AN EVALUATION OF CULTURAL TRADITIONS AND THEIR IMPACT ON THE OCCURRENCE OF OBSTETRIC FISTULA IN NORTHERN NIGERIA

CHAPTER ONE INTRODUCTION 1.1 Background of the Study Obstetric fistula is a severe maternal health condition primarily caused by prolonged and obstructed labor, and it is frequently observed in regions where healthcare services are inadequate. This condition, known as a vesicovaginal fistula, involves an abnormal passageway between the birth canal and either the bladder or rectum, leading to continuous leakage of urine or feces (WHO, 2020). These complications are especially prevalent in Sub-Saharan Africa and parts of South Asia, where timely and professional maternal care is scarce, and cultural factors often obstruct effective management of childbirth complications (Tebeu et al., 2022). In Nigeria, the Northern region experiences an especially high incidence of obstetric fistula, largely due to unique cultural practices and socio-economic challenges (Wall, 2022). This part of the country records some of the highest maternal mortality rates globally, with obstetric fistula being a major contributing factor (Adamu et al., 2019). According to the World Health Organization (WHO), approximately 50,000 to 100,000 women globally are affected by obstetric fistula each year, with a significant portion of these cases occurring in Nigeria, especially in the North (WHO, 2020). Research by Johnson et al. (2018) indicates that around 80% of the country's obstetric fistula cases are concentrated in Northern Nigeria. This is primarily due to factors such as early marriage, inadequate access to skilled birth attendants, and limited emergency obstetric care services. Cultural norms play a major role in shaping maternal health outcomes, especially in rural and semi-urban areas of Northern Nigeria. One of the key cultural drivers of obstetric fistula is the prevalent practice of early marriage. In many Northern communities, girls are married off at a very young age, sometimes as early as 13 (Musa et al., 2021). Early marriage leads to early pregnancies, increasing the risk of obstetric complications such as fistula due to the physical immaturity of the young mother’s body (Browning, 2004). Studies show that younger women are more likely to experience obstructed labor, which can result in fistula if not promptly addressed (Ahmed et al., 2020). In addition, cultural beliefs in Northern Nigeria often discourage the use of medical services during childbirth, favoring the assistance of traditional birth attendants (TBAs) or home births. Ibrahim et al. (2020) reported that many women in rural areas believe childbirth is a natural process that does not require medical intervention unless complications arise. Unfortunately, this belief contributes to delayed responses to issues such as prolonged labor, increasing the risk of obstetric fistula. Poverty further exacerbates the situation. A large proportion of the women affected live in rural areas with limited access to healthcare services, resulting in high rates of maternal morbidity and mortality (Fistula Foundation, 2019). Many families cannot afford the costs associated with hospital deliveries or emergency care, compelling women to give birth at home or in poorly equipped facilities. Under such circumstances, complications like obstructed labor often go untreated for extended periods (Bello et al., 2017). The combination of poverty, limited education, and entrenched cultural norms creates an environment in which obstetric fistula continues to thrive. Moreover, the healthcare infrastructure in Northern Nigeria faces serious challenges, including a lack of well-trained medical personnel, insufficient emergency obstetric services, and poor infrastructure (Wall, 2022). The United Nations Population Fund (UNFPA) reports that many women in rural areas live far from facilities capable of performing caesarean sections or managing complicated deliveries, posing a significant obstacle to the prevention of obstetric fistula (UNFPA, 2021). Shortages of skilled health workers, delays in medical care, and lack of postnatal services all contribute to the high susceptibility of women to fistula. Additionally, awareness of obstetric fistula remains low in many parts of Northern Nigeria, and affected women often face severe social stigma and exclusion from their communities (Amosu et al., 2018). This stigma discourages many women from seeking treatment, thereby worsening the situation. Those living with fistula often endure long-term social isolation, psychological trauma, and financial hardship due to their inability to control their bladder or bowel movements (Muleta, 2015). In response, various government and non-governmental organizations have made ongoing efforts to combat obstetric fistula in Nigeria. Initiatives by groups such as the Fistula Foundation and UNFPA focus on offering free surgical repair services to affected women and raising public awareness about the condition (Fistula Foundation, 2019). There have also been attempts to train health professionals and upgrade healthcare facilities in Northern Nigeria to improve maternal health services and reduce fistula incidence. However, the persistence of cultural practices like early marriage and the continued reliance on traditional birth attendants continue to pose significant barriers to progress. Consequently, this study aims to explore how cultural practices influence the prevalence of obstetric fistula in Northern Nigeria. 1.2 Statement of the Problem Obstetric fistula is a serious postpartum complication that predominantly affects women in under-resourced settings. In Nigeria’s Northern region, cultural traditions significantly impact maternal health outcomes. Estimates suggest that Nigeria records up to 2,000 new cases of obstetric fistula annually, with a large portion coming from the North (Nwogu et al., 2020). This high prevalence is closely linked to cultural practices such as early marriage, preference for home births, and insufficient maternal healthcare services (Adetayo et al., 2018; Olufunke et al., 2019). In many Northern Nigerian communities, cultural expectations that emphasize female obedience and family honor contribute to widespread early marriage and childbearing. These practices increase the risk of childbirth complications due to the physical immaturity of young girls, often resulting in prolonged labor and eventually fistula (Musa et al., 2021). Additionally, the reliance on traditional birth methods, often administered by untrained attendants, further raises the likelihood of delivery-related complications (Ibrahim et al., 2020). Cultural stigmatization of women with obstetric fistula also discourages them from seeking timely medical care, creating a cycle of neglect and social isolation (Giwa et al., 2022). Understanding the intersection of cultural practices and obstetric fistula prevalence is vital in crafting effective solutions to this major public health issue. Thus, this study seeks to assess how cultural traditions contribute to the incidence of obstetric fistula in Northern Nigeria. 1.3 Objective of the Study The general aim of this study is to examine the cultural practices and their impact on the prevalence of obstetric fistula in Northern Nigeria. The specific objectives are: i. To explore the prevalence of obstetric fistula in Northern Nigeria. ii. To evaluate the role of early marriage in increasing the risk of obstetric fistula among women in the region. iii. To assess the influence of traditional birth practices on maternal health outcomes and the incidence of obstetric fistula. iv. To identify the barriers women face in accessing skilled maternal healthcare services in Northern Nigeria. 1.4 Research Questions The study will be guided by the following research questions: i. What is the prevalence of obstetric fistula in the Northern region of Nigeria? ii. Does early marriage contribute to the increasing risk of obstetric fistula among women in Northern Nigeria? iii. Do traditional birth practices impact maternal health outcomes and increase the incidence of obstetric fistula? iv. What are the key challenges preventing women from accessing skilled maternal healthcare services in Northern Nigeria? 1.5 Significance of the Study The outcomes of this research will be valuable to the Ministry of Health by offering evidence-based recommendations for enhancing maternal healthcare in the Northern region. The insights gathered will help health professionals and related organizations design culturally appropriate maternal health interventions that better address the specific needs of Northern communities. Moreover, the study will benefit both governmental and non-governmental agencies working in the area of maternal health by aiding the development of policies and programs that target the root causes of obstetric fistula. This includes advocating for laws to curb early marriage and promoting the use of skilled birth attendants. The research will also be of academic interest, contributing to the existing literature and serving as a useful reference for future studies on similar topics. 1.6 Scope of the Study This study will focus on the cultural practices that influence the incidence of obstetric fistula in Northern Nigeria. Specifically, it will investigate the prevalence of the condition in the region, analyze the relationship between early marriage and obstetric fistula, examine the role of traditional birth practices, and identify obstacles that limit women's access to skilled maternal healthcare services. Geographically, the study will be confined to Kano State. 1.7 Limitation of the Study As with many academic endeavors, this study faced a few challenges. One of the primary limitations was time, as the researcher had to balance the demands of this project with other academic responsibilities, including attending lectures and completing coursework. Another constraint was financial, as the study incurred costs for printing, data collection, literature sourcing, and other logistical needs. Additionally, there was a challenge in finding adequate research materials on the subject, given the limited availability of scholarly work on obstetric fistula in the specified context. 1.8 Definition of Terms Obstetric Fistula: A childbirth-related injury resulting in an abnormal opening between the birth canal and bladder or rectum, typically caused by prolonged obstructed labor, leading to continuous leakage of urine or feces. Cultural Practices: Shared beliefs, customs, and behaviors that define a community’s way of life. In this study, it refers to norms such as early marriage, traditional birthing methods, and reliance on untrained birth attendants. Early Marriage: The practice of marrying individuals, especially girls, before the age of 18. Common in parts of Northern Nigeria, early marriage often leads to early childbearing and increased childbirth complications. Traditional Birth Attendants (TBAs): Individuals who assist during childbirth based on cultural knowledge and experience, without formal medical training. They are prevalent in rural Northern Nigeria. Maternal Healthcare: Services provided to women during pregnancy, childbirth, and the postnatal period to ensure maternal and infant health, including antenatal care, skilled delivery, and emergency obstetric services. Prolonged Obstructed Labor: A delivery complication where the baby cannot pass through the birth canal due to physiological barriers. Without timely medical intervention, this can lead to obstetric fistula. Socio-Economic Factors: Social and economic conditions, such as poverty and education level, that influence individuals' or communities' access to healthcare and other services.