Zinder, NIGER%u2013For two days, 14-year-old Sari Zainabou pushed and pushed, her narrow body stubbornly refusing her baby safe passage into the world. At a clinic in her village outside the Sahelian trading town of Zinder, the women could do little more than wipe Sari's brow and encourage her to keep trying.

When the baby boy finally emerged, he was dead. And after two solid days of labour, with her baby's head pushed up against her pelvic bone, Sari was left with necrotic tissue that ate a hole in the lining separating her vagina from her bladder. The result was a constant trickle of urine splashing down at the grieving girl's feet.

Now 15, Sari sits in the courtyard of the Central Maternity Hospital waiting for a second surgery to finally repair the fistula.

It's a condition the United Nations hopes to erase from the developing world in the next seven years, spending $20 million (U.S.) on prevention, education and training in 40 countries and enlisting the help of celebrities like Australian singer Natalie Imbruglia to drum up attention in the West.

Eradication is not likely to happen unless the more worrying problem of child marriage is solved, says Dr. Lucien Djangnikpo, one of six doctors in Niger trained to surgically repair fistulas. Judged the poorest country on the planet by the United Nations in 2006, more than half of Niger's girls are married before the age of 15.

Nearly 90 per cent are pregnant before the age of 18. In a country where malnutrition and difficult living combine to create small, sinewy women, the conditions are ripe for fistula. "The body isn't mature enough to handle (giving birth)," Djangnikpo says.

In developed countries, fistula is mostly confined to complications from colon cancer surgery or botched hysterectomies. But in the developing world, where women suffer without proper medical care, the condition is devastatingly common. About 2 million women worldwide are thought to suffer the embarrassing incontinence that fistula brings.

Niger is estimated to have one of the highest rates in the world: one to two of every thousand births in the country result in a permanently disfiguring fistula.

Girls need the chance to grow into women before being pressed into pregnancy, Djangnikpo says, otherwise they will continue to suffer fistula no matter how much money is spent on the problem.

For Sari, that means a foley catheter tube now stretches from her bladder into a pink plastic bucket at her feet. Still, a smile brightens her face.

After an agonizing birth and a year of embarrassing smells and soiled wraps, Zainabou knows she is six weeks away from returning to her husband. She says she can't wait to see him and hopes to conceive again.

That's the real problem, Djangnikpo says. There is no law against teenaged marriage in Niger. Many of the women sitting clustered in the shade of a tree outside his office were married before they experienced their first period. Their first pregnancies often coincided with the arrival of puberty.

That leads to patients like Djoumer Habou, who had a fistula repaired six years ago. Now 23, with tight braids and an intricate pattern of dark facial scars, she lies on a gurney in the hallway of the hospital, a plastic tube snaking from her arm to a clear bag of pain drugs.

Beneath her brightly coloured wrap is a bandage covering an incision that runs length of her abdomen. Nestled by her left side is a tiny baby boy, born the night before by Caesarean section. Habou's first two children died; if this baby survives his first seven days, he will be named by his father.

For women with fistula who are culturally accustomed to wanting big families, a costly Caesarean section is the only way to ensure a safe birth.

"In Africa, the women are in the bush, in the country, a long way from a hospital," Djangnikpo says, "She's in difficulty and it's 15 to 20 kilometres just to get to the road. At the road, it's still a two- to three-hour wait to find a vehicle to come to the hospital."

Two dusty ambulances sit outside his office, each immobilized by a flat tire. Women like Zainabou are completely isolated if they aren't treated, says nurse Soueba Koudou.

"They live with the odour from 16 to 60, every day, until the end of their days," says Djangnikpo. The women are shunned, the smell and soiled clothes turning away their husbands. They're perceived as unclean, leaving them unable to help cook or care for children.

"Her husband cannot have a normal life with her and one to two years later, he chases the woman away," he explains. "She returns to her family and her family, after four to five years, they also chase her away. She finds herself alone with this problem. She cannot work. She's excluded," he says.

In the past decade, the clinic has treated about 650 women, averaging about three women per week. The operation %u2013 costing about $300 (U.S.) and paid for by a UN program %u2013 is relatively simple and involves removing scar tissue and sewing up the fistula hole.

"We give them back their dignity," Djangnikpo says simply.

A few years ago, he started a non-governmental organization called Solidarite, which gives the women a $125 microcredit loan and the skills to make soap to start a business to support themselves.

Otherwise, he says, the women were being surgically repaired, then working as prostitutes.

"It's a reality in Niger, and no one is thinking about it," he says.

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