8th March, 2008
Frances, a woman aged around 50 who lives in the West African nation of Sierra Leone, would barely say a word - and certainly not smile - when Australian surgeon Dr Judith Goh met her in 2004.
Three decades ago she developed a genito-urinary fistula during a prolonged labour and, like many of the estimated 100,000 women who develop the problem around the world every year, found herself shunned by her family and friends, embarrassed by her subsequent incontinence.
CELEBRATING NEW LIVES: Dr Judith Goh with some of her patients in Africa.
"There are estimated to be two million women living with obstetric fistulas - sometimes described as the ‘African epidemic’ - around the world today. Often affecting the young and poor who can’t afford to go to hospitals, the condition is usually caused by an obstructed labour coupled with a lack of skilled medical care and most often leads to a permanent state of incontinence."
Dr Goh, who was working with a surgical team at a permanent fistula hospita in the nation's capital of Freetown run by international charity Mercy Ships, says that the fistula was able to be closed during an operation.
Dr Goh describes the transformation of this small, thin woman: “Frances was sent home with a new dress, as a symbol of a new start. The farewell ceremony involved dancing and singing with music, African-style. Frances danced and sang, and I felt privileged to have participated in her care."
There are estimated to be two million women living with obstetric fistulas - sometimes described as the ‘African epidemic’ - around the world today. Often affecting the young and poor who can’t afford to go to hospitals, the condition is usually caused by an obstructed labour coupled with a lack of skilled medical care and most often leads to a permanent state of incontinence.
As in Frances’ situation, this, in turn, often leads to a life of shame and isolation and can also cause a premature death as a result of infection and kidney failure.
Obstetric fistulas are most prevalent in areas where there is a high maternal mortality rate - in Liberia, one of the nations where Mercy Ships operates which lies south-east of Sierra Leone, women have a one in 16 chance of dying of childbirth related causes in their lifetime.
Mercy Ships are this year running a year-long program in Liberia to reduce the prevalence of obstetric fistula through surgical treatment, training and awareness. It’s anticipated that over the course of the year, 125 women will receive corrective surgery, others will be counselled and public education sessions held looking at the issue for the wider community. In addition, three local surgeons, and three obstetric nurses will be trained in the procedures to deal with the problem.
Dr Goh, a 45-year-old gynaecologist who lives on Queensland’s Gold Coast, first encountered the issue in 1995 when she spent six months working in Ethiopia, mostly in rural areas, and spent several weeks at the Addis Ababa Fistula Hospital learning about fistula management. She returned to the hospital - which treats about 1,200 women with the problem every year - for a further six months a year later and since then has worked in Bangladesh (where she assisted with the establishment of a fistula unit), and, for the past three years, in West Africa working with Mercy Ships.
Dr Goh says the fistula surgery is something any Australian surgeons have little experience in - “we have so few in Australia” - and says that while, thanks to her experience with the problem, she sees about a dozen cases a year in Australia, in Africa she’s treating three to four women a day, five days a week.
While simple fistula is easily treated surgically, Dr Goh says that difficult fistulae can taken a few hours of surgery and even then, a significant percentage of those women will suffer from problems such as urinary incontinence, fertility problems, and foot drop which leads to an inability to walk properly.
She says that for those women with the condition who are left untreated, total incontinence is a lifelong condition.
“They are outcasts,” Dr Goh says, adding that because many of these women also deliver a stillborn baby, they are also seen as failures in the eyes of their family, community and themselves. “(H)aving children is crucial to the woman’s role in her community.”
She says many of those who develop fistulas are teenagers - the majority of fistulae develop during a woman’s first childbirth - and says that she often sees women like Frances who have lived with the condition for much of their lives.
“If not treated, they live with the fistula until they die,” she says. “So I often see older women who have been living as outcasts from the fistula for years.”
Many of those who have fistulae have to beg or depend on the generosity of others to survive.
Dr Goh, who is once again heading to Sierra Leone to work at Mercy Ships’ permanent fistula hospital later this year for a period of three weeks, says that because many women with fistulae cannot afford surgery, the free care provided by organisations like Mercy Ships, which relies on volunteers, is vital.
Having been a Christian for 25 years, Dr Goh never planned to be a fistula surgeon but believes God has led her in that direction.
“God has given me surgical skills and I have to be a steward of my skills - not just live comfortably at home,” she says, explaining why she has given up so much of her time to work as a volunteer oversees.
“I don’t want to only be available to work overseas when I retire. As a believe that this is (something) God wants me to do, I want to be available now. It’s a bit tricky at times to juggle work here and taking time off to go overseas, but I try to make working overseas a priority and fit my work at home around it.
“God willing, I hope to keep doing this for a while yet. It definitely helps me appreciate things at home...I am always humbled to observe the extraordinary changes in these women when fistulas are closed. It is always a great privilege to use the skills that have been given me to assist the fistula women. It gives me a bigger picture on life.”