Daughters as young as 12 in the villages surrounding Antsohihy, the capital of Sofia Region, in Madagascar's remote, traditional north, often suffer the harmful consequences of falling pregnant and giving birth too young when parents accept zebus (cattle) or cash as a dowry.
Noeline Razafindradera, 16, wishes she had listened to the warnings of her mother and her teachers. Instead, she went out with one of the boys she met at school and became pregnant. After going into labour, she waited two days before leaving her village of Ambongabe and then travelled two more days by ox-cart to reach the Baptist Good Hope Hospital in the town of Mandritsara. By then, the baby was dead and it had to be removed.
Three months later, Razafindradera is back at the hospital for a procedure to repair an obstetric fistula - a severe medical condition in which a hole (fistula) develops between the bladder and the vagina, or between the rectum and the vagina - caused by difficult delivery. The surgeon performs the operation for a subsidized price of 10,000 ariary (US$5 dollars).
"Many young girls have this problem," said hospital director and surgeon Adrien Ralimiarison. "Girls as young as 13 become pregnant. The pelvis of the girl is too small, so during delivery the head of the baby gets stuck. As it takes a long time to reach a hospital, the bladder can then erupt. After the delivery, these girls are often rejected because of the smell of leaking urine and the additional expense of soap and pads. In some villages, people even believe that these women are evil. Depression often follows."
This is confirmed by his next patient, Rasoanirina, 21, who also developed the condition after a protracted labour and a three-day journey to the hospital from her village. "People reject you, they don't want to stay near you because of the smell," she said.
At the Good Hope Hospital, a relative haven in the midst of a neglected and inadequate health sector, Yolande Zafindraivo is the only gynaecologist in this region of over 1 million inhabitants. "There are no doctors or trained midwives in the villages, so people deliver with the help of the village matron, the elder woman of the village who has knowledge of traditional medicine," she told IRIN. "It's dangerous - the matrons give the girls traditional herbs to induce the baby, [but] these are very strong and can cause a shock reaction in the body."
Zafindraivo concentrates on saving the mothers, and says she succeeds most of the time. Nonetheless, figures from the UN Population Fund (UNFPA) reveal that the Sofia region has one of the highest maternal death rates in the country, with 1 in every 10 mothers dying during childbirth.
Nationwide, 3,750 mothers and 16,500 babies die each year during or soon after delivery. Another 75,000 women experience medical problems as a result of childbirth, and an estimated 40 percent of these women receive insufficient care.
"These are the official hospital and health clinic figures. We don't know how many die at home with the matrons," said Zafindraivo. "Often people prefer the matrons, as they think hospitals are expensive and they know these women."
Hospitals in the region, as well as UNFPA, are training community health workers and matrons to avoid delays in getting women in need of care during childbirth to a hospital. Dr Jean Francois Xavier of UNFPA said the goal was to reduce the three kinds of delay: leaving home, reaching a hospital, and finding care once they arrive.
"We try to shorten all this lost time by building capacity in the community," he said. "This includes training for the matrons, who are taught that a woman in labour should not see the sun rise twice. After 24 hours, she needs to be sent on to a health clinic or hospital. We also support the network of clinics and maternity wards, where women can deliver for free. There we train community health workers and provide kits for delivery and for caesarean sections."
This system worked in the case of Volasaina Ratongarizafy, 19, who is recovering from a caesarean section after coming by car from Port Berger, 122km to the south of Antsohihy. The midwife sent Ratongarizafy to the hospital after she had been in labour for two days, and she waited only an hour to be operated on.
UNFPA is trying to reach more young people with birth control. Madeleine Razanajafy, a health worker at the maternity clinic in Antsohihy said girls rarely used birth control once they marry. "Often, the husbands don't want their wives to use birth control… [they think] it opens the way to promiscuity [for the wives]," she said.
Reaching girls before they become sexually active is also not easy because many leave school early, said Xavier. "After they have a baby, they give the child to the grandparents to raise - this problem puts pressure on society everywhere."
In an effort to overcome some of the obstacles, UNFPA has built a special clinic for young people on the premises of the maternity clinic in Antsohihy, where it supplies birth control options that last several months, such as hormone patches, injections or intra-uterine devices (IUDs).
Local NGOs, like Vilavila, are also training young volunteers to talk to their peers about HIV, sexually transmitted infections (STIs), and birth control, while village elders lead group discussions with parents to try to counter the custom of trading young girls for cows or money.
"These parents are poor, so it's hard for them to refuse - sometimes they are offered as much as 2 million ariary ($1,000)," said Vilavila director Piantoni Rabarison. "We show movies and have discussions with them. Often, they admit they hadn't thought about the effect their actions could have on the young girls."
At the New Hope Hospital, surgeon Ralimiarison asks his patients to reach out to other girls through a radio programme. "I can say many things, and I regularly do, but these girls are my ambassadors. They can tell their peers to be careful, to make sure that they don't fall pregnant."