by Lynn Heinisch, Press Officer

Nearly 50 women between 15 and 37 live at the National Hospital in Niamey. All suffer from obstetric fistula. All photos by Josh Estey © CARE 2001.

NIAMEY, Niger -- The courtyard could be anywhere in this vast country of the Sahara Desert. Dozens of women prepare dinner. While they work and talk, children dart about, amidst clothes hanging out to dry. Similar scenes of village activity play out each day throughout the country.

But this courtyard is different. It lies in the middle of the National Hospital in Niger's capital of Niamey, tucked between overcrowded rooms that smell of urine and teem with flies. The women -- nearly 50 of them between the ages of 15 and 37 -- live at the hospital, where they share a common pain.

Each suffered a gruesome pregnancy, one that tore apart internal organs and more often than not resulted in a stillborn child. Many can no longer bear children and have been abandoned by their husbands. Some are paralyzed. Most have undergone multiple operations. All have obstetric fistula.

Fistula occurs when a woman experiences a particularly difficult labor, compounded by poor medical practices or because her body is not fully mature. The walls between the vagina and bladder and rectum rip, causing fluids to mingle, resulting in infection and, sometimes, death.

While the technical description of fistula is dramatic, the human toll it takes is even more so.

Ai Boubacur, a resident of the hospital, married at 11. The older sister who raised Boubacur chose her husband, a boy from their village in Nigeria. Boubacur was pregnant by 12.

Her labor lasted four days. At one point, a birth attendant stuck her hand inside the birth canal, tearing the tissue. By the time Boubacur made it to the hospital, she was paralyzed and suffering from a pain she says she couldn't handle. Her baby boy was delivered by a caesarian. He was dead.

Boubacur is now 15 and has undergone two operations, during which her external sexual organs were removed. Her greatest worry, she says, is that she can no longer have children. Doctors say there is nothing more they can do for her. Her husband has never come to visit. She says they are divorced.

At 37, Fati Tahinou is the oldest woman living at the hospital, and she has been there the longest -- 10 years. When she was 15, Tahinou's parents married her to a boy of the same age who lived in their compound. Her first pregnancy -- at 18 -- resulted in a stillborn child. Two years later, she was pregnant again. This child also was born dead and Tahinou had fistula.

During her decade at the hospital, her husband has never visited.

"I don't know where to find him," she says, slapping her hands decisively against one another, as if washing him away.

Doctors have operated on Tahinou eight times in an effort to restore her body. Still, she cannot have children.

Down the hall from where Boubacur and Tahinou sleep, a room of nine cots holds the young girls and women who are awaiting surgery to rebuild their bodies.

Clinging desperately to the metal frame of her cot, a skeleton of a woman lies motionless on her side, as her mother fans flies off her. The cotton cloth wrapped around her body seems small protection from the thin, ripped plastic mattress on which she lies.

The traumatic deliveries frequently result in temporary paralysis. Girls and women awaiting surgery stay on cots in one room.

Zeinabou Seyni pulls off the cloth to show the scars of her recent caesarian, which came too late. Her baby was born dead, and she remains paralyzed from the waist down. Zeinabou, who thinks she is 22 or 23, has four children. She cries out in pain as her mother helps her to move her legs.

An estimated 100,000 Nigerien girls and women suffer from fistula. Two out of every 1,000 births result in the condition. But CARE estimates that there are thousands of unreported fistula cases and resulting deaths.

CARE and local organizations are working to help these women, and to prevent others from having similar experiences. CARE intends to open a guesthouse in Niamey, where the women will live while they receive counseling and vocational training. CARE also will help train health-care providers on how to prevent fistula, and work with political, judicial and religious leaders to educate people on the risks of early pregnancies.

Early Motherhood and High Mortality
In countries like Niger where it is common for women to marry and bear children at a young age there are high incidences of fistula. Nigeria and Ethiopia also have relatively high rates. American women in the 19th century suffered from fistula often enough that a New York hospital specialized in treating the condition. However, this ailment is now practically nonexistent in developed countries, so medical schools no longer train doctors to do the relatively simple and inexpensive surgery.

In Niger, only a handful of doctors perform the surgery. The National Hospital can do just one or two operations a week. The women who make it to the hospital typically come from poor families in rural areas, and have traveled a great distance.

Niger's fistula problem stems from a number of factors. A 1995 study by the government of Niger found that 88 percent of women with fistula were married before 15, and 45 percent before 13. Nine percent were married at the age of 10 or 11.

More than 60 percent of Nigerien births take place at home under poor hygienic conditions. Some women experience a labor of three to five days. It's believed a sign of weakness to cry out during childbirth, says a CARE physician, so even as a woman suffers through a difficult delivery, she won't complain. The resulting delay in seeking proper medical care can result in fistula, if not death.

This combination of limited medical services, early pregnancies and poor health practices contributes to the fact that Niger has the highest maternal mortality rate in the world -- 1,200 deaths per 100,000 births. Each year, some 5,000 Nigerien women die while attempting to deliver their babies.

"People know it happens, but sometimes they don't make the link [between early pregnancies and fistula]," says Dr. Sani Aliou, health sector coordinator for CARE in Niger. "They think it is a spirit or God punishing them."

Having suffered fistula, and being therefore unable to bear children, women are often rejected by their husbands and shunned by others in their community. Their condition carries a heavy stigma, and families may view them as an unwanted burden.

"They suffer and no one knows. No one takes care of them," says Adama Oumarou, who works for a local organization trying to help the women at the National Hospital.

Despite the grim circumstances, there is a sense of camaraderie among the women at the hospital. They sleep on mats in one large room. During the day, they roll the mats up and push them against the walls. They make handicrafts to sell -- stringing beads into bracelets and necklaces, knitting shawls and embroidering dresses and linens. But their future is unclear.

"A hospital is supposed to be a place you go for a short time. It's not for living," said Dr. Aliou. "This is like a prison for the women."

Addressing the Problem
In collaboration with local organizations and the Ministry of Health, CARE intends to open the Niamey guesthouse, where women with fistula can live while they rebuild their lives. Residents will receive vocational and literacy training, as well as counseling to prepare them to return to independent living.

The women at the hospital share a common living space, where they sleep, eat and support themselves by making handicrafts to sell.

CARE also plans to educate health care providers on fistula and safer practices during childbirth. Lastly, CARE aims to work with political, judicial and religious leaders to advocate against early pregnancies, with the intent of encouraging the enactment of legislation to protect girls from being forced into early marriages.

"The general aim of this campaign will be to break the silence surrounding this practice and how it destroys the lives of so many young women," says Mark Wentling, CARE's assistant director in Niger.

With its partners, CARE aims to make fistula a thing of the past for the women and girls of Niger. The team has embraced the slogan: "No woman should have to give her life while giving life." If successful, CARE's efforts would protect other girls from experiences like those of Ai Boubacur and Fati Tahinou.