For most women, becoming a mother comes with a bundle of joy and happiness. Nonetheless, this process of becoming a mother is sometimes marred by certain occurrences which may include complications from pregnancy, diseases, and even death. One of such issues that have been a perennial concern and a threat to motherhood is the problem of obstetric fistula. Obstetric fistula (OBF) describes a medical condition in which there is an abnormal opening or connection between a woman’s genitals and the urinary tract or rectum (Ryan, 2019).
Globally, there are about 2 million women residing in Asia and Africa who are living with untreated OBF (World Health Organisation, 2018). The same report by the WHO (2018) indicates that every year, between 50,000 and 100,000 new cases are recorded worldwide. Moreover, statistics on the incidence of OBF is quite staggering in Sub-Saharan Africa as there are about 10 cases in every 1,000 live births (Azanu, Dassah, Agbeno, Ofori & Opare‐Addo, 2020). Zooming into the Ghanaian context, the Ghana Health Service (2015) reports that between the period of 2011-2014, a total of 1,538 cases were reported. This figure is likely to be more than what has been reported since majority of women who face OBF often feel ashamed and stigmatised, and will therefore not report to the health facility until it is too late.
As emphasised in the preceding paragraph, women who experience OBF are ashamed and are often subjected to ridicule and stigmatisation from the society. This is due to the fact that the abnormal opening created by OBF usually leads to perpetual leaking of urine and faeces (Ghana Health Service, 2015). Such response from the society and the immediate family of OBF victims can result in long-term psychosocial trauma and distress. It is important to note that not only does OBF mothers or women’s psychosocial health; it also has serious implications on maternal mortality. Some studies in Ghana posit that, OBF is a major contributor and escalator of maternal mortality (Mantey, Kotoh, Barry & Redington 2020). OBF therefore is a threat to the attainment of the Sustainable Development Goals target 3.2 which envisions to reduce the global maternal mortality to less than 70 per 100,000 live births by 2030 (Waniala et al., 2020). Hence, it is imperative to act now to mitigate the consequences of OBF on motherhood and by extension maternal health and wellbeing.
What is perpetuating OBF?
Like all health conditions, OBF does not happen in vacuum. It is driven by multiplicity of factors that can be discussed from the individual, structural/institutional, or socio-cultural perspectives. At the individual level, maternal age of marriage has been identified as one of the major contributors to OBF. According to Nuertey, Sackey, Gandau and Aikin (2018), giving birth at ages less than 20 years is often associated with higher risk of OBF. From the structural/institutional level, the inaccessibility to health care facilities appears to be the main predictor of OBF among Ghanaian women (Mwini-Nyaledzigbor, Agana & Pilkington, 2013). In many rural communities, accessibility to health care facilities is challenging; the nearest facility could be miles away. Such barriers caused as a result of distance to the nearest facility results in delays and prolonged obstruction which may eventually lead to OBF. Beyond the individual and structural bottlenecks that exacerbate the risk of OBF, some harmful socio-cultural practices such as female genital mutilation and child marriage increase the risk of women to experience OBF, thereby making motherhood a distressing life process.
What has Ghana done to remedy OBF?
The government of Ghana through its agencies like the Department of Gender and Ghana Health Service have played important roles in mitigating OBF in Ghana, and make motherhood an exciting and stress-free process. There is the National OBF Taskforce which is commissioned to work assiduously to find lasting solutions to Ghana’s OBF situation. Over the years, there have been more campaigns that seek to eliminate early marriages so as to reduce the likelihood of teenage pregnancy which is a major contributor or risk factor for OBF. Along this line, the Ghana Health Service on behalf of the government of Ghana has partnered with international agencies and non-governmental organisations such as the United Nations Population Fund (UNFPA) Ghana. Therefore, in May 2018, the UNFPA Ghana and its partners of which Ghana Health Service is inclusive launched the 100 in 100 Initiative which is positioned to create awareness of OBF as well as raise funds for the repair of a hundred OBF within hundred days (UNFPA Ghana, 2018).
What more can be done to engineer Ghana to end Obstetric Fistula?
Fortunately, OBF is preventable and is also repairable. Therefore, in summary, all of Ghana’s strategies to engineer Ghana towards the elimination of OBF must be centralised on preventing new cases and helping to repair existing OBF. On the prevention side, Ghana has a lot more to do in terms of awareness and sensitisation of women and the general population about OBF. Azanu et al. (2020) indicates that 56.6 percent of women and midwives have misconceptions about OBF. In that vein, we need to strengthen efforts to educate general public about OBF by actively leveraging on the power of the social media and other traditional media platforms. If we are going to make heads way as a country, then we would have to invest enough resources to champion the education of midwives in order to provide them with the necessary knowledge and skills to detect (early) and deal with possible obstetric conditions that could potentially escalate into OBF.
Still on the prevention bit, prioritisation sexual and reproductive health of particularly girls aged below 20 is a step in the right direction towards an end to OBF. Early pregnancies are not good for girls as it predisposes them to higher risk of OBF. Therefore, if we come to a consensus as a country to champion comprehensive sexuality education (CSE), our girls and women will be empowered and assertive. In that instance, they will be able to prevent teenage pregnancy which is a major risk factor for OBF. Again, if CSE is fully and properly implemented, girls will become aware of their SRH rights and will therefore insist on no early/child marriage. This is one of the surest ways to propel Ghana towards a future where there are no cases of OBF. One might argue that CSE alone cannot prevent teenage pregnancy and child marriage. Although this might be true to some extent, I postulate that having CSE along side technical support for girls who are at risk of child marriage would yield faster results.
The government of Ghana together with its agencies and partners should increase processes and national efforts that clamp down on harmful socio-cultural practices which predisposes females to OBF. To that end, female genital mutilation should be completely eradicated from the Ghanaian culture and tradition. This calls on collaborative efforts from the government, traditional leaders, religious leaders and other relevant stakeholders such as the Domestic Violence and Victim Support Unit (DOVVSU), Commissioner of Human Rights and Administrative Justice (CHRAJ) and then friends from the media. All of these interest groups would have to use their platforms to educate the Ghanaian populace about the ripple effects FGM has on the OBF. The enforcement agencies would also have to ensure strict compliance and bring perpetrators of FGM to book. This will serve as a deterrent to others who may be contemplating on whether to indulge in this barbaric act of violence against women. In the long run, we shall see a corresponding effect of eliminating harmful practices on the incidence of OBF.
It is important to note that even though there have been remarkable achievements in gender equality in recent times, patriarchal ideologies still dominate in some areas, particularly in rural and remote rural areas where there is likely to be higher incidence of OBF due to the inaccessibility to emergency obstetric services. Therefore, males would have to be involved in the processes to end OBF. Men have an active role to play by encouraging and even accompanying their partners to receive antenatal care services. With such active roles by male partners, women would have the WHO’s recommended eight contacts of antenatal care. During antenatal care, pregnancy that are likely to lead to OBF cases can be detected early and remedial actions initiated to prevent any incidence of OBF.
In rural communities where accessibility to health care facility is challenging, the government would have to ensure that there is at least a Community Health Planning and Services (CHPS) compound there. This CHPS compound should have a qualified midwife and a standard emergency obstetric set up, equipment and resources. The purpose of this is to reduce the distance covered by pregnant women when they are due for delivery. Consequently, it will eliminate the occurrence of obstructed labour and ultimately prevent or lower the risk of OBF.
Another critical issue is the need to invest in research on OBF. Currently, Ghana lacks credible, real-time data on the number of OBF cases, the national incidence, prevalence and fatality rates. Such absence of empirical data stifles the country’s capacity to plan, organise and implement solid-proof strategies that will bring an end to OBF in Ghana. Therefore, I recommend that the Ghana Health Service collaborate with the Ghana Statistical Service to organise yearly or biennial nationally representative surveys that cover a host of issues pertaining to OBF. In these surveys, we would as a country, need to invest in geographic information system (GIS). This will allow us to have spatial data that will inform government and its partners such as UNFPA Ghana about which communities have the most burden of OBF. Consequently, there will be real difference and impact in interventions rolled out in each identified community. In addition to investment in research on OBF, there would be the need to institute an OBF registry that will record every single case of OBF recorded in any of the 16 regions in Ghana. Data from the registry can be used for surveillance purposes as well as monitoring and tracking the progress Ghana is making towards the elimination of OBF. Without clear and transparent account of the progress made, funders and other interested international agencies and motherhood organisations will not be motivated to invest in OBF preventive programmes. Therefore, it is imperative to keep track of the past situation as well as the progress that have been made.
From the perspective of repairs, the government of Ghana through the Ghana Health Service and the National OBF Taskforce should focus attention on repairing existing OBF in order to reduce the prevalence. Currently, the “100 in 100” initiative by the Ghana Health Service and UNFPA Ghana is a reflection of what must be done to reduce the prevalence of OBF. However, more has to be done in this regard. Ghana must prioritise OBF by looking out for sustainable funding alternatives for the repair of existing OBF cases in the country. This could be done by setting a proportion of the national budget for the repair of a number of OBF cases per annum. If possible, the national health insurance scheme (NHIS) must fully cover or partially cover say, 70 percent of the cost of repair of OBF. According to the UNFPA Ghana (2018), it costs around US$ 700 to repair OBF. Therefore, if the NHIS cannot cover the full cost of US$ 700, then it must be able to cover at least 70 percent of that amount (i.e., about US$ 490). This subsidy that comes as a result of the integration of OBF repair into the national health insurance will go a long way to enable many women who would have otherwise wallowed in misery and shame to have an improved quality of life and better appreciation for motherhood. In the long term, we would require sustainable financing for OBF repairs in Ghana and that cannot come from reliance on funds from foreign agencies and donors. Therefore, the country must think of establishing a fund that is uniquely set to fund OBF repairs.
Related to the repairs, evidence suggests that the are a few surgeons who have been trained to perform OBF repairs. This is a serious challenge to Ghana’s quest to end OBF. Therefore, in order for the country to engineer itself towards the attainment of zero OBF cases, there is the need to invest heavily in the training of medical staff in the repair of OBF. If it demands the provision of scholarships to some medical students to further abroad and come back to help our health system, then that must be done. Essentially, there must be no room for mediocrity if we are going to win this fight against OBF and completely obliterate it. This means that health care providers would need to undergo rigorous training with respect to how to screen and diagnose obstetric fistula as well as how to appropriately repair the damage caused.
Conclusion
Motherhood is a desired phase and transition in the life of many women. Sadly, it is fraught with many complications, complexities and intricacies. In this essay, I expound the theme, “Motherhood in Distress: Engineering Ghana to end Obstetric Fistula”. It can be observed from the arguments levelled in this essay that OBF is an emerging threat to the SDGs, particular target 3.1. Moreover, is can be inferred from this essay that despite Ghana’s commitment to eliminate OBF through the establishment of the National Obstetric Fistula Taskforce as well as the “100 in 100” Initiative, the country still experiences high reported cases of OBF. The risk factors may be individual-level related (e.g., early maternal age – usually births among women <20 years), structural/institutional related (e.g., inaccessibility to health care facilities and emergency obstetric services), and/or socio-culturally driven (i.e., harmful practices such as FGM, early marriages, etc.). I therefore conclude that in order for Ghana to engineer itself towards the elimination of OBF, it would have to accomplish a number of tasks which include the following: creating awareness and sensitisation about OBF to the general population; including males in the processes to end OBF; prioritising sexual and reproductive health and rights; implementing comprehensive sexuality education; providing technical support for girls who are at risk of child marriage; clamping down on harmful socio-cultural practices (such as FGM and early marriages) which predisposes females to OBF; working collaboratively with relevant stakeholders; establishing emergency obstetric services at the various CHPS compound; investing in OBF research; establishing a national registry for OBF; repairing existing OBF; training of health care providers on OBF repairs; as well as the integration of OBF repair into the national health insurance scheme. By doing so, Ghana would be positioning itself at an advantageous point to end obstetric fistula in Ghana. Ultimately, it will translate into a significant decline in Ghana’s maternal mortality ratio and thus, increase Ghana’s capacity to attain the sustainable development goals, target 3.1. Motherhood is a beautiful experience. As such, we all need to work collaboratively to protect women from dangers and threats that nullifies the beauty of motherhood.
Motherhood should be free from harm and distress; end obstetric fistula in Ghana now!
References
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