YAOUNDE, July 18 (Thomson Reuters Foundation) - From training community ambassadors to encourage women with fistula to seek treatment, to cash for transport to hospitals, African nations are finding new ways to deal with the agonising childbirth injury that ruins the lives of millions of girls and women.
In Western countries, obstetric fistula was eradicated more than a century ago, and is today almost unheard of.
Yet despite being preventable, across the developing world, more than 2 million girls and women still suffer from the painful, debilitating condition.
Almost all of them live in poverty in remote areas with little or no access to health care and often abandoned by their communities - the modern day equivalent of lepers who were ostracised and isolated.
Women who birth at home, often in far-flung rural areas where hospitals are too far away or expensive to reach, are especially at risk of obstetric fistula - a hole that develops between the birth canal and bladder or rectum, caused by prolonged, obstructed labour.
Women are left leaking urine, faeces or both.
"People tell me: here, the women are witches," said Marie Sebo, a community health worker from eastern Cameroon who helps fistula victims access free surgery.
"A woman who has fistula is completely isolated. People refuse even to eat with her. Her husband abandons her."
But in recent years, local and international organisations, with support from African governments, have launched a series of initiatives to try to bring the scourge of fistula to an end.
Mobile phones can play a role in both fistula diagnosis and repair.
Cost is one of the biggest barriers to accessing treatment - in Cameroon, for example, each fistula repair is priced between 300,000 and 600,000 Central African francs ($520-$1,050).
But today, in Tanzania and Kenya, the cellphone-based money transfer service M-PESA covers upfront transportation costs for women who otherwise would not be able to pay for surgery, as part of programmes funded by Western governments and NGOs.
And in Burundi, Kenya, Malawi, Sierra Leone and other countries, telephone hotlines connect women in remote locations to medical information and care.
Initiatives vary from country to country, said Lois Boyle from the Freedom From Fistula Foundation, a UK charity.
"We use M-PESA in Kenya a lot to help women access free treatment, but for example in Sierra Leone, almost none of our patients have a mobile phone," she said.
In Sierra Leone, instead of transferring credit, the group reimburses the women at the end of their journeys, also providing free accommodation and meals before and after surgery.
PREVENTION BETTER THAN CURE
Djenna Ousmane, 18, developed fistula while giving birth after a forced marriage at the age of just 14.
"My stepmother said she was afraid that if I didn't get married quickly, I would become a prostitute," she told the Thomson Reuters Foundation in a hospital in Batouri in eastern Cameroon.
Last month, Ousmane underwent a successful, free fistula repair operation funded by the United Nations Population Fund (UNFPA) and Fondation Orange.
But while such operations are necessary to enable girls and women to return to their normal lives, prevention is better than cure, experts say.
With childbirth at a young age a key cause of fistula, "patient ambassadors" - women and girls who have been cured - are being trained to inform others of the dangers of early pregnancy, give advice on safe deliveries, and help refer fistula cases for treatment.
In Ethiopia, the Healing Hands of Joy group has trained 524 ambassadors, who have reached more than 13,000 pregnant women, according to a 2016 U.N. report.
Freedom from Fistula launched a similar scheme in Malawi two years ago.
"We provide them with a bike, a mobile phone and cover their transport costs," said Boyle. In the past year, the ambassadors were responsible for bringing in half of all patients.
Men also being enlisted to help drive change.
The UNFPA trains male volunteers as part of so-called "husband schools" in different African countries.
Going door-to-door, the men talk to their neighbours about anything from the dangerous consequences of child marriage to encouraging families to save money for prenatal checks.
"When we come across fistula, we tell people it's not witchcraft - they need to get to a hospital," said Suleiman Blaise, a volunteer in eastern Cameroon.
In Kenya, the "Action on Fistula" programme, launched in 2014, aims to tackle the problem nationwide. Setting out to help 1,200 women, today it has treated more than 2,500.
Kate Grant, CEO of the Fistula Foundation which funds the programme, said a network of six hospitals had been built around high population areas, where treatment is offered all year round. Surgeons are also being trained.
The initiative works with community groups around the country, as well as a national women's football team, to "kick fistula out of Kenya". The programme is now being replicated in Zambia.
In Ethiopia, after treatment at the Hamlin Fistula Hospital, the world's leading hospital for the condition, women go to a purpose-built village where they learn vocational skills and how to set up their own businesses, said Muna Abdullah, a health system specialist with the UNFPA.
The hospital, set up by Nobel Prize-nominated surgeon Catherine Hamlin, also trains fistula surgeons and runs an internationally accredited midwifery school.
"The Hamlin Fistula Hospital has come closest to eradicating it in one country - but that's 30 years of work," said Boyle, urging African governments to invest more in maternal health.
While there may be no silver bullet, Boyle is optimistic that fistula can be eradicated in Africa.
"Look at... the US, the UK - they've done it," she said.
Reporting by Inna Lazareva; editing by Megan Rowling.
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