"I was depressed for four months," Mubarak said. "Everyone around me could smell my urine and I could do nothing about it. I was very embarrassed and I felt very alone."

Smiling as she breast-fed her healthy baby daughter Sarah, she added: "I am happy. Now that the smell is gone, I can go back and see my people and everything will be the way it was before."

Tareeq Ahmed, a gynaecologist at Abbo's Fistula Centre in Khartoum hospital who assisted in Mubarak's surgery, said the surgery had been difficult.

"The fistula was very large, and it had been neglected for four months. So the tissue of the bladder and surrounding areas was dead. Most of it had to be cut away," he explained.

Despite the complexity of the surgery, however, it was a success.

Mubarak is of the 20 new patients that come to the centre each month. They come from all over Sudan in search of treatment for obstetric fistula - a rupture of tissue that results in an opening between the vagina and the bladder or the rectum, or both, which is reparable only with surgery.

Most often, it occurs when a woman endures obstructed labour, often for several days, without appropriate medical care. The lack of medical attention and trauma affects the baby as well, and many die as a result.

The condition, which is caused by the pressure of the baby's head on the mother's bladder or rectum, leaves the mother unable to control her urine or faeces and vulnerable to infections.

Curing fistula

According to the United Nations Population Fund (UNFPA), factors that contribute to the fistula problem are early pregnancy, poverty, illiteracy, gender inequality and limited geographic, financial and sociocultural access to family planning and emergency obstetric care.

Abd el Rahman, the medical director of the centre and a fistula surgeon, explained that women affected by this condition were usually young, poor and living in rural areas. As a result, they neither had access or transport to health facilities nor the money to pay for the services.

"Most of the patients that come to us are young girls. Because their bodies have not yet matured, they are more susceptible to difficulties during labour," Rahman noted.

A 2003 demographic health survey of Sudan revealed that 63 percent of girls between the ages of nine and 13 in rural areas are married. Some of these suffer from fistula.

"When they come to us, they are desperate. They have this bad smell and have been humiliated by the people in their communities," he added.

Abbo's Fistula Centre is the second largest fistula treatment facility in Africa and the Middle East. Abbo Hassan Abbo, a "pioneer of fistula surgery in Sudan" since the 1970s, founded the facility in 1992.

The centre, which has treated about 2,000 patients, is the only clinic treating fistula in Sudan. It offers surgery and post-operative care free of charge. The staff, which consists of six surgeons, four medical officers, five officers and two assistant anaesthetists, work several shifts a week on a purely voluntary basis.

Women who come to the centre usually have to wait about two weeks to receive treatment. The recuperation period ranges from two weeks to two months.

"It is difficult to care for all the patients because we have no regular funding and no sponsoring organisation," Rahman said. "But we do this because these are our poor brothers and sisters and if we don't help them, nobody will."

Prevention

"It is a miserable, heartbreaking condition, and these women are usually neglected by their families. They are not included in the social life, cannot go into public places because all the time the smell like urine," Rogaia Abuelgasim, UNFPA Sudan programme officer for reproductive health, said.

In some cases, Abuelgasim added, the women were abandoned by their husbands and forced to live alone, away from the community.

In 2003, UNFPA began an international campaign to treat, prevent and reintegrate women affected with fistula back into their communities.

"If you focus on perfecting the methods of surgery, buying expensive equipment or building big hospitals then the problem will just continue. We need to stop the problem in the beginning," Abuelgasim said.

In order to prevent obstetric fistula, UNFPA, along with the Sudanese government, had assisted in the training of 500 midwives, who would help women living in villages without access to hospitals or transportation.

"The midwives are also there to diagnose and assist in the obstructed labour or if they cannot, they will get them the necessary medical care that they need before the fistula is developed. This will help to prevent fistula rather than to cure it. Prevention is much cheaper than the fistula operation itself," Abuelgasim said.

Although the staff of the fistula centre supported prevention but insisted that surgery was crucial in those cases where prevention was not an option.

"Abbo opened the centre so that fistula patients would not have to live in the shadows of anyone. He wanted them to be cured and to go back to their societies to share in the building of a bright future," Rahman said.

The World Health Organization estimates that at least two million girls and women are currently living with obstetric fistula throughout the world, with an estimated 50,000 to 100,000 new cases occurring each year.