You have been writhing in torment in the bush for five days. You are in prolonged, obstructed labour and you cannot push your baby out. You needed an emergency Caesarian section days ago. But you are in the African bush, far from medical help.
Eventually, after days of agonising, fruitless labour, your baby emerges. It tears a gaping hole between your rectum and vagina, or between your bladder and vagina - or even both. Your baby is dead.
By the time your body arrives, barely alive, at hospital, your genitals have become an oozing wound. You are now permanently incontinent. Urine and faecal matter constantly dribble down your legs from your vagina. You stink. No one will go near you. You are shunned and called a witch. You are not allowed to prepare food. Your husband abandons you. You will never have sexual intercourse again, never menstruate again, never have another pregnancy. You are destitute and resort to begging. You would be better off dead.
You are 11 years old.
Obstetric fistula is the name for this appalling condition. It occurs when girls whose bodies are too immature to give birth become pregnant, and are then denied access to Caesarian sections.
Usually, these girls are married off as young as 10 years old, since traditionally a woman is not supposed to have her first menstrual period in her father's house. Sexual relations begin prematurely, and the girl is pregnant soon after she begins to menstruate.
There are two types of obstetric fistula: vesicovaginal fistula (VVF), when the wound is between the bladder and the vagina, and vesicorectal fistula (VRF), when the wound is between the rectum and the vagina. Some women are unlucky enough to have both.
Obstetric fistula affects two million women and occurs up to 100,000 times a year, mainly in Ethiopia, Tanzania, Nigeria and Sudan, where girls are married off young before they are physically ready to procreate.
Dr Ann Ward (72) is obstetrician/gynaecologist at the Family Life Centre at Itam, south-east Nigeria, a state-of-the-art medical centre and residential community on the edge of the bush. She is a nun with the Medical Missionaries of Mary and has spent the past 42 years in Nigeria repairing the torn bodies of thousands of these young girls.
Originally from Donegal, Dr Ward was in London last week with the International Federation of Obstetricians and Gynaecologists to discuss obstetric fistula with the United Nations Population Fund. She says her job is as much about psychology as surgery. Reversing incontinence requires skilful use of the knife, and each damaged girl requires four delicate operations. But relieving her shame is a far greater challenge.
"These young teenagers are stigmatised as witches because people think they are being punished by evil spirits for having done bad things," says Dr Ward. "They can't go to market, can't go on a bus, and because they are smelly people won't go near them. After surgery, these girls are transformed and put on good clothes and act like normal young women again, but when all that excitement has worn off, they have to face the fact that they are infertile.
"My greatest job is to persuade them that they are not bad people and that what happened to them occurred because they are poor, they have no medical services, and they could not get to hospital in time for a Caesarian section.
"There is no way to prevent these girls getting pregnant. There is no way to stop it - not at all. We tried to abolish childhood marriage, but it is in the Koran that a man can have four wives and marry them young."
Obstetric fistulas carry a 60 per cent chance of fatality in Nigeria. They are now unheard-of in developed countries, but were common throughout Europe and North America until the mid-20th century. The first surgery to repair a fistula was on a woman from the west of Ireland in the US 100 years ago.
There are two centres in Africa specialising in fistula repair - the first is Dr Ward's and the second is in Addis Ababa, Ethiopia. But the reality is that most victims, because of distance or cost, never get appropriate care because their families' resources are exhausted before they reach the centres.
"Medical services are at rock bottom; the situation is getting worse. There are few emergency services and doctors are poorly trained," says Dr Ward. "The services are just not there. Transportation in the middle of the night when a woman is in labour is just not possible in the dark. It's unimaginable what they suffer. By the time they get to hospital, they are half-dead. Their families bring them to hospital to die, because they do not want them to die at home, otherwise the in-laws would complain."
Nigeria has the highest maternal mortality rate in the world - 3,000 deaths per 300,000 births as of June 2001, or one in 100 deliveries, according to The Family Life Centre's statistics. The mortality rate is worsening by the month. Obstetric fistula has not had a high profile in the West. Far more attention has been paid to female circumcision, which has dominated media attention upon the area of reproduction and women's rights.
But Dr Ward says we've got it all wrong. Many Western women are horrified by the concept of female circumcision, where the clitoris and labia minora are surgically removed. But Dr Ward says that women don't mind female circumcision and willingly partake in it. It's not circumcision, but VVF and VRF that are actually "the worst thing that can happen to a woman", she says. It's impossible to disagree.
Dr Ward's own 42 years in Nigeria have been "very happy", she says. "It's wonderful to be able to return women to their dignity, because it is such an injustice the way these women are pushed around like cattle."
What's her budget? "What budget?" she laughs. The Irish Government have been very supportive, and, she says, have called her programme one of the best projects they have. Mobil oil has also made large donations to pay doctors' salaries. Dr Ward lives on eggs, bread and butter, fruit and vegetables. She is one of four qualified obstetricians with the Medical Missionaries of Mary, although she fears she may be one of the last. It takes an extraordinary person to spend 42 years of their life treating such a depressing condition while totally surrendering any personal comfort.
"The demands made on sister-doctors are too great," she says.
The Medical Missionaries of Mary: 087-9701891. Website: www.medical -missionaries.com