The Cleft Palate–Craniofacial Journal 51(2) pp.

189–199 March 2014

Ó Copyright 2014 American Cleft Palate–Craniofacial Association

ORIGINAL ARTICLE

Factors Influencing Maternal Mental Health After the Birth of a Child With a
Cleft in Benin and in Switzerland
Stephanie Habersaat, M.A., Ph.D., Camille Peter, M.A., Chloe Hohlfeld, B.A., Judith Hohlfeld, M.D.

Objective: The main objective of the study is to identify practical and cultural factors
influencing the mental health of mothers of children with an orofacial cleft in Benin and to
compare it with a sample of Swiss mothers in the same conditions.
Method: Thirty-six mothers of children with an orofacial cleft in Benin and 40 mothers of
children with an orofacial cleft in Switzerland were interviewed about practical and emotional
aspects concerning their child and their own lives. Then, they completed the Perinatal
Postraumatic Stress Questionnaire and the Beck Depression Inventory.
Results: Mothers in Benin had significantly higher posttraumatic stress and depression
symptoms compared with mothers in Switzerland. Depression symptoms were higher in
Beninese mothers coming from urban areas, in Beninese mothers with few or no other children,
and in Beninese mothers whose child was operated on at a more advanced age.
Discussion: This study stressed the importance of cultural differences in perceptions of
orofacial clefts in order to provide appropriate care to patients and their families. In particular,
wide campaigns of information should help parents to understand the cleft origin and the
medical staff in small dispensaries to provide adequate support and care. This may diminish
anxiety concerning the child’s short- and long-term prognosis. Creation of a Beninese parental
support group for children with clefts and their families could be another way to provide
information and support where multidisciplinary care is not available.

KEY WORDS: orofacial clefts, cultural impact, humanitarian surgery

Despite the development of health care and surgical
practices in emerging nations, some very specialized
domains such as neuro- or maxillofacial surgery are not
performed by local physicians. This gap is filled by
international nongovernmental organizations (NGOs;
Brauman, 2010). In the beginning of humanitarian surgery
in sub-Saharan Africa, indigenous caregivers were extreme-
ly rare among occidental medical teams. Confronted with
cultural differences, the need to involve local caretakers
became obvious for better communication and for transfer
of medical competence in the long term. For example,
during the war in Somalia, occidental humanitarian
surgeons were confronted with hostile reactions of young
militiamen following a limb amputation. Indeed, even if
Ms. Habersaat is Ph.D. Student and Psychologist and Ms. Peter
is Psychologist, Department of Child and Adolescent Psychiatry,
University Hospital of Lausanne; Ms. Chloe Hohlfeld is Nurse and
Ms. Judith Hohlfeld is Head, Department of Pediatric Surgery,
University Hospital of Lausanne, Switzerland.
This study was supported by Terre des Hommes Foundation,
Switzerland; the Fondation pour la Psychiatrie de la Petite Enfance,
Switzerland; and Perbonum Foundation, Liechtenstein.
Submitted May 2012; Accepted September 2012.
Address correspondence to: Ms. Stephanie Habersaat, Research
Unit–SUPEA, Rue du Bugnon 25A, 1011 Lausanne, Switzerland. E-
mail shabersaat@bluewin.ch
DOI: 10.1597/CPCJ-51-02.189
European medical practices during wartime respond to
vital emergency, for Somalian fighters, amputation repre-
sented a bodily injury detrimental to human dignity. Many
fighters preferred to die rather than to survive mutilated
(Brauman, 2010). Even if, from a medical point a view, the
amputation was reasonable, it was socially intolerable. This
example shows the importance of social perception of the
surgical act in different cultures. In the words of the well-
known French philosopher and practitioner Georges
Canguilhem (1966), ‘‘Patients are not interested in the
function of such or such organ threatened by illness, but in
their ‘pace of life,’ this means the relationships and
integration to their environment’’ (p. 96). Humanitarian
surgery is confronted with difficult situations regarding
cultural comprehension and may become deleterious,
losing its first objective of ‘‘repairing’’ (Wall et al., 2006;
Habersaat et al., 2012). Therefore, it is of great importance
to study the cultural impact of disease and surgery in the
developing world, as well as potential risk and protective
factors in the development of mental health problems after
surgery.
Orofacial cleft surgery is one of these specialized domains
performed by humanitarian occidental teams, especially in
West Africa’s poorest countries, such as Benin or Togo.
Moreover, as it affects many aspects of daily life and
concerns a visible deformity, it may have a great impact on

189
190 Cleft Palate–Craniofacial Journal, March 2014, Vol. 51 No. 2
families and communities. Therefore, it is important to
study the cultural influence on perceptions of clefts and the
impact of cleft surgery on the ‘‘pace of life’’ of Beninese
children and their families.
Orofacial Cleft Management in Benin
In Benin, a large part of the population lives in rural
areas without access to medical care, and so cleft
prevalence estimation is difficult. However, studies
concerning other sub-Saharan countries reported a
prevalence of 7 per 10,000 births in Malawi (Msamati
et al., 2000), of 9 per 10,000 in Sudan (Suleiman et al.,
2005), and of 50 per 10,000 births in a rural community
in Ghana (Agbenorku et al., 2007). Since the latter study
was conducted using a community-based sample, the
high rate of clefts can be explained by genetic bonds
between members of the village and therefore cannot be
extrapolated to the whole population (Agbenorku et al.,
2011). Nevertheless, extensive epidemiological studies
usually report few differences in cleft prevalence among
countries (Tanaka et al., 2012).
In Benin, monitoring of pregnancies by a physician
and ultrasound are rare, and most clefts are discovered
only at birth. The delivery occurs at home or in local
dispensaries, where information concerning clefts is
largely absent among occasional caregivers and neigh-
bors helpers (Kodjogbé et al., 1997; Habersaat et al.,
2012). Adequate medical support may not be provided,
as larger hospitals are usually far away and expensive
(Lule and Ssembatya, 1995; Hodgkin, 1996; Borghi et
al., 2003; Habersaat et al., 2012). Indeed, a study
showed that in Ghana, a country much more developed
in medical assistance than Benin, many clefts were not
repaired because of financial barriers (Donkor et al.,
2007).
Young infants cannot be fed efficiently; there are no
breast pumps or bottles available to help them use
breast milk or palatal prostheses to obdurate the
communication between mouth and nose. Mothers feed
infants with a spoon or cup and have to buy extra milk
(Masarei et al., 2007). This can represent an enormous
expense for poor families, in which breast-feeding a
child usually continues until 2 years of age. The adverse
conditions often lead to loss of weight during the first
months of the infant’s life, increased susceptibility to
infection, failure to thrive, and often death (Jones,
1988).
Moreover, it is common in Benin, especially in poor
and rural zones where Voodoo traditional beliefs are
deeply rooted, to associate inexplicable deformities in
newborns to witchcraft (Tall, 1995; Habersaat et al.,
2012). On the contrary, Christian families coming from
big cities usually associate the cleft with a divine
intervention or to destiny, as it is in Swiss mothers.
Mystical explanations may be exacerbated by friends
and family in an attempt to explain the unexplainable.
For the family, the mother is often assumed to be
responsible for this situation: She must have done
something wrong to deserve this. The child in itself is
not bad but represents a punishment inflicted on the
family in return for some sin committed. For midwives,
the mothers have been bewitched (Saizonou et al.,
2006). The child can be seen as a bad omen or a
vengeance from a mortal enemy (Habersaat et al., 2012).
An unrepaired cleft has severe consequences for the
child’s life, such as difficulties in speaking (Agbenorku
et al., 2007), chronic otitis media, and mild to moderate
hearing impairment (Ramana et al., 2005). Along with
functional problems, children and adolescents suffering
from orofacial cleft often face rejection from the
community and chronic psychological aggression.
Rationale for the Study
For 20 years, the pediatric surgery team of the
University Hospital of Lausanne, Switzerland, has
carried out surgical missions in Benin. It is important
for specialists working in developing countries to
understand how the cleft is perceived in the local
culture. Migrations of populations and mobile surgical
teams are the source of intercultural contacts and
collaboration, making it important to identify the
specific needs of the families so as to better understand
their anxieties and provide long-term support.
In Switzerland, pluridisciplinary and long-term care
of clefts has proved its positive impact on families and
the children’s development. Indeed, clefts are detected
early, and extensive information and support are
provided to reduce the impact of the shock of the
announcement and help parents and relatives welcome
and accept the child. A continuous follow-up is then
planned from birth to adulthood involving surgeons,
orthodontists, psychologists, and psychiatrists. How-
ever, occidental programs of care do not necessarily
correspond to the needs of Beninese families and
cannot be implanted without adjustments. Above all,
it is crucial to investigate how Beninese mothers
experience the birth of a child with a cleft and the
presence of occidental surgeons who repair it. A better
understanding of the local traditions and cultural
viewpoints should help provide a more adequate
therapeutic program and better long-term results
regarding the quality of life of children with a cleft
and their families.
Therefore, it is important to compare the impact of a
cleft on the lives of Beninese and Swiss mothers and to
consider some sociodemographic factors that may have
an influence on the perception of clefts, such as
religion, siblings, type of cleft, or living environment.
For example, religious people reported more life
satisfaction, well-being, and ability to cope with
 Habersaat et al., OROFACIAL CLEFT CARE IN BENIN AND SWITZERLAND
adversity (Koenig and Larson, 2001; Koenig et al.,
2001). The presence of siblings has also been recog-
nized as having an impact on the emotional and social
support to the mother, especially in the case of
domestic or marital difficulties in sub-Saharan Africa
(Niehaus, 1994). Indeed, siblings usually participate in
the household work and care of younger children. If
the mother cannot earn because of injury or illness,
siblings work. Siblings can then be of a great support in
the case in which a younger child has a cleft. In
addition, the type of cleft, which influences the
possibility of breast-feeding and the visible appearance
of the child, may also have a serious impact on
maternal mental health. A last important factor is the
residential area. Families living in rural area are far
from medical centers and more dependent on the
community, which has an influence on the support
provided to the mothers and potential repercussions on
her mental health. Some studies found greater depres-
sion in rural compared with urban areas (Husaini et al.,
1982; Linn et al., 1989).
Studies on occidental samples, despite the support
given to families of a child with a cleft, showed an
influence of the cleft on maternal mental health and,
more precisely, on symptoms of depression and
posttraumatic stress (Field and Vega-Lahr, 1984; Tyl
et al., 1990; Dolger-Hafner et al., 1997; Habersaat et
al., 2009; Skrivan-Flocard and Habersaat, 2009;
Despars et al., 2011). Therefore, we can suppose that
in countries without financial and medical support,
such as Benin, these psychological symptoms may be
enhanced.
The present study will investigate the impact of the
birth of a child with a cleft on maternal depression and
posttraumatic stress symptoms in Benin, as compared
with Switzerland, considering sociodemographic factors
(religion, residential area, cleft type, and siblings). We
expect Beninese mothers to report more symptoms of
depression and posttraumatic stress than Swiss mothers.
Moreover, we expect religion, siblings, and living in an
urban area to be protective against these symptoms in
Beninese but not in Swiss mothers. We expect that
mothers of a child with a severe cleft will report higher
rates of depression and posttraumatic stress symptoms
compared with mothers of a child with a less severe cleft
in Benin.
Second, we will investigate the cleft perception in
Beninese versus Swiss mothers, as well as the families’
and community’s reaction to the child’s deformity and
perceptions of life after the cleft surgery. We expect
Beninese mothers to report less acceptance of the child’s
cleft by the family and community than Swiss mothers,
because of religious beliefs and less access to medical
information. We also expect that Beninese mothers will
consider the surgery as very beneficial.
191
METHOD
The general design of the study is comparative. We
considered two samples of mothers having a child born
with an orofacial cleft, one from Switzerland and one from
Benin. A mixed design was considered, incorporating
qualitative and quantitative methods. The qualitative
component consisted of a semistructured interview to
investigate beliefs, representations, emotions, and aspects
of life with a child with a cleft. The quantitative component
consisted of a self-report questionnaire with both Swiss and
Benin samples and will consider potential factors influenc-
ing positively or negatively the impact of a cleft on maternal
mental health.
Participants
Swiss Sample
All families having given birth to a child with an
orofacial cleft between 2005 and 2009 in the University
Hospital of Lausanne were considered for inclusion in
the study. Families were recruited at the maternity ward
soon after childbirth by the surgeon, who addressed
them to the research team. The whole study was clearly
explained to each family, and they signed a consent
form in accordance with a protocol accepted by the
University Ethics Committee. Seventy-eight percent of
families of infants with an orofacial cleft agreed to take
part in the research. Exclusion criteria were children
with other malformations or medical complications.
Three families were excluded for these reasons. A
dropout of six families between 2 and 12 months of
infant age was registered. Finally, the cleft group was
composed of 40 families.
Beninese Sample
The Terre des Hommes Foundation Bureau in Benin
was in charge of contacting families having given birth
to a child with orofacial cleft in Benin and Togo and
bringing them to Abomey for a 2-week hospital stay,
during which surgical repair was performed. Families
were then recruited by three psychologists of the Swiss
research team at the Zou-Collines hospital of Abomey
during the presurgical consultation occurring in January
2010 and January 2011. The whole study was clearly
explained to each family, and they signed a consent
form in accordance with a protocol accepted by Terre
des Hommes Foundation, the head of the Paediatric
Department of the Zou-Collines Hospital, and the
Beninese Ministry for Public Health. All of the families
accepted to take part in the research. Exclusion criteria
were children with other malformations or medical
complications. Two families were excluded for these
192 Cleft Palate–Craniofacial Journal, March 2014, Vol. 51 No. 2
reasons. Finally, 36 families of children with an
orofacial cleft were included in the study.
Procedure
Swiss Sample
Families were contacted by the study team when the
children were 2 months old, before cleft surgery, for an
appointment at the University hospital of Lausanne. A
short semistructured interview with the mother was
conducted by the first or second author, based on the
Clinical Interview for Parents of High-Risk Infants
(CLIP; Meyer et al., 1993). During this interview, the
mothers could express their subjective emotional expe-
rience in relation to their infant’s cleft and surgery.
Questions such as, ‘‘What did you think when you first
saw your child?’’ or ‘‘How did your family react when
they learned of the cleft?’’ were asked. The interviews
were videotaped and then transcribed by the research
team. Then, the mothers were asked to fill out two
questionnaires, one concerning symptoms of posttrau-
matic stress disorder (PTSD; Perinatal Postraumatic
Stress Questionnaire [PPQ]; Quinnell and Hynan, 1999)
and another concerning symptoms of depression (Beck
Depression Inventory [BDI]; Beck et al., 1996).
Beninese Sample
Interviews with families were conducted in a medical
office of the pediatric service at Zou-Collines hospital in
Abomey by the first, second, and third authors. The
same protocol as for the Swiss sample was applied in
Benin. Mothers participated in a semistructured inter-
view (CLIP). Even if the administrative language in
Benin was French, many uneducated woman could
speak only their tribal language. In these cases, local
nurses were present during the interview to translate
questions and answers and to serve as a cultural bridge.
Because of frequent electrical breakdowns, the inter-
viewed participants were not videotaped but transcribed
directly by a second researcher present in the room. The
two questionnaires (PPQ and BDI; French version) were
completed with the help of the nurse and the research-
ers.
Instruments
Instruments were the same for both samples. The
PPQ (Quinnell and Hynan, 1999) was used to assess
maternal posttraumatic stress symptoms. The PPQ is a
14-item questionnaire based on Diagnostic and Statisti-
cal Manual of Mental Disorders, fourth edition (DSM-
IV), criteria. Each symptom can be rated as present or
absent. The PPQ is exclusively designed to examine the
prevalence of the three components of PTSD: unwanted
intrusions, avoidance, and increased arousal. The score
is computed by adding positive responses. The alpha
coefficient of the PPQ is .85, and the test-retest was
reliability of .92 over 2- to 4-week intervals (Hynan,
1998). Concerning the French validation (Pierrehumbert
et al., 2004), the authors found an internal consistency
of .82.
To assess maternal depression symptoms, the BDI
(Beck et al., 1996) was used in its short version to assess
maternal depression symptoms, as mentioned in the
DSM-IV. Each of the 13 items is rated on a 0 to 3 Likert
scale. The final score is computed by summing up the
items. The internal consistency is a ¼ .86 for psychiatric
patients and a ¼ .81 for nonpsychiatric patients.
Correlations with clinical ratings were .72 for psychiat-
ric patients and .60 for nonpsychiatric patients (Beck et
al., 1988). Concerning the French validation, a coeffi-
cient of .92 for reliability was found, and the test-retest
procedure indicated adequate stability over a 4-month
period (Bourque and Beaudette, 1982).
The semistructured interview based on the CLIP
(Meyer et al., 1993) was used to obtain qualitative
information about family life after the birth of the child
with a cleft. The CLIP was originally designed for
parents of preterm infants but can be extended to other
clinical situations. This qualitative instrument is
traditionally used by psychologists for planning psy-
chosocial care in families of high-risk infants. The
interview lasted between 45 minutes and 1 hour and
was composed of 20 questions, covering eight themes
(infant’s current condition, pregnancy course, delivery,
relationship with the baby and feelings as a parent
[including mental health and beliefs about the cleft],
reaction to and of medical staff, relationship with the
family and social support [including sibling and
community], medical discharge after birth, and advice).
For the present study, we added a question concerning
the perception of the surgery. Mothers’ narratives were
reported on a coding scheme regarding main themes of
the interview. Mothers’ main narratives were then
extracted by the first and second authors separately.
Coders’ agreement was made by consensus after
discussion.
Data Analysis
Sociodemographic comparisons were computed using
crosstabs and v2, except for infants’ age (a t test was
used).
Regarding the sample properties, nonparametric
tests were more appropriate. We used a Mann-Whitney
U-shaped test to compare posttraumatic stress and
depression symptoms between the Beninese and the
Swiss sample of mothers as well as to compare
posttraumatic stress and depression symptoms regard-
ing residential area. We used a crosstab with v2 to
 Habersaat et al., OROFACIAL CLEFT CARE IN BENIN AND SWITZERLAND 193

TABLE 1 Information About Beninese and Swiss Samples* TABLE 3 Rate of Depression and Posttraumatic Stress (PTS)
Symptoms According to Residential Area in the Beninese Sample*
Switzerland Benin
(n ¼ 40) (n ¼ 36) P Urban Area Rural Area
(n ¼ 12) (n ¼ 24) P
Gender (male) 30 (75) 15 (42) .001
Infant’s age (mo) 2.28 (.34) 34.9 (19.0) .000 Symptoms of depression 12.16 (6.98) 5.65 (6.97) .018
Birth rank (first) 18 (44) 10 (28) ns Symptoms of PTS 5.75 (2.89 4.45 (3.02) ns
Cleft
* Numbers represent means, with standard deviations in parentheses.
Lip or palate 15 (37) 15 (41)
Lip and palate 9 (23) 6 (18)
Complex 16 (40) 15 (41) ns
Residential area (urban) 12 (28) 12 (34) ns
in cleft populations (Jensen et al., 1988; Gregg et al.,
Religion
Muslim N/D 2 (5)
1994; Lees, 2001). In the Beninese sample, there was a
Christian N/D 24 (67) female predominance (Table 1).
Animism N/D 10 (28) - Residential areas (urban/rural) are assigned regarding
Marital status
the place where the family lives most of the time and the
Married 27 (67) 28 (78)
Not married, but living together 10 (25) 4 (11) possibility of accessing public services. Towns are
Single, divorced 3 (8) 4 (11) ns defined according to United Nations criteria (.20,000
Education (educated) 40 (100) 17 (47) .001
inhabitants, less than 200 m between compounds). Most
* Numbers represent actual numbers, and percentages are in parentheses, except for Beninese participants came from isolated villages in the
infants’ ages, which are means and standard deviations in parentheses. Tests performed
are v2 for all variables, except for infant’s age (t test). north (of Benin and Togo) and were farming or selling.
In the Swiss sample, half of the participants lived in
town and half in the countryside.
assess the repartition of religion considering residential Concerning religion, we have no information about
area in the Beninese sample and a Kruskal-Wallis test the Swiss sample. However, with all of the families being
to assess the influence of cleft type on posttraumatic Swiss from birth, we assume that a large majority are
stress and depression symptoms on the Beninese and from a Christian church,1 with a few possible exceptions
the Swiss samples. Finally, we used correlations to (Bovet and Broquet, 2000). In the case of Beninese
determine a possible association between the numbers families, there is much more contrast. Although 67% of
of offspring in a family and the posttraumatic stress the sample profess to be Christian (mostly Roman
and depression symptoms, as well as between child’s Catholic), many mothers also admit belief in traditional
age at cleft repair and posttraumatic stress and religions, such as Voodoo and Animism.
depression symptoms in mothers. Significance was Educational level was computed based on maternal
considered at P , .05. schooling. If the mother went to school and knows how
Qualitative analyses of the interviews were carried out to read and write, she is considered educated. In the
by two trained psychologists in order to extract relevant Beninese sample, half of the participants were not
information from the mothers’ narratives. Every inter- educated.
view transcription was summarized, and the more
Quantitative Analyses
striking emotional aspects were reported in a table for
both samples.
Results show that mothers of children with a cleft in
the Beninese sample express significantly more symp-
RESULTS
toms of depression and posttraumatic stress compared
with mothers in the Swiss sample (Table 2).
Sociodemographic Comparison
The influence of residential area on symptoms of
posttraumatic stress and depression in mothers was
In the Swiss sample, three-fourths of the participants
tested in the Beninese and Swiss samples (Table 3). In
were men. It is well-known that men are overrepresented
the Beninese sample, we found that mothers of children
with a cleft expressed significantly more symptoms of
TABLE 2 Rate of Depression and Posttraumatic Stress (PTS)
depression when the family lived in an urban area as
Symptoms According to Groups* compared with a rural one.
Such differences in depression symptoms between
Benin Switzerland rural and urban areas were not found in the Swiss
(n ¼ 36) (n ¼ 40) P

Symptoms of depression 7.88 (7.55) 1.56 (2.08) .000

Symptoms of PTS 4.97 (2.99) 1.59 (1.69) .000 1
According to the Swiss Federal Statistical Office (2000), 80% of
* Numbers represent means, with standard deviations in parentheses; the P values the Swiss population is Christian, 11% are agnostic, and 4% are
are calculated using Mann-Whitney U tests. Muslims.
194 Cleft Palate–Craniofacial Journal, March 2014, Vol. 51 No. 2
TABLE 4 Religion in Residential Areas in the Beninese Sample*
Residential Area, N (%)
Religion Urban Rural
Christian 11 (91) 13 (54)
Animist 1 (9) 9 (37)
Muslim 0 (0) 2 (9)
* v2 ¼ 5.138; P ¼ .07.
sample. No significant differences in posttraumatic
stress symptoms between residential areas were found
in either the Beninese or the Swiss sample.
Table 4 shows the repartition of religion between
residential areas in the Beninese sample. In urban areas,
most families were Christian, whereas Christians repre-
sented only half of the rural population. For the most
part, Animists and Muslims were living in rural zones.
However, this difference cannot be tested because there
were fewer than five values in three cells, and it remains
only indicative.
Concerning the impact of cleft type on posttraumatic
stress and depression symptoms, only a tendency was
found. Swiss mothers tend to express more symptoms of
posttraumatic stress when the cleft is severe. However,
the number of symptoms remained low compared with
the Beninese sample. Moreover, standard deviations
were very high (Table 5).
A negative correlation was found between the number
of children in the family and depression symptoms (r ¼
.356; P , .05) in Beninese mothers. This was not found
in Swiss mothers. Finally, a positive correlation was
found in Beninese mothers between the child’s age at
cleft repair and symptoms of posttraumatic stress (r ¼
.455; P , .01).
Qualitative Analyses
The qualitative analyses of the interviews showed that
aspects of greatest concern in the Beninese population
were centered on survival and rejection from the
community (Table 6).
Table 6 shows a summary of the main concerns on
each CLIP theme and the additional question about
surgery of the two samples. The presence of siblings is
considered more positive in the Beninese compared
with the Swiss sample, as they are seen as more
supportive and helpful to their mothers. No particu-
larity related to residential area was mentioned in the
Swiss sample, except for two families living in a small
village on the mountain, who reported certain tiredness
related to questions asked by neighbors. In Benin,
mothers from rural communities reported high levels of
rejection and a deep emotional impact related to
rejection. In town, Beninese mothers mentioned
loneliness. These two phrases of Beninese mothers
TABLE 5 Symptoms of Depression and Posttraumatic Stress
(PTS) in Mothers Regarding the Cleft Type in the Beninese and the
Swiss Sample*
Beninese Sample Swiss Sample
Cleft Type Depression PTS Depression PTS
Lip or palate 9.1 (8.5) 4.8 (3.3) 1.25 (1.1) 0.66 (.81)
Lip-palate 3.1 (4.8) 5.8 (4.9) 2.6 (3.6) 2.1 (2.0)
Complex1 8.6 (7.0) 4.8 (1.8) 1.3 (1.1) 2.1 (1.7)
P ns ns ns .027
* Numbers represents means, with standard deviation in parentheses.
living in Cotonou, and reported during interviews,
explain more clearly the social loneliness in towns: ‘‘I
didn’t want to go out with my child, because everyone
stared and laughed at us. I was completely alone’’
(Benin 213), and ‘‘I never went out with him. I even
didn’t go to Mass because people laughed at me and
talked behind my back’’ (Benin 224).
No difference was found concerning the perception of
cleft among Christians coming from Switzerland and
Christians coming from Benin. However, for Christians
in Benin, the cleft repair was more complicated, as it is
illustrated in the following narrative of a Christian
mother: ‘‘My family did not want me to come here.
They say I should not go against God’s will. They said
that, if I brought the child here, I would be a sinner and
should be punished’’ (Benin 204). Animists report heavy
rejection from the community. Posttraumatic stress
symptoms, such as nightmares, flashbacks, and so forth
were mostly related to the announcement of the cleft in
the Swiss sample and about fear for survival in the
Beninese sample.
Lack of information among medical staff is often
reported by Beninese mothers. For example, a mother
said, ‘‘At delivery, when the nurse saw my child, she said
that I had been bewitched or cursed’’ (Benin 213),
whereas another mother reported, ‘‘When I saw my
child at birth, I was very shocked. Doctors said that it
was very serious and that my child would die. They put
some tubes and oxygen, and they took the baby away
from me’’ (Benin 209).
DISCUSSION
The main purpose of the study was to assess maternal
symptoms of depression and posttraumatic stress after the
birth of a child with a cleft in Benin and Switzerland. We
considered sociodemographic factors as playing a potential
role on maternal mental health, such as residential area,
siblings, cleft type, and religion. These factors may be
important in understanding the perception and represen-
tation of the cleft among African cultures and may help
humanitarian occidental surgeons to communicate better
with patients and their families.
 Habersaat et al., OROFACIAL CLEFT CARE IN BENIN AND SWITZERLAND 195

TABLE 6 Main Representations Concerning the Cleft in Beninese and Swiss Narratives Regarding the CLIP Themes

Benin Swiss

Infant’s current condition Low weight, cannot speak, rejected, lonely, eats little
Pregnancy course No difficulty mentioned
Delivery Infant was hidden from the mother, anxiety, feeling of
loss, fear of rejection, and fear for the child
Relationship with baby and Depression in relation to loneliness, exclusion and fear of
feelings as parent death; stress symptoms in relation to practical
difficulties, survival risk, and exclusion
Reaction of medical staff Rejecting, makes feel guilty, lack of appropriate
information and care, traditional beliefs
Relatives’ support Siblings: help for household and for caring for the child,
are supportive; father: rejecting and accusing;
community: the mother has been cursed, rejection
(Animists); God sent this burden because they can carry
it (Christians)
Discharge and beyond In urban area, neighbors help, family feels anonymous,
financial difficulties, but close to medical care if child
has health problems, loneliness; in rural area: rejection
of the child and the mothers, bullying, financial
difficulties, lack of medical follow-up
Advices for care Give more information to medical staff and family
improvement
Perception of the surgery Possible rehabilitation in the community; fewer financial
and practical problems; in Animists, mother is guilty for
the cleft; the surgery will erase mother’s sin; in
Christians, mother has no right to go against God’s will
and repair the cleft
No problem related to the cleft mentioned
Announcement before birth was a difficult time
No problem related to the cleft mentioned, relief to see to
child
Anger related to first reactions of stranger to the child;
stress symptoms related to the announcement of the
cleft and child appearance
Overall supportive but sometimes not diplomatic enough
Siblings: additional emotional and caring burden; father:
supportive and helpful; community: the cleft is an
accident, none is to blame, unlucky (nonbelievers); God
sent this burden, because they can carry it (Christians)
In urban area: no difficulty mentioned; in rural area:
everybody knows each other and asks questions, a bit
tiring
Be more supportive when announcing
Fear of anesthesia; painful for the child

Socioeconomic Data and Comparability of the Samples
Discussion
The comparability of the samples can be questioned
as the cultural and economical backgrounds are very
different. For instance, the Swiss sample is composed of
families having given birth to a child with an orofacial
cleft in the Hospital of Lausanne, and they are closely
followed up and supported by the multidisciplinary
team from childbirth to adolescence. On the other hand,
the Beninese sample is mostly composed of poor
families not able to afford hospital costs and therefore
sponsored by an NGO. Moreover, as it has been noted
in women with genital fistulas (Murphy, 1981; Mafakh-
kharul Islam and Begum, 1992; Wall, 1998; Wall, 2002),
mothers of a child with an orofacial cleft are often
rejected by their families and by their community and
stigmatized (Habersaat et al., 2012). These women are
destitute, without any financial and familial resources.
Thus, it is a very fragile and indigent population.
The Swiss and the Beninese sample are also difficult to
compare regarding many other parameters, for example,
the percentage difference between boys and girls. These
differences are difficult to explain and might be due to
chance. However, we found two studies in Africa
reporting higher rates of girls among the cleft popula-
tion (Msamati et al., 2000; Suleiman et al., 2005). The
discrepancies could be related to a greater importance
for girls to have a nice face and marry, which is
sometimes the only way to survive. Thus, we would find
more girls in clinical services where the epidemiological
statistics are computed. It is also possible that the
neonatal survival rate of boys with clefts is lower than
for girls (Table 1).
Concerning educational status, we used only the
information ‘‘can read’’ and ‘‘can write.’’ It would have
been better to use a standardized socioeconomical
instrument to assess standards of living. However, most
families in the Beninese sample had no bank account, no
salaries, and no idea how much they were earning per
month, as they were living on their land income and
used barter. Moreover, the educational system, the gross
domestic product, and social insurances are very
different between the two countries and make compar-
ison of socioeconomical levels very complex.
In Switzerland, parents anticipate cleft surgery with
anxiety. The anesthesia is their principal worry, for the
child is very young when it is performed. It is not rare to
see parents ambivalent about repairing the cleft; they
have adjusted to their child with his cleft and do not
want him to suffer or risk his life in surgery (Skrivan-
Flocard and Habersaat, 2009). In Benin, even if the
surgical act primarily responds to functional require-
ments, such as feeding and language, for many mothers
it also represents a possible rehabilitation into the
community. Indeed, with the cleft repaired, the visual
aspects of sins imputed to the mothers are erased.
Therefore, if, for surgeons, the cleft surgery is a
functional repair, for many Beninese families it is a
social repair (Habersaat et al., 2012). Thus, the way cleft
surgery is anticipated may be very different among
196 Cleft Palate–Craniofacial Journal, March 2014, Vol. 51 No. 2
populations and must be considered when comparing
samples of different cultures.
Concerning the instruments used in the study,
although the BDI has been validated in many languages
and for many cultures outside the occidental world (e.g.,
Carro et al., 1998; Alansari, 2005; Ghassemzadeh et al.,
2005; Jo et al., 2007), as far as we know, there is no
validation for sub-Saharan countries. Thus, we propose
caution in interpreting the results in the Beninese
sample. Indeed, we have no information about how
depression and posttraumatic stress symptoms are
represented or expressed among the different ethnic
groups living in Benin and Togo. Moreover, potential
negative consequences of clefts on maternal mental
health may be influenced by the interval between birth
and operations. Indeed, in Switzerland, clefts are
repaired around the third month of age, whereas in
our Beninese sample, cleft repair is done at 3 years of
age on the average, ranging from 6 months to 7 years
old, when parents come into contact with the NGO.
For all the sociodemographic reasons cited above, it is
extremely tricky to compare these two samples and must
be considered as a major limitation in this study.
Therefore, the following results must be interpreted with
caution.
Quantitative and Qualitative Data Discussion
Our results suggest that mothers of the Beninese
sample are more depressed and more stressed compared
with mothers of the Swiss sample. However, as it has
been mentioned before, these results have to be taken
with caution as the instruments are not validated in sub-
Saharan cultures and as many confounding variables
may intervene.
Nevertheless, semistructured interviews showed that
posttraumatic stress symptoms in Beninese mothers
concerned aspects of survival (e.g., alimentation, med-
ical costs, severity of potential associated diseases) and
exclusion of the community, whereas posttraumatic
stress symptoms in Swiss mothers were more centered
on the shock at the prenatal announcement of the cleft
or at childbirth. This difference in the content of
posttraumatic memories may also explain the impor-
tance of the cleft type for Swiss mothers. Indeed, stress
in Swiss mothers especially concerned the physical
appearance of the child, but no worries about the
child’s survival were mentioned, for it is not an issue.
For Beninese mothers, the striking aspect of the child’s
face was secondary to the fear of death and social
exclusion.
Concerning the residential area, our results showed
that depression symptoms were higher in urban areas,
but only in the Beninese sample. It is possible that the
social rupture caused by the birth of a child with a cleft
is more important in town. Indeed, women living in
town often had left their village and their family to find
work. Therefore, these mothers are deprived of any
social support from a close family and have to face the
child’s problems alone. They also often cannot give the
child to a relative because of feeding difficulties and the
child’s appearance, cannot work, and are then con-
fronted with financial problems.
Our results showed that the more siblings, the less
depression symptoms. Siblings may provide an emo-
tional and material support for Beninese mothers, as the
eldest may help to raise their youngsters, as is the
traditional setting in sub-Saharan Africa.
Another possible explanation for the difference found
in depression symptoms between residential areas in
Beninese mothers is related to religion. Indeed, our
results showed that there were more Christian mothers
in urban areas. In the Beninese sample, mothers were
interviewed shortly before or during the child’s cleft
repair. If, for Animist families, the surgery was
anticipated as a possible social repair, for Christian
mothers, surgery may produce intense conflicts within
the family. Indeed, in Christian families, the cleft is
perceived as a divine hardship to be endured as a test of
faith. Repairing the cleft is considered a denial of God’s
will. At the time of surgery, Christian mothers may be
very worried about the future compared with Animist
mothers.
Keys to Improve Humanitarian Pediatric Surgery in Sub-
Saharan Countries
Even if quantitative aspects may have an importance,
qualitative aspects resulting from interviews with the
mothers of children with a cleft brought a very
interesting light on perceptions of malformations among
West African cultures. Aside from the child’s well-being,
it appears that their mothers are severely affected in
their daily life by their child’s affliction. Habits such as
going to Mass, to market, and going out are perturbed
by the presence of the cleft. In a culture in which social
aspects are associated with survival and in which there
are no maternal, social, or medical insurances, it is of
great importance to consider the impact of a visible cleft
on the whole social group and not only on the child.
It appears, during the interviews, that when mothers
were well informed about the origin and repair of the
cleft, they were less stressed and had fewer problems
with family and relatives. Moreover, they would inform
the father and the family about the cleft, cutting short
mystical explanations. The rejection from peers was
almost absent. This observation supports medical
information campaigns in developing countries. Indeed,
it is important to undertake prevention campaigns
against diseases, but it is also of great importance to
inform the public about malformations, as they may
have disastrous long-term social implications.
 Habersaat et al., OROFACIAL CLEFT CARE IN BENIN AND SWITZERLAND
Most mothers in our Beninese sample were surprised
to meet so many families with the same problems when
they arrived at the hospital. The simple fact of being
hospitalized with other parents in the same situation
was in itself supportive, and the sharing of experiences
was therapeutic. This underlines the pertinence of the
creation of an association for families of children with
clefts. For example, in Switzerland, such associations
support families from before birth to adulthood. Aside
from psychological support, parents may call the
association to ask for information about surgeries and
treatment. In Benin and Togo, such an association may
provide a platform of communication between families
and serve as a bridge between NGOs, local clinics, and
patients. Moreover, it could promote or conduct
information campaigns about clefts. Unfortunately, a
cleft association is difficult to organize in countries
where the communication between towns and villages is
made difficult by the absence of phones, lack of
electricity, bad roads, and long distances.
Many mothers in our study reported anecdotes
showing that the medical staff in small clinics or
dispensaries was uninformed about clefts. Moreover,
personal interpretations came from them at first.
Medical staff is usually considered the authority when
it comes to disease, so their misunderstandings of clefts
can have a serious impact. Improving knowledge
about clefts in general will also help orient appropriate
care.
Children with clefts should be referred to care
centers and operated on as soon as possible. Our
results showed that mothers of children with late
repaired clefts showed significantly more symptoms of
posttraumatic stress. The longer the cleft is apparent,
the longer the mother and child will remain socially
excluded, with the deleterious consequences that we
mentioned before. There is a need for long-term
follow-up of these children, who do not benefit from
speech therapy, and it is difficult to determine if the
children with a late repaired cleft will have full
language recovery. The usefulness and effectiveness
of surgery can be confirmed only if the child’s social
and educational development is normal. This intro-
duces another key concept, often missing in humani-
tarian surgery, which is the continuity of care. When
operating in the developing world, humanitarian
surgeons must ensure that patients receive appropriate
postoperative care (Wall et al., 2006) and follow-up,
including the development of a viable surgical backup
plan in case late complications develop (Wall et al.,
2006). In the Lausanne program, the agency of the
NGO Terre des Hommes has a permanent delegation
in Benin and keeps in contact with families in case of
long-term problems after surgery. Moreover, as the
same surgical team returns every year, surgeons may
reoperate the child if necessary, and every child is part
197
of a computerized program to plan follow-up consul-
tations. Even good surgical repair is not enough;
frequent massages of the scar, exercises of lip muscle
reinforcement, and speech therapy are necessary for a
good result. These postoperative measures cannot be
provided by the surgeon and are up to mothers or local
doctors, who must be properly informed to provide
optimal care. Over the past 10 years, the pluridiscipli-
nary team speech therapist has accompanied the
surgical team to provide workshops for the children
and their parents. Even if there is no certified speech
therapy in Benin, the parents can replace this essential
part of follow-up care if properly trained. The speech
therapy sessions also provide a platform for continued
psychological support.
Finally, this study stressed the importance of under-
standing cultural differences in the perception of clefts
to provide a better global care to patients and their
families. In particular, campaigns of information
directed to maternity personnel and the public should
help parents and medical staff in small dispensaries to
give appropriate care. This may diminish anxiety
concerning the child’s vital prognosis and magical
representations that exist concerning the cleft. More-
over, a Beninese association of families with a child with
a cleft providing support to others from the same
cultural background would probably be very helpful,
especially if we take into consideration the intense
activity in the blogs dedicated to parent information
sharing. Surgical teams should consider spending part of
their time giving classes and providing information
pamphlets in an effort to raise public awareness and
understanding of cleft lip and palate. The long-term
impact on the quality of life of the children benefitting
from surgical repair could be enormous.
CONCLUSION
Our study considered different factors potentially
affecting mothers of children with an orofacial cleft in
Benin. Our results showed that Beninese mothers of
children with a cleft express more symptoms of
depression and posttraumatic stress as compared with
Swiss mothers. Symptoms of posttraumatic stress were
higher in Beninese mothers when cleft surgery occurred
later after birth. Symptoms of depression were higher in
Beninese mothers coming from urban areas compared
with mothers coming from rural areas. This difference is
explained by the lack of a close family in town and by
religious beliefs regarding perception of clefts. Finally,
we found that mothers with other children reported less
symptoms of depression compared with mothers with
few or no other children than the one with the cleft,
perhaps because her ability to produce perfect children
was not in question.
198 Cleft Palate–Craniofacial Journal, March 2014, Vol. 51 No. 2
REFERENCES
Agbenorku P, Agbenorku M, Iddi A, Abude F, Sefenu R, Matondo P,
Schneider W. A study of cleft lip/palate in a community in the
South East of Ghana. Eur J Plast Surg. 2011;34:267–272.
Agbenorku P, Agbenorku M, Sefenu R, Matondo P, Osei D.
Endemicity of cleft lip/palate in a rural community in South-East
Ghana. J Sci Technol. 2007;27(1):45–50.
Alansari BM. Beck Depression Inventory (BDI-II) items characteris-
tics among undergraduate students of nineteen Islamic countries.
Soc Behav Pers. 2005;33(7):675–684.
Beck AT, Steer RA, Brown GK. The Beck Depression Inventory. San
Antonio, TX: Psychological Corporation; 1996.
Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck
Depression Inventory: twenty-five years of evaluation. Clin Psychol
Rev. 1988;8(1):77–100.
Borghi J, Hanson K, Acquah CA, Ekanmian G, Filippi V, Ronsmans
C, Burgha R, Browne E, Alihonou E. Costs of near-miss obstetric
complications for women and their families in Benin and Ghana.
Health Policy Plan. 2003;18(4):383–390.
Bourque P, Beaudette D. Etude psychométrique du questionnaire de
dépression de Beck auprès d’un échantillon d’étudiants universi-
taires francophones. Can J Behav Sci. 1982;14(3):211–218.
Bovet C, Broquet R. Le paysage religieux en Suisse. OFS, ed.
Neuchâtel: Swiss Federal Statistical Office; 2000.
Brauman R. La médecine humanitaire. Paris: PUF; 2010.
Canguilhem G. Le normal et la pathologique. Paris: PUF; 1966.
Carro IL, Bernal IL, Vea HB. Depression in Cuba: validation of Beck
Depression Inventory (BDI) and the Dysfunctional Attitudes Scale
(DAS-A) with Cuban population. Psicologia Clinica Latinoamer-
icana. 1998;16:111–120.
Despars J, Peter C, Borghini A, Pierrehumbert B, Habersaat S,
Müller-Nix C, Hohlfeld J. Impact of a cleft lip and/or palate on
maternal stress and attachment representations. Cleft Palate
Craniofac J. 2011;48:419–424.
Dolger-Hafner M, Bartsch A, Trimbach G, Zobel I, Witt E.
Parental reactions following the birth of an infant with a
congenital malformation: a hypothetical model. Pediatrics.
1997;56:710–717.
Donkor P, Bankas DO, Agbenorku P, Plange-Rhule C, Ansah SK.
Cleft lip and palate surgery in Kumasi, Ghana: 2001–2005. J Sci
Technol. 2007;18:1376–1379.
Field TM, Vega-Lahr N. Early interactions between infants with
cranio-facial anomalies and their mothers. Infant Behav Devel.
1984;7:527–530.
Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani N.
Psychometric properties of a Persian-language version of the Beck
Depression Inventory-Second Edition: BDI-II-Persian. Depress
Anxiety. 2005;21(4):185–192.
Gregg TD, Boyd D, Richardson A. The incidence of cleft lip and
palate in Northern Ireland from 1980–1990. Br J Orthod.
1994;21:387–392.
Habersaat S, Peter C, Borghini A, Despars J, Pierrehumbert B,
Müller-Nix C, Ansermet F, Hohlfeld J. Effet du stress sur
l’évolution des représentations parentales au cours des 12 premiers
mois de vie d’un enfant né avec une fente faciale. Neuropsychiatrie
de l’enfance et de l’adolescence. 2009;57:199–205.
Habersaat S, Peter C, Hohlfeld C, Hohlfeld J. Intervention chirurgi-
cale en Afrique subsaharienne: médecine humanitaire ou médecine
gratuite? Enfances Psy. 2012;53:139–147.
Hodgkin D. Household characteristics affecting where mothers deliver
in rural Kenya. Health Econ. 1996;5:333–340.
Husaini BA, Neff JA, Newbrough JR, Moore MC. The stress-
buffering role of social support and personal competence among
the rural married. J Community Psychol. 1982;10:409–425.
Hynan MT. The perinatal post traumatic stress disorder (PTSD)
questionnaire (PPQ). In: Wood R, Zalaquette CP, eds. Evaluating
stress: A handbook of resources. Lanham, MD: Scarecrow Press;
1998:193–199.
Jensen BL, Kreibord S, Dahl E, Fogh-Andersen P. Cleft lip and palate
in Denmark 1976–1981: epidemiology, variability and early somatic
development. Cleft Palate J. 1988;25:258–269.
Jo SA, Park MH, Jo I, Ryu SH, Han C. Usefulness of Beck
Depression Inventory (BDI) in the Korean elderly population. Int J
Geriatr Psychiatry. 2007;22(3):218–223.
Jones WB. Weight gain and feeding the neonate with cleft: a three-
center study. Cleft Palate Craniofac J. 1988;25:379–384.
Kodjogbé N, Mboup G, Tossou J, de Souza L, Gandaho T, Guédémé
A, Houedokoho T, Tohouegnon T, Zomahoun S, Capo-Chichi V,
et al. Enquête démographique et de santé, République du Bénin
1996. Calverton, MD: Institut National de la Statistique et de
l’Analyse Economique et Macro International Inc.; 1997.
Koenig HG, Larson DB. Religion and mental health: evidence for an
association. Int Rev Psychiatry. 2001;13:67–78.
Koenig HG, McCullough M, Larson DB. Handbook of Religion and
Health: A Century of Research. New York: Oxford University
Press; 2001.
Lees M. Genetics of cleft lip and palate. In: Watson ACH, Sell DA,
Grunwell P, eds. Management of Cleft Lip and Palate. London:
Whurr Publishers; 2001:87–104.
Linn J, Husaini BA, Whitten-Stovall R, Broomes LR. Community
satisfaction, social support and mental health in rural and urban
southern Black communities. J Community Psychol. 1989;17:78–
88.
Lule GS, Ssembatya M. Intention to deliver and delivery outcome. In:
Hatcher RJ, Vlassoff C, eds. The Female Client and the Health-Care
Provider. Ottawa, Canada: IDRC; 1995.
Mafakhkharul Islam AIM, Begum A. A psycho-social study on
genito-urinary fistula. Bangladesh Med Res Council Bull.
1992;18(2):82–94.
Masarei AG, Sell D, Habel A, Mars M, Sommerlad B, Wade A. The
nature of feeding in infants with unrepaired cleft kip and/or palate
compared with healthy non-cleft infants. Cleft Palate Craniofac J.
2007;44(3):321–328.
Meyer EC, Zeanah CH, Boukydis CFZ, Lester BM. A clinical
interview for parents of high-risk infants: concept and applications.
Infant Ment Health J. 1993;14(3):192–207.
Msamati BC, Igbibi PS, Chisi JE. The incidence of cleft lip, cleft
palate, hydrocephalus and spina bifida at Queen Elizabeth Central
Hospital, Blantyre, Malawi. Cent Afr J Med. 2000;46:292–296.
Murphy M. Social consequences of vesico-vaginal fistula in Northern
Nigeria. J Biosoc Sci. 1981;13:139–150.
Niehaus IA. Disharmonious spouses and harmonious siblings:
conceptualising household formation among urban residents in
Qwaqwa. Afr Stud. 1994;53(1):115–135.
Pierrehumbert B, Borghini A, Forcada-Guex M, Jaunin L, Muller-Nix
C, Ansermet F. French validation of the ‘‘Perinatal PTSD
Questionnaire’’ assessing parent’s posttraumatic stress reactions
following the birth of a high risk infant. Annales médico-
psychologiques. 2004;162(9):711–721.
Quinnell FA, Hynan M. Convergent and discriminant validity of the
perinatal PTSD questionnaire (PPQ): a preliminary study. J Traum
Stress. 1999;12(1):193–199.
Ramana YV, Nanda V, Biswas G, Chittoria R, Ghosh S, Sharma RK.
Audiological profile in older children and adolescents with
unrepaired cleft palate. Cleft Palate Craniofac J. 2005;42(2):570–
573.
Saizonou J, Godin I, Ouendo EM, Zerbo R, Dujardin B. La qualité de
prise en charge des urgences obstétricales dans les maternités de
référence au Bénin: le point de vue des ‘‘Echappées Belles’’ et leurs
attentes. Trop Med Int Health. 2006;11(5):672–680.
 Habersaat et al., OROFACIAL CLEFT CARE IN BENIN AND SWITZERLAND
Skrivan-Flocard V, Habersaat S. Analyse du discours parental lors de
la naissance d’un enfant avec une fente orofaciale. Enfance Psy.
2009;43.
Suleiman AM, Hamzah ST, Abusalab MA, Samaan KT. Prevalance
of cleft lip and palate in a hospital based population in Sudan. Int J
Paediatr Dent. 2005;15:185–189.
Tall ER. On democracy and Voodoo in Benin. Cahiers d’Etudes
Africaines. 1995;35(137):195–208.
Tanaka SA, Mahabir RC, Jupiter DC, Menezes JM. Updating the
epidemiology of cleft lip with or without cleft palate. Plast Reconstr
Surg. 2012;129(3):511e–518e.
199
Tyl J, Dytrych Z, Helclova H, Schuller V, Matejcek Z, Berankova A.
Psychological and social stress in children with cleft lip and palate.
Ceskoslovenska Pediatrie. 1990;45:532–536.
Wall LL. Dead mothers and injured wives: the social context of
maternal morbidity and mortality among the Hausa of Northern
Nigeria. Stud Fam Plann. 1998;29(4):341–359.
Wall LL. Fistari ‘dan Duniya: an African (Hausa) praise-song about
vesico-vaginal fistulas. Obstet Gynecol. 2002;100:1328–1332.
Wall LL, Arrowsmith SD, Lassey AT, Danso K. Humanitarian
ventures or ‘‘fistula tourism?’’: the ethical perils of pelvic surgery in
the developing world. Int Urogynecol J Pelvic Floor Dysfunct.
2006;17:559–562.