|The Female Client and the Health-care Provider (IDRC, 1995)|
|A Selection of Essays|
This paper examines the various factors that contribute to the incidence of vesicovaginal fistula (VVF), a condition that arises from obstetric complications. The goal is to present the gender-based factors that lead to VVF, as well as a comparison of the clientprovider relationship within two existing health systems, the modern/orthodox system and the traditional health system, in terms of accessibility, acceptability, and adaptability.
Causal Factors for Vesicovaginal Fistulae
VVF is a health condition caused by the interplay of numerous physical factors and the social, cultural, political, and economic situation of women. This interplay determines the status of women, their health, nutrition, fertility, behaviour, and susceptibility to VVF (WHO 1989).
The physical factors that influence the incidence of VVF include obstructed labour, accidental surgical injury related to pregnancy, and crude attempts at induced abortion. Obstructed labour leads to VVF when prolonged and unrelieved pressure on the woman's pelvic wall causes a puncture in the bladder.
Surgical procedures that cause VVF are of two types. The first, which may be termed orthodox medical accidental injury, refers to injury caused to the bladder during obstetric operations performed within the formal/modern health care system, such as the hospital. Such procedures include caesarean sections and difficult forceps delivery.
A table prepared for a comparative report by Kelly (1979) presented the cause of fistulae in 161 patients in Africa, particularly Ethiopia, and in Britain. Some subjects became VVF patients as a result of operative delivery performed in orthodox hospitals. Table 1 shows a breakdown of the causes.
A study carried out by Mustafa and Rushwan (1971) in Khartoum in the late 1960s confirmed that the major cause of VVF is prolonged, obstructed labour which is often followed by instrument delivery (mainly forceps) and gynecological operations. Between 1966 and 1968, 91 (74.8%) of the women studied demonstrated VVF resulting from obstructed labour, 25 (20.5%) from instrument delivery, and 6 (4.7%) from gynecological operations.
The second form of surgical procedure that may lead to VVF is performed within the traditional health care system. These procedures are commonly employed during pregnancy and labour, and lead not only to VVF, but may also cause hemorrhages and sepsis. Examples include female circumcision, the Gishiri cut,1 and Angurya, a traditional practice in which tissue is removed from the vagina by traditional surgeons for the treatment of coital pain, infertility, obstructed labour, amenorrhea, dyspareunia, vulva rash, goitre, and generalized body aches and pains (Sambo 1990; Tahzib 1985; Harrison 1985).
In an unpublished paper, Darrah and Froude (1975) estimated that some 40% of the patients attending Zaria hospital (Nigeria) with VVF had received Gishiri cuts. This finding is substantiated by a study conducted by Tahzib (1983) involving 1443 VVF patients at the Ahmadu Bello University Teaching Hospital, Zaria, between January 1969 and December 1980. In a table titled "Aetiological factors leading to fistula," Tahzib showed that 1209 (83.8%) of VVF resulted from prolonged labour, 188 (13.0%) from Gishiri cuts, 14 (1.0%) from surgical trauma, 10 (0.7%) from infections, and 22 (1.5%) from "other" causes including congenital injuries, insertion of caustic materials into the vagina, and so on.
Sociocultural Factors Affecting the Prevalence of VVF
The World Health Organization (WHO) argues that poor socioeconomic development is the basic underlying factor responsible for maternal ill-health, including the prevalence of obstetric fistulae. It further argues that the standards of health in developing countries are low and that natural hazards such as malnutrition and infections remain largely unchecked. The situation worsens where health services are deficient or absent, particularly in isolated rural areas. Logistic problems compound the problem, including the failure of existing health systems to provide appropriate health care that is accessible, acceptable, and adaptable; the sole development of urban areas to the marginalization or total exclusion of rural areas; unequal distribution of government resources; and the lack of appropriate basic infrastructure such as roads, water, health centres, schools, and electricity (WHO 1989).
Marriage and Child Birth
The sociocultural factors that contribute to the prevalence of VVF in women focus on their status in society. For example, girls are given in marriage at very young ages in some cultures, often before or during the process of puberty, and childbearing is seen as an indicator of the attainment of "married woman" status. This helps to explain why VVF sufferers are often very young girls.
Study results on VVF vary geographically. In Africa, where the problem appears to be most prevalent, studies have shown that at least 70% of women with fistulae are aged 30 years and under. Tahzib's 1983 study, in fact, showed that 5.5% (80) of VVF sufferers were under 13 years of age (see also Murphy 1981; Mustafa and Rushwan 1971; Tahzib 1985; Harrison 1985). In some parts of the continent, therefore, children beget children. Another finding of these case studies is that women often develop VVF during their first pregnancy.
In Asia, the same trend holds true, except that a greater concentration of women with VVF fell within the 20 to 24 year age group (except in Bangladesh, where almost half were under 20 (Begum 1989)). This suggests that the age of marriage in Asia is generally higher than it is in Africa (WHO 1991).
The case is different in Latin America, in that VVF has only been reported in Ecuador. A study by Calle (1989) indicated that 75% of the women with fistulae were primiparous, but the numbers were reported to be so small as to make the findings inconclusive.
It is possible that there are more women and children with VVF than appear in the data. This possibility is supported by a 1991 WHO statement that data used in most analyses, except those of Murphy (1981), were obtained from hospital records (WHO 1991). It can be argued that these hospital records show only the incidence of VVF which were actually treated in hospitals.
In areas where malnutrition is an indicator of a community's nutritional status, women have been noted to be more acutely malnourished than men due to differential feeding practices for boys and girls from birth. This reflects a fundamental undervaluing of girls and women which leads to discrimination and their neglect. The effects of malnutrition contribute greatly to the underdevelopment of women's physiology, and eventually to some of the physical problems addressed earlier (Royston and Armstrong 1989). Evidence to support this is found in Murphy and Baba Tukur's 1981 study.
With respect to education, Murphy and Baba Tukur's study also demonstrated that only boys attend school in Zaria (this research coincided with Universal Primary Education in Nigeria). Girls were seen hawking foodstuffs and other goods prepared by the women, who were confined to their compounds. Adult education for women was not fully accepted. In three villages, home economics was the only course offered to girls, while in six villages, adult literacy classes were for men only.
In many instances, a lack of health education hinders VVF prevention. Most rural dwellers see obstetric complications either as a result of the pregnant woman's sin, the anger of the gods, a curse, evil spirits, or heredity. For example, studies conducted across West Africa by the Prevention of Maternal Mortality Network (1992) demonstrated that certain behaviour, including infidelity and disregarding the authority of one's husband or elders, is believed to lead to obstructed labour and hemorrhage.
According to the study, women in Accra (Ghana), Benin, Calabar (Nigeria), and Freetown (Sierra Leone) reported that when complications arose, oracles were consulted. If the oracle confirmed insubordination, the pregnant woman was forced to apologize and to preform cleansing rites before she was taken for treatment. Similarly, in Bo, Sierra Leone, complications determined to have arisen from infidelity led to forced confessions of sin and the husband spitting water on the woman's abdomen to appease the gods. Only then was further help sought in hospitals, and only if the complication was thought to be serious enough (The Prevention of Maternal Mortality Network 1992).
Illiteracy is also a factor which determines what kind of medical help is sought (Mustafa and Rushwan 1971; Murphy 1981; Harrison 1983). Illiteracy deters people from attending hospitals, particularly when they are made to feel stupid and when hospital staff come from an alien culture with differing traditions, customs, and language (Murphy 1981; Murphy and Baba Tukur 1981; Prevention of Maternal Mortality Network 1992).
According to Edström (1992) and Royston and Armstrong, (1989) education gives young women better access to profitable employment alternatives. It also reduces the incidence of high-risk pregnancies, unwanted pregnancies, and abortions by increasing contraceptive use and reducing fertility. As girls stay in school longer, the average age at marriage tends to rise, as does the average age at first birth, especially when family planning services are promoted, readily available, and accepted by the women (Royston and Armstrong 1989; Edström 1992).
Another social contributor to VVF is the lack of decision-making power available to women, even in decisions pertaining to their own health. This situation has been found to be particularly true for women in seclusion or "purdah" 2 (Prevention of Maternal Mortality Network 1992). The existence of this problem is a major determinant in the health seeking behaviour of women. For example, if labour becomes obstructed and all local methods fail, a woman may be taken to hospital only if consent is given by either her husband, the village chief, or sometimes her mother-in-law. Most times the decision comes too late. Depending on the distance to the nearest hospital, such women and/or their babies may not make it alive; if they do, permanent damage to the internal organs would have occurred (Harrison 1985). This situation is reported in Margaret Murphy's research in Zaria (1981), where it is characteristic for VVF patients to come from rural areas. In her study, part of which involved 100 fistula patients, 71% of the new patients at the clinic came from distances of at least 100 km. The greatest number of new patients came from distances of between 100199 km from Zaria. Eleven new patients even came from as far away as 800 km to attend the clinic (Murphy 1981).
The timing of decisions to go to a hospital has been linked to knowledge of the possible complications and a mistrust of orthodox or modern health care services (WHO 1991). One such mistrust arises from the fact that most of the women are examined by male doctors (Ojanuga 1992).
Economic Factors Contributing to the Prevalence of VVF
The single most important economic factor contributing to the prevalence of VVF is poverty, especially poverty in rural areas. According to the WHO 1991 Report on Obstetric Fistulae, women with fistulae come almost exclusively from poor families and communities. In her 1981 Zaria study, Murphy indicated that her data pointed to the fact that fistula patients usually come from poor subsistence farming backgrounds (Murphy 1981; Murphy and Baba Tukur 1981).
Poverty also serves as a disincentive or deprives fistulae patients from using modern health facilities in two ways: personal costs incurred as a result of attending these facilities, and cuts in services and provisions at these facilities as a result of insufficient funding or budget cuts. Examples of the first type of cost include costs of transportation to the hospitals, costs of medication, hospital fees, costs of bandages and sutures, and costs associated with feeding both the patient and those who accompany her. Examples of the second type of costs include lack of sufficient hospital beds, inadequate numbers of staff, and a poorly equipped establishment (Ojanuga 1992; Prevention of Maternal Mortality Network 1992).
Health and Social Consequences of VVF
With some of the causes of VVF established, it is important to demonstrate their impact on women. Women with VVF suffer from urinary incontinence which, if not managed properly, causes them to smell of urine. This continuous urine leakage makes them vulnerable to urinary tract infection, vaginitis, and excoriation of the vulva (that is, injury to the surface of the skin or a mucous membrane caused by physical abrasion, such as scratching). Stricture of the vagina (vaginal stenosis), whereby the vagina narrows, secondary amenorrhea, possible future inability to carry a child even after obstetric repair of VVF, and a low child survival rate are also conditions related to VVF (WHO 1991).
The most traumatic aspects of VVF from the social point of view are the resulting incontinence, childlessness (which may lead to marital breakdown and eventually divorce), and social excommunication (Murphy 1981; Harrison 1983). Data from Murphy's study revealed that 14% of the new patients were divorced as a direct result of their illness, while 42% were still living in their husband's compound. When the condition persisted, the proportions changed (28% and 11%, respectively).
According to Murphy, no women in control groups A or B were divorced or living apart from their husbands. By contrast, only 11% of the long-term fistula patients were living with their husbands and 77% had been living apart for at least 2 years. Of the 22 cured patients interviewed during a subsequent confinement in the hospital, 16 were still married to the same husband as when they first developed fistulae. More childless women were divorced by their husbands as a result of their disorder, than were women with living children (36% and 14%, respectively). Childlessness, therefore, is obviously an important factor in marital breakdown, but so too is the fact that the illness is regarded as incurable (Murphy 1981).
It seems that excommunication would be the hardest consequence to bear psychologically for women with VVF. This is indicated by a lack of support not only from society but also from their own families. These women for example, are not welcome in society because they smell. They are not permitted to live in the same house as their families or husbands, neither are they allowed to handle food, cook, or pray. Murphy (1981) observed that women hospitalized for fistula repair enjoyed less support and interest from their husbands than other patient groups, and the amount of practical support provided by family members diminished with prolongation of the illness. Interviews with women with this condition also revealed that patients felt they were a social disgrace to their families and so deserved to be outcasts (Murphy 1981). These women had developed psychological self-labelling and self-esteem problems.
Vaginal fistulae are repaired through orthodox surgical correction; a successful repair is gauged by whether the woman is continent of urine. The study by Mustafa and Rushwan (1979) revealed the types of surgical procedures used to repair VVF in 122 cases treated in the Khartoum Teaching Hospital between 1966 and 1968. These are presented in Table 3.
Repairs are generally successful, depending on the extent of damage and duration of condition before medical attention was sought. Kelly (1979) reports that 100 of 128 African women (78%) were cured at the first attempt. Of 33 British women, 31 (91%) were cured, while 2 (6%) faced continued stress incontinence.
Given the causal factors addressed above, the health of women in VVF endemic areas depends greatly on prevention, which itself is an indicator of social change. To be effective, social change must include an improvement in the status of women, as stated by the WHO's Maternal Health and Safe Motherhood Programme:
[o]bstetric fistula lies along a continuum of problems affecting women's reproductive health, starting with genital infections and finishing with maternal mortality. Because of its disabling nature and dire consequences - social, physical and psychological - it is the single most dramatic aftermath of neglected childbirth. As with all of these problems, its prevention must ultimately lie in a profound change in the status of women. This change must involve, among other things, recognition of women's value, starting with adequate nutrition in childhood and continuing with access to primary education as a very minimum. It must include the eradication of harmful traditional practices and raising the age of marriage, giving women other ways of achieving social status than early child bearing. These are long-term goals, not easy to achieve, but vitally important to women's health and lives (WHO 1991).
In Nigeria, the National Council of Women's Societies of Nigeria (NCWSN) launched an exemplary program in 1989, selecting the prevention and treatment of fistulae as one of their top priorities. One interesting feature of this program is the provision of physical, psychological, and social rehabilitation to women recovering from fistula repair to facilitate reintegration into their social group (Murphy 1989).
It is encouraging that women are now raising awareness of this issue, and are trying to make real changes. Given that VVF is solely a woman's problem, this issue will remain unresolved far into the future without the active participation of women.
Analysis of Issues Affecting ProviderClient Relationships
This section of the paper will analyze VVF providerclient relationships in the modern health sector using three indicators: accessibility, acceptability, and adaptability.
Accessibility (Distance, Time, and Cost)
The literature states that the geographic distance to the nearest hospital is an important factor in accessibility. With most hospitals established in urban areas, people in rural areas are marginalized in terms of health provisions, health infrastructures including local health centres, good roads, and experienced health personnel. This has been established as a disincentive to using modern health facilities.
The travel distance is also a direct variant of the time spent. Most rural dwellers, particularly pregnant women, consider it a waste of time to travel long distances to visit clinics for just a few hours. To most rural dwellers, particularly those who work on family farms, time management is very important. Time waste does not encourage women to go to hospitals (Leslie 1992). The costs of going to and receiving health care in hospitals or health centres is also too dear for women, including those with VVF.
With regards to accessibility, then, it can be concluded that modern health care is not accessible to most potential VVF patients.
Acceptability (Cultural Practices, Status of Women, Faith in Modern Health Care)
The issue of acceptability is an extremely important indicator when examining health service use by VVF patients. It determines in part what happens when there is an obstetric emergency, and how quickly VVF patients or their family members will respond.
The literature states that cultural practices pose the greatest danger to both potential VVF patients and to those with the condition. Within most VVF-endemic cultures, women are subordinate to men. Two results of this gender-determined hierarchy are that many women live in seclusion, and that cultural attitudes toward women with obstructed labour endangers their lives. Women must ask for permission to visit modern, orthodox medical centres, they need permission to leave the house (as is the case with women in purdah), they need permission to go ahead with measures that concern their own health. Women in these cultures lack decision-making power. These women's health needs appear on their husband's or family's list of opportunity cost, as all finances are controlled by the males.
This is a great reflection of the status of women in these cultures. It implies that husband and community decisions and needs supersede and override a woman's right to safe health. How else could one explain marrying a 1213 year old girl? Women's bodies are possessions and are controlled without their permission. Women are not permitted to visit hospitals because their culture does not allow them to expose themselves to a male doctor. Thus, only their husbands and other women may see them naked, even when their lives are in danger.
None of the above arguments against acceptability of modern medical health care helps when women cannot trust the system that is supposed to take care of them. In studies carried out in some West African countries by the Prevention of Maternal Mortality Network (1992), focus groups demonstrated that community members were acutely aware of problems within the health care system, such as administrative and management problems (lack of supplies, attitude of staff, and waiting time), inadequate staff, hospital fees, and the fear of seeing a male doctor. A combination of these factors contributes to maternal deaths in developing countries.
A difference in medical cultures, whereby women encounter behaviour to which they are not accustomed, also contributes to a lack of acceptability. Women are sometimes verbally abused by nurses. The intolerance of medical cultures is clearly demonstrated when nurses and patients do not have an understanding and respect of each other. For example, in Ilorin, Nigeria the nomadic Fulani women reported that the health facility staff (who are largely Yoruba) insult them and tell them that they behave like the cows they herd. When interviewed, the staff complained that the Fulanis do not come to the hospital until they are in serious condition, and that they resist buying supplies (Prevention of Maternal Mortality Network 1992). These women are also faced with having to tip staff before they can actually see the appropriate medical personnel.
It appears, therefore, that modern health care is not acceptable to most potential VVF patients, nor those with the condition. Neither their status within their cultures, nor the way they are received in hospitals, encourages them to visit hospitals which are the only source of VVF repair.
In this section, we examine how the modern health sector is trying to incorporate VVF patients to make them more comfortable in the hospital environment. Apart from performing surgical operations, hospitals represent a hierarchical structure, both in terms of a health structure and in terms of a health personnel pyramid. It is similar to other bureaucratic institutions, with many rules and red tape procedures consuming a lot of time before anything is accomplished. It has rigid guidelines and is criticized as impersonal and sometimes inhuman. Most women coming for VVF repair are not used to this kind of structure and are not used to impersonal relationships.
In Nigeria, for example, the medical structure is such that the teaching hospitals stand at the pinnacle, followed by state hospitals, health centres in local government areas, and comprehensive health centres and dispensaries at the bottom. Similarly, in the medical personnel structure, doctors are seen as the most important, then other professionals such as pharmacists and biomedical researchers, followed by nurses and technical staff. At the very bottom may be the janitors and gatekeepers. Most of the doctors are of course men, who VVF patients refuse to see.
In terms of health participation, hospitals have not done much to encourage patient participation. Rather, they have indirectly continued to encourage discrimination against these women. This is sometimes due to a lack of funding or lack of interest. Prevention in the form of intensive health education for current and potential VVF patients and their family members should be a hospital initiative. Hospitals do not have efficient follow up systems to ensure that patients are reintegrated into their communities.
One of the critiques against modern health care systems is their focus on curative rather than preventive health care. Curative health does not eradicate the problem, it only soothes it. It is a "band aid" measure against the problem of poor health, especially in rural areas. With most of the hospitals located in urban areas, health coverage remains minimal in most countries, particularly those in the developing world. Preventive health care, on the other hand, encourages participation of the potential users of health care, as it involves intensive health education of women and men. It involves health care representatives discussing the problems of health in their communities with the people, and suggesting how they can participate in solving them.
The establishment of hospitals in the urban centres encourages discrimination across socioeconomic lines. It means that a person living in an urban area has a better chance of receiving hospital care and social amenities than those living in rural areas. This in turn suggests that data on the actual numbers of women with VVF are inaccurate.
Given this situation, it would appear that traditional health systems are more accessible and acceptable to VVF patients. Most of the patients who are eventually taken to hospitals have previously contacted either traditional healers or faith healers, who are found in their communities and who have a better understanding of their culture and cultural practices. These healers have won the respect of the community and vice versa. As a result, there is a better understanding in the clienthealth provider relationship.
Adaptability of the traditional health system is an indicator that is by itself not adequate. Most of the techniques administered by traditional healers to women with VVF further endanger the women's lives and leave them more susceptible to permanent disability or maternal death.
In most societies, cultural and spiritual aspects of pregnancy and childbirth have a strong influence on behaviour. It is important that [modern] health care providers are aware of these aspects so that they can organize services that are appropriate and acceptable to the people. Unfortunately, there are usually limited opportunities for [modern] health personnel to explore the sociocultural context of childbirth (Royston and Armstrong 1989).
Recognizing the limitations of both systems, WHO, United Nations Fund for Population Activities (UNFPA), and the United Nations Children's Fund (UNICEF) have over the past 15 to 20 years established a collaborative effort between national governments to deal with the training of traditional birth attendants (TBAs) so that they may be incorporated into the orthodox health care system (Royston and Armstrong 1989; WHO 1992). The term partnership may, however, be preferable to the word incorporated, because each system has a status of its own. The former makes it appear as if TBAs are a mere bonus to the existing formal system.
One of the most important arguments in favour of greater "collaboration" is that it serves as a means of bridging the gap between the medical cultures of the two systems. As a result of this collaboration of organizations and governments, TBAs have been, and continue to be, trained. This initiative has given rise to many positive results. It has ensured safer and faster delivery of health care to certain communities. It has increased the participation of women in the health of their families. It is cost effective in that it promotes health prevention and health education, thereby saving more lives by encouraging people not to wait too long to seek help. TBAs are trained to be accountable for the health of their communities, and as such are responsible for safer deliveries under cleaner conditions. They are also trained to recognize and refer obstetric complications within the community to the first referral level, the health centre, or to hospitals directly.
Trained TBAs could contribute much to the prevention of VVF in rural areas. This statement is based on deductions and assumptions from both personal analysis and the literature. Their services will be more accessible, acceptable, and adaptable as most trained TBAs are women from within the same community as the patients, with an understanding of the culture. This way women do not have to fear exposing themselves to men other than their husbands. As well, trained TBAs will be in a good position to educate their community against early marriages. They will be able to teach hygiene to pregnant women, and speak against unhealthy behaviour that endangers the lives of pregnant women and their children. In other words, trained TBAs will approach health care in the communities from a holistic approach.
Observations, Criticisms, and Suggestions
While researching this paper, it became evident that there has not been much literature on the sociocultural aspects of VVF. Rather, the majority of papers have focused on the medical aspects of the condition. To further compound the issue, most literature concerning VVF are full of medical terminology that require frequent consultations of the medical dictionary to be able to follow the flow of thought. I realize that the terms are medical, but they also have simple meanings. It would benefit a reader if there were appendices with the meaning of the terms. In addition, I did not come across any paper written on the role of TBAs or traditional midwives in the prevention of VVF.
I also observed that most literature on VVF approach the issue from a curative aspect. Most authors are doctors working within urban hospitals and who are more involved with repair of fistulae. Preventive measures were most times omitted.
Appendix 1: Definition of Medical Terms (Dorland's 1981)
Absence or abnormal stoppage of the menses
Difficult or painful coitus
Painful or difficult urination
The science of the forms and structure of organisms
The sum of the morphological changes indicative of cell death and caused by the progressive degrative action of enzymes
Giving origin to disease or to morbid symptoms
Bearing or having borne but one child
The presence in the blood or other tissue of pathogenic microorganisms or their toxins
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Kikelomo Bello is with the International Development Studies Department, Saint Mary's University, Halifax NS, Canada.