CHAPTER TWO

LETERATURE REVIEW

2.0 CONCEPTUAL REVIEW

2.1 DEFINATION OF VESICO – VAGINAL FISTULA

Vesico- viginal fistula (VVF) is a medical condition which a hole ( fistula) develops

between the bladders and the vagina due to prolonged labour or obstructed labour, when

adequate medical care is not available Greanga, Genadry,2017). World health organization,

(2015) referred vesico- vaginal fistula as the single most dramatic aftermath of neglected

childbirth 9browning 2014), considered VVF as a disease of poverty because of its tendency

to occur in women on poor countries that lack health resources compares to developed

countries.

CAUSES OF VESICO- VAGINAL FISTULA

The causes of VVF could be either:

i. Direct causes

ii. Indirect causes

Direct Causes include:

a. Unrelieved prolong labour and obstructed Labour: are responsible for 76%- 97% obstetric

fistula. When a woman is in labour over the cause of 3 to 5 days and a cesarean section cannot

be obtain, the fetus presses against the mother’s bladder and vaginal very tightly. The constant

pressure of the fetal head against the soft tissues of the bladder and vagina restricts (cuts off)

blood supply to the bladder and the vagina causing these tissues to disintegrate. A fistula (hole)
 is then formed, leading to continuous and uncontrollable leakage of urine (Browning Andrew,

2012 and F. Donnay, K, Ramsey, 2016)

b. Orthodox Medical Accidental Injuries: are injuries caused to the bladder and vagina during

surgical procedures performance in health care systems. Example of surgical procedures

performance are poorly performed abortion, caesarean section, cancer radiation therapy targeted

at pelvic region and difficult forces deliver (Doonnay, Ramsey, 2016 and the Acquire project

/engender health, 2015)

c. Harmful Tradition practices: are traditional practices commonly employed during labour,

such as encouraging women to drink water to aid childbirth. But a full in labour actually slows

the second and third stage of labour and also increases the risk of female Genital mutilation

(FGM) Gishiri and Angurya cuts (which is said to be treatment for coital pain, infertility,

obstructed labour, amenorrhea, Vulva rash etc. such harmful traditional practices also increases

the risk of vesico –Vaginal fistula (Ballo, 2012) indirect causes: include the social, political and

economic factor that indirectly leads to the development of vesico –Vaginal fistula.

Indirect causes include: Social political and factors that indirectly needs to the development of

VVF.

a. Poverty: is the number one indirect cause of VVF around the world. Impoverished countries

have low income and lack adequate infrastructure, trained and education profession, lack of

resources and a centralized Government that exist in developed countries t effectively eradicate

VVF. Thus, impoverished countries have higher rate of obstetric fistula (Middleton, Miller 2008

and Chandiramani, payal 2012).

b. Malnutrition: is due to poverty and lack of access to proper nutrition, malnutrition causes

stunted growth/short stature. Stunted growth causes women to have in

 unequipment/underdeveloped skeleton (pelvis) for child birth. Underdeveloped Pelvis increase

the risk of obstructed. Malnutrition also causes vulnerability to disease or medical condition

(Brodma et al 2016, Cook, Dicken, Syed (2014) and Miler, Middleton (2018).

c. Lack of Education: Illiteracy and lack of information on antenatal, intra-natal and postnatal care

results in poor uptake and utilization of antenatal clinic and hospital delivery coupled with

restriction of movement imposed by husbands, have led many women to arrive delivery without

any antenatal care, leading to a development of unplanned complications that may arise during

home deliveries in which traditional techniques are used. These techniques often fail in the

event of unplanned emergencies, leading women to go to the hospital for care too late,

desperately ill and vulnerable to the risk of anesthesia and surgery that must be used to them. In

addition, studies have shown that education families make use of contraceptive and professional

medical service and are more likely to be able to afford material health care (Kristoff, Nicholas,

Sheryl,Affred Knoff 2019).

d. Early marriage and early childbirth: in sub- sahara Africa, many girls go into marriage (arrange

marriages) soon after menarche ( usually between 9-15 Years ) a social cultural and economic

factor contributes to this practices of early marriage. Society and culturally, some grooms want

to ensure their brides are virgins when they get married so an earlier marriage is desirable

economically, the bride price received and have one les person to feed in the family helps

alleviate the financial burden of the bride’s family (Mc kenney, et al 2018).

e. Lack of quality maternal health care: poverty hinders women from being able to access normal

and emergency obstetric care, because of the long distances and expensive procedure. For some

women, the closest maternal health care facility can be more than 50 kilometer away, leading to

delay in accessing necessary obstetric care (United Nations population fund 2014). Even the
 women who make it to the hospital may not get proper treatment because countries that suffer

from poverty, civil and political conflicts and other public health issues suffer from a severe

breakdown within the health care system this breakdown puts people at risk, especially women.

Hospitals in this countries suffer storage of staff, supplies and other forms of medical

technology that would be necessary to perform caesarean section which can help prevent fistula

caused by prolonged or obstructed labour and also perform reconstructive obstructive fistula

repair (ROFP) in in obstetric fistula develops. (Rai, Dev Kumari Shrestha 2011).

f. Role of status of women: in developing countries women do not have full agency, over their

babies their households. Rather, the husbands and their family members have control in

determining the health care that the women receive ( Broadman et al 2012) for example a

woman ‘s family may refuse medical examinations for her ( patient by male doctor even when

female doctors are not available. Thus, excluding women from prenatal care ( cook, Dickens

syed, 2014). Furthermore, many societies, believe that women are supposed to sufer in child

birth, thus are less inclined to maternal health support efforts (Kristoff, Nicholas Wudum,

Alfered, knof 2019)

2.2 PROBLEMS ASSOCIATED WITH VESICOO- VIGINAL FISTULA

Vesico- vagina fistula has fistula has far physical, social, economic and psychological

problems of VVF are the constant breaking of urine due to hole ( fistula) between the bladder and

the vagina. The acud in the urine urine causes severe burn wounds on the thighs and leg due to

continuous dripping (kristoff, Nicolas, 2010) furthermore, only a quarter of women who suffer

from fistula in their first birth are able to a living baby and there have minimum change of

delivering a healthy baby later on ( Bradma et al 2010).

This physical problem leads to the health consequences of VVF which is the point of

consideration.

CULTURAL PROBLEMS

In sub sahara countries, off springs are viewed as an indicator of a family’s wealth. A

woman suffering from VVF is unable to successfully produce children for her family and

she is believe to make her family socially and economically inferior. The woman’s urinary

incontinence and the pain also render her unable to perform household chores such as a wife

and childbearing as a mother thus devaluating her worth ( Lita, Ana 2018).some

misconception above VVF are that ‘is is caused by venereal disease, it is also viewed as

divine punishment for sexual misconduct” ( Roush 2019). As a result of such

misconceptions, many girls/ women are divorced or abandoned by health their husbands,

disowned by family ridicule by the friends and are even isolated from VVF ranges from

50% to as high as 89% (Roush 2016)

SCOCIAL PROBLEM

Stigmatizations and marginalization of these girls/women suffering from VVF by family

friends and community at large, force them to the brims of their villages and towns and

often live in isolation where they will likely die from starvation or infection in the birth

canal (Donnay, Ramsey 2016).

The unavoidable odour is viewed as offensive, thus removal from the society is seen as

essential. The intense loneliness and shame these women suffer from sometimes lead to

clinical depression and suicidal thoughts (Mc Kinney 2016). These women are sometimes

forced to turn into commercial sex workers as a means of survival, since all other income

opportunities are eliminated due to social isolation (Mwangi, Waren 2018).

 2.3 SIGNS AND SYMPTOMS OF VESICO-VAGINA FISTULA

 Urinary incontinence

 Fowl smelling vaginal discharge

 Irritation and pain in the vaginal and surrounding areas (the perineum)

 Pain during sexual intercourse (dysperunea)

 Repeated vaginal and urinary tract infection

 Severe ulceration of the vaginal tract

 Paralysis of the lower limbs caused by nerve damage (foot drop) (women’s health

resource centre, 2012)

Other symptoms of vesico-vaginal fistula include:

 Fever

 Diarrhea

 Weight loss

 Nausea

 Vomiting

 Abdominal pain

2.4 RISK FACTORS OF VESICO-VAGINAL FISTULA

a. Primary risk factors are:

 Place of birth and presence of skilled birth attendant

 The duration of labour and the use of a pantograph

 Lack of access to emergency obstetric care

 Lack of prenatal care

  Early marriage and young age at delivery

 Early or closely spaced pregnancies

b. Secondary risk factors includes women affected with “chrohn’s disease and ulcerative

colitis”. These women have a higher risk of developing obstetric fistula (Women’s Health

2012).

2.5 COMPLICATION OF VESICO-VAGINAL FISTULA

 The continuous dripping of urine which is acidic cause severe burn wounds, dermatitis and

skin erosion on the logs (Kristoff, Nicholas 2010)

 Recurrent formation of the fistula (Miklos Jr 2013)

 Injury to ureter, bowel or intestines

 Vaginal shortening, vaginities, vaginal structure/stenosis and excoriation of the vulva caused

by abrasion from scratching the vulva (Donnay, Ramsey 2016, Health Resourch centre

2021)

 Urinary incontinence (The fistula foundation 2012)

 Foot drop resulting from nerve damage (Brodma 2011)

 Dehydration as a result of women limiting water/fluid intake in an attempt to avoid

continuous dripping of urine

 Urinary tract infections which can ascend into the kidneys and cause kidney disease, kidney

failure and possibly lead to death (Brodma et el 2013)

 Amenorrha (Andrew 2014)

 Dyspareunia: due to vagina stenosis (Health Resource Centre 2012)

 Bladder stones as result of limited water intake.

 Secondary infertility (Brodma 2012)

  Increased risk of infant mortality (Nour, Semere 2018)

2.6 TREATMENT OF VESICO-VAGINA FISTULA

Treatment of vesico-vagina fistula depends on the size and location of the fistula. The surgeon will

need to examine the size and location (Arrowsmith, Briggs Wall et al2015.

 Small fistulas can cured naturally through “urethral catheterization” if identified early

enough. Inserting an indwelling foley catheter to drain urine and relief pressure on bladder.

This decompresses the bladder wall so that the wounded edges come and stay together,

giving it a greater chance of closing naturally. The foley catheter is recommended because it

has a ballon to hold it in place (Waaldjik 2018).

 Big fistulas cannot be cured through catheterization except through surgery, so a surgeon

with experience is needed to improvise on the spot (Wall L, Arrowsmith S.D) (Briggs N.D

et al 2015). Treatment is available through reconstructive surgery (The fistula foundation

2012). Before the patient undergoes surgery, treatment and evaluation of conditions such as

anemia, malnutrition and malaria.

Quality treatment in low resource settings are possible (As in Nigeria and Ethiopia)

([Link], [Link] 2016). For primary fistula repair, there is a 91% success rate

(Timothy, Mc Kinney et al 2010/2012).

Successful surgeries enable women to live norm lives and are able to have children but is

recommended to have a caesarean section in future pregnancy and childbirth to prevent

fistula from reoccurring. Post-operative case is vital to prevent infection (Gralandivk S.

Kimberling J, Almishalab T.G et al2015).

  VVF are also typically repaired either transvaginally or lasparoscopically, although patients

who have had multiple transvaginal procedures sometimes attempt a final repair through a

large abdominal incision, or laparotomy. The laporascopic (minimally invasive) approach to

VVF repair has become more prevalent due to its greater visualization, higher success rate,

and lower rate of complications (Miklos Jr 2010). Beside physical treatment, mental health

services are also needed to rehabilitate fistula patients who experience a great deal of

psychological trauma from being ostracized is excluded by her community and from fear of

developing a fistula again.

Rehabilitation of fistula patients is to achieve the following:

a. Counseling the women to improve their self esteem

b. Provision of physical and psychological support to fully reintegrate into the society.

c. Provision of education and vocational skills to help the women to return to their

communities with skills and knowledge that makes them valued and economically

independent.

d. At rehabilitation centres, the women are empowered to make their own decision (best

decision possible, forward Nigeria 2014).

2.7 PREVENTION OF VESICO-VAGINA FISTULA

Prevention of VVF comes in form of access to obstetrical care, support from trained health care

professional throughout pregnancy, providing access to family planning, promotion the practice of

spacing between births, support girl education and discouraging early marriage.
Fistula prevention also involves education local communities about the cultural, social and physical

factors those conditions and contributes to the risk for fistula. Prevention is achieved through the

following strategies.

 Organizing community level awareness campaigns to educates women on preventive

measures such as proper hygiene and case during pregnancy and labour (United Nation

Population fund 2012).

 Availability and provision of emergency obstetric labor and for mothers with

underdeveloped pelvis (Mc Kinney T.B 2016).

 Ensuring access to timely and safe delivery/childbirth.

 Prevention of prolonged/obstructed labor and fistula should preferably begin as early as

possible in a woman’s life. Improved nutrition and outreach programs should be done to

raise awareness about the nutritional needs of children especially girls to prevent

malnutrition as well as improve physical maturity of the young mothers.

 Emergency obstetric care such as “induction of labor” in a woman with prolonged labor

resulting from in-coordinate uterine action and medical or fatal distress.

 Promoting education for girls is also a key factor to preventing obstetric fistula in the long

term former fistula patients often act as “community fistula advocates” or “Ambassador of

hope” a UNPEA – Sponsored initiative to educate the community and dispel cultural myths

about obstetric fistulas have been cause by adultery or evil spirits (UNPEA 2010, Wegner

M.N, Runinjo J Sindair E. et al 2017).

 Educate community on family planning and grant women access to family planning

(UNPEA 2012 and Engender Health 2013).

  Discourage early marriage: according to study, most women who suffer from obstetric

fistula are under the age of 30 between 50% and 80% of women under the age of 20 in poor

countries develop obstetric fistula especially younger girsls or 12 – 13 years (Mc Kinney T.

et al 2010).

2.8 THEORITICAL FRAMEWORK

This study adopted the “critical theory and critical discourse analysis” “Critical theory stress on the

reflective assessment and critique of society and culture by applying knowledge from the social

science and humanity. Critical theory has two meaning with different origins. The first originated

sociology and political philosophy. The second originated in literary studies and literary theory.

Max Horkhemiem from Frankfurt school development this theory with other scholars at Germany

in 1937.

Critical theory is oriented towards critiquing and changing society as whole. While critical

discovers analysis is socially constitute (in the sense that it helps to sustain and reproduce the social

status quo and contributes to transform it) as well as socially condition. It constitutes situations,

objects of people. Critical theory under which critical discourse analysis is classified and aimed at

producing and conveying critical knowledge that enable human being enlighten and free themselves

from forms of domination through self-reflection. The theory further seeks to create awareness in

the agents (people) of their own needs and interest and aims at revealing structures of power and

unmasking ideologies. Norman fair Clough developed the theory at the university of East Anglia

with fellows scholars on the 1970’s and the terms new often interchangeable. Critical discourse

analysis aims to investigate social inequality as it is expressed; constituted or legitimized in

discourse critical theory is based on the following three principles:

a. Groups and society are characterized by shared valuable and conflicts of interest.

b. Social life involves continuous process of negotiation, compromise and coercion, because

agreement about values and social organization are never permanent.

c. Values and social organization change over time and from one situation to another as there

are shift in power balance between groups of people in society. Guided by critical theory

and critical discourse analysis, the women in the study (vesico-vaginal fistula victims) and

in most developing countries find themes in complex patriarchal dominated and mostly

exploited by men through cultural and male dominated made policies that doesn’t provide

equity to both men and women. The structure are maintained within the institutions social

mechanisms such as stereotyping of women, unequal pay for comparable work,

discriminatory practices at school and work place, less emphasis of women’s health concern

by national budgets thus theory, it is the gender based inequities and inconsistencies in

expectations that produce the exposers or risk factors that’s adversely influence women’s

health.

Critical theory primary focuses on the following:

 The process, through which culture it produced, reproduced and changed.

 The ways that power and social inequalities are involved in process of cultural

production, reproductive changes.

 The ideologies of that people use as they form identities interact with each other

transform the condition of their lives. Critical theory also encourage oppression and

seeking justice and equity in social life. It can also be applied in examination women’s

exposure to fistula’s risk factors and intervention programs for women, also women in

relationships where there is an imbalance in poor are inclined to depend on their

 husbands as the bread winners, thus affecting health outcome as husbands dictate or

decides where to go for appropriate health services during pregnancy, delivery, and post

partum being vulnerable to divorced and separation when fistula result.

2.9 EMPERICAL REVIEW

 About half a million women die yearly from causes related to pregnancy and delivery and

for each maternal death approximately 10 – 15 other women sustain serious morbidity

including vesico – vaginal (VVF) (Ashford, 2012; Lewis & Orji 2017; Rizvi, 2018).
 Vesoco-vaginal fistula is an abnormal connection between the urinary tract and the vagina

such that there is an uncontrollable leakage of urine into the vagina tract. According to

Veleria and Reiley (2014)

 Globally, over two million women are estimated to be living with vesico-vaginal fistula and

majority is in sub-sahara Africa and south Asia, according to Kelly and Kwast (2013).

 In developed countries on the contrary, fistula are related to crynacologies surgery or

radiation therapy according to (Wall et al 2014).

 In a study by Alio, Merrel, Roxburgh, Clayton, Marty, Bomboka, Traore and Salihu (2017)

in Niger, women reported many psychological consequences of VVF including depression,

feelings of shame and loneliness.

 The rate of separation of divorce increase the longer a woman lives with a fistula,

particularly if she remains childless (Browning and Member, 2018)

 It is estimated that currently more than 2 million women are waiting for surgery worldwide

and about 50 to 100,000 new cases are added each year mostly in Africa and Asia (Nawz,

Khan, & Tareen, 2010).