TULEAR, Madagascar - When she was 20 years old, Alphonsina Zara was pregnant with her first child. After three days of excruciating labour, though she was in a health centre, her baby was stillborn.
Doctors found that she had developed a hole in her birth canal, a severe medical condition called obstetric fistula. She not only lost her baby, it disrupted her life for the next 14 years.
The injury is usually caused by complications during childbirth, such as a prolonged labour that can cause muscle tissues to tear, creating a hole in the birth canal.
If left untreated - as it is for tens of thousands of women - it causes them to urinate or defecate continuously.
Fistula can occur when care is inadequate, when women give birth at home, at an early age, or with traditional healers.
"It is really a problem of poverty," said Edwige Ravaomanana of the UN Population Fund, and a simple and cheap operation could turn around many lives.
The condition was eradicated in wealthy countries in the 19th century, but the World Health Organisation says it still afflicts two million women in Africa and developing Asia.
"It's also because women can't go to a (clinic). Maybe because of the distance, maybe because they don't know," said Ravaomanana. "The women who live far try to give birth with a matron," a traditional birth attendant.
Madagascar, one of the world's poorest countries, alone accounts for 2,000 of the more than 50,000 new fistula cases each year around the globe, according to UN data.
Eighty-one per cent of the population on this island nation off southeast Africa live on less than US$1.25 (S$1.56) a day.
Health facilities are widely scattered across the country, the world's fourth-largest island where 80 per cent of the population lives in rural areas.
About 65 per cent of them reside more than 10 kilometres (six miles) from their nearest health centre, according to the health ministry.
That distance often is travelled by foot because Madagascar has few roads and little transport, forcing women to give birth at home with traditional midwives.
Money she doesn't have
Widespread fistula is also blamed on early pregnancy, which is very common in Madagascar.
"It's also the tradition. Starting from 18, they are considered old. At 30, a woman can already have 10 children," Ravaomanana said.
A surgical procedure that costs about US$300 can close the hole and return a woman's life back to normal.
But until 2011, only two doctors in Madagascar could perform the operation.
A 300,000-euro (S$466,520) campaign by the health ministry and the UN Population Fund has trained 14 more, and performed 106 operations in the tourist beach town of Tulear.
Alphonsina was one of them.
In the soft red sun of a winter afternoon, Alphonsina said her baby's father left her because of the constant smell of urine.
"People were talking about me, they were saying I smell bad. When I was getting close to people, they would leave," Alphonsina said with a shy voice.
Fortunately, her parents did not reject her. She lived with them and worked as a fish vendor for years. She consulted the nearest hospital, which eventually sent her to Tulear.
"When I came here, the doctor made me come every three months and still didn't heal me," she said. In Tulear, she started selling fabric.
"Where I live right now, I'm making friends, not like before. Though I still don't have a lot of friends," Alphonsina said. She lives in a small grass hut on a sandy road, has a mattress and very few objects in her house, which she rents for about US$5 a month.
Her life has improved, but she's not cured, having the misfortune to be among the 10 per cent of women who aren't completely healed after the surgery.
Alphonsina's doctor said she needs another operation which, with medicine, will cost US$100 - money that she doesn't have.