Sr. Ann Ward, pioneer of Obstetric Fistula repair

'The arch-enemy of compassion is pity.' Sister Ann Ward looks you straight in the eye when she says this, and you get the feeling that she knows a thing or two about the subject.

'Pity puts distance between you and person you are pitying. Compassion puts the two of you on the same level, enabling you to work together to change the situation, or at least to make it more bearable.'

A deep sense of compassion is what drove Ann Ward to leave her Donegal home more than fifty years ago, when she joined the Medical Missionaries of Mary. The same desire impelled her as she entered medical school in Dublin, and later when she pursued her post-graduate studies to obtain her Master's and her Fellowship in Obstetrics and Gynaecology.

Drawing attention to the plight of women
When her peers at University College Dublin, presented her with the Distinguished Graduate Award for outstanding achievement in the field of medicine, she told them, 'If you found yourself in the same circumstances I work in, you would have done just as much as I have done.'

Sister Ann had previously received international recognition for her 'outstanding contribution to women's health'. Over the years, she was frequently invited to prestigious medical schools or conferences to present papers, or to demonstrate the surgical procedures she has pioneered. But Sister Ann shuns publicity.

'Please don't write about me,' she protests. 'The focus needs to be placed on the women who suffer this terrible condition, and on the services that need to be put in place to bring relief and proper treatment.'

In southeastern Nigeria, more than 3,000 women have now been successfully treated for what is surely one of the most distressing conditions a  woman can have inflicted upon her.

Sister Ann's patients come to Itam because of obstetrical fistula, usually vesico-vaginal fistula (VVF). The condition usually develops from prolonged and obstructed labour. Usually the infant is dead upon delivery, and the mother is left with severe internal damage, leaving her incontinent of urine and/or faeces, in acute pain, and with great difficulty in walking.

Added to this is the terrible stigma and the ostracism because of the smell, and the fact that she has no living child. She will probably have difficulty in having another child. In communities where women's rights are not valued, she may even be driven from her home or her village.

'The sad part is that today most of the patients are teenagers whose pregnancies have gone wrong. Unfortunately they never get back to school again because their parents have been let down. The money that was put aside for their schooling is often swallowed up on their treatment instead.'

At Itam, the charge for treatment is kept to an incredibly low level, and nobody is ever turned away for lack of ability to pay. Unfortunately, before women discover what is available in Itam, they may have spent elsewhere all the money they can manage to scrape together.

Prevention is key
Most fistulae can be prevented if women have access to adequate antenatal care and skilled personnel available at the time of labour and delivery. Unfortunately, this is not the case for many women in the developing world.

'Unfortunately, the problem of VVF is growing,' says Sister Ann. 'When I started this work, I thought I would work myself out of a job and that VVF would be unheard of by now. Sad to say, it is on the increase. Not only that, the cases coming in seem to be much worse now, much more difficult. The girls are much younger and, consequently, they are much more damaged. The majority of them, sadly, are damaged for life.

'Another thing we have noticed is that young women from the same family are becoming inflicted with VVF. Girls that were here looking after their sisters when they had it, are back in with us now with the same problems. It shows the terribly low standard of living and of healthcare in the villages. Life is so difficult for them. There is no transportation to get to hospital in their hour of need, or else the hospitals are in such an appalling condition there is nobody to attend to them, or they haven't the money to pay for the treatment.'

Many specialists from overseas want to spend a short time at Itam to get experience, but this is not a solution to the Nigerian problem.

"They would ask me to let them come and to keep the easier cases for them but I would have to tell them there are no easy cases. They are all difficult and there is no point in coming to learn just the surgical techniques. The post-operative care is critical. You have to be able to stay with these patients and you have to be in this work for the long haul."

'With an illness like this, you have to have somebody that has compassion,' repeats Sister Ann. 'There is no other way it can be done.'

Nigerian MMM, Sister Therese Jane Ogu, as well as being a Senior Nursing Officer, is responsible for the hostel where the young women live while awaiting their surgery. Most patients need several operations to repair the internal damage done during their obstructed labour, and this can take up to a year. The hostel is a cheery place. It is part of the large, leafy, compound. Sister Therese Jane also tries to interest the residents in her poultry and produce from the land. A donation from friends in Canada has made it possible to buy new sheets and coloured plastic chairs and to have the whole place painted in bright colours.

'It is very hard to know what is the best way to keep the young women occupied while they are in the hostel,' according to Sister Ann. 'They make their own fun. They are glad to be this far on the road to their eventual recovery, even though there is still such a long way to go.'

In some ways the hostel resembles a second-level boarding school. UNICEF gave desks, blackboards, etc., and paid a teacher, but it is hard to know whether this is the right time for these young women to be at school. Their only interest is having their operation, but of course, we believe the best rehabilitation they could have is education.

Sister Ann says, 'In countries that are better off financially there is much talk of rehabilitation after VVF, but for our young women the rehabilitation they want is to be able to return home and become integrated in society once again, to be able to work on the farm, or to sit in a bus, or go to the market, or to the church, without stigma.'

While the situation looks bleak enough, the MMMs and staff at Itam do what they can to make a difference. As part of the primary health care programme, women who are healed from VVF are trained as ambassadors to go back to their villages and explain to the women there how they may get into difficulty in childbirth and the consequences if they don't get help in time.

Many women still feel that their difficult labour is due to witchcraft. Hearing those who have been cured speak about their experiences reveals to them that it is not due to witchcraft, but due to a medical and mechanical difficulty. It brings them the greatest relief to be freed from their superstitions and to know that they are not bad people and not the victim of a curse.

Clearly, the work is hard, but the need is great.

Sister Ann Ward retired to Ireland in 2006. MMMs at Itam continue the work she began and help hundreds of women every year. For several years there has been no resident surgeon doing repair surgery but during repair 'camps' organized several times a year, visiting Nigerian surgeons work with staff at Itam to assess patients and perform repair operations.