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RACHEL MARTIN, host:

We're going to talk now about a health condition you may not ever have heard of, if you haven't gone through childbirth, but it cripples the lives of hundreds of thousands of women, especially in Ethiopia. It's called fistula, and it's an affliction that strikes pregnant women who spend days and days in labor.

They usually lose the baby if there are complications, which is bad enough, but then they suffer a tear in the birth canal which causes chronic incontinence. The smell of leaking urine or feces is constant and humiliating. Women are made into social pariahs, outcasts, in their communities. The thing is, a simple surgery can fix it and give them their lives back, but many women don't even know that option exists.

A new documentary follows the plight of three Ethiopian women who make a harrowing journey, crossing miles on foot, to make it to the only clinic in their country that can cure them. Joining us here in studio is the producer and director of the film "A Walk to Beautiful," Mary Olive Smith. She spent more than two years in Ethiopia making this heartbreaking film for New York-based Ingle Entertainment and her film airs tonight on PBS's NOVA.

Mary Olive, thanks for coming in. We appreciate it.

Ms. MARY OLIVE SMITH (Director, "A Walk to Beautiful"): Thank you.

MARTIN: So your film deals with the subject most people wouldn't hear about in the developed world. When people go through complicated labors if something like this happens, there's a quick surgery that's done to repair it, correct?

Ms. SMITH: Well, there's a quick surgery that's done to prevent it. Women who are in obstructed labor for more than - I'm not sure how long we let it go in this country, but five percent of all women in the world do have obstructed labor. Even though we have a tendency - some people believe - to have too many cesareans in this country, it's the very thing that will save a person's life in many parts of the world, and it's completely unobtainable for them.

MARTIN: Let's talk a little - we briefly outlined what this is, but for people who are just hearing about it for the first time, explain what fistula is.

Ms. SMITH: It's - fistula is technically a hole between an internal organ and the outside world. So we're talking about obstetric fistula here, and that's a fistula that's caused from prolonged, unrelieved, obstructed labor, and these women who maybe are in labor anywhere from two to ten days. A third of women in Ethiopia in obstructed labor die.

So these are women who've survived and although if you speak to them many of them might have preferred to die, because as you said, the life they're left with usually is one of isolation and shame. They're stigmatized and they live alone, often behind their parents' home in a shack. They don't mingle with other people. They don't - they women can't go to the well, which is where all the socializing happens. And they just feel completely hopeless and useless.

MARTIN: Are the rates higher in Ethiopia? Why Ethiopia?

Ms. SMITH: No, actually, the highest number of obstetric fistula is in Nigeria. But it's high in all the developing countries of the world, primarily in Africa and Southeast Asia. They have less of it in Latin America, probably because there are better roads, so even if you're far from a hospital, there's a way to get to one.

MARTIN: It's a condition, as you said, that makes many women outcasts in their communities and you profile one woman in the film named Iau (ph). She had a stillborn child, and then she got fistula. Her husband kicked her out and married someone else. Even her own mother isolates her in a shack behind the house out of shame and disgust. We've got a clip from the cofounder of the Addis Ababa Fistula Hospital, Dr. Catherine Hamlin, who's in the film. Here she is describing the experience for women like Iau, after a long and painful process.

(Soundbite of documentary "A Walk to Beautiful")

Dr. CATHERINE HAMLIN (Cofounder, Addis Ababa Fistula Hospital): By that time, the little girl is exhausted, dehydrated, and she finally pushes out a dead baby. But she wakes up to a worse horror.

Dr. AMBAYE WOLDE MICHAEL (Surgeon, Addis Ababa Fistula Hospital): The fistula presents not only physical trauma they are suffering of, they are social and psychological.

Dr. HAMLIN: Her life is ruined, so they'll build her a little hut outside, and there she will stay 'til death.

MARTIN: I mean, sometimes these women, they're girls, which is part of the problem, right?

Ms. SMITH: Oh, yeah.

MARTIN: That is why their labor can be so long is that they're sometimes, you know, 12 years old, 13 years old.

Ms. SMITH: That's right. One of the contributing factors is early marriage. In countries like Ethiopia, girls are often married as early as eight, nine years old, maybe having intercourse a couple of years after that, and get pregnant pretty quickly. It's strange to me that you can get pregnant when you're that small, but you compound this with the fact that, in Ethiopia, at least, many of them are undernourished. So even though we'd all think you know, age 13, 14 would be too young to have a baby, it especially is for girls who are not fully grown and whose hips are very small.

MARTIN: And they also, women in those communities, are doing so much manual labor, right? This also affects their physical wellbeing.

Ms. SMITH: Exactly. I mean, they may get enough food for to kind of life that we live, but when you are burning thousands of calories a day - well, thousands, a few thousand...

MIKE PESCA, host:

Yeah.

Ms. SMITH: Carrying water and sticks and really doing a lot of heavy, heavy labor and walking. From age two up, they say, these women and girls are really working hard.

PESCA: If a woman has developed the fistula not on her first child, and so she already has children, but then is shunned, what happens to her children? Are they adopted by someone else, or...?

Ms. SMITH: Well, that's a good question and it's important to understand that fistula does occur in about 44 countries. It's around that. You can actually look at the United Nations Population Fund website. It - campaign to end fistula, the campaign to end fistula will tell you about the international statistics. So I really only have experience in one country, in Ethiopia, although I did do some filming in Niger for another program...

MARTIN: But the situation in Ethiopia, if women have other children, did you see...

Ms. SMITH: Right...

MARTIN: What happened to them?

Ms. SMITH: Well, one of the women who was not in the NOVA version, but in our feature-length version, which was released in festivals and had a theatrical release, she had five children prior to getting obstetric fistula. She was 38, certainly capable of having a child, but who knows what happened? Maybe a breach birth, and her sixth child died and she came down with fistula.

She was not - her husband left her, but she had a strong extended family who stayed by and helped her and helped take care of the kids. Her oldest daughter actually came home and took care of the kids. So, in other situations, I would imagine, that the mother, sisters, would end up helping take care of the family. These countries, you know, there's usually a big extended family and they take care of each other.

MARTIN: Let's talk about this surgery. I mean, some of the people in your film are the founders of this hospital. It's the one hospital that focuses on this condition in Ethiopia. What is the complexity level of this surgery? What's actually happening?

Ms. SMITH: It can be anything from a simple one- to one-and-a-half-hour surgery, where you've got an epidural, and they literally can sew up this hole that's, for Iau, was about two centimeters wide. That sounds horrific, but wasn't real complicated to repair. But then you have the more complicated surgeries, where women have lost a lot of the vagina wall. They often lose the urethra and sometimes the entire bladder can be destroyed.

Dr. Ambaye Wolde Michael, who we actually heard speaking in there with Dr. Hamlin, she's a brilliant Ethiopian surgeon who tends to do the most complicated surgeries and they can last up to five hours. So one of the women in our film, who, I believe, we're going to talk about next, Wabete, she's this beautiful, young teenager who has already had fistula surgery and was not cured.

She's - half of her bladder was destroyed, so she's still in that balance of, will she be cured? Will she not be cured? It can be a horrible situation for a lot of women. They're also left with stress incontinence from the weakening of the pelvic-floor muscles. But about 90, 93 percent of the women their fistula can be closed.

MARTIN: You mentioned this young woman, this 17 year old who's profiled in the film, Wabete, and she just - she can't get cured and she's so sad...

Ms. SMITH: Yeah.

MARTIN: And doesn't want to go home. She's decided she has nothing left there. If she's not cured this time around, she's not going back. We've got another clip. Let's listen.

(Soundbite of documentary "A Walk to Beautiful")

Dr. WOLDE MICHAEL: Fistula, it's a hated predicament. It's silent epidemic, nobody talks about it, because it's a poor woman. It's a poor woman. It's 100 percent preventable.

Dr. HAMLIN: For a population of 77 million people now in Ethiopia, we've only got 146 gynecologist and obstetricians and most of these are in the cities. So the country women are just completely neglected. This is a tragedy.

MARTIN: Wabete was staying at this clinic, and what was her story? How did you find her?

Ms. SMITH: My colleague, Amy Bucher at Engel Entertainment, was directing in the field at the same time that I was. I was in the countryside looking for women who were hiding with fistula, and that took a long time, and I was afraid, well, what if I didn't find anyone? So Amy was back at the hospital interviewing women right there at the hospital. I believe she interviewed anywhere from 12 to 15.

And Wabete, from what Amy says, was sort of hovering around. She was really drawn to the crew, and you see in her there's a lot of curiosity and a certain spark. And I think that's why people really fall in love with her. And she's so hopeful at the beginning, and excited that, you know, it's her third time returning to the hospital. And surely this time she's really going to be cured. So we follow her story. You'll have to watch tonight to see what happens.

MARTIN: That's right. You spent almost three years, more than two years, making this film. Why this subject?

Ms. SMITH: It was really a decision of the company that I work for, Engel Entertainment, and the head of Engel Entertainment, Steve Engel. Several of us had read a column in the New York Times by Nicholas Kristof. We always mention him because he's done a lot of writing on women with childbirth injuries, and fistula particularly, but he wrote this passionate column in 2003 that we read. Steve decided the company would do this film, and I got the great honor of being able to direct it and produce it.

So it did take, from that time, it took four years in total, from planning and doing proposal and scouting out. I wasn't in Ethiopia the whole time, but I went four different occasions filming. It took a ten-month edit. And again, it was a big theatrical release, and a feature-length film, which can take a long time. But the subject really just pulled at our heartstrings. I've considered myself knowledgeable in human rights and women's rights and really didn't know about this topic. The United Nations didn't even have a plan to deal with this until five years ago. So it really was shocking, and we thought, let's tell this story.

PESCA: Is there some sort of game plan to make it something more than a documentary, to try to, you know, really raise attention and maybe get Kristof to write another column on it? And get some momentum behind it? Other than, hey, we hope you see it when it airs on PBS?

Ms. SMITH: Well, we had a lot of momentum at the 20 festivals and the theatrical release, and around that, really tried to do big media push in every city. And with NOVA, which reaches an average of five million viewers, we're getting huge outreach. But I'm glad you mention that, because on top of it, we do have an extensive outreach plan working with a lot of different NGOs, particularly the Fistula Foundation in the United States, which supports this hospital. And their goal is to raise money for this hospital. And the film is going to screenings all over the country, at universities, at high schools. So we're trying to do as much as possible with that to reach people.

MARTIN: This hospital - you talk about getting more funds and investing in this particular hospital, but I imagine one other problem is the geography, the long distances that women have to walk in order to reach this hospital, often on foot. Are there any efforts to build more rural clinics to deal with this?

Ms. SMITH: Yeah, the Addis Ababa Fistula Hospital, which is, as you said, the only one of its kind in the world, is now opening outreach centers around this big country. And I believe they will open their third now in eastern Ethiopia. It's the - the idea is that people, women and girls who can't reach Addis can get to the clinics at their outreach centers and get surgery there. And maybe at some point they'll also be able to come for maternal care, for childbirth. But ultimately we need the government to get involved, and we need more roads, and we need more hospitals and more doctors. And there's a lot to do.

MARTIN: Well, it's a really compelling film. It's called "A Walk to Beautiful." Mary Olive Smith is the producer and director and it airs tonight on PBS's NOVA. Mary Olive, thanks very much for coming in.

Ms. SMITH: Thank you. It was a pleasure.

MARTIN: We appreciate it.

PESCA: Thank you.

(Soundbite of music)

PESCA: The Bryant Park Project is directed by Jacob Ganz and edited by Trish McKinney. Our technical director is Manoli Wetherell, assisted by Josh Rogosin.

MARTIN: Our staff includes Dan Pashman, Ian Chillag, Win Rosenfeld, Angela Ellis, Caitlin Kenney, Nathan Deuel, Zena Barakat and Jeanne Baron.

PESCA: Laura Conaway edits our website and blog.

MARTIN: Our newscaster is Mark Garrison.

PESCA: Our senior producer is Matt Martinez. Sharon Hoffman is our executive producer.

MARTIN: My name is Rachel Martin.

PESCA: And I am Mike Pesca. We are online all the time at npr.org/bryantpark. This is the Bryant Park Project from NPR News.

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