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 Ethiopia

She 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.

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.

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. 

With her baby wedged in her birth canal, Jemate walked many miles to Gimbie Hospital.Her baby, Emanuel, is now holding on, yet fading fast.

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.

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.

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

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

gynecologists, Dr. 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 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 obtain-ing relief?The idea of a Prolapse Surgery Project became the focus of con-versation during the late evenings.

Future Goals1. Collaborate 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 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. Physicians in training will learn to manage complica-tions of prolonged obstructed labor such as obstetric fistula and spontaneous rupture of uterus, and perform vaginal and abdominal surgeries, including hysterectomies. 3. Build a strong educational capacity through sharing of clinical andsurgical expertise, and providing educational resources.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.

The main goals of this project are to: