospital, Jos, Nigeria.  Bingham University Teaching Hospital Fistula Centre is located within BHUTH in Jos North local Government of Plateau State. This Centre was founded in 1983 by Steven Arrow Smith, an American Urologist. It is a 20 bed capacity Centre with 5 administrative offices, 2 Clinic offices, VVF theatre (equipped with 2 operating tables and 1 anaesthetic machine), rehabilitation centre, 90 bed hostel accommodations and a kitchen facility. The hostel accommodates those awaiting repairs or those who have had surgeries done and have been discharged from the ward; it also houses care givers of the patients. Patients stay for an average of 8-20 days in the ward receiving treatment. After being discharged, the patients have an option of dwelling in the VVF hostel or going home.

The Centre receives patients from every part of Nigeria. The Fistula Centre also offers physiotherapy, psychological counselling, health and nutrition classes, a post-surgery skill acquisition program, extensive community outreach and patient screening/identification. Currently, The VVF Centre has 3 fistula Surgeons, 6 Nurses, 3 Nursing aids and 3 Attendants

The VVF Centre runs a weekly out-patient clinic on Tuesdays for new clients and another clinic on Fridays to review patients on the ward. Surgeries are done twice in a week (Thursdays and Fridays). The study was done using descriptive cross sectional study design. This was a total population study. All the women with Obstetric Fistula within the Fistula Centre who gave informed consent to be part of the study were included. Data was collected using an Interviewer-administered structured questionnaire that sought to describe socio-demographic information of the respondents, reproductive history, and the knowledge of the women on Obstetric Fistula. The data collection took place from February to March, 2019. At the end of the data collection period all 49 of women with of interviewed

Data was analyzed using Statistical Package for the Social Science (SPSS) version 20.0 Descriptive statistics, proportions, tables and diagrams were generated to illustrate findings. Limitations of this study include, the knowledge will be assessed based on recall information; therefore, it is open to bias. Responses were based on self-report by the respondents; communication with respondents may pose a little challenge because of language barrier. Ethical approval for the study was given by the Bingham University Teaching Hospital Ethical Committee (NHREC/21/05/2005/00617).

Results

1. Awareness and Knowledge of Obstetric Fistula (OF) Among Patients

Table 1 above shows that 34 (69.4%) of the patients have had no prior knowledge of O.F, only 15 (30.6%) of the patients have heard about obstetric fistula. About half of respondents 21 (59.2%) of respondents believe fistula is caused by prolonged obstructed labour, 10 (20.4%)  had no idea of the cause, 7 (14.3%)  believe it is due to the will of God, while those that believe that the cause is Iatrogenic and due to early marriage constituted 8 (16.3%) respectively.  More than half 28 (57.1%) of the women had no idea on ways fistula can be prevented, 7 (14.3%) believe it can be prevented by early Obstetric care during labour, 6 (12.2%) believed in stoppage of early marriage and surgery respectively while 2 (4.1%) believed it can be prevented by contraception.

More than a two thirds 34 (69.4%) of the women had no idea on ways fistula can be prevented by the members of the community 7 (14.3%) believed that pregnant women should be taken to the Hospital early in the course of labour while 5 (10.2%) believed that it can be prevented by ensuring every woman in the community goes for routine ANC. 2 (4.1%) community should support pregnant women as a means of prevention.

Two third 33 (67.3%) of the women had no idea on ways fistula can be prevented by family members. 7 (14.3%) believed that the family should encourage the uptake of ANC services while 5 (10.2%) believed that the culture and practice of early marriage should be discouraged, 3 (6.1%) family should give support for the surgery, 1 (2.0%)

Table 1. Awareness and knowledge of Obstetric Fistula (of) among Patients

Awareness of Obstetric Fistula (OF) before Development of	No of fistula patients	Percent (%)
Heard of Fistula	15	30.6
Not heard of Fistula	34	69.4
Knowledge of the causes of Fistula	No of fistula patients	Percent (%)
No idea	10	20.4
The will of God	7	14.3
Prolonged obstructed labour	29	59.2
Iatrogenic	8	16.3
Early marriage	8	16.3
Knowledge of fistula prevention methods	No of fistula patients	Percent
No Idea	28	57.1
Go To Hospital For Surgery	6	12.2
Stoppage of Early Marriage	6	12.2
Go To Hospital Immediately Labour Starts	7	14.3
Stop Getting Pregnant	2	4.1
Knowledge of Community action in of prevention	No of fistula patients	Percent
No Idea	34	69.4
Rush Women To Hospital Early	7	14.3
Hospital Should Refer/ Do Surgery	1	2.0
Ensure Every Woman Goes For ANC	5	10.2
Support Them	2	4.1
Knowledge of family action in of prevention	No of fistula patients	Percent
No Idea	33	67.3
Stop Early Child Marriage	5	10.2
Give Support For Surgery	3	6.1
Prayers	1	2.0
ANC	7	14.3
Total	49	100.0

2. Type of Fistula, Source of Awareness of Treatment, Duration before Seeking Treatment, Reason for Waiting before Seeking Treatment

Table 2 above shows that Majority 45 (91.8%) of patients had only Vesico-Vaginal Fistula (VVF), only 3 ( 6.1%) of patients had Recto-Vaginal Fistula (RVF), while 1 (2%) had both VVF and RVF. On source of awareness, 17 (34.7%) patients heard about the treatment of O.F from Family and Friends, 7 (14.3%) heard from testimony of OF patients, 8 (16.3%) heard from outreaches while 3(6.1%) heard about the treatment from media services.

Twenty 20 (40.8%) of patients took less than a month before coming for treatment and 17 (34.7%) took between 1-4months; 4 (8.2%) took 5-8mpnths before seeking treatment, 3 (6.1%) spent 8-12 months before seeking treatment, 3 (6.1%) stayed more than 3 years, whereas 2 (4.1%) took between 1-3years before coming for treatment. Majority 47 (95.9%) sought treatment within 1 year of occurrence of O.F.

Just below half, 22 (44.9%) of patients revealed that preparation for surgery was the reason for waiting, 14 (28.6%) indicated lack of money, 5 (10.2%) said lack of information was the reason for the waiting, 7 (14.3%) had no reason for waiting while 1 (2.0%) revealed that poor transportation was the reason for the delay.

Table 2. Type of Fistula, Source of Awareness of Treatment, Duration before Seeking Treatment, Reason for Waiting before Seeking Treatment

Type of Fistula	No of Fistula Patients	Percent
Recto-Vaginal Fistula (RVF)	3	6.1
Vesico-Vaginal Fistula (VVF)	45	91.8
Both	1	2.0
Source of Awareness of Treatment	No of Fistula Patients	Percent
Hospital	14	28.6
Media	3	6.1
Family And Friends	17	34.7
Testimony From VVF Patients	7	14.3
Outreaches	8	16.3
Duration before seeking treatment	No of Fistula Patients	Percent
< 1 Month	20	40.8
1-4 Months	17	34.7
5-8 Months	4	8.2
8-12 Months	3	6.1
1-3 Years	2	4.1
>3 Years	3	6.1
Reason for Waiting before seeking treatment.	No of Fistula Patients	Percent
To Prepare	22	44.9
Lack Of Money	14	28.6
Transportation	1	2.0
Lack Of Information	5	10.2
No Reason	7	14.3
Total	49	100.0

3. Pregnancy and Labour Characteristics of Obstetric Fistula Patients

Table 3 above, the fistula developed in the 1st pregnancy in 21 (42.9%) of patients, developed in the 2nd pregnancy in 11 (22.4%) of participants whereas it developed in the 4th, 6th, 8th, and 11th pregnancy in 4.1% of patients respectively. That is a third 17 (34.7%) of the patients had developed fistula after the 3rd pregnancy.

Labour took 1-3days in about half 26 (53.1%) of women, 12-24hours in 11 (22.4%) of the women, 7 (14.3%) of the women stayed in labour for 4-6days and greater than 7days in 2 (4.1%) of women.

A third 37 (75.5%) of patients took 1-3days from onset of labour before seeking care, while 4 (8.2%) took greater than 7days from onset of labour before seeking care. 4 (8.2%) took less than 12 hours to seek care, 8 (16.4%) stayed for more than 3 days.   

 Over a quarter 14 (28.6%) had no reason for the delay,  14(28.6%) indicated lack of Transportation as a reason for delay in seeking care, 10 (20.4%) indicated lack of money as the reason for not seeking care and 10 (20.4%) had nurses on standby to provide care.

Less than half 22 (44.9%) of patients took less than an hour to reach a health care facility, while15 (30.6%) took between 1-5hours, 6-10 hours distance for 3 (6.1%) of the women, 2 (4.1%) of the patients took between 11-15hours to seek care. 3 (6.1%) spent more than 25 hours to get to a health care facility.

Table 3. Pregnancy and Labour Characteristics of Obstetric Fistula Patients

No of Pregnancy Fistula Developed	No of Fistula Patients	Percent
1st Pregnancy	21	42.9
2nd Pregnancy	11	22.4
3rd Pregnancy	5	10.2
4th Pregnancy	2	4.1
5th Pregnancy	3	6.1
6th Pregnancy	3	6.1
8th Pregnancy	2	4.1
9th or more Pregnancy	2	4.1
Duration of labour	No of Fistula Patients	Percent
< 12 Hours	3	6.1
12-24 Hours	11	22.4
1-3 Days	26	53.1
4-6 Days	7	14.3
>7 Days	2	4.1
Duration from onset of labour to Seeking Health Care	No of Fistula Patients	Percent
< 12 Hours	4	8.2
1-3 Days	37	75.5
4-6 Days	4	8.2
>7 Days	4	8.2
Reason For Delay	No of Fistula Patients	Percent
No Reason	14	28.6
Transportation	14	28.6
No Money	10	20.4
There Was A Nurse	10	20.4
Traditional Belief	1	2.0
Time Taken from home to reach Health Care facility	No of Fistula Patients	Percent
< 1 Hours	22	44.9
1-5 Hours	15	30.6
6-10 Hours	3	6.1
11-15 Hours	2	4.1
21-25 Hours	4	8.2
>25 Hours	3	6.1
Total	49	100.0

4. Delivery Features in Obstetric Fistula Patients

Table 4 shows that 34 (69.4%) of fistula patients did not get a referral to another facility, while 15 (30.6%) got referrals. Over two third, 34 (69.4%) had their deliveries in a hospital facility when the fistula developed. 11 (22.4%) had their delivery at home when the fistula developed, 4 (8.2%) delivered on the way to the hospital.

Just above half 27 (55.1%) had their deliveries via Caeserean section (C/S), 17 (34.7%) delivered via spontaneous vaginal delivery (SVD) while 5 (10.2%) had their deliveries via instrumental delivery.

Majority 42 (85.7%) had their deliveries taken by Hospital Based staff, Traditional Birth Attendants (TBAs) delivered 5 (10.2%) of the participants while 2 (4.1%) had their deliveries taken by family members.

About a third, 19 (38.8%) of fistula patients developed fistula immediately after delivery and it took greater than 12hours (half of a day) after delivery for fistula to develop in 21 (42.9%) of patients, while it took 7-10hours in 1(2%) of patients. 2 (4.1%) occurred after removal of catheter, while 6 (12.2%) developed fistula after 1-6 hours.

Table 4. Delivery Features in Obstetric Fistula Patients

Referral to Another Facility	No of Fistula Patients	Percent
Referred	15	30.6
Not Referred	34	69.4
Place of Delivery when Fistula Developed	No of Fistula Patients	Percent
Home	11	22.4
Hospital	34	69.4
On the way to Hospital	4	8.2
Mode of Delivery	No of Fistula Patients	Percent
Spontaneous Vaginal Delivery (SVD)	17	34.7
Caesarean Section ( C/S)	27	55.1
Instrumental delivery	5	10.2
Attendant at Delivery	No of Fistula Patients	Percent
Hospital Based Staff	42	85.7
Traditional Birth Attendants (TBA)	5	10.2
Family Members	2	4.1
Duration after Delivery to Development of Fistula	No of Fistula Patients	Percent
Immediately	19	38.8
After Removal Of Catheter	2	4.1
1-3 Hours	3	6.1
4-6 Hours	3	6.1
7-10 Hours	1	2.0
Greater Than 12 Hours	21	42.9
Total	49	100.0

Discussion

Two third of the patients have had no prior knowledge of Obstetric fistula while a third had heard about obstetric fistula before development of the condition. This finding is similar to findings from the 2018 NDHS, [31] were 31% had heard of Obstetric fistula. This trend has been same for over a decade. This may be due to the fact that the patients are usually silent about the situation because of fear, anxiety and shame associated with the features [32]. This is similar to findings in study done in Burkina Faso [33] which aimed to evaluate knowledge on obstetric fistula among young women in a health district of Burkina Faso, where only a third of participants were aware of obstetric fistula. This awareness level maybe due to the level of education and the silence and secrecy attributed to Obstetric fistula [34]. In contrast, a study done in Tanzania [35] showed 60% of women were aware of obstetric fistula. This seaming higher level of awareness may be due to the presence of local names and discussions among community women. In Tanzania, different local names exist using terms like “Fistula/Kistula/Vistula/ Pistula”, “Jolojolo/ Mjolojolo” and other names ending with “mkojo” (urine) [35]. Initiating local discussion and awareness about obstetric fistula will serve as a good strategy in its prevention.

Six in ten correctly knew obstetric fistula is caused by prolonged obstructed labour, 20% had no idea of the cause, other felt it was due to the will of God, iatrogenic, others felt it was due to early marriage. It is possible that due to interaction between the health care workers and the patients, the must have been told the reason for disease [34] A study done in Uganda showed that fistula women still have a few misconceptions about the cause of obstetric fistula, women said it was due to misuse of family planning, having sex during the menstruation period, curses by relatives, sexually transmitted infections, rape and gender-based violence [36]. This indicates the need for community sensitization and health education for women on causes, clinical presentation and prevention of obstetric fistula. Studies done in Ile Ife, [37] Ilorin, [38] and [39] Port Harcourt [40] has demonstrated that the commonest cause of Obstetric fistula was prolonged labour.

Despite this seemingly high level of knowledge of the causes of obstetric fistula, more than half of the women had no idea on ways fistula can be prevented by women, a low proportion believe it can be prevented by early Obstetric care during labour, One in ten believed in stoppage of early marriage, and surgery respectively as a means of prevention of obstetric fistula, while 4% believed it can be prevented by contraception. Women believed the community can help prevent obstetric fistula via support for pregnant women, community emphasis on antenatal care, and prompt visit to hospital during labour.  More than two thirds of the women had no idea on ways fistula can be prevented by the community members. This presents a huge challenge as women who lack the knowledge of prevention will be unable to participate in conversations that will help promote all community interventions that can prevent obstetric fistula. Similarly, two third of the women had no idea on ways fistula can be prevented by family members. A small proportion believes that the families should encourage pregnant women to attend antenatal care; they also believed that the culture and practice of early marriage should be discouraged among women and family should give support for the surgery of the patient when the need arises. These strategies have been proven to be effective in prevention of obstetric fistula is stated in studies done in Nepal [41]. Individual, family and community support is important in stemming the tide of obstetric fistula in developing countries.

Commonly, Vesico-vaginal fistulas are more common in our setting, [27, 41] this is situation was found in this study as majority of women had only Vesico-Vaginal Fistula (VVF), only 6.1% of patients had Recto-Vaginal Fistula (RVF), while 2% had both VVF and RVF. These findings are similar to studies done in Ethiopia where 6.5% had RVF and 90% had VVF [27]. This was similar to finding in a study done in Fistula referral hospital in eastern Democratic Republic of Congo, [42] in Ile Ife [37], Jigawa [43], Zamfara state, Sokoto and Katsina state [44]. This is partly due to the fact that obstructive labour is the most common cause of obstetric fistula.

About of third of women heard about their treatment source from family and friends, a fewer proportion heard from testimony of Obstetric fistula patients, outreaches and media services. This finding demonstrated the need for support from families and friends as part of a treatment model. Patients with obstetric fistula require support from families to seek treatment and reintegrate into society without shame [6, 32]. Similar studies have shown this pattern [36, 45, 46].

Literature [23, 45, 46] has document the importance of early treatment in obstetric fistula management, four in ten sought treatment within a month, and 60% waited till after a month to seek treatment. Just below half of patients revealed that preparation for surgery was the reason for delaying seeking treatment, a third indicated  lack of money, one in ten said lack of information was the reason for the delay, 14% had no reason for delaying while 2% blamed poor transportation was the reason for the delay. This was similar to finding in Jos [47]. This reason for delaying in seeking treatment is a huge challenge for prompt intervention.

Most Fistulas developed in the first (43%) and second (22%) and third (35%) pregnancy. The fact that 35% of the women in this study developed obstetric fistula after three or more births just reminds us that multiparous women are also at risk of obstetric fistula. This could be explained by increased birth weight, decreased uterine contractility and abnormal fetal presentation, coupled with inadequate obstetric care [42]. This finding is in consonance with studies done in Democratic republic of Congo [42]. Similarly, labour took 1-3days in about half of the women; just a quarter had labour for 12-24hours, 18% of the women stayed in labour for greater than 4 days. This is similar to findings done in Democratic Republic of Congo [42].

 Ile Ife [37]. A third of patients took 1-3days from onset of labour before seeking care; one in ten took greater than 7days from onset of labour before seeking care. In fact, 16% stayed for more than 3 days before seeking care. Only a few took less than 12 hours to seek care, this show the low level of responsiveness and birth preparedness among the respondents.

Over a quarter had no reason for the delay and a same proportion indicated lack of transportation as a reason for delay in seeking care. About 20% said they preferred home care with a nurse on standby. Findings from a study done in Jos on reasons for delay in seeking care  included non-permission from husband/family to seek emergency obstetric care (28%), lack of accessible transportation (25%) and attempted traditional remedies (7.4%). Other reasons were unawareness of availability of hospital obstetric care (6.5%), unavailability of health facility (5.6%), while 26.8% had no reason [47]. This scenario presents a huge challenge, especially when reviewing the fact that the respondent’s definition of a nurse may not mean a skilled birth attendant. Commonly, it is the traditional birth attendants that handle these deliveries. This group may not be able to identify the danger signs of delivery that will require referral for expert care [38].

Availability of funds to access care remains a major stumbling block in disease control, as individuals, families and communities are unable to pay for services. Twenty percent (20%) of women complained that lack of money as the reason for not seeking care. This situation plays out very commonly in our communities. It calls the need for Universal Health Coverage for all people in all communities, such that, individuals are able to access health care. The NDHS revealed that 45.8% of Nigerians delay in accessing care due to waiting to get money for treatment [48]. Another source of delay is time to reach the health care facility and 26% will delay in seeking treatment due to distance between their homes and health facility [48]. About half (45%) of patients took less than an hour to reach a health care facility, while 31% take over an hour to five hours, 11% more than 6 hours and  6% over a day to get to a health care facility.

Over two third, (69%) had their deliveries in a hospital facility when the fistula developed, 22% had their delivery at home when the fistula developed, eight percent delivered on the way to the hospital. This contrasts with studies done in in Ile, Ife, Osun State, [37] where 56% had home delivery, 44% had delivery in a health care facility. It is important to ensure that all deliveries are attended to by skilled birth attendants. The National Demographic and Health Survey, 2018 [31] revealed that 39% of live births in the 5 years preceding the survey took place in a health facility. Forty-three percent of births were assisted by a skilled provider [48]. Similarly, majority (86%) had their deliveries taken by hospital based staff (Skilled birth attendant), 10% were delivered by Traditional Birth Attendants (TBAs) while 4% had their deliveries taken by family members. This is in direct contrast to findings from the NDHS 2018 [31] and Ile Ife study [37]. It is possible that in most cases the delivery started at home and that transfer to the health facility occurred too late [42]. There has been reported unskilled birth attendance as shown in about 90% of Maiduguri study [49], 70.8% of Sagamu study [50] and 47% of Jos [47] study who had unskilled birth attendance in preceding pregnancy.

Just above half had their deliveries via Caeserean section (C/S), a third (34%) delivered via spontaneous vaginal delivery (SVD) while 10% had their deliveries via instrumental delivery. This differs from finding in a study done in Ife [37] where CS was 21%, 35% were SVD, 21% was instrumental delivery. The difference was mainly in Caesarean sections, which is indicative of the fact that the patients must have presented on emergency to the fistula center.

About a third, of fistula patients developed fistula immediately after delivery and it took greater than 12 hours (half of a day) after delivery for fistula to develop in 43% of patients.

One of the limitations of our study includes the relatively small sample size and the fact that all respondents are facility based and had come for treatment, we are unable to get prevalence or incidence of obstetric fistula.

Conclusion

A third of the patients are aware of Obstetric fistula. More than half know fistula is caused by prolonged obstructed labour, 20.4% had no idea of the cause, 14.3% believe it is due to the will of God, while those that believe that the cause is Iatrogenic and due to early marriage constituted 8 (16.3%) respectively.

Majority of patients had only vesico-vaginal Fistula (VVF), 6.1% had recto-vaginal fistula (RVF), while 2% had both VVF and RVF. A third heard about treatment from family and friends. Majority sought treatment within 1 year of occurrence of obstetric fistula.

Forty three percent of the women developed fistula after the 1st pregnancy, 22% in the 2nd pregnancy and a 35% after the 3rd pregnancy. Labour took more than 24hours in 78% of respondents. Three quarters of patients took 1-3days from onset of labour before seeking

Delays were due to no reason for the delay (28.6%), lack of transportation (28.6%), lack of money (20.4), availability of nurses on standby to provide care (20.4%). Forty five percent of respondents spent less than an hour to reach a health care facility, 31% took between 1-5hours, 24% spent a 6 hours distance or more.

Over two third, (69.4%) had their deliveries in a hospital facility when the fistula developed, 22.4% at home and 8.2% delivered on the way to the hospital. Just above half (55.1%) had their deliveries via Caeserean section (C/S), 34.7% via spontaneous vaginal delivery (SVD) while 10.2% via instrumental delivery.  Majority (85.7%) had their deliveries taken by Hospital Based staff, 10.2% by Traditional Birth Attendants (TBAs) and 4.1% by family members.

Recommendations

To Women

Ensure they seek immediate care in good time where there is skilled birth attendant, once labour begins and avoid delays. Women should make efforts to seek care once labour is prolonged.

To Health Facilities & Health Care Workers

There is need to properly inform and educate women during their regular antenatal clinic visits about the risk factors for obstetric fistula and where to find care when faced with this challenge. Health workers should improve knowledge and attitude towards the danger signs of obstetric complications to hasten appropriate and timely referral to obstetric care at higher level.  Ensure health education of women in the community on need for Antenatal care and promotion of institutional deliveries. Immediately, initiate emergency obstetric care once labour is prolonged.  Lower health facilities and Traditional birth attendants should refer patients with risky obstetric history and prolonged labour to health facilities with Caesearean section services. Conduct regular community sensitization and mobilization on obstetric fistula and promote maternal and child health.

To Government

Government ensure increase of skilled personnel at delivery in Primary Health Care Centres. Provide affordable and accessible emergency obstetric care in health care facilities and ensure continuous retraining of health care worker. Government should ensure health insurance for pregnant women and families in the community to reduce delays caused by finance. Government should ensure that roads to health facilities are good and there is available transportation at all times. Government can provide community ambulances for health centers to help transport women and emergencies to higher centers.

References

1. MA Ijaiya, AG Rahman, AP Aboyeji, et al. (2010) Vesicovaginal Fistula : A Review of Nigerian Experience Vesicovaginal Fistula : A Review of Nigerian Experience. West Afr J Med 29: 294-299. [Crossref]
2. Donnay F, Weil L (2004) Obstetric fistula: The international response. Lancet 363: 71-72. [Crossref]
3. Njoku CO, Njoku AN (2019) Obstetric Fistula: The Agony of Unsafe Motherhood. A Review of Nigeria Experience. J Adv Med Med Res 28: 1-7.
4. De Bernis L, Lewis G (2007) Obstetric fistula: guiding principles for clinical management and programme development, a new WHO guideline. Int J Gynaecol Obstet 99: 117-121. [Crossref]
5. 10 facts on obstetric fistula (2014). Geneva: World Health Organization. [Crossref]
6. Kayondo M, Wasswa S, Kabakyenga J (2011) Predictors and outcome of surgical repair of obstetric fistula at a regional referral hospital, Mbarara, western Uganda. BMC Urol 11: 23. [Crossref]
7. Maulet N, Keita M, Macq J (2013) Medico-social pathways of obstetric fistula patients in Mali and Niger: An 18-month cohort follow-up. Trop Med Int Heal 18: 524-533. [Crossref]
8. Wall L L,  Arrowsmith SD, Briggs ND, et al. (1996) Urinary Incontinence in the Developing World : The Obstetric Fistula.
9. Lufumpa E, Steele S (2016) Obstetric Fistula: A Narrative Review of the Literature on Preventive Interventions in sub-Saharan Africa. Afr J Reprod Health 20: 118-126. [Crossref]
10. Semere L, Nour NM (2008) Womens Health in the Developing World: Obstetric Fistula : Living with Incontinence and Shame. Rev Obs Gynecol 1: 193-197. [Crossref]
11. Federal Ministry of Health (2011) Standard of Practice on Obstetric fistula in Nigeria. [Crossref]
12. Banke Thomas AO, Kouraogo SF, Siribie A, et al. (2013) Knowledge of Obstetric Fistula Prevention amongst Young Women in Urban and Rural Burkina Faso : A Cross-Sectional Study. PLoS One 8: 1-8. [Crossref]
13. Phaneuf, Louis E (1944) Genital Fistulas in Women: the Life of J. Marion Sims and the History of Vesicovaginal Fistula—Management of Rectovaginal Fistulas and Complete Tears of the Perineum. AM J SURG 114: 3–27. [Crossref]
14. Drew LB, Wilkinson JP, Nundwe W (2016) Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: A qualitative study. BMC Pregnancy Childbirth 16: 1-12. [Crossref]
15. Rock JA, Jones HW (2008) Telinde’s Operative Gynecology. Philadelphia: Lippincott Williams & Wilkins; 10TH Edition 825-841.
16. Gebresilase YT (2014) A qualitative study of the experience of obstetric fistula survivors in Addis Ababa, Ethiopia. Int J Womens Health 6: 1033-1043. [Crossref]
17. Ezeonu PO, Ekwedigwe KC, Isikhuemen ME (2017) Awareness of Obstetric Vesicovaginal Fistula among Pregnant Women in a Rural Hospital. ARSci  5: 39-46.
18. Barageine JK, Tumwesigye NM, Byamugisha JK, et al. (2014) Risk factors for obstetric fistula in western uganda: A case control study. PLoS One 9: e112299. [Crossref]
19. National Population Commission (NPC) [Nigeria] and ICF International (2014). Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International [Crossref]
20. Banke Thamas AO, Kouraogo SF, Siribie A, et al. (2013) Knowledge of Obstetric Fistula Prevention among Young Women in Urban and Rural Burkina Faso: A Cross-Sectional Study. PLoS One 8: e85921. [Crossref]
21. LL Wall, Jonathan A Karshima, Carolyn Krischner, et al. (2004) The Obstetric Visicovaginal fistula: Characteristics of 899 patients from Jos, Nigeria. AM J OBSTET GYNECOL 190: 1011-1016. [Crossref]
22. Muleta M, Rasmussen S, Kiserud T (2010) Obstetric fistula in 14,928 Ethiopian Women. Acta Obstet Gynecol Scand 89: 945-951. [Crossref]
23. Adler AJ, Ronsmans C, Calvert C, et al. (2013) Estimating the prevalence of obstetric fistula: A systematic review and meta-analysis. BMC Pregnancy Childbirth 13. [Crossref]
24. P Hilton (2003) Vesico‐vaginal fistulas in developing countries. Int J Gynaecol Obstet 82: 285-295. [Crossref]
25. Lilian T Mselle, Thecla W kohi (2015) living with constant leaking of urine and odour: thematic analysis of socio-cultural experiences of women affected by obstetric fistula in rural Tanzania. BMC Womens Health [Crossref]
26. Umoiyoho AJ, Inyang EC (2012) Community Misconception about the Aetiopathogenesis and Treatment of Vesicovaginal Fistula in Northern Nigeria. Int J Med Biomed Res 1: 193-198.
27. Browning A, Menber B (2008) Women with obstetric fistula in Ethiopia: A 6-month follow up after surgical treatment. BJOG an Int J Obstet Gynaecol 115: 1564-1569. [Crossref]
28. Browning A, Lewis A, Whiteside S (2014) Predicting women at risk for developing obstetric fistula: A fistula index? An observational study comparison of two cohorts. BJOG An Int J Obstet Gynaecol 121: 604-609.
29. Adler AJ, Fox S, Campbell OMR, et al. (2013) Obstetric fistula in Southern Sudan: Situational analysis and Key Informant Method to estimate prevalence. BMC Pregnancy Childbirth 13.
30. Umoiyoho AJ, Inyang Etoh EC, Etukumana EA (2012) Obstetric fistula repair: experience with hospital-based outreach approach in Nigeria. Glob J Health Sci 4: 40-45. [Crossref]
31. National Population Commission (NPC) [Nigeria] and ICF. 2019. Nigeria Demographic and Health Survey 2018. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF: 2018.
32. Gwyneth L Bernis Luc De (2016) Obstetric Fistula: Guiding Principles for Clinical Management and Programme Development. [Crossref]
33. Banke Thomas AO, Kouraogo SF, Siribie A, et al. (2013) Knowledge of obstetric fistula prevention amongst young women in urban and rural Burkina Faso: A cross-sectional study. PLoS One 8: 1-8. [Crossref]
34. Luwan Semere Nawal Nour (2011) Obstetric Fistula: Living With Incontinence and Shame. Rev Obstet Gynaecol 4: 193-197. [Crossref]
35. Kazaura MR, Kamazima RS, Mangi EJ (2011) Perceived causes of obstetric fistulae from rural southern Tanzania. Afr Health Sci 11: 377-382. [Crossref]
36. Kasamba N, Kaye DK, Mbalinda SN (2013) Community awareness about risk factors, presentation and prevention and obstetric fistula in Nabitovu village, Iganga district, Uganda. BMC Pregnancy Childbirth 13. [Crossref]
37. Orji E, Aduloju O, Orji V (2007) Correlation and impact of obstetric fistula on motherhood. J Chinese Clin Med 2: 448-454. [Crossref]
38. Ijaiya M, Rahman A, Aboyeji A, et al. (2011) Vesicovaginal Fistula: A Review of Nigerian Experience. West Afr J Med 29. [Crossref]
39. Ijaiya MA,  Aboyeji AP, Ijaiya ABB (2002) Epidemiology of Vesico-vaginal Fistula at the University of Ilorin Teachin Hospital, Ilorin, Nigeria. Trop I Obs Gynaecol 19: 101-103.
40. Inimbga NM, John CO, Ekeke NO (2018) Genitourinary Fistulae Experience in a University Teaching Hospital : A South-South Nigeria Perspective. Greener J Med Sci 8: 5-10.
41. Dangal G, Thapa K, Yangzom K Kari (2014) Obstetric Fistula in the Developing World: An Agonising Tragedy. Nepal J Obstet Gynaecol 8: 5-15. [Crossref]
42. Sjøveian S, Vangen S, Mukwege D, et al. (2011) Surgical outcome of obstetric fistula: A retrospective analysis of 595 patients. Acta Obstet Gynecol Scand 90: 753-760. [Crossref]
43. Tukur J, Jido TA, Uzoho CC (2006) The Contribution of Gishiri Cut to Vesico vagial Fistula in Birnin Kudu, Northern Nigeria. African J Urol 12: 121-125.
44. Tukur I, Ijiaya MA, Su TT, et al. (2015) Analysis of 137 Obstetric Fistula cases seen at Three Fistula Centers in Northwest Nigeria. East Afr Med J 92: 408-414.
45. Tuncalp O, Tripathi V, Landry E, et al. (2015) Measuring the incidence and prevalence of obstetric fistula: Approaches, needs and recommendations. Bull World Health Organ 93: 60-62. [Crossref]
46. Wall LL (2012) Obstetric Fistula Is a Neglected Tropical Disease. PLoS Negl Trop Dis 6: 8-10. [Crossref]
47. Wall LL, Karshima AK, Kirschner C, et al. (2004) The obstetric vesicovaginal fistula: Characteristics of 899 patents from Jos, Nigeria. Am J Obstet Gynecol 190: 1011–1019. [Crossref]
48. National Population Commission (NPC) [Nigeria] and ICF. 2019. 2018 Nigeria DHS Key Findings. Abuja, Nigeria and Rockville, Maryland, USA: NPC and ICF; 2018.
49. Audu BM, Kullima AA, Bako B (2008) Epidemiology of vesico-vaginal fistula: No longer a calamity of teenagers. Journal of Obstetrics and Gynaecology 28: 432-433. [Crossref]
50. Odusoga OL, Oloyede OAO, Fakoya TA (2002) Obstetric Vesico-Vaginal Fistula in Sagamu. Nig Gynaecol 19: 101-103.