A Woman’s Lifein Rural Ethiopia

She is uneducated, married at a very young age to a man she has never met. She per-

forms 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, car-rying the load on her shoulders through moun-tainous 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 hus-band at her time of need.

Maternal Health Issues In Africa

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 Ethi-opia, 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.

Jemate’storyS

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, and there is an air about her and her family that is hard to ignore. 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 hold-ing on, yet fading fast. Jemate’s family sits in silence.

There is stillness between these family members that is difficult to describe. Coming from a cul-ture where maternal and infant mortality is low, we might not know the signs of impending death very well. 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 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 en-large. 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 pul-monary 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.

Another consequence of lack of emergency obstetric care is pro-

longed 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 associ-ated social isolation can be devastating.

It has been estimated that as many as 3.5 million women around the develop-ing world suffer from obstetric genito-urinary 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 dis-tance, poor transportation, lack of re-sources to pay for care, or inadequately staffed and equipped medical facilities.

Obstetric Fistula

Amognesh’storyS

“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 Amog-nesh, 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 atten-dants 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 clos-est hospital where surgical delivery can be done was a one-day trip from where she lived, including several hours on foot.

When Amognesh finally 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 aban-doned by their husbands. Like Amognesh, women become weak and immobile in order to avoid contaminating their sur-roundings, 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 Fistu-la Hospital at this outreach post, sat next to Amognesh roasting coffee on a coal fire. She has been feeding Amognesh and per-forming 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 had what is called “destruc-tive 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 rec-tovaginal fistula. The blood supply to the bladder and rectal tissue that surrounds the compressive fetal head becomes com-promised, 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 be-yond the urine and fecal incontinenence, physically, psychologically and socially.

In addition to obstetric fistula, wom-en 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 dys-function such as stress urinary incon-tinence and uterovaginal prolapse.

The additional burden of heavy physi-cal 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 com-plete uterovaginal prolapse are almost non-existent.

Although the prevalence of pelvic or-gan prolapse in Ethiopia is unknown, reports by rural providers suggest what may be a hidden epidemic.

Uterovaginal Prolapse

Jisse’storyS

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 students 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. She knows how old her oldest son is and he is 25 she says, making it

unlikely that she is 30. The doc-tors 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 fortunate few to be healed of this dreaded condition. She cries uncontrollably as she thanks the hospital staff.

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 com-plete 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 traveled to Gimbie, Ethiopia for a

Prolapse Repair Project at Gimbie Adventist Hospital (GAH) in Gimbie, Ethiopia. They were: Dr. Rahel Nar-dos, a Urogynecology Fellow at Oregon Health & Science University, three Oregon gynecologists, Dr. Philippa Ribbink, Dr. Kim Suriano and Dr. Mi-

chael 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 condi-tions, 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 uterovagi-nal prolapse for years and walked between 3-6 hours through mountainous terrain to reach the hospi-tal 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 rectovaginal fistula. Although the surgical conditions were less than ideal (hot non-airconditioned rooms, dim lighting, poorly functional in-struments), these hardships were overshad-owed by the enthusiasm and collegiality of the team, and the hospitality and support of the staff at GAH. When possible, the surgi-cal 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 sur-gical care in a higher skilled capacity after the surgical team returned home.

Rural bush 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 pro-lapse 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 GoalsThe 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 Project became the focus of conversation during the late evenings.

1Collaborate with local Ethiopian providers 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 ser-vices, 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 bur-den of disease and gender disparities. Physicians in training will learn to manage complications

The main goals of this project are to:

of prolonged obstructed labor such as obstetric fistula and spontaneous rupture of uterus, and perform vaginal and abdominal surgeries, includ-ing hysterectomies. 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.

4 Build clinical and field research infra-structures 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.

3 Build a strong educational capacity through sharing of clinical and surgi-cal expertise, and providing educa-

tional resources.

Many people are astonished upon finding out that women in a rural setting in Sub-Saharan Africa are living in such dire cir-cumstances 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.

How You Can Help

Here are a few ways an individual can extend support:1Relay these stories to others so that in-

creased awareness is attained.

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

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

4 Organize fundraisers to benefit the Pro-lapse Surgery Project.

5 Invite us to share our slideshow to your organization.

6 Purchase these books to enable greater distribution.

“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

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

Written by: Dr. Rahel Nardos & Dr. Philippa RibbinkPhotos & personal stories compiled by: Joni KabanaDesign by: Mark Graybill

Dr. Philippa Ribbink’s blog www.pribbink.wordpress.com Joni Kabana’s blog: www.jonikabana.com/blogWorld 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

Dr. Rahel Nardos | nardosr@ohsu.edu | (314) 753-8117

Other information: