Battle to treat women for debilitating fistula

"Get rid of the girl who stinks," they said about Sana Rodiny who for three years had to endure unrelenting abuse after developing a fistula.

Now at 18 she hopes the people of her small village in southern Madagascar will leave her in peace after she underwent surgery for the debilitating condition that left her incontinent.

"I've had fistula since suffering a gang rape by cattle rustlers at the age of 15," Sana told AFP sitting beside her mother.

But she got help and had an operation. Lying on a handmade mat in the shade of a tamarind tree, she recovered in the sandy courtyard of Ambovombe's Monja Jaona hospital.

Following her procedure, the constant urine odour she suffered as a result of her fistula is now a thing of the past.

"I wasn't interested in boys because they weren't going to support a girl who smells all day long," Sana recalled of those difficult years.

Obstetric fistula refers to the rupturing of tissue between the vagina and the bladder or rectum after prolonged, obstructed labour or, less commonly, violent rape.

The condition typically results in urinary or faecal incontinence.

Madagascar is one of the worst-hit countries, with 4,000 women affected every year.

An estimated two million female patients have the condition worldwide -- most of them in developing countries. It has been nearly eliminated in Western countries due to improved obstetric care and the use of caesarean delivery.

Sana was likely "the victim of an assault with a blunt object which perforated her organs," said Yoel Rantomalala, a professor in genitourinary medicine who travelled to southern Madagascar specially to operate on 82 affected women.

His mission is part of a targeted assault on fistula being waged jointly by the UN Population Fund and Madagascar's health ministry, funded by Japan.

Unable to seek help

Most of the patients, who live far from hospitals, have been forced to give birth alone or with poorly-equipped and untrained traditional midwives.

Insecurity and gang crime in remote southern regions of the Indian Ocean island nation complicate the situation.

Fear of attack means that pregnant women who go into labour at night refuse to venture out onto isolated roads to seek medical help.

"Remoteness, insecurity or the lack of supplies in village pharmacies are the root causes of fistula's persistence," said the head of the Monja Jaona hospital, Paubert Tsivahiny.

"Fistula cases (also) affect young mothers and smaller women who can have difficult deliveries."

Then there are the traditions of poor societies like Madagascar, where it is not uncommon for parents to trade their daughter's hand in marriage for a dozen or so cattle.

Women like Marilina who married young -- in her case in an arranged marriage for which her parents received several humped cattle -- are particularly vulnerable.

After suffering a miscarriage at the age of 14, she had fistula for three years.

Abandoned by husbands

"I had a complication during pregnancy in which the child moved upwards in the womb instead of downwards and after surgery the baby was stillborn -- and I had fistula," she said.

Marilina's husband abandoned her following the ordeal.

Another woman, Molina, now 40, suffered a similar fate after a stillbirth a decade ago.

"My husband didn't love me any more. He couldn't make love to me because urine was flowing all the time," she said.

Those affected often stay silent and even those who come forward have to be persuaded to undergo corrective surgery.

"People think there's a risk of organ trafficking or dying on the operating table," said social worker Yvette Brechard.

"They even think we're going to take their organs while we're operating on them."

The procedure in surgical terms is relatively simple. It entails trimming and then rejoining the ruptured tissue, and can usually be done on an outpatient basis.

Afterwards, patients must avoid falling pregnant for several months to allow adequate healing time.

"But married women aren't in control of their lives and they are always told what to do by their in-laws," said Brozany Andriamino, head of the maternity ward at Monja Jaona hospital.

"The in-laws often refuse to consider any form of family planning."