A Global Commitment To Improving Women’s Health in Rural Ethiopia

By: Rahel Nardos and Philippa RibbinkPhotos and personal stories by: Joni Kabana

Footsteps To Healing

A Woman’s Life in Rural EthiopiaShe is uneducated, married at a very young age to a man she has never met. She performs hard work daily to get through the day.

Before the sun rises, she wakes and prepares breakfast for the family.

She fetches water from the river, often miles away, carrying her large clay pot on her back, walking barefoot for hours daily.

She collects firewood from the forest, carrying the load on her shoulders through mountainous terrain.

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 probability that a fifteen-year-old girl will eventually die in childbirth is 1 in 26. According to the World Health Organization, this risk in the developed world is about 1 in 7300.

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

This extraordinary high maternal mortality is the direct result of the lack of access to prenatal care, family planning and delivery assistance by health care professionals. Only 6% of births in Ethiopia are attended to by skilled healthcare personnel and only 28 % of mothers have at least one consultation with a midwife or other provider before delivery.

Maternal Health Issues In Africa

prolonged labor or the traumatic vacuum delivery attempt. There is no neonatal unit at Gimbie Hospital and the baby was left to stay at its mother’s side.

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.

A young girl stands out from the rest of the patients on the recovery ward at Gimbie Hospital in Gimbie, Ethiopia. She has beautiful deep black skin. As nurses check on her, each one appears gravely concerned.

Her name is Jemate and she has arrived last night from a health clinic. There, she had tried to give birth to her baby, but the baby could not move through her birth canal. They tried many things to extract the child, but to no avail.

With her baby wedged in her birth canal, Jemate walked many miles to Gimbie Hospital, and her baby was delivered swiftly by a cesarean

section. Her baby, Emanuel, is now holding on, yet fading fast. Jemate’s family sits in silence.

Everyone here knows that the baby will soon die, and they sit in this accepting silence as healthy babies cry and are nurtured by other mothers in the hospital beds surrounding Jemate. In addition to baby Emanuel’s fragile condition, Jemate’s body is also recovering from this trauma birth, yet she musters a few smiles through her devastating sadness.

Two days after Jemate is admitted to Gimbie Hospital, baby Emanuel is still holding on, being fed formula via a syringe. But, as often happens in Ethiopia, Jemate has slipped into death’s grips while the doctors’ concern was focused toward her child.

Jemate experienced prolonged obstructed labor with an attempt at vacuum delivery at a health center that was not successful. The baby suffered brain injury, most likely caused by

Jemate’s Story

Another consequence of lack of emergency obstetric care is prolonged obstructed labor. This can result in the development of obstetric fistula, an abnormal communication between the bladder and the vagina or between the rectum and the vagina, causing uncontrolled leakage

of urine and feces. Beyond the obvious physical and psychological suffering endured by women with obstetric fistula, the associated social isolation can be devastating.

It has been estimated that as many as 3.5 million women around the developing world suffer from obstetric genitourinary fistula as a result of prolonged obstructed labor with approximately 130,000 new cases every year. This may be due to failure to seek timely care with women laboring for several days at home, lack of access to care due to distance, poor transportation, lack of resources to pay for care, or inadequately staffed and equipped medical facilities.

Obstetric Fistula

Women and their families wait outside of Gimbe Adventist Hospital in hopes of seeing a doctor.

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 recto vaginal 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 incontinence, physically, psychologically and socially.

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

“Will I see my daughter walking again?” “Will I see my daughter walking again?” Amognesh’s mother asked repeatedly with a sense of urgency and fear, while Amognesh, emaciated and weak, barely whispers a word. The mere act of sitting up seems to exhaust her. Amognesh is about 20 years old and comes from a region in central Ethiopia. Three months prior, with her first pregnancy, she was in labor for three days tended to by traditional birth attendants at home. The fetus was stuck in the birth canal, unable to dislodge.

“My husband was away working for days and I didn’t have anyone to carry her to the health center” said her mother, when asked why no one sought care. The closest hospital where surgical delivery can be done was a one-day trip from where she lived, including several hours on foot.

When Amognesh made it to the hospital, the baby was already dead.

“They took my baby out vaginally piece by piece, without anything to help the pain,” Amognesh whispered with a blank and tired look on her face.

For women like Amognesh, most are abandoned by their husbands.

Like Amognesh, women become weak and immobile in order to avoid contaminating their surroundings, to the point that their limbs are contracted and their bodies are emaciated, unable to move.

This was Amognesh’s predicament as she sat outside the Adet Health center outside of Bahirdar awaiting for a transfer to the Bahirdar Obstetric Fistula Center. The nurse aid, who was also a previous fistula patient placed there by the Hamlin Fistula Hospital at this outreach post, 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.

Her mother tearfully and eagerly awaits the day that her daughter will become healthy again.

Amognesh’s Story

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.

Uterovaginal Prolapse

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 nurs-ing students walked three hours to her village to remind her to come in. She has lived with complete uterine pro-lapse 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. She knows how old her oldest son is and he is 25 she says, making it unlikely that she is 30. The doctors point this out to her, and she giggles.

If she is nervous on her way to the operating room, she does not show it. She hears that these are the “good doctors” and that she will not be hurt.

Four days later, it is time for her to go home. She puts on her new donated dress, and gets ready for the long walk home with her son. She is ecstatic to have been one of the fortu-nate few to be healed of this dreaded condition.

She cries uncontrollably as she thanks the hospital staff.

Jisse’s Story Uterovaginal prolapse is a condition in which the uterus and the vagina losses its support and protrudes out of the vaginal canal causing dif-ficulty with bowel movements or urination, pain, fatigue and sexual dysfunc-tion.

In Ethiopia, women with complete utero-vaginal prolapse complicated by 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

In February 2010, a team of doctors traveled to Gimbie, Ethiopia for a Prolapse Repair Project at Gimbie Adventist Hospital (GAH) in Gimbie, Ethiopia. They were: Dr. Rahel Nardos, a Urogynecology Fellow at Oregon Health & Science University, three Oregon gynecologists, Dr.

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

Philippa Ribbink, Dr. Kim Suriano and Dr. Michael Cheek, and an anesthesiologist, Dr. David Cheek. Dr. Nardos, an Ethiopian native, has high hopes that this was a chance not only to provide much needed surgical care to women with prolapse conditions, but also to engage with the GAH staff and administration regarding a long-term global collaboration between GAH and other hospitals.

The surgical team brought donated

used surgical instruments, sterile sutures and desperately needed medications to Gimbie. Many of the women who arrived at the hospital to be helped by these doctors have had complete uterovaginal prolapse for years and walked between 3-6 hours through mountainous terrain to reach the hospital for their surgery. Most of these women were between 30 and 40 years old, likely the only ones strong enough to make their journey. These

patients also had to be strong enough to walk back home after a major abdominal or vaginal surgery.

The doctors worked fervently repairing close to 30 prolapses and one recto vaginal fistula. Although the surgical conditions were less than ideal (hot non-air conditioned 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.

Dr. Rahel Nardos Dr. Philippa RibbinkDr. Michael Cheek (left). Dr. David Cheek (right).Dr. Kim Suriano

The surgeons determined quickly that a one-time visit only made the dire situation more frustrating for the local physi-cians 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 Project became the focus of conversation during the late evenings.

Future Goals1.Collaborate with local Ethiopian pro-viders to reduce maternal mortality and morbidity, and improve women’s health and quality of life in rural Ethiopia. This includes emergency obstetric care in the setting of high risk obstructed labor, obstetric fistula repair, uterovaginal prolapse and incontinence surgery, family planning services, midwifery training, and community health education.

2.Pilot a project with Oregon Health & Science University (OHSU) to provide OHSU OB/GYN residents, fellows, medical students and other women’s health care providers first hand global experience in the provision of women’s health care in a resource poor setting with a disproportionately high burden of disease and gender disparities. Phy-sicians 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-ies, including hysterectomies.

3.Build a strong educational capacity through sharing of clinical andsurgical expertise, and providing educational resources.

4.Build clinical and field research infrastructures and collaborations to better understand the social, economic and pathological factors affecting the health of women. By so doing, evidence based solutions that are culturally sensitive and sustainable can be implemented.

The main goals of this project are to:

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

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

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

Here are a few ways an individual can extend support

How You Can HelpMany 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.

“An individual has not started living until he can rise above the narrow confines of his individualistic concerns to the broader concerns of all humanity.” -Martin Luther King

4.Organize fundraisers to benefit the Prolapse Surgery Project.

5.Invite us to share our slideshow to your organization.

6.Purchase these books to enable greater distribution.

For more information regarding this effort, or to obtain a copy of the detailed project proposal and budget, please contact:

Dr. Rahel Nardosnardosr@ohsu.edu(314) 753-8117

Written by: Dr. Rahel Nardos &Dr. Philippa Ribbink

Photos & personal stories compiled by: Joni Kabana

Designed by: Toni DeWeese

Contact Information

Other InformationDr. Philippa Ribbink’s blog- www.pribbink.wordpress.com Joni Kabana’s blog- www.jonikabana.com/blogWorld Health Organization- www.who.int/enPopulation Reference Bureau- www.prb.orgFistula Foundation- www.fistulafoundation.org World Wide Fistula Fund- www.worldwidefistulafund.orgGimbie Adventist Hospital- Facebook: “Gimbie Hospital”Barbara May Foundation- Facebook: “Barbara May Hospital”Desert Angel- Valeria Browning: “Maalika”, by John Little