Martha Rial, Post-Gazette Harira Isyaku, 18, is recovering from surgery to repair an obstetric fistula at Kwali Rehabilitation Center in Kano, Nigeria. Isyaku, who married at age 15 and is now separated from her husband, suffered a fistula two years ago when she tried to give birth after being in labor for two days. Click photo for larger image.

KANO, NIGERIA -- First you notice the flies. Scores of them.

They're on the warped, wet bench where Furera Ali is seated. They're on her urine-soaked dress and on the pool of urine at her feet.

For three years, they've shadowed her, a constant reminder of the incontinence she suffers because of a childbirth injury that left her son dead.

Rejected by her husband, Ali has lived with her parents at their home in this northern city. She hasn't left their house because of the shame and embarrassment.

Hers is a common story among the estimated 2 million women here and in other sub-Saharan countries, as well as in South Asia and Arab states, who have fistulas, an opening from the birth canal into the bladder or rectum that occurs after several days of obstructed labor without proper medical intervention to relieve the pressure. In almost all cases the babies die.

The women are left with extensive tissue damage that causes chronic incontinence. It destroys their marriages and makes them social outcasts.

According to the U.N.'s Web site www.endfistula.org, fistulas can leave women "with few opportunities to earn a living, and many have to rely on others to survive, or turn to begging or commercial sex. In some communities they are not allowed to have anything to do with food preparation and may be excluded from prayer or other religious observances.

"For many women, the profound social isolation is worse than the physical torment," the U.N. says.

The condition, rarely seen in the United States, is getting new attention in a special two-week pilot program, Fistula Fortnight, that concluded yesterday in Nigeria, which has one of the highest fistula rates in the world.

Teams of doctors from Nigeria and other nations are providing free surgical repairs to more than 500 women, many of whom have traveled hundreds of miles for care.

	Martha Rial, Post-Gazette Zuwaira Yusuf, 17, left, talks with nurse Hayiya Nafisat outside the Babbar Ruga Fistula Hospital. Yusuf said she married at 14 and became pregnant at 15. The child did not survive the day-long labor and Yusuf suffered a fistula as a result. Yusuf has been staying at the hospital awaiting surgery. Click photo for larger image.

Like the public-private partnership that has worked to eradicate polio, the United Nations Population Fund has put together a similar group for a global program called the Campaign to End Fistula. It hopes to correct and prevent these injuries, which often occur in teen brides with pelvises too small to give birth.

The cost of the surgery is $300, generally out of reach for most African women.

Until a few years ago, treating this condition was a pet project of a handful of humanitarian doctors, namely Australian-born Catherine Hamlin and her late husband at the Addis Ababa Fistula Hospital in Ethiopia and Dutch surgeon Kees Waaldijk at Babbar Ruga Fistula Centre in Katsina, Nigeria, near the Niger border.

Waaldijk came to Nigeria 20 years ago to treat leprosy. But he was disturbed to see the high number of fistulas and how they ruined women's lives. His center has since performed more than 21,000 corrective surgeries.

Now, more doctors are being trained to provide care. Dr. William Meyer, 55, of Tucson, Ariz., who has practiced obstetrics for 27 years, has been one of two U.S. doctors working since Feb. 21 at Kano's Murtala Muhammad Specialist Hospital in the fortnight campaign.

He looks forward to the eighth or ninth day after surgery for each patient. "That's when they start to smile," he said. "They see their bed dry."

Obstetric fistula is common in countries with high maternal mortality rates. In Nigeria, where 58 percent of women deliver at home -- 11 percent without assistance -- a woman has a 1 in 18 lifetime risk of dying of complications of childbirth. In Europe, the figure is 1 in 2,400.

	Martha Rial, Post-Gazette Maria Huruma, 18, is recovering at the Babbar Ruga Fistula Hospital n Katsina, Nigeria, after surgery that repaired her obstetric fistula. The fistula occured during a five-day labor with her first pregnancy. The child was stillborn. Click photo for larger image.

In other parts of Africa, women have suffered fistulas after forcible rapes, particularly in the turmoil-ridden Democratic Republic of Congo.

Because it's a hidden problem, prevalence is hard to measure. An estimated 400,000 to 800,000 Nigerian women are living with the condition and there are 20,000 new cases a year.

Although many of the cases occur among young brides, inadequate access to health care is the main contributor, especially in rural areas.

The route from the village to the main road may be several miles, said Kori Habeeb, a population fund spokeswoman. "They may be carried on a horse or donkey. Then they need to find a vehicle to take them to the hospital. Then when they arrive, there could be more delays."

Procedures such as Caesareans, in which babies are surgically removed from the womb to relieve pressure, can prevent the tissue tearing, but are not readily available.

There are also cultural hurdles. Many villagers eschew hospitals, fearing that women who go there for care always will have a Caesarean. They encourage women to tough it out at home. Those who go to hospitals are labeled "weak."

The resulting fistula may be as small as a pinpoint or so large it requires major reconstructive surgery. During the fistula correction surgery, women are given a spinal block, which numbs the lower torso and legs. Operations to close the opening can take from 30 minutes to as long as four or more hours.

One day recently at Murtala hospital, several women were being operated on at a time on tables specially designed for this surgery. The success rate for uncomplicated cases is 90 percent, and 60 percent for complicated ones. After treatment, most women can bear children.

Proper post-operative care for four to six weeks is imperative and a special rehabilitation center was set up in another part of Kano to house the women and their families during their recovery. They need proper fluids to prevent infection and receive counseling to help them re-enter society.

Ali, 30, was one of three patients still waiting for surgery at Murtala hospital late Thursday afternoon. She had been there since early morning. Her nephew had brought her to the hospital after hearing radio reports about the free campaign. Until then, Ali thought she was the only person with this embarrassing problem.

"I kept praying to God that this would stop," she said.

Since the campaign started at Babbar Ruga in Katsina, women have been dropped off in busloads, some traveling more than nine hours from Niger, whose border is about 80 miles from Katsina.

Some women don't want to return home. Maria Huruma, 18, of Niger, was recovering from a severe injury suffered during five days of labor at home. The hole has been repaired in two procedures over the last two years.

Thrilled that she no longer is leaking, she says she'll stay in Katsina to go to school.

Meyer said the best approach is to prevent the problem in the first place by increasing access to health care, education and family planning; by improving girls' nutrition to prevent stunted growth that can leave a mother's pelvis too small; and by postponing pregnancy for young girls.

But he recognizes the challenge this presents in the developing world.

"It's a utopian dream," he said.

	Martha Rial/Post-Gazette
	For 10 years Mairo Hassan has suffered the consequences of a fistula that occured when she was trying to give birth. The resident of Gaya, Nigeria, is among 500 women chosen to have the birthing injury repaired during the "Fistula Fortnight" surgical pilot program.