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By Rahel Nardos, MD and Philippa Ribbink, MD Photos and personal stories by Joni Kabana


She is uneducated,

Before the sun rises,

She fetches water from

She collects firewood

married at a very young

she wakes and prepares

the river, often miles

from the forest,

age to a man she has

breakfast for the family.

away, carrying her large

carrying the load on

never met. She performs

clay pot on her back,

her shoulders through

hard work daily to get

walking barefoot for

mountainous terrain.

through the day.

hours daily.

She carries the young on her back while she makes “injera”, the staple bread, inhaling the smoke from the open fire in the corner of her windowless one-room mud “tuckul”.

She repeats this daily from sunrise to long after sunset, 365 days a year while bearing multiple children and hoping that she has earned the good will of her husband at her time of need.


In Sub-Saharan Africa, the

This extraordinary high maternal

Only 6% of births in Ethiopia are

probability that a fifteen-year-old

mortality is the direct result of

attended to by skilled healthcare

girl will eventually die in childbirth

the lack of access to prenatal

personnel and only 28 % of

is 1 in 26. According to the World

care, family planning and delivery

mothers have at least one

Health Organization, this risk in

assistance by health care

consultation with a midwife or

the developed world is about 1 in


other provider before delivery.

7300. In some parts of Ethiopia, 1 in 14 women may die delivering a baby.

A young girl stands out from the rest of the patients on the recovery ward at Gimbie Hospital in Gimbie, Ethiopia.

JEMATE’S STORY She has beautiful deep black skin,

was delivered swiftly by a cesarean

surrounding Jemate. In addition to

and there is an air about her and

section. Her baby, Emanuel, is now

baby Emanuel’s fragile condition,

her family that is hard to ignore.

holding on, yet fading fast. Jemate’s

Jemate’s body is also recovering

As nurses check on her, each one

family sits in silence.

from this trauma birth, yet she

appears gravely concerned.

musters a few smiles through her There is stillness between these

devastating sadness.

Her name is Jemate and she has

family members that is difficult to

arrived last night from a health

describe. Coming from a culture

Two days after Jemate is admitted

clinic. There, she had tried to give

where maternal and infant mortality

to Gimbie Hospital, baby Emanuel

birth to her baby, but the baby

is low, we might not know the

is still holding on, being fed formula

could not move through her birth

signs of impending death very

via a syringe. But, as often happens

canal. They tried many thing s to

well. Everyone here knows that

in Ethiopia, Jemate has slipped into

extract the child, but to no avail.

the baby will soon die, and they sit

death’s grips while the doctors’

With her baby wedged in her birth

in this accepting silence as healthy

concern was focused toward

canal, Jemate walked many miles

babies cry and are nurtured by

her child.

to Gimbie Hospital, and her baby

other mothers in the hospital beds

A couple of days after her c-section, Jemate developed abdominal distention. It was initially suspected that she may have an ileus (a slowing of the bowel) which can cause the bowel to enlarge. An ultrasound evaluation showed enlarged uterus at which point we checked her blood level to make sure she wasn’t bleeding inside. The next day, her condition worsened, and she developed high blood pressure, elevation of her liver enzymes and lowering of her platelets, all of which go along with a hypertensive disease of pregnancy suspected to be what we call HELLP syndrome. She was taken to the operating room because of her concerning abdominal distention. During this surgery, her uterus was found to have lost all its blood supply and was necrotic. Her uterus was removed. She never regained consciousness. She developed what we call pulmonary edema in which her lungs began to fill up with fluid. Gimbie Hospital has no intensive care unit. Blood products are limited. She was given medication to decrease the fluid but she expired that night. This happened in a hospital that had operating rooms and surgeons who tried their best to help her. Many women never make it to a hospital like she did or they bounce around from health centers or hospitals where not much can be offered.

JEMATE’S STORY Jemate experienced prolonged

point we checked her blood level to

Her uterus was removed. She never

obstructed labor with an attempt at

make sure she wasn’t bleeding inside.

regained consciousness. She devel-

vacuum delivery at a health center that

The next day, her condition worsened,

oped what we call pulmonary edema

was not successful. The baby suffered

and she developed high blood pres-

in which her lungs began to fill up with

brain injury, most likely caused by pro-

sure, elevation of her liver enzymes

fluid. Gimbie Hospital has no intensive

longed labor or the traumatic vacuum

and lowering of her platelets, all of

care unit. Blood products are limited.

delivery attempt. There is no neonatal

which go along with a hypertensive

She was given medication to decrease

unit at Gimbie Hospital and the baby

disease of pregnancy suspected to

the fluid but she expired that night.

was left to stay at its mother’s side.

be what we call HELLP syndrome.

This happened in a hospital that had

She was taken to the operating room

operating rooms and surgeons who

A couple of days after her c-section,

because of her concerning abdominal

tried their best to help her. Many

Jemate developed abdominal disten-


women never make it to a hospital like

tion. It was initially suspected that she may have an ileus (a slowing of the bowel) which can cause the bowel to enlarge. An ultrasound evaluation showed enlarged uterus at which

she did or they bounce around from

During this surgery, her uterus was found to have lost all its blood supply and was necrotic.

health centers or hospitals where not much can be offered.



Another consequence

Beyond the obvious physical

130,000 new cases every

of lack of emergency

and psychological suffering

year. This may be due to

obstetric care is prolonged

endured by women with

failure to seek timely care with

obstructed labor. This can

obstetric fistula, the associated

women laboring for several

result in the development of

social isolation can be

days at home, lack of access

obstetric fistula, an abnormal


to care due to distance,

communication between the

poor transportation, lack of

bladder and the vagina or

It has been estimated that as

resources to pay for care,

between the rectum and the

many as 3.5 million women

or inadequately staffed and

vagina, causing uncontrolled

around the developing

equipped medical facilities.

leakage of urine and feces.

world suffer from obstetric genitourinary fistula as a result of prolonged obstructed labor with approximately

3.5 million women around the developing world suffer from obstetric genitourinary fistula

“Will I see my daughter walking again?”


“Will I see my daughter walking again?” “Will I

“My husband was away working for days and

“They took my baby out vaginally piece by

see my daughter walking again?” Amognesh’s

I didn’t have anyone to carry her to the health

piece, without anything to help the pain,”

mother asked repeatedly with a sense of

center” said her mother, when asked why no

Amognesh whispered with a blank and tired

urgency and fear, while Amognesh, emaciated

one sought care. The closest hospital where

look on her face.

and weak, barely whispers a word. The

surgical delivery can be done was a one-day

mere act of sitting up seems to exhaust her.

trip from where she lived, including several

For women like Amognesh, most are

Amognesh is about 20 years old and comes

hours on foot.

abandoned by their husbands. Like Amognesh,

from a region in central Ethiopia. Three months

women become weak and immobile in order to

prior, with her first pregnancy, she was in labor

When Amognesh finally made it to the hospital,

avoid contaminating their surroundings, to the

for three days tended to by traditional birth

the baby was already dead.

point that their limbs are contracted and their

attendants at home. The fetus was stuck in the birth canal, unable to dislodge.

bodies are emaciated, unable to move.

Her mother tearfully and eagerly awaits the day that her daughter will become healthy again. This was Amognesh’s predicament as she sat outside a health center outside of Bahirdar awaiting for a transfer to one of the nearby fistula hospitals. The nurse aid, who was also a previous fistula patient, sat next to Amognesh roasting coffee on a coal fire. She has been feeding Amognesh and performing physical therapy until she is strong enough to have her fistula repaired. Amognesh had what is called “destructive delivery� in which instruments (often makeshift and not sterile) are used to crush the fetal head and deliver parts vaginally. Following this, Amognesh suffered one of the most terrible consequences of obstructed labor: vesicovaginal and rectovaginal fistula. The blood supply to the bladder and rectal tissue that surrounds the compressive fetal head becomes compromised, causing the tissue to become necrotic and slough off, leaving behind a hole between the bladder and vagina and/or the rectum and the vagina. The consequence of this extends far beyond the urine and fecal incontinenence, physically, psychologically and socially.


In addition to obstetric fistula, women with obstructed labor and those with multiple vaginal deliveries who are at high risk for pelvic nerve and muscle injuries are suspected to have a high incidence of pelvic floor dysfunction such as stress urinary incontinence and uterovaginal prolapse. The additional burden of heavy physical exertion suffered by women in rural Ethiopia starting at a very young age is an additional yet

unrecognized risk factor. Given the rarity of centers that can provide surgical services in rural Ethiopia, procedures for non-life-threatening conditions such as complete uterovaginal prolapse are almost non-existent. Although the prevalence of pelvic organ prolapse in Ethiopia is unknown, reports by rural providers suggest what may be a hidden epidemic.


She hears that these are the “good doctors” and that she will not be hurt.

Jisse lies in her hospital bed waiting to be seen. Several months ago she heard about the prolapse project at one of the outlying clinics. One of the nursing studen ts walked three hours to her village to remind her to come in.

She has lived with complete uterine prolapse for five years, and the mucous membranes of her cervix is cracked and ulcerated. Living with prolapse has made it hard, if not impossible, to work in the fields and gather firewood.

Her son sits next to her in the open hospital ward. When the team walks on the ward, he rushes up to them to make sure Jisse gets seen. This is her only chance to have surgery. Like most Ethiopian women, Jisse does not know how old she is. After 20 years most woman stop keeping track of their age. When the team asks her how old

she is, she guesses 30.

Four days later, it is time

She knows how old her

for her to go home. She

oldest son is and he is 25

puts on her new donated

she says, making it unlikely

dress, and gets ready for

that she is 30. The doc-

the long walk home with

tors point this out to her,

her son. She is ecstatic

and she giggles.

to have been one of the fortunate few to be healed

If she is nervous on her

of this dreaded condition.

way to the operating room, she does not show it. She

She cries uncontrollably

hears that these are the

as she thanks the

“good doctors� and that

hospital staff.

she will not be hurt.

Uterovaginal prolapse is a condition in which the uterus and the vagina losses its support and protrudes out of the vaginal canal causing difficulty with bowel movements or urinating, pain, fatigue and sexual dysfunction. In Ethiopia, women with complete uterovaginal prolapse with severe ulceration and infection of the exposed vaginal tissue are often simply given antibiotics and sent home to live their days sitting in one position.

A SOLUTION Prolapse Surgery Project: A Global Collaboration in Women’s Health

In February 2010, a team of doctors

much needed surgical care to women

complete uterovaginal prolapse for

traveled to Gimbie, Ethiopia for a

with prolapse conditions, but also

years and walked between 3-6 hours

Prolapse Repair Project at Gimbie

to engage with the GAH staff and

through mountainous terrain to reach

Adventist Hospital (GAH) in Gimbie,

administration regarding a long-term

the hospital for their surgery. Most of

Ethiopia. They were: Dr. Rahel Nardos,

global collaboration between GAH and

these women were between 30 and 40

a Urogynecology Fellow at Oregon

other hospitals.

years old, likely the only ones strong

Health & Science University, three

enough to make their journey. These

Oregon gynecologists, Dr. Philippa

The surgical team brought donated

patients also had to be strong enough

Ribbink, Dr. Kim Suriano and Dr.

used surgical instruments, sterile

to walk back home after a major

Michael Cheek, and an anesthesiologist,

sutures and desperately needed

abdominal or vaginal surgery.

Dr. David Cheek. Dr. Nardos, an

medications to Gimbie. Many of the

Ethiopian native, has high hopes that

women who arrived at the hospital to

this was a chance not only to provide

be helped by these doctors have had

The doctors worked fervently repairing close to 30 prolapses and one rectovaginal fistula. Although the surgical conditions were less than ideal (hot non-airconditioned rooms, dim lighting, poorly functional instruments), these hardships were overshadowed by the enthusiasm and collegiality of the team, and the hospitality and support of the staff at GAH. When possible, the surgical team was assisted by the GAH in-house gynecologist and general surgeon on a few of these prolapse surgeries, ensuring that the local providers can continue to provide surgical care in a higher skilled capacity after the surgical team returned home. Rural communication is swift, and the success of this team to provide much needed surgical care was harrowed by the increasing flow of patients arriving for prolapse surgery long after the surgical team left. A one time surgical mission is surely not the solution for this problem, which makes it all the more vital to engage in a long-term collaboration.

FUTURE GOALS The surgeons determined quickly that a one-time visit only made the dire situation more frustrating for the local physicians and patients. How can someone select who gets surgery and who does not, realizing that many of the women walked days with their painful condition to reach the hospital in hopes of obtaining relief? The idea of a Prolapse Surgery Pro ject became the focus of conversation during the late evenings.

women’s health care in a resource poor setting with a disproportionately high burden of disease and gender disparities. Physicians in training will learn to manage complications of


prolonged obstructed labor such as obstetric


fistula and spontaneous rupture of uterus, and perform vaginal and abdominal surger-


Collaborate with local Ethiopian

ies, including hysterectomies.

providers to reduce maternal mortality and morbidity, and improve women’s health and


quality of life in rural Ethiopia. This includes

through sharing of clinical and surgical exper-

emergency obstetric care in the setting of

tise, and providing educational resources.

Build a strong educational capacity

high risk obstructed labor, obstetric fistula repair, uterovaginal prolapse and incontinence


surgery, family planning services, midwifery

infrastructures and collaborations to better

training, and community health education.

understand the social, economic and patho-

Build clinical and field research

logical factors affecting the health of women.


Pilot a project with Oregon Health &

By so doing, evidence based solutions that

Science University (OHSU) to provide OHSU

are culturally sensitive and sustainable can be

OB/GYN residents, fellows, medical students


and other women’s health care providers first hand global experience in the provision of

started living until he can rise above the narrow confines of his individualistic concerns to the broader concerns of all humanity.” Martin Luther King

Many people are astonished upon finding out that women in a rural setting in Sub-Saharan Africa are living in such dire circumstances from a healthcare standpoint. But why give attention to African women when we have so many issues in our own country? Because in Africa, the most basic infrastructure and programs do not exist to help these women. We live such insular lives in a developed country, and our own strength can be enhanced from an extended hand toward those who live in a desperate state.

Here are a few ways an individual can extend support: 1.

Relay these stories to others so that increased awareness is attained.


Donate money, skills or medical supplies to the Prolapse Surgery Project.


Sponsor one woman’s surgery ($150) in Ethiopia.


Organize fundraisers to benefit the Prolapse Surgery Project.


Invite us to share our slideshow to your organization.


Purchase these books to enable greater distribution.


“An individual has not

CONTACT INFORMATION For more information regarding this effort, or to obtain a copy of the detailed project proposal and budget, please contact: Dr. Rahel Nardos (314) 753-8117 Other information: Dr. Philippa Ribbink’s blog Joni Kabana’s blog: World Health Organization Population Reference Bureau Fistula Foundation Maternity Africa Gimbie Adventist Hospital Facebook: “Gimbie Hospital” Barbara May Foundation Facebook: “Barbara May Hospital” Desert Angel: Valeria Browning “Maalika”, by John Little

Written by: Dr. Rahel Nardos & Dr. Philippa Ribbink Photos & personal stories compiled by: Joni Kabana Designed by: Chelsea Carter Deep appreciation to Pro Photo Supply for their support of this project.

Ethiopia Book After  

revised Ethiopia book

Ethiopia Book After  

revised Ethiopia book