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In Ruth Del Fulani's native nigeria, where labor in childbirth can stretch on for a week and trained birth attendants rarely oversee deliveries, her two days of labor seemed routine.

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But the toll was horrible. The child's head stuck in her pelvis. This "obstructed labor" cut off blood supply to delicate tissues until the tissues died.

Del Fulani delivered a stillborn baby and then discovered she could no longer control her urine. Del Fulani had suffered a vesicovaginal fistula (VVF), a hole between her vagina and bladder caused by unproductive labor. The fistula left her incontinent and smelling like a sewer.

Obstetric fistula is almost as old as childbirth. It has all but disappeared in wealthier nations, where cesarean sections are readily available during difficult labor.

But VVF remains a complex, intractable health-care problem in the developing world, especially in sub-Saharan Africa. For tens of thousands of women like Del Fulani, the injury becomes the defining moment in their lives. It relegates them to the ranks of the living dead.

Childbirth-related injuries are cruelly effective in destroying a woman's ability to do traditional duties, from manual labor to producing a male heir. According to the Worldwide Fistula Fund, a charitable organization based in St. Louis, Missouri, "These women become social outcasts, isolated from family, friends, village society, and religious life."

In the poorest countries, women and girls often have no say concerning when and whom they marry. Many contract VVF as adolescent brides, their immature bodies unable to handle the demands of childbirth.

In industrialized countries, 1 in 4,100 women die in childbirth. According to UNICEF studies, sub-Saharan Africa's maternal mortality rate is 1 in 13. The United Nations estimates between 50,000 and 100,000 new cases of VVF each year. But missionary urologist Steve Arrowsmith, VVF program director for Tyler, Texas-based Mercy Ships, believes the actual number of fistula patients is significantly higher due to almost nonexistent record-keeping and the embarrassing nature of the affliction.

In many parts of the world, it means little to say that fistulas are preventable. Roads from a village to a hospital may not exist or may be impassable during the rainy season. The hospital may lack electricity and surgical supplies.

Worldwide, only six hospitals specialize in fistula repair. In the 1990s, Arrowsmith served in Ethiopia's Addis Ababa Fistula Hospital, where 1,200 such surgeries are performed annually. Mercy Ships performs 450 fistula surgeries annually at its Sierra Leone clinic and on the floating hospital Anastasis. Women in many countries have no access to the surgery.

Although surgery is crucial to restoring the lives of patients, their needs extend far beyond the physical. Their babies are stillborn more than 70 percent of the time. Scar tissue usually renders the women barren and often unable to have sex. In Del Fulani's case, her husband, like most men whose wives suffer from fistula, divorced her. Everyone but Del Fulani's grandmother and her church abandoned her.

Del Fulani is a Christian. Muslims with fistula suffer an additional censure. Since Islam considers these women unclean, they are forbidden from mosque worship, utterly cutting them off from society.

These women are why Carolyn Kirschner, a gynecologic oncologist, and her husband, family physician Greg, came to Nigeria as SIM missionaries in 1995. Carolyn began working at the Evangel VVF Centre associated with the Evangelical Church of West Africa's Evangel Hospital in the Plateau State city of Jos. Founded in 1992 by Arrowsmith, the 50-bed clinic annually performs 350 surgeries free of charge, mainly on women from northern Nigeria.

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December 2005, Vol. 49, No. 12