UNIVERSITY OF LAGOS COLLEGE OF MEDICINE, IDI ARABA

DEPARTMENT OF COMMUNITY HEALTH AND PRIMARY CARE MSc. IN PUBLIC HEALTH (2010/2011 SESSION)

COURSE: SUBMITTED TO: SUBMITTED BY: CONTRIBUTORS:

COMMUNICATION AND HEALTH (MAS 850) PROF. RALPH A. AKINFELEYE Ph.D, GROUP 4 ADEBOGUN, Adeola Adetoro EKWERE, Timothy Amos IWUCHUKWU, Nduka Omokwe OJERINDE, James Adetunji ADEJUMO, Oluwatola Esther 109093070 109093059 109093078 109093075 109093037

ASSIGNMENT TITLE: VESICO -VAGINAL FISTULA (VVF)

DATE:

FRIDAY, 1st JULY, 2011

INTRODUCTION

In vast areas of the world, in South East Asia, in Burma, in India, in parts of central America, South America and Africa, 50 million women will bring forth their children this year in sorrow as in ancient biblical times, and exposed to grave dangers. In consequence, today as ever in the past, uncounted hundreds of thousand of young mothers annually suffer childbirth injuries; injuries which reduces them to the ultimate state of human wretchedness. Consider these young women, belonging generally to the age group of 15-23years, and thus at the very beginning of their reproductive lives, they are more to be pitied than the blind, for the blind can sometimes work and marry. Their desolation descends below that of the lepers who though scarred, crippled and shunned, may still marry and find useful work to do. The blind, the cripple and the lepers with lesion obvious to the eyes and therefore appealing to the heart, are all remembered and cared for by great charitable bodies, national and International. Constantly in pains, incontinent of urine or faeces, bearing a heavy burden of sadness in discovering their child stillborn, ashamed of a rank personal offensiveness, abandoned therefore by their husbands, outcasts of society, unemployable except in the fields, they exist without friends and without hope. Because their injuries are pudenda, affecting those parts of the body, which must be hidden from view and which a woman may not in modesty easily speak, they endure their injuries in silent shame. No charitable organization becomes aware of them. Their misery is utter, lonely and complete. RHJ Hamlin & E Catherine Nicholson (Hamlin & Nicholson, 1966). The above quote gives a good grasp on the understanding of the miserable and gloomy life of young girls who are victims of Vesico-Vaginal Fistula (VVF), a gynaecological condition which results from childbirth difficulties. VVF is considered a major public health problem in Nigeria with the prevalence rate on the increase because of rising poverty and declining quality of maternal care. However, since the National safe motherhood conference in Nigeria in 1990, the problem of maternal mortality has been placed on the National agenda, but very little has been done to address the problem of VVF. Whatever effort at redressing the problem, has so far remained limited in scope, coverage and uncoordinated with most of the interventions initially being spearheaded by NGOs notably NF-VVF (National Foundation on VVF) and NCWS (National council of Women Societies). Some state governments and lately the Federal Government have begun to make inputs in responding to the VVF concern in the country. DEFINITION: VVF is an abnormal communication between the vagina and the bladder/urethra, which results in the continuous dribbling of urine and sometime faeces, if there is an associated recto-vaginal fistula. There are usually related conditions such as dermatitis and erosion of the skin and other tissues in the

vulva and vagina from the constant leaking of urine or faeces. In extreme cases, the urethra, bladder and vaginal wall can be completely eroded. If nerves to the lower limbs are damaged the patients can develop foot-drop: a loss of co-ordination with one or both of the lower limb. Historical prospective of VVF: The earliest and oldest evidence of obstructed labour was discovered in the remains of Queen Henhenit, who was the wife of King Mentuhoted II of Egypt sometime in 2050BC. This observation was made when the Queens Mummy discovered by Edouard Naville was sent to Metropolitan Museum of Art, New York in 1907. A thorough examination of the Queens mummy indicated that the vaginal was normal while there was a mass of tissue 10cm long possibly intestine sticking out through the anus. In 1923, following a thorough clinical examination of the mummy by Prof. D. E. Derry in Cairo, he observed that there was a tear in the bladder connecting to the vagina. A closer examination also indicated that the pelvic bone was abnormal in shape. Considering the width of the pelvis, the examiner believed it was too small or narrow to allow a passage of fetal head and that the severe pain and damage done to the bladder and vagina could have been responsible for the death of Queen Henhenit (Zacharin 1988:5). Prior to this discovery, an Arabo-Persian physician, named Avicema, was the first to observe that urinary incontinence in women may be as a result of fistula, consequent upon obstructed labour (Zacharin, 1988:2). While linking difficult labour to fistula, he advised on prevention of pregnancy especially among young girls; in cases in which women are married young, and in patients who have weak bladders the physician should instruct the patient in the ways of prevention of pregnancy. In these patients, bulk of fetus may cause a tear in the bladder, which results in incontinence of urine. The condition is incurable and remains so till death. The end of 1600 BC however, became a remarkable period because that was when several clearer descriptions of fistula started coming up. In 1957, Felix platter Basle gave the following description of fistula: as a consequence of a first labour, the young country girl had the opening of the bladder rent to such a degree that there was a long gapping furrow in place and the open bladder could be seen. On account of this injury, there is constant involuntary discharge of urine, and the surrounding parts become excoriated and inflamed (Zacharin 1998:3). At the beginning of the 19th century, major progress was made in the repair of VVF. Notable among the physicians at the time were: de-Lmballe, Wutser, Simon, Sims, Emmet and Bozeman (Zacharin, 1988:11). Between 1845 and 1859, Doctor Marion Sims become famous for his aggressive discoveries of instruments and materials used in closing enormous fistula. Till date Sims has been praised for recognizing that health problems faced by women require urgent medical and surgical attention (Medscape, 2003).

Epidemiology of VVF Global view of VVF Historical understanding of VVF has shown that the condition is not a new phenomenon. As a matter of fact, this condition used to be a common scourge throughout the World. However, improved and advanced obstetric care in areas such as Europe and North America has made the scourge relatively unknown in these geographical regions of the world. Metro (2006) observed that fistula is almost in oblivion in countries where there is universal health care, which takes womens health more seriously. Metro further comments that VVF resulting in urinary incontinence in developing countries, centre around obstetric difficulties. A report by Wall et al (2003) observed that there are cases of VVF in industrialized countries, however, these are due to radiation therapy or surgery, thus distinguishing the aetiology from that of developing countries, which results mainly from neglect of obstetric complications, which occur under very different circumstances (Wall et al 2003: 1408). According to Villey (2006), the incidence of VVF in United State of America (USA) is debated while most authors quote an incidence of 0.5-2% after total abdominal hysterectomy (TAH), others suggest only 0.05% incidence rate of injury either to the bladder or urethra. Thus in approximately 10% case of VVF, obstetrical trauma was the associated aetiology. Radiotherapy and surgery for malignant gynaecologic disease each accounted for 5% of cases. Most discussions about VVF center on Africa, this is however misleading because several other parts of the world also faces this problem. To this end, a report by Wall et al brings out the fact that there has not been an up to date study around the world, to actually determine the extent and places where the scourge occurs. According to them, questions regarding the incidence and prevalence of obstetric fistulas have never been included on the standardized demographic and health surveys (DHS) that are carried out to evaluate population characteristics and overall health state in developing countries (Wall et al , 2003: 1408). However a WHO report indicates that a cautious estimate of 2 million young women live with untreated VVF, and new cases of between 50,000-100,000 are reported every year (WHO, 2006:4). These figures can be argued to be highly under represented because of the stigma associated with the problem, hence several other unknown and unreported victims of VVF live with the condition in fear and isolation. In spite of the stigma associated with VVF, it still remains one of the commonest distressing conditions which bring women to hospital in many Africa Countries (Kabir et al, 2003). High maternal mortality rate has been directly linked to the incidence of VVF. Poor countries with high maternal mortality have therefore been observed to have high prevalence of VVF (WHO 2006:1407). These countries are undoubtedly located in the third world. The Nigerian situation In the case of Nigeria, there is a VVF rate of 350 cases per 100,000 deliveries at a leading university hospital. This condition is so enormous that the Federal Minister for Women Affairs and Youth

Development, has estimated that the number of untreated VVFs in Nigeria stands between 800,000 and 1,000,000 (Waaldijk K., 2001). Corroborating the above report, the Minister of Health estimated that 800,000 women are plagued by the scourge of VVF, a majority of who are living in the rural areas where there is inadequate or complete lack of primary health care facilities. The Minister thus recalls that the country accounts for 40% of the global burden of VVF (The Guardian, 2007). The condition is prevalent in the northern part of Nigeria, especially the North Western states. Some of the victims of VVF are very young and are not even privileged to have basic primary school education. Magashi (2006) explains that when a woman in the rural part of the country is in labour, she usually stays at home for about 3 days trying to push. Her traumatic experience may be further worsened by lack of proper, easy and affordable transportation to the closest obstetric centre, which may be 70km away. If her family finally takes her to the clinic, there is no skilled attendant and facilities to handle the emergency obstetric procedure. If she survives the labour, she hardly survives the waiting and gruesome grasp of VVF. Magashi (2006) reported that Nigerias maternal mortality ratio of 948 per 100,000 live births with a range of 339 to 1716 ranks among the worst in the world. For each maternal death that occurs, about 15 to 20 other women suffer either short or long- term maternal morbidities, prominent among these morbidities is obstetric fistula, the major one being the VVF. Incidence of obstetric fistula is directly linked to maternal mortality (WHO, 2006: 1407). Maternal mortality and morbidity is more likely in nations and cultures which give little priority to the needs, status and situation of girls; where girls and women are routinely discriminated against; where girls are married off as soon after puberty as possible; where education levels are low; and where the only role of women is seen as wives and mothers. In many of these cultures, maternal illness, suffering and health are viewed as natural, inevitable and part of what it means to be a woman (Sadik, 2001).

Aetiology of VVF The causes of VVF could be direct or indirect. Direct causes of VVF The main and direct cause of VVF is Unrelieved obstructed labour. The likelihood of obstructed labour is minimized where there are health facilities to prevent obstructed labour and where pregnancy has been monitored for at least 6 month before onset of labour ( Braddock M & Mohammed R, 1996). Other factors that influence the incidence of VVF include: accidental surgical injury related to pregnancy and crude attempts at induced abortion. Surgical procedures that cause VVF are of two types.

The first: orthodox medical accidental injury, which refers to injury caused to the bladder during surgical obstetric procedure performed within a formal/modern health care system such as hospital. Such procedures include caesarean sections and difficult forceps deliveries. The second: traditional procedures commonly employed during pregnancy and labour, and which sometimes result not only to VVF but also to haemorrhage and sepsis. Examples include female genital mutilation (FGM), Gishiri and Angurya cuts. The later two are traditional practices in which a tissue is removed from the vagina by traditional surgeons for the treatment of coital pain, infertility, obstructed labour, amenorrhea, vulva rash, goitre and generalized body aches and pains (Bello K: 2001). Indirect causes of VVF The indirect causes of VVF are multiple and affect poor, uneducated and young women/girls who are usually found in rural areas of Nigeria. Profile of girls/women who develop VVF 1. Poverty and gender discrimination, especially within the family result in under-nourishment and poor physical development, particularly of girls. In communities where early marriages are the norm, many girls become pregnant in their early teens before the pelvis is fully developed. These girls have a high risk for developing obstructed labour and ultimately VVF or maternal death. 2. Lack of education, coupled with low status and powerlessness of young wives, result in poor uptake of ante-natal services. Where these services are available, these girls are often unaware of the importance of their utilization. The dangers of early pregnancy are often not understood by the girl herself, her husband, family, community or even the traditional birth attendants (TBA). High risk pregnancies are therefore not identified in time. 3. Culture, traditions or poverty A high percentage (87%) of rural child birth take place at home. Problems occurs when complications arise and there is absence of adequately qualified attendant to identify these complications and/or seek medical attention in good time. 4. Access to service: Where there may be adequate information on the need for adequate medical attention during pregnancy and childbirth, many women in rural areas do not have access to medical services. This is often due to factors such as un-availability of primary healthcare, lack of obstetric care, physical isolation or lack of transport. Where Maternal and Child Health (MCH) services are available, services are not free, therefore many women lack funds to pay for medical care, particularly expensive procedures such as caesarean sections. Mechanism of fistula formation The head of the baby may be too large relative to the maternal pelvis, mal-rotate or present abnormally and get stuck inside the birth canal i.e. obstructed labour. The soft tissues of the vagina are compressed between the hard fetal skull and the bony maternal pelvis. If not relieved on time,

pressure necrosis develops with resultant sloughing off of the wall of the vaginal and bladder thus creating and abnormal communication (fistula) between these two structures. Signs and Symptoms of VVF Consequent upon the nature of the pathology as described earlier, the symptoms (what the patient complains of) and signs (what the observer or Doctor sees) include:

1. Prolonged and non progressive labour ( 24hours)

2. Maternal exhaustion and thirst 3. Attempt at home delivery or by Traditional Birth attendant or poorly staffed health centre. 4. Urinary incontinence 5. Vaginal bleeding 6. Young maternal age ( 18years) 7. Still birth from prolonged labour

8. Cephalo-pelvic disproportion
9. Obstructed labour 10. Sepsis 11. Fistula formation between the vaginal wall and bladder 12. Foot drop 13. Excoriation of the vulval skin and dermatitis. Consequences of VVF on the victims Clinical consequences: WHO reports that uncontrollable passage of urine causes vulnerability to urinary tract infection, vaginitis and excoriation of the vulva (i.e. injury to the surface of the skin or mucous membrane caused by physical abrasion, such as scratching). Stricture of the vagina which narrows the vagina, secondary amenorrhea, inability to carry a child in future even after repair of VVF, and low child survival rate are also related to VVF (WHO 1991). Psycho-social consequences of VVF This by far constitutes the most devastating complication the VVF victim has to put-up with. The major problems being incontinence, childlessness, divorce, poverty and stigmatization. Often times, the victims become a social outcast with suicidal tendencies. (Moir,1964:136). Often a womans role in the family centres around a strong obligation to satisfy the sexual needs of her husband and to provide them with offspring (WHO, 2006). If a victim of VVF is fortunate enough to be in the same compound with the husband, they obviously will not share the same bed. Since victims can neither satisfy their husbands sexual urge nor produce offspring, they became useless in the eyes of their husband and even the society. Also, because women in most African societies have accepted their low status role, the inability to produce children or satisfy their husbands sexual desire further destroys their own self esteem (WHO, 2006). Muslims, according to their belief, consider cleanliness to be ritually important while praying and during sexual intercourse and therefore whoever is afflicted with

VVF is considered unclean and so cannot pray. She could however be granted permission to pray only when her condition is considered as incurable (Moir, 1967:137). Therefore because of the magnitude of the stigma involved and its consequences, families and sufferers alike may decide not to reveal the existence of VVF, thus denying themselves access to treatment. Medical Management of VVF VVF treatment in hospital: Conventional approach to intervention is surgical repair of the fistula. This intervention is carried out in hospitals that are located in towns where few at risk women/girls can gain access or afford, therefore missing out on the majority of those with VVF in the rural areas. The medical treatment commences with catheterization of the patient for 4 6 weeks. The aim is to rest the bladder. About 20% of the cases may be resolved with just catheterization alone. There are certain conditions necessary to qualify an individual for surgery which majority of sufferers are unable to meet. For instance, it is important that patients awaiting surgery take as much as 2-4 litres of clean water a day, to help clear the bladder in preparation for surgery. With the low economic status of women with VVF, affording that amount of water in addition to good nutrition pre and post operation is hardly achievable. Some VVF patients may need 2 to 3 surgeries to attain complete recovery. This means 2-3 times return journey to the hospital, which is usually difficult as funds are not always available for subsequent journeys. Community Intervention/control: This package will be one that will take care of the physical, mental, social and economic damage that has been the lot of the girls/women suffering from VVF. More importantly, any appropriate intervention must also be preventive in nature, with emphasis on behavioural change communication, particularly in the communities where it is prevalent. This type of intervention cannot be achieved in the hospital environment, which is more adapted to curative than preventive care. Also, the hospital is not a place to address issues of economic and social development, thus not appropriate for sustained healing of women suffering with VVF. The component of these interventions will therefore include prevention, treatment, rehabilitation and reintegration of the victims back to their communities (Braddock M, Mohammed R: 1996). Several Non-governmental Organizations (NGOs) have taken up roles in this regard. One of such intervention programmes, is that undertaken by FORWARD-Nigeria a Nongovernmental organization based in Kano, known as the Womens Health and Development project in Dambata & Makoda LGA in Kano. This foundation takes a holistic approach as detailed above in addressing these problems.

The main components of this project are: 1. 2. Strengthening existing community based health provisions and delivery services. Improving the socio-economic status of women through strengthening adult literacy services with high component of vocational training to develop and build skills for income generating activities. 3. 4. 5. 6. Creating community awareness through cultural sensitive information, education and communication (IEC) for behavioural change. Counseling (peer and professional), surgical treatment and appropriate pre and post surgery nursing care. Residential rehabilitation, where activities are co-ordinated and managed to educate and train women on income generating skills. Physical and psychological rehabilitation at the centre and subsequent reintegration of women into the communities, with a 12 month follow-up and monitoring of re-assimilation. After 3 years of intervention, this project was evaluated (July, 1999-June, 2002) and was found to have a direct positive impact on the girls/women affected with VVF and indirectly on women in the communities around the centre. Armed with skills to generate income for economic independence, beneficiaries of the project return to their communities living normal lives and delivering babies normally (Forward Nigeria evaluation report, 2002). National Policy: The National Strategy for the elimination of Obstetric fistula was formulated in 2005 through a participatory approach by Non Governmental Organizations, Professional associations, Development partners, Government ministries and the National Poverty eradication agency. The strategy adopted a multidisciplinary and multi-sectoral approach and consists of 6 components: 1. Advocacy and resource mobilization: This aims at increasing awareness and securing commitment on VVF among policy makers, traditional and religious leaders. It also aims at mobilizing funds for the prevention, treatment and rehabilitation of VVF patients. 2. Social Mobilization and Behavioural change Communication(BCC):This aims at developing and maintaining dialogue with communities where VVF is common. The BCC aims at promoting behaviours that reduce the incidence of VVF, such as: delayed marriage and child birth, increased girls education, skilled birth attendants, gender equality and empowerment of women. 3. Human resource Development: This focuses on equipping health workers with the necessary skills and expertise to manage fistula as well as assist patients in re-integration into the community. 4. Infrastructural development: This is geared towards the establishment of 3 fistula training and research centres as well as the strengthening of existing facilities such as teaching hospitals, general hospitals and district hospitals. The provision of medical supplies for treatment as

well as basic emergency obstetric care were identified as vital aspects of long term capacity building efforts. 5. Research: This aims at determining the magnitude and distribution of fistula cases in the communities as well as understanding the socio-demographic profile of fistula patients and their rehabilitation needs. Research is also to be conducted with the aim of improving the performance of the health system and optimize implementation protocols of programmes. 6. Coordination and management: This aims at putting in place a monitoring and evaluation plan to ensure that the strategy remains focused as well as determine roles and responsibilities of each of the participating sectors based on their areas of strength. The strategy set time bound objectives that it hoped to accomplish in 5years (2005-2010) as follows: i. Reduce the incidence of fistula by 80% ii. Clear 80% of the backlog of fistula patients iii. Increase access to fistula cases by 300% from levels at inception\ iv. Ensure the rehabilitation and reintegration of 90% of repaired cases into their communities. v. Mobilize and consistently make available at least 80% of resources required for obstetric fistula intervention in the country. vi. Increase the proportion of skilled health personnel actively involved in the management and rehabilitation of fistula clients by 200% vii. Reduce behaviours that increase the risk of obstetric fistula by 50% viii. Conduct operational national research on fistula and use it to influence policies and programmes. Sadly, till date, there has been no published evaluation report on the strategy to determine how it has fared particularly towards the attainment of its time bound objectives. However, if the establishment of the National fistula centre is used as yard stick, then, the policy may not have achieved much, since the centre (initially cited at Jos, but relocated to Abuja due to incessant community clashes in plateau) is yet to be actualized despite the commitment of huge amounts of funds. Message Design: According to Akinfeleye (2008), effective social mobilization of the masses must precede of their behavior. This communication mechanism constitutes the message design. The content, scope and structure of our message design therefore would be Horizo-vertical. We shall K-A-P our message having taken time to study the knowledge, attitude and practice of our target population (The Northern part of the Nigeria) towards VVF. Our messages will be based on the prevailing local language- Hausa, in order to reach and appeal to our target audience. Our strategy based on our understanding of our target audience would therefore be as follows: the modification and / or change in their attitude, which will in turn bring about the desired modification

1. Enter the communities through the Traditional rulers (Emirs) and religious leaders (Imams) who have a high level of credibility in their communities. Appeal to them and enlighten them on the causes of VVF and particularly on the relationship between early marriage and child birth and VVF. Their support would ensure that our message is not rejected by the communities. 2. We shall capitalize on the radio listening culture of the communities by packaging radio jingles in Hausa. Our appeal shall be definite, for instance, early marriage and child birth results to VVF as well as hanging (to prick their consciences), for instance: VVF: Together, we can stop the pain. We shall also package short drama in Hausa language harping on the undesirability of VVF and the need to allow the young girls to mature physiologically before commencing child birth. 3. We shall also specifically target opinion leaders in the community such as market leaders, politicians and teachers, and hold meetings with them on the topic. 4. We shall make use of the Television, to address the policy makers who must see the need to pursue the execution of the National strategic framework for eliminating obstetric fistula in Nigeria. 5. Finally, Information, education and communication materials (IEC) such as banners, handbills and posters would be used to create awareness in communities. This would however not be the main stay of action in view of the low level of literacy in the communities where VVF is prevalent. It is therefore obvious that the place of mass communication, which is the process of or the art of making things of common knowledge (Akinfeleye, 1989) cannot be overemphasized in the prevention of VVF.

Conclusion: The problems of womens health and their low socioeconomic status have been of great concern to a number of different international and regional organizations. There is increased awareness that the best approach is to adopt comprehensive programme that examines all key periods in a women life cycle: infancy childhood, adolescence, childbearing age, menopausal and old age. The Global commission on womens Health established under the auspices of WHO has adopted Health security for women throughout their span as the platform for its future advocacy effort to improve quality of women lives. The commission recognizes that education and schooling rank first amongst the most powerful means of improving the health and girls and women There is growing evidence that interrelated projects focused on effort to improve the health and overall status of women will provide substantial benefit in terms of human welfare, poverty alleviation and economic growth. Household food and economic security has emerged as a priority

and programmes have been initiated in Burkina Faso, Burundi, Malawi, Nigeria and Tanzania. However Nigeria especially the Northern area continues to lag behind in focusing effort on integrated programmes to improve the health and overall status of women. Finally, the Dambatta initiatives can be seen as an example of holistic approach with community participation to address a problem whose causes are multi-dimensional. FORWARDS approach has changed not only the lives of those who have been affected by VVF but also that of their families and communities at-large. The cost of the approach is minimal and sustainable. RECOMMENDATIONS Federal Ministry of Health (FMOH): The laudable maternal and child health initiative e.g. making pregnancy safer (MPS) initiatives, Women and children friendly health services (WCFHS) initiatives and Birth preparedness and complication readiness (BPCR) are all stated in the ministrys fact sheets on safe motherhood. The ministry should move down to the beneficiaries at the grassroots to ensure that these initiatives are implemented and properly monitored and evaluated for positive impact. State Ministries of Health (SMOH): Should provide maternity waiting areas for women at risk of VVF recurrence as well as those at risk of developing VVF identified during antenatal period, where they are admitted for monitoring of labour progress and hopefully avoid development of VVF during child birth. Federal Ministry of women Affairs (FMWA): should be part of the principal stakeholder in addressing issues of VVF in Nigeria. This is necessary in order to add a tender supporting perspective to the problem of VVF. Residential rehabilitation centres, custom-built near hospitals should be established and run by the FMWA in all state with high prevalence of VVF and linked to communities for sustainability. Mother and Child Nutrition: is very important in improving the quality of psychological and physical health of women and children. A malnourished child is not likely to have physical development appropriate for carrying preparing and childbirth. Nutrition rehabilitation centres as well as feeding centres should be instituted in every local government of Nigeria. Appropriate use of local foodstuff used in these centres to feed women and children will go a long way to address issues of malnutrition in the communities. Involving local expertise: The use bodes like the medical women Association of Nigeria to join effort with society of gynaecologist of Nigeria (SOGON) in addition to other relevant professional association will go a long way in providing lasting solution to the problem of maternal and child health in Nigeria.

NGO such as national council of women societies (NCWS) who started the campaign on VVF in early 1980 should reclaim the issue and address it the way that it will help to make it have community ownership as such ensure sustainability. Millennium Development goals (MDG): Achieving the objectives of the MDG will go a long way to improve the health of mother and child in Nigeria. And since the achievement of the goals is tied to community empowerment and economic development, it is necessary that the policy makers both at federal and state level commit adequate funds to carefully thought-out policies to achieve the MDGs. Legislation of child Right Bills and its implementation in all the states including FCT, will also go along way in improving the health of mother and child in Nigeria. Education of the girl child: Appropriate collaboration between the FMOH and FMOE will help ensure this especially in the area of nomadic education in the northern part Nigeria. Political Commitment: Commitment on the part of the government both at the federal, state and local government level must be total otherwise above recommendations will be fertile.

REFERENCES Akinfeleye, Ralph A., Health Communication and Development, Ibadan, Spectrum Books Ltd., 1989. Bello K. Vesico-vaginal fistula-only a woman Accursed. Internet Canada. Braddock M, Mohammed R. Feasibility study of the situation of vesico-vaginal fistula in Ethiopia and Nigeria- a Report 1996. Forward Nigeria Womens Health Development Project-evaluation Report: 2002. Hamlin and Nicholson. Experiences in the treatment of 600 vagina fistula in the management of 80labours which have followed the report of these injuries. Ethiopia medical journal 1974; 4(5): 189192. Kabir M. The vesico-vaginal fistulae scourge: A preventable social tragedy. Grass root health 1995: Zaira. Magnshi A. (Female Genital Mutilation and Our societies Retrieved from the Web http://www. Nigeriamasterweb.com/pepertimes Metro. Modification of Oconnors technique for the treatment of VVF repair described. Retrieved from the web www.medicalnewstoday.com/medical news.php?newsid= 40490. Moir J. C. The Vesico-vaginal fistula. Bailliere Tindall & case W. London. Sadik N. Saving women lives. A public Health Approach, lecture delivered at mailman school of public Health, Columbia university, April 2007. Retrieved from web httpwww.mailman.hs.columbia.edu/news/sadik.html. The Guardian. Fasing the scourge of vesico vagina fistula Nigerian Guardian newspaper sept 9, 2002: Pg 7. Waaldijk K. Evaluation report XVII National VVF project Nigeria. Federal Ministry of Health. 2001 Pg 2. Wall L. et al. Dead mothers and injured wives: The social context of maternal morbidity and mortality among Hausa of Northern Nigeria. Studies in family planning 1998, 29: 341-359. Zacharin RF. Obstetric fistula. Springer verlag. Wien, New York. 1998 pg 281.