By Rahel Nardos, MD and Philippa Ribbink, MD

Photos and personal stories by Joni Kabana

FOOTSTEPS TO HEALINGA GLOBAL COMMITMENT TO IMPROVING WOMEN’S HEALTH 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”.

A WOMAN’S LIFE IN RURAL ETHIOPIA

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

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.

JEMATE’S STORYShe 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 thing s 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.

There is stillness between these

family members that is difficult to

describe. Coming from a culture

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.

A young girl stands out from the rest of the patients on the recovery ward at

Gimbie Hospital in Gimbie, Ethiopia.

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 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 pro-

longed 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 disten-

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

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 pres-

sure, 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 devel-

oped 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

GIMBIE ADVENTIST HOSPITAL

OBSTETRIC FISTULA

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.

3.5 million women around the developing world suffer from

obstetric genitourinary fistula

AMOGNESH’S STORY

“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 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

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.

“Will I see my daughter walking 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.

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

UTEROVAGINAL PROLAPSE

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.

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

JISSE’S STORY

She hears that these

are the “good doctors”

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.

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.

A SOLUTIONProlapse 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 Nardos,

a Urogynecology Fellow at Oregon

Health & Science University, three

Oregon 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 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 idea of a Prolapse Surgery Pro ject

became the focus of conversation

during the late evenings.

THE MAIN GOALS OF THIS PROJECT

ARE TO:

1. 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 re-

pair, 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 set-

ting 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-

ies, including hysterectomies.

3. Build a strong educational capacity

through sharing of clinical and surgical exper-

tise, and providing educational resources.

4. Build clinical and field research

infrastructures and collaborations to better

understand the social, economic and patho-

logical factors affecting the health of women.

By so doing, evidence based solutions that

are culturally sensitive and sustainable can be

implemented.

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?

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 Af-

rica, 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.

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

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

4. OrganizefundraiserstobenefittheProlapseSurgeryProject.

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

6. Purchase these books to enable greater distribution.

HOW YOU CAN HELP

“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

CONTACT INFORMATION

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

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 RibbinkPhotos & personal stories compiled by: Joni Kabana

Designed by: Chelsea Carter

Deep appreciation to Pro Photo Supply for their support of this project.