Our critical analysis of the National Strategic Framework for the Elimination of Obstetric Fistula, 2011–2015 in Nigeria generated four main themes: (1) overall, there are contradictions in the obstetric fistula policy goals; (2) the policy takes a downstream approach to obstetric fistula management; (3) the policy uses a victim blaming discourse and focuses on individual behavioural change as a solution to high rates of obstetric fistula; and, (4) there is stakeholder ambiguity.
Contradictions in policy goals
Constitutional misalignment with obstetric fistula policy goals
Although the policymakers claimed that they consulted a plethora of policies in developing the NSFEOF, it is not clear how these other policies align with the goal of eliminating obstetric fistula. For example, although the Nigerian constitution supposedly provides a foundation of social justice and equity to support the NSFEOF, activists and political observers alike have questioned the constitution’s commitment to social justice. While the constitution states the “right to dignity of human persons” and the “right to personal liberty” in its chapter on “Fundamental Rights,” , the Nigerian constitution makes no reference to the prevention of child marriage—a cultural norm that has long violated these rights [10, 30]. Our findings demonstrate that there is overt silencing of the issue of forced marriage and early childbearing which is a strong determinant of obstetric fistula in Nigeria. Although women of all ages are affected by obstetric fistula, underdeveloped pelvises which is the case when girls are young or malnourished, is a major biological predisposing factor to obstetric fistula [16, 31]. In other words, the federal government is constitutionally detached from the responsibility of protecting the rights of minors, which complicates its role in the elimination of obstetric fistula, despite the downstream approach of the NSFEOF that gives primary authority to the federal government.
Another paradox arises in the constitutional efforts to protect girls from early marriage. In Nigeria’s constitution, the Sharia judiciary system presides over marriages at subnational levels, particularly in northern states of Nigeria. This means that the Sharia Court of Appeal is responsible for deciding “any question of Islamic personal law regarding marriage,” including the validity or dissolution of a marriage and questions about family relationships and the guardianship of infants . This means that the constitution hands over control of women’s reproductive rights to the Sharia Court of Appeal in northern regions of Nigeria. Sharia law itself contradicts the constitution, specifically section 29(4) (b) of the constitution which states that “any woman who is married shall be deemed to be of full age” . Sharia law permits the marriage of minors under certain circumstances which trumps this constitutional assertion that a girl who is married should be considered automatically of full age. Moreover, constitutional laws do not control regional regulations. In particular, northern states’ rulings on child marriage do not align with the federal constitution. In northern Nigeria, Islamist jurists believe that a minor can be married under Sharia law if she has attained menarche . There is a concept known as ij bar, or “fatherly power,” where a father can force a daughter to be married [34, 35] (p. 10). Sharia law also states that men can take up to four wives while women can have only one husband . Marriage can occur at any time but, according to Sharia law, consummation should only occur when the girl reached menarche . Hence, girls are given in marriage to men with the hope that these men will wait until the girls are “of age” before they have sex, nevertheless some men have reportedly raped these child brides .
Although the Nigerian government passed the Child Rights Act, which sets the legal age for marriage at 18, in 2003, federal legislation is only effective if it is passed at the state level . As of May 2016, only 23 of Nigeria’s 36 states have passed the act . In 2016, a bill supporting gender parity and further legislative efforts to end child marriage met stiff resistance from the National Assembly of Nigeria on the grounds that gender equality contradicts Islamic traditions and culture . The NSFEOF also employs the rhetoric of “reproductive rights”, which helps make the framework seem attentive to justice. However, the precise regulations that are being applied to accomplish justice within the NSFEOF is not clear. The framework refers specifically to the Nigerian Labour Law, the Marriage Act, the Matrimonial Causes Act, and the constitution, but it characterizes particular parts of these pieces of legislation as controversial: “Section 54 of the Nigerian Labour Law, Chapter 21 and Part 5 of the Criminal Code, and sections 18 of the Marriage Act as well as section 3 of the Matrimonial Causes Act contain relevant but controversial provisions related to reproductive health and rights” (p. 18). Although the NSFEOF does not explain what the controversies are, the use of the word “controversial” here alludes to Islamic objection to gender equality. The desire to avoid the “controversial” aspects of these laws means that the federal government can sidestep responsibility for legislating women’s reproductive rights.
The Marriage Act and the Matrimonial Causes Act reinforce a similar mismatch. For instance, neither the Marriage Act  nor the Matrimonial Causes Act  prescribes a specific minimum age of consent for the marriage of minors. They do give an age of consent (21) so that they appear to regulate the age of consent. However, under section 18 of the Marriage Act , there is no limit to the age of consent as long as there is parental approval. The rhetorical strategy is to offer a regulation that offers parental liberty to betroth daughters. The ambiguities concerning age of consent and minimum age for marriage in the Nigerian constitution and the Marriage Act provide evidence to suggest that that Nigerian legislative environment is inconsistent with an agenda to eliminate obstetric fistula. At the textual level the NSFEOF performs a disturbing discursive feat by rhetorically separating early childbearing from early marriage:
“Possible factors in the formation of obstetric fistula include static gender norms…poverty, ignorance, illiteracy, preference for home delivery and the desire to avoid Caesarean section, early childbearing (as opposed to early marriage); harmful traditional practices like “gishiri cut,” (female genital cutting), low social status of women coupled with poor access to and utilization of EMOC services are other reasons proffered for the higher incidence of obstetric fistula in Nigeria.”  (p. 22).
Downstream approach to obstetric fistula management
Like many downstream health interventions, which involve individual-level behavioural approaches for prevention or management of illness, the Nigerian obstetric fistula framework focuses on the treatment of existing cases, despite its claim to be concerned with prevention and rehabilitation as well. The framework measures success in terms of the “number of repairs”  (p. 25), whereas an upstream approach might measure success in reducing rates of poverty, for example, as one of the social determinants of health that affects rates of obstetric fistula. In the foreword, the minister of health makes the policy’s downstream approach clear: “the goal of this document is to provide a standard reference material that can be used to train health workers and also guide them in the provision of holistic, respectful, simple, affordable, quality and evidence-based care for obstetric fistula women that will guarantee improved quality of life for these women and their families”  (p. 2). The phrase “obstetric fistula women” emphasizes that this framework was designed not to address the social realities of women who are at risk for developing obstetric fistula, but to treat obstetric fistula in the women who are already experiencing it. On the other hand, the literature establishes that maternal health services are weak in Nigeria. Antenatal care coverage in Nigeria is around 66% and, institutional child birth and contraceptive prevalence rate falls well below 50% . This shortage in maternal health services heighten women’s risk to obstetric fistula in Nigeria. While improved medical management of fistula does enhance the lives of affected women [24, 42], there are ambiguities in the long-term appropriateness of discrete curative approaches to the broader mission of eliminating obstetric fistula in Nigeria. For example, in Nigeria, fistula repair camps are conducted intermittently where certain numbers of fistulas are repaired . Although these fistula treatment sites are a promising strategy for reducing the number of women awaiting fistula treatment, this method does not suffice for preventing new cases of fistula. Moreover, evidence suggests that many of the trained repair experts tend not to be committed to this field of fistula treatment for reasons related to professional development. In addition, these short-term medical treatment campaigns often do not reach women in more isolated, rural communities, which reflects the inequality in access for rural women . In many cases, the women’s voices are never heard because of the shameful and marginal circumstances they find themselves . There is no data to suggest that the elimination of obstetric fistula was the NSFEOF’s actual goal. In fact, the discrepancy between the title’s professed goal of the “elimination of obstetric fistula” and the content’s explicit aim for a “reduction” of obstetric fistula incidence by 50% from current level  (p.9), suggests that the strategy to eliminate obstetric fistula was grandiloquent and unrealistic.
Victim blaming discourse and behaviour change strategies
In the NSFEOF’s Executive Summary, access to appropriate care is emphasized as a key issue in addressing obstetric fistula: “Improving service delivery by increasing the uptake of family planning, delaying marriage and early births, increasing access to quality maternal health services are also important in the national response”  (p. 8). It is difficult to comprehend how increasing “uptake” translates to improving “service” delivery. This statement shifts the focus from the service delivery as an issue, to service uptake by women, making it appear that the unavailability of health service is somehow a result of women not accessing the services. According to this statement, demand of maternal services is a problem of supply. This is a form of gerrymandering gone wrong, fallible on many fronts. It is well known that Nigerian women’s needs grossly outweigh the available services [22, 45]. In addition, many women do not patronize medical services because of the unsatisfactory antenatal and obstetric care they receive from grossly under-motivated staff particularly working in rural areas [45, 46].
Furthermore, the policy equates low levels of formal education with women’s ability to access maternity services. The language used in the executive summary: “obstetric fistula woman” suggests stereotyping, as well as a focus on women who already have obstetric fistula rather than targeting those at risk also. The use of terms such as “obstetric fistula woman,” “uneducated,” and “ignorance” serves to pathologize women and undermine their knowledge and voice, suggesting that inherent intellectual deficit is at the core of their obstetric fistula calamity. This language connotes subjection, blames the victim, and negates other factors in women’s lives that contribute to obstetric fistula. Victim blaming can obscure the unique experiences of affected women, and can be an effective tool used by government to focus intervention on the affected woman as the one who needs a behavioural change, while entrenched administrative shortcomings are deemphasized. By labeling an already oppressed group with more stigmatizing terms, attention shifts from broader facets of the problem to a behavioural change focus of intervention . Newer studies challenge this common instrumental narrative of women with obstetric fistula [47,48,49]; they suggest a need to look into the problem of obstetric fistula purposefully to describe it contextually, rather than to label it. That is, to explore the economic, political, moral and religious dimensions of the problem. Additionally, in the NFSEOF and the reproductive health policy in Nigeria, behavioural change communication is referenced as a focus of policy initiatives  (p. 34), yet, there is failure to identify an explicit strategy for capacity building of frontline staff, particularly nurses and midwives, for implementing behaviour change programs for women at grassroots levels in Nigeria. Discrete behavioural change interventions have become a gospel of “safe motherhood” for Africa [50,51,52] and is long-established as a toothless strategy when it comes to dealing with the systemic issues—namely, the forces of paternalism in government, in law and in health systems that downplay the issue of maternal health access and sustain reproductive rights abuse of girls and women. Nigeria may be wasting public funds on behaviour change interventions for women on a path to eliminate fistula while structural limitations such as lack of skilled birth attendance and practices of child marriage remains so prevalent and are maintained by cultural and political hegemonies .
The seventh of ten overarching NSFEOF principles reads, “Since health is an integral part of overall development, inter-sectoral cooperation and collaboration between the different health-related Ministries, development agencies and other relevant institutions shall be strengthened”  (p. 31). Despite a commitment to inter-sectoral collaboration, the VVF Technical Working Group relied disproportionately on the Federal Ministry of Health and the philosophy of its national health plan, which espouses health paradigms that ignore the impact of broader social policies on health, particularly in the case of obstetric fistula. The NSFEOF describes the national health plan as “developed in a fully participatory manner that involved all the key stakeholders in health—Federal, State, Local government, international and domestic partners, and civil society organizations”  (p. 19). In this description, civil society is notably subsumed under the umbrella of “stakeholders in health”; thus, references to “civil society”, which occur throughout the policy, implicitly refer back to the vaguely defined “stakeholders in health.” Moreover, the term “fully participatory” is bombastic rhetoric that appears inclusive of grassroots sectors but in practice defines stakeholders as those within the professionalized sectors of health and global development. Therefore, the question arises, how do Nigerian sub-national governments and communities of citizens influence the health sector and development agencies’ decision making?
The lack of specificity of the role of civil society organizations is further shown by the NSFEOF’s emphasis on the centrality of the Federal Ministry of Health: “In the last 5 years of implementation of this lapsed strategy [the previous five-year plan], the Federal Ministry of Health remained in the lead in coordinating the work of multiple actors at the Federal, State, Local levels, Civil Society and international partners”  (p. 13). With this statement, the NSFEOF makes it clear that the Ministry of Health is the primary authority; it holds the power to regulate the administration of the framework. Hence, civic participation may not imply public sector participation as control of policy operations is maintained by the federal government and the Federal Ministry of Health. Although the obstetric fistula policy claims to embrace a social justice model, the tone of the policy is discursively palliative rather than emancipatory.