The current intervention schemes to eradicate obstetric fistula in Africa are historically linked to two landmark conferences. In 1987, at an international conference in Nairobi, the Safe Motherhood Initiative was launched to address the appalling state of maternal health in developing countries. The conference set a goal to reduce maternal mortality by three-quarters between 1990 and 2015. The second conference, the International Conference on Population and Development (ICPD), was held in Cairo, Egypt, in 1994. This conference declared that women’s and girls’ reproductive rights were at the heart of sustainable development. When the UN Millennium Development Goals (MDGs), particularly MDG 5 (improve maternal health), were adopted in 2000, many of them were premised on ICPD principles, prominent part of which included the elimination of obstetric fistula in Africa [
11‐
13]. The eight MDGs were meant to be time-bound, achieved by 2015; however, MDG-5, improving maternal health, has not been accomplished in many African countries, and obstetric fistula persists [
5,
8]. In 2003, the Fistula Care Project began conducting a six-year, facility-based needs assessment and policy intervention project in nine sub-Saharan African countries. Supported by the United Nations Population Fund (UNFPA) and implemented by EngenderHealth, in partnership with IntraHealth International, the assessment was intended to understand the causes and impact of obstetric fistula, country capacity to manage obstetric fistula and to identify clinical and programmatic gaps [
1,
14]. The assessment demonstrated that although fistula prevalence can be reduced through surgical management, there are other complex determinants in the setting where women live such as poor referral and transportation system and poor access to perinatal support services that influence prevalence rates of obstetric fistula and preclude uptake of fistula treatment [
14]. United Nations agencies and partners then encouraged each country to take ownership of their respective policy agenda for the eradication of obstetric fistula [
15]. This meant integrating the policy on obstetric fistula within broader national development plans and poverty-reduction strategies of African nations. The ultimate goal of this agenda was to establish a country-specific “levels of care” model, where prevention is factored into all levels of the health system in each country [
15,
16]. Nigeria was one of the first countries to implement such a model. Although policy was developed to eliminate obstetric fistula in Nigeria, obstetric fistula continued to be prevalent as of 2015 [
5,
8]. Moreover, there was no comprehensive strategy to estimate progress made or to evaluate community ownership of the interventions within the sociopolitical context in Nigeria [
14]. Likewise, country-specific obstetric fistula initiatives were modelled on the earlier Safe Motherhood Initiative and MDG-5 principles, which basically focus on technical improvement in biomedical maternal and obstetric care services and on awareness and education about reproductive health services [
12].These initiatives were vertical, running parallel to local political and leadership structures within the countries; hence, there was no true ownership of the initiatives, and capacity building for sustainability was not achieved [
12,
14].
In the UN General Assembly report on ending obstetric fistula published in 2016, it was identified that the three most cost-effective strategies to address obstetric fistula are the implementation of skilled birth attendance, emergency obstetric and newborn care and family planning [
17]. Approaches developed in isolation of these manifold prerequisites are relatively ineffective [
15,
17]. Also, midwives have a crucial role to reduce the high number of maternal disability from obstetric fistula [
17]. While global strategy on addressing obstetric fistula continues to shift in theory, the administration of strategies is generically problematic at the national level because there is partial understanding of the structural, social and political conditions intersecting affected women’s experiences. These conditions include maternal healthcare access challenges, poverty, marginalization, gender and sociocultural inequality, barriers to education, especially for girls, child marriage and adolescent pregnancy [
15,
17], 3. p. Prevention and treatment of obstetric fistula contributes to achieving Sustainable Development Goal 3, which is ensuring healthy lives; specifically, improving maternal health [
17]. The agenda puts strong emphasis on country leadership and highlights the need to strengthen accountability through monitoring national progress and strengthening capacity to collect, analyze and use fistula program data. Nigeria’s obstetric fistula policy was one of the first strategic plans in West Africa and has been a model for other African countries. Taking Nigeria as a case study, this paper presents an analysis of how social and political systems are implicated in the problem of obstetric fistula.
Nigeria
Nigeria is the most populous country in Africa with about 180 million people [
18]. Although Nigeria constitutes only 2% of the world’s population, it accounts for 10% of the world’s maternal mortality rate in childbirth [
19]. Maternal health initiatives began in Nigeria in 1990 after the Nairobi conference when Nigerian attendees organized a national Safe Motherhood conference convened by the Society for Obstetrics and Gynecology in Nigeria. After the country transitioned from military to civilian rule in 1999, a precarious political space was created to address some of the social issues related to maternal morbidities and mortalities. However, this transition concurrently diffused political power, making it easier to siphon public funds into private purses [
20,
21]. Global attention was drawn to the problem of obstetric fistula in Nigeria in 2003 when UNFPA launched the landmark Campaign to End fistula. The initiative largely focused on improving treatment supplies and supporting existing fistula care centers. In 2005, the UNFPA began collaboration with the International Society of Obstetric Fistula Surgeons (ISOFS) to develop the National Strategic Framework for Eradication of Fistula (NSFEOF). The resulting guideline was an important initial step in the establishment of a cohesive obstetric fistula taskforce in Nigeria. ISOFS further grounded the strategy to address obstetric fistula by simultaneously formulating a competency-based training manual for fistula repair experts. The goal of the Strategic Framework was to reduce the incidence of obstetric fistulas by 80% and to have a 300% increase in fistula repair procedures between 2005 and 2010 [
22]. Also during this period, a community screening module for detecting obstetric fistula symptoms was developed in Nigeria; and incorporated into the Nigeria Demographic and Health Survey to produce a community-based prevalence estimate. Within a decade, fistula treatment rate increased from 2000 repairs in 2003 to 6000 in 2013 [
23]. In spite of progress in fistula treatment, there was evidence of continued inequity in access to maternal health care, reproductive rights, and distribution of social resources for women, which together constitute key factors in the aetiology of obstetric fistula [
24].
After the initial framework lapsed in 2010, Nigeria’s federal government structured a new policy to eliminate obstetric fistula. The policy, titled
National Strategic Framework for the Elimination of Obstetric Fistula in Nigeria (2011–2015), was developed to increase access to prevention, treatment, and rehabilitation services. The priority focus of the policy was to deal with the underlying determinants of obstetric fistula [
25]. Although the new policy initiative was ostensibly focused on elimination of obstetric fistulas in Nigeria, there is no tangible evidence to suggest that this goal was achieved [
26]. The persistence of obstetric fistula and comorbidities in Nigeria [
26] suggests that there is failure to truly integrate the lapsed obstetric fistula policy into national health and human rights initiatives, and to address the underlying determinants of this maternal health problem. The global agenda for obstetric fistula is to strengthen country-specific frameworks and reinforce national ownership, sustainability, and accountability for obstetric fistula policy development and problem solving toward 2030. The goal to strengthen country ownership of obstetric fistula eradication mandate engenders the need for a critique of policy discourses related to obstetric fistula to understand gaps in policy and program development. In line with this objective, we present an analysis of the 2011–2015 framework for obstetric fistula in Nigeria [
25] and supporting social and reproductive health policies. Our aim in this paper is to understand how the legislative environment and the National Reproductive Health Policy framework, on which the obstetric fistula policy (2011–2015) is premised, embody the goal of ending obstetric fistula in Nigeria. Using critical discourse analysis, we examine the language and dominant paradigms in these policies to understand how the reality of obstetric fistula in Nigeria is conceptualized. We are specifically concerned with how the dominant paradigms in the policy texts construct the social reality of affected women.