Every day, some 326 babies are born in North Carolina. Those babies and their mothers are fortunate—we live in a state with a strong health care system, and we have the benefit of first-rate hospitals, medical research, and pharmaceutical development right in our back yards.

For every 1,000 babies born in North Carolina, seven will die in infancy. This is seven too many, but in a global sense, we are far more fortunate than many other countries. In Mali, for instance, 78 of every 1,000 babies die before they reach their first birthdays.

And far too often, mothers fare little better than their lost children. Many women die in childbirth or suffer life-altering disabilities.

Imagine for a moment: After many long months of looking forward to the birth of your child, you suffer a prolonged, excruciating labor, and give birth to a stillborn baby. You are traumatized, both bodily and emotionally. Then you realize with horror that you are now chronically incontinent and prone to infections. Your family abandons you. You’re left to live alone, sick and unable to provide for yourself, on the fringes of your community. Your health and dignity have been stripped away.

Over 2 million women around the world are experiencing this right now, all because of a childbirth injury called obstetric fistula. A consequence of prolonged or obstructed labor, a fistula is a hole that forms between the vagina and the bladder and/or rectum. It will not usually heal on its own and can last for decades if left untreated.

We don’t hear much about fistula here in North Carolina, thanks largely to our strong health system. But many women across sub-Saharan Africa and Asia know it all too well.

The happy news is that obstetric fistula is entirely preventable. All it takes is a trained, observant health worker to recognize the danger signs and provide mothers with the care they need to deliver their babies—safe and alive.

And more happy news: When obstetric fistula does occur, it is almost always curable with a surgery to close the wound.

Why, then, do 2 million women continue to suffer from it?

Because many countries do not have the relative wealth of health workers that we enjoy in North Carolina. (Though even here, there are not enough nurse practitioners and other health workers to meet everyone’s needs). In fact, according to the World Health Organization, there is a global shortage of 7.2 million doctors, nurses, and midwives—the very health workers who can prevent fistulas from occurring.

For instance, in 2008, Mali had just one doctor with the skills to perform complex fistula repair surgeries. One doctor in a country that is home to 15.3 million inhabitants and is vaster than Texas and California combined.

That is why one North Carolina-based nonprofit, IntraHealth International, began training more fistula surgeons in Mali and working to get the word out to women with fistulas—many of whom are in remote areas and don’t even know their conditions can be treated—that help was on the way. After much suffering, these women had a chance at health, happiness, and dignity once more.

Now, through its new Restore Dignity campaign, IntraHealth is working to give even more women in Mali this chance. They are training more surgeons in more regions throughout the country, providing hundreds of fistula repair surgeries, establishing care centers to address women’s psycho-social needs, and fostering entrepreneurial opportunities so that, when they do rejoin their communities, recovering women can support themselves.

These are the kinds of lasting solutions that strengthen countries’ health systems for the long haul.

As Secretary-General Ban Ki-moon of the United Nations says: “Fistula is fully preventable when all women and girls have access to high-quality, comprehensive sexual and reproductive health services. Let us join forces to eliminate this global social injustice.”

Obstetric fistula is certainly an injustice we can eradicate. We have the solutions we need to transform the lives of millions of women around the world. But we must invest in those solutions.

This Saturday, May 23, is the International Day to End Obstetric Fistula. Let us take this opportunity to join forces, help more babies survive their births, and restore dignity for women in Mali and around the world.

To learn more, please visit the Restore Dignity campaign at www.intrahealth.org.

Diarahi, 27, is hopeful about her life.

Her tenacious spirit has wavered over the last twelve years, but somehow has never broken—not when she suffered from more than three days of obstructed labor and mourned the loss of her baby, not when weeks later she realized she could no longer control her bladder, and not when her husband shunned her. Not even when the grandmother who took her in passed away shortly thereafter.

Diarahi used to be among the two million women and girls worldwide who suffer from a devastating childbirth injury called obstetric fistula. Fistula is a preventable, treatable condition caused by prolonged, obstructed labor that leaves women with chronic incontinence of urine, feces, or both. It’s often accompanied by pain, nerve damage, kidney disorders, and infections.

The effects are not only physical. They are compounded by social isolation, depression, abandonment,  shame, and deepening poverty. Many women resort to begging.

Fistula is almost entirely preventable for women who have access to skilled health workers for prenatal care and assisted delivery.

Before developing fistula, Diarahi and her husband cultivated a cotton field in her village of Banco in the region of Kayes. After, she worked the fields alone, and her husband sold the harvest without sharing  any of the profits with her. When he eventually brought home a new wife, Diarahi left and took shelter with her grandmother.

A Condition of Social and Economic Inequities

Most fistulas occur among women and girls who live in poverty in countries that have significant gender-based social and economic inequities, where access to health workers is limited and health systems are weak.

Fistula is almost entirely preventable for women who have access to skilled health workers for prenatal care and assisted delivery, and who are supported by health systems that provide reliable emergency obstetric care, including cesarean sections.

Adolescents are more prone to fistulas as their bodies haven’t fully developed.

This is what happened to Diarahi. Her family had forced her to marry a cousin when she was just 15 years old. When she became pregnant, she received no prenatal care and was three days into an arduous labor before her brother-in-law arranged transportation to the closest health facility in Kita. Diarahi delivered her baby—who had already died—in the car en route.

Weeks later, when a health worker diagnosed her with obstetric fistula, she was told she’d need to travel to Bamako, the capital city, about 160 kilometers from her home for surgery. Her husband initially agreed, but then changed his mind because of the cost.

In Mali, an Ambitious and Feasible Goal of Zero Fistulas (Visons Zéro Cas)

The government of Mali is committed to “zero fistulas,” and we are proud at IntraHealth to be a key partner in this effort. We are working to restore dignity for the thousands of Malian women like Diarahi who suffer from the physical, psychological, social, and economic effects of this devastating condition. Our goal is to work alongside the government to end fistula and establish a holistic, sustainable model of care that goes beyond treatment to enable women to rebuild their lives.

This takes a health systems-approach.

Three weeks after my operation, I no longer leaked urine and the doctors confirmed that I was completely healed.

When we first partnered with the government in Mali on fistula in 2008, there was less than a handful of Malian surgeons in the country able to perform  the surgery. Since then, we have expanded local capacity to prevent and treat fistula, decentralized services to be closer to where women and girls with fistula are living, and assisted community-based organizations’ efforts to reduce stigma, end child marriage, and recruit and support women who need fistula repair to re-integrate into their families and communities.

We conduct on-the-job training for surgical teams in their normal work settings through monthly fistula campaigns. At each one, about 30 women and girls have their fistulas surgically repaired. They also receive treatment for other conditions like malnutrition or infections. There are now nine Malian surgeons qualified to provide basic repair surgeries at two hospitals in Bamako and three regional hospitals. Twenty additional surgeons are undergoing training.

Mali can now reach about 400 women annually, but given the insufficient supply of qualified health workers, a weak health system, and ongoing insecurity in the north, reaching the current backlog of women and girls living with fistula plus the estimated 2,000 women at risk every year in Mali remains unsurmountable.

The Road to Independence

After Diarahi’s grandmother passed away, her uncle took her to Bamako, where she learned about one of our campaigns at Kayes Hospital. There, she could receive treatment free of charge.

“Thanks to God, upon arriving at the hospital I found a second family and was well taken care of day and night,” says Diarahi. “Three weeks after my operation, I no longer leaked urine and the doctors confirmed that I was completely healed.”

Diarahi intends to return to her family home, restart her social life in the community, and sell firewood—a business she started alongside her grandmother—to ensure economic independence and her ability to influence decisions that affect her health and her community.

It is a tragedy that the most vulnerable among us—women and girls representing the most marginalized and underserved groups—continue to suffer needlessly. We know what it takes to have strong and resilient health systems staffed with health workers who can prevent fistula. We can also offer urgently needed services like psychosocial counseling and economic livelihood training to help women and girls already affected.

It is possible to end fistula. The International Day to End Obstetric Fistula is May 23. IntraHealth joins this global call for renewed commitment, action, and investment.

Progress is possible. Zero new cases is possible. Dignity is possible.

IntraHealth’s work addressing fistula in Mali is currently conducted through the USAID-funded Capacity Building for Fistula Treatment and Prevention in Mali and is extended by IntraHealth’s 2014 Clinton Global Initiative (CGI) commitment. IntraHealth’s current partners in this CGI commitment include USAID/Mali, Orange Mali Foundation, UNFPA/Mali, Direct Relief, SamaHope, Inner Wheel Mali, the Peter C. Alderman Foundation, and three Malian NGOs (AMCP, IAMANEH, and GREFFA).This work is also made possible with private donations. Photo by Oumou H. Saade for Fistula Mali and IntraHealth International.

Malado Traoré had a lot of firsts last month. In early May, Malado learned her condition could be treated, something she had never been told in the 30-some years she lived with an obstetric fistula. Early last week, she received her first, and hopefully last, fistula repair surgery at Koulikoro Referral Health Center (or CSRef). And a few days later, she met Aminata Maïga Keita, the First Lady of Mali.

In a celebration of the International Day to End Obstetric Fistula, the First Lady visited fistula clients bedside in Koulikoro.

Obstetric fistula is a childbirth injury caused by prolonged, obstructed labor that leaves women with an opening—or fistula—between the birth canal and the bladder and/or rectum. It affects nearly two million women worldwide. The majority of fistula clients are women who are illiterate and from disadvantaged backgrounds. Their plight does not often draw crowds. Their voices are rarely heard. But that is changing.

A Battle for Women

Aware of the magnitude of the problem both globally (between 50,000 and 100,000 new cases each year) and in Mali (between 1,800 and 2,400 new cases each year), the First Lady is giving a voice to the voiceless. She spoke at the ceremony IntraHealth held prior to visiting the thirty women who had just been operated on.

“Before it can be a battle for all,” the First Lady said, “fistula must be a battle for women.” I agree. As an American woman, I am protected from this condition because of access to family planning and emergency obstetric care. This condition is associated with poverty and limited decision-making power, and I am drawn to stand by these women.

Before it can be a battle for all, fistula must be a battle for women.

Of the 30 women participating in the fistula repair campaign in Koulikoro, fewer than half have husbands who stood by them. Fistula causes chronic incontinence of urine, feces, or both. Women with the condition are often abandoned, ostracized by society, and divorced.

Malado developed her fistula following prolonged labor during her first pregnancy, and, as is often the case, her baby was stillborn. She was lucky enough to have one daughter after she developed the fistula, and this daughter’s daughter—her granddaughter—learned about the repair campaign and brought her to the Koulikoro CSRef. No one in her village knew the condition was treatable. Everyone there will be shocked when she comes home cured, she says.

Bringing a fistula campaign to Koulikoro CSRef marks a milestone that could not have happened without synergy across a variety of partners and champions. This repair campaign was not only the first campaign in Koulikoro, it was the first campaign in a CSRef rather than a national or regional hospital. This marked an important step in bringing fistula services closer to the women who need them.

A Road Paved by Many

The road that led Malado and the 29 other women to treatment in Koulikoro was paved by many.

There is a time for sickness, and there is a time to be healed.

USAID funds our Fistula Mali project that leads campaigns both to heal fistula clients and build the capacity of surgeons and their surgical teams to conduct routine fistula repairs. Through the campaigns, the surgeons receive training at their own health facilities. Professor Ouattara—a national surgical trainer who has championed fistula repair for over 25 years—is currently helping IntraHealth train more than 20 new surgeons.

The Koulikoro Regional Health Director—the only female regional health director in Mali—advocated for bringing the services to her region, and the ministry of health was open to the type of institutional task-shifting that is bringing these services to lower level facilities throughout the country.

The clients would never have been identified without the deep engagement of the AMCP, a local community health NGO working in Koulikoro. AMCP educated communities about fistula and recruited the women for this campaign. Inner Wheel Mali, a women’s organization, provided the women with dignity kits – a collection of fabric for clothing, soap, bleach, and other hygiene products for the women.

The commitment of these partners and champions will help end fistula in Koulikoro—and ultimately in Mali. “Our collective efforts will always be stronger than the sum of our individual efforts,” stated Dr. Cheick Touré, IntraHealth’s country director in Mali.

Toward the end of the ceremony, the First Lady gave one of Inner Wheel’s dignity kits to a woman suffering from fistula. The client thanked the First Lady for her dedication and for coming to visit them in Koulikoro. The women were flattered and reassured by the First Lady’s visit. They talked of feeling certain that her involvement would not stop there and their belief in her commitment to fight for the goal of zero cases of fistula in Mali.

“There is a time for sickness, and there is a time to be healed,” said Malado.

Thirty years is too long for sickness. It is time for Mali to take care of its most vulnerable women, and finally Malado’s time to be healed.