FOOTSTEPS TO HEALING A GLOBAL COMMITMENT TO IMPROVING WOMEN’S HEALTH IN RURAL ETHIOPIA
By Rahel Nardos, MD and Philippa Ribbink, MD Photos and personal stories by Joni Kabana
A WOMAN’S LIFE IN RURAL ETHIOPIA
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
through the day.
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.
MATERNAL HEALTH ISSUES IN AFRICA
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
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
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 wasnâ€™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.
GIMBIE ADVENTIST HOSPITAL
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 Amogneshâ€™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 â€œdestructive deliveryâ€? 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
â€œgood doctorsâ€? and that
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 Womenâ€™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
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
THE MAIN GOALS OF THIS PROJECT
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.
HOW YOU CAN HELP
“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 firstname.lastname@example.org (314) 753-8117 Other information: Dr. Philippa Ribbink’s blog www.pribbink.wordpress.com Joni Kabana’s blog: www.jonikabana.com/blog World Health Organization www.who.int/en/ Population Reference Bureau www.prb.org/ Fistula Foundation www.fistulafoundation.org Maternity Africa www.maternityafrica.org 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.
revised Ethiopia book