Neglected no longer
Fistula is a maternal healthcare issue that leaves a woman incontinent after childbirth. It impacts over 2 million women in Africa and there are over 50,000 new cases each year. Due to the smell these women are often left isolated and shunned by their communities and families, however in Ethiopia the crusade to help these women is well underway.
Fistula is a maternal healthcare issue that develops during childbirth. It is primarily seen in African regions such as Ethiopia and Somalia, where there are limited healthcare professionals, as a result women often give birth alone.
The labour becomes obstructed, the babies’ shoulders are unable to pass through the vagina and this can cause a prolonged birth, which can last for days. During this time the soft tissue between the babies’ head and the pelvic bone is destroyed, a hole develops between the rectum and the bladder and the woman loses the baby.
At a later date she realises that she is incontinent of urine and faeces. The smell means that often her community shuns her and she has to eat sleep and work alone. Her husband may divorce her and she is neglected. The shame can leave her feeling abandoned.
Neusu, a young girl from Barhar Dar a rural area of Ethiopia, was just 20 years old when she gave birth to her baby, the clinic that she arrived at had no medical equipment, which meant that when the babies’ head could not pass through the vagina and her labour was prolonged. Her baby was stillborn and a fistula developed.
Neusu said, “After three days of delivery a fistula developed. I lost my baby. I came to Hamlin Hospital to receive treatment and after two months I had been treated. I have no problem now and I am happy.”
Hamlin fistula, founded by Dr Catherine Hamlin and her late husband Reginald Hamlin has rescued over 40,000 women with a fistula. It began in 1974 after seeing an influx of women come down from the countryside for treatment. The Hamlin fistula hospital offers treatment, prevention and rehabilitation to women who have fistulas and those at risk of developing one due to the lack of adequate treatment in the rural area.
Like Neusu many other women from the rural area have also undergone long labours than perhaps those who live in the cities and towns and this is because of the access to a local healthcare facility.
There are 160 health centres in Ethiopia. These have to provide care to a population of 85 million. The midwives who work in these health centres provide antenatal care and are able to detect fistulas a lot earlier. Tirngo Yihunie has been a midwife for over three years in the rural town of Barhar Dar, she said, “I have only had to deal with five fistula cases since I have been here. We can refer these cases to the local hospital or even to the Hamlin Fistula hospital in Addis Ababa for treatment.”
However the issue still remains that if you live in the rural areas of Ethiopia than the likelihood of you reaching a Healthcare centre is very slim. “The road access is poor and therefore women struggle to reach here if they live far away.”
The Ethiopian government is working on providing a better strategy to reach women who live in the rural area. Government minister for women and children, Abey Eframe said, “ We have deployed 34,000 health extension workers, who will work alongside the midwives in the hospitals and health centres to help those women who are pregnant or about to give birth. They will encourage the women to go to a health centre, or if need be assist the woman when she is about to give birth.”
This new initiative by the government will enable more women in the rural areas to be treated for maternal healthcare issues such as fistula and means that if they do develop a maternal healthcare problem that they will be able to be treated immediately like Neusu as opposed to living with the condition for years.
There are many cases however in Ethiopia where women do live with the condition for years and left untreated. In a country that has yet to establish an adequate birth registration system, it can be hard to detect how many women are of child bearing age and thus at risk of developing a fistula.
Alma, from Wollo, in the northern region of Ethiopia, was married at 15 years old, but did not fall pregnant until she was 18. Her labour was prolonged and the baby eventually died. Alma developed a fistula and had to be taken to the health centre. The access to the centre was blocked due to a big river, which prevented her from attending a hospital. “I was in labour for five days and I lost my baby and developed obstetric fistula. I waited for three months to have treatment; it took two days to get there. They were unable to treat me and my fistula remained.”
As soon as Alma’s husband heard this he divorced her and she had to be looked after by her aunt. She than returned home to her family and she lived there for seven years.
“I recently found out about the Hamlin hospital and that they treat women like me, my brother brought me here and now I am awaiting treatment.”
Almas hope is that she will be cured and that she will be able to live a normal life. “One day I want to become a mother and have children again, that is my hope.”
Almas story echoes those of thousands of other women, many still living with a fistula, isolated and neglected.
Dr Catherine Hamlin said, “This condition is tragic and I hope that in my lifetime we will end this horrible condition by providing more health centres and skilled doctors to treat these women.”
The Hamlin’s rehabilitation centre also helps women who have developed a fistula and are unable to return to their local community as well as those who have inoperable fistulas.
Beletshachew Tadesse, the rehabilitation lead at the centre said, “We help women to find jobs, so they can pay their bills and return to their communities. It is important that we rehabilitate these women back into their communities so that they can start to live a normal every day life again.”
So far the rehabilitation centre has helped six women return to their communities and has at present 42 women living ion site in the compound who have also found employment.
The initiatives of local non-government organisations (NGOs) to provide better treatment are a crucial step towards helping fistula survivors.
The government has also started a new scheme, called the womens development army. The womens development army works with local communities empowering them when it comes to their health care. Abey Eframe, Government Minister for Women and Children said, “These are modern women, who really understand the pain of women. They are chosen by their communities and work in different areas, such as HIV, maternal health care and sanitation. They help fistula survivors rejoin their community and giving them hope and enabling them to take charge of their healthcare.”
‘To be struck down with a condition like fistula at such an early stage of your life is very hard, the world needs to wake up to the needs of these people and it needs to try and make changes to improve this condition for all,” said Dr Hamlin
These women now have better maternal healthcare and hope has been restored, no longer neglected, the treated and the untreated women can live in confidence that they will have a normal life again.
The rural woman
With a population of over 85 million and the majority of the people living in the rural area, women who are about to give birth often become isolated from a healthcare centre, which can lead to complications. However midwives are working across Ethiopia to try and prevent maternal healthcare problems and provide the best care to expectant mothers.
Tringo Yihunie a midwife here at the health centre in the rural village of Brackat, Ethiopia, she has worked here for three years. Trained and deployed by Hamlin Fistula hospital, she has is an expert in her field. “We provide antennal care to these mothers as well as help and assistance during birth. We also inform women on the best type of contraceptive.
The midwives at this health centre in bracket look after a population of 36,000, and deliver 30 to 40 healthy babies every month. However this was not always the case. Dr Bitwe Abebe, from the Hamlin hospital said, “Before the Hamlin trained midwives went to the health centres, many of them were only delivering five healthy babies every few months. This has increased since the Hamlin trained midwives were sent there.”
The Hamlin trained midwives work in conjunction with the government trained midwives. Some believe that the increase in deliveries of healthy babies is purely down to the fact that the Hamlin midwives have better and more extensive training than the government ones.
Dr Hamlin said, “The government does do a good job, but we train our midwives for four years, I believe the government only train them for three.”
The Hamlin midwives are also exposed to more births and their experience of delivery is vastly different from the governments own midwives. “Our girls see and assist with deliveries very early on, they are exposed to a lot, and this is why they are very good at what they do.”
Minister for Women and Children Abey Eframe said, “The ministry of health has worked extensively to improve the care that is provided to expectant mothers.”
The difference between the government midwives and the Hamlin ones is not something that is clearly noticeable on the ground however.
The midwives at this health centre here in the village of Brackat work side by side. They meet with women daily assisting them with pregnancy and delivery.
Ms Yihunie said, “I have only seen five fistula cases since I have been here, this is because we can assess if a woman may be at risk of a fistula earlier on.“
Tingo and her colleagues are also work in conjunction with the health extension workers.
The governments’ initiative to help women in the rural area has stretched to providing healthcare to women at their homes.
“We have deployed 34,000 health extension workers to the rural are of Ethiopia to help women who are finding it increasingly difficult to travel to a hospital. They will assist the women with antenatal care and they will also encourage them to try and go to the healthcentre,” said Mr Eframe.
The midwives meet with the health extension workers and work towards a referral process. This means that any mother who is visited by a health extension worker and maybe in need of medical assistance, will be referred to the health centre and if need be they can refer the woman to the federal hospital.
The referral process is helping to save the lives of many women who live in the rural area. Partnership between the health extension workers and the midwives is leading to greater success for the women.
The government believe that this new initiative will decrease the number of maternal healthcare cases being seen, by having a health assistant assist throughout the womans pregnancy and during the birth.
For midwives like Tringo this type of work is more than just a job, healthcare in Ethiopia is changing. With maternal healthcare, child and infant mortality rates improving, a new harvest is waiting to be reaped.
Ms Yihunie said, “I have had many successes since I have been here, however the one I am proudest of is when we saw a woman come in, she was having complications during birth and we managed to help her and save the baby.”
Ethiopia has come a long way from the famine and poverty it once knew and a brighter future seems to be appering on the horizon.
The importance of rehabilitation for women who have had a fistula or any maternal healthcare issue is vital, with efforts being made by the government and local non-government organisations (NGOs) to improve the lives of these women, the impact being made is evident.
“When I arrived here, I had been living with a fistula for five years. I was so young when I married only 18 years old. Now my life has changed, I am happy, and there are others here who are happy as well.” Adina is one of the Hamlin Fistula hospitals success stories.
Arriving in Barhar Dar for treatment, Adina knew that her life would change and she would be able to receive help for her condition. Four years on and she is now living a normal life, working and paying bills.
Once the fistula had developed Adina’s husband left her and her community rejected her. Over time her condition got worse. When she was finally able to reach a healthcare facility her fistula had become inoperable.
“I was very upset; it was the last thing I could have imagined.” Fortunately for Adina she was able to have a type of therapy which would still allow her to live a better life.
Dr Fekade Aynachew, the medical director at Hamlin Fistula hospital said, “When we have a fistula that is inoperable we offer them diversion therapy. They will have to walk around with a bag for the rest of their lives, but this is a better solution than leaving them incontinent.”
Once the treatment was over, Adina lived at the hospitals rehabilitation centre; they helped her to find work and housing. “I work here at Hamlin fistula, I am very happy now.”
Hamlin fistula rehabilitation centre is home to 42 women who live on site. They work and pay bills. Belechachew Tadesse, the rehabilitation lead at the centre said, “The women are happy here, they really enjoy themselves and that is important.”
The centre have managed to rehabilitate a further six women back into their local communities. “We see that it is important for these women to return to their homes in the rural area. We therefore have to carry out a risk assessment to ensure they are ready to go home,” said Ms Tadesse.
The rehabilitation work that is being carried out here in the Hamlin centre is not just about connecting these women back into their local communities. It also involves providing educational classes so that the women can learn practical skills such as decision making.
Ms Tadesse said, “We provide educational facilities for the women that help them for when they return home. We prepare them for live back in the rural area.
My hope for the future is that one day this will be a maternal ward, where people with all types of maternal healthcare issues can come and be helped.”
The government is also starting similar efforts to those of the Hamlin fistula centre.
The millennium development goals have given the Ethiopian government a chance to work towards improving maternal health and other areas for the next generation.
Infant and child mortality has halved over the last five years. Changes are certainly taking place and with the assistance of new initiatives such as health extension workers, there maybe even further improvement to come. Abey Eframe, Government Minister for Women and Children said, “We have started the womens development army. These are modern women who have been chosen by their communities. They empower the community to take charge of their health.
Mr Eframe also believes that the womens development army will be able to help women with fistulas. “We want these women to be rehabilitated back into their communities so the womens army will work with the women as well as their local villages so that they can return to where they lived.”
The initiatives of Hamlin Fistula and the government to help these women and give them a better life is transforming lives and impacting the people.
Adina said, “I am very happy now, my life has changed.”
Ethiopia's contraception success
Contraception is now a readily available tool in Ethiopia and has been for some time, with women being able to make the choice on what contraception they would like to use. The revolution has begun and its impact on prevention against sexually transmitted infections is proving a positive one.
“Look at the board behind you; you will see we have every type of contraceptive available. We offer women the choice, they can have condoms or we give them an injection,” said Tringo Yihunie, a midwive at the healthcentre in the rural town of Brackat.
Contraception in Ethiopia is changing, there is now a greater emphasis on patient choice, with women coming into health centres across the country and choosing the contraception that is right for them.
“We talk them through what is on offer,” said Tringo Yihinne a midwives at the health centre in Brackat. It is entirely up to the women to decide what they want.”
Ms Yihunie and her colleagues offer women education on contraception with everything from condoms, to the pill and even the injection now being offered, the choice for women in Ethiopia is vast.
“It’s not easy for a woman to pick the right method of contraception, so we have a guide that we talk them through. Based on their circumstances they are able to pick the one that is right for them,” said Ms Yihinne.
Women are offered one to one consultations with the midwives and within minutes they have made a choice. The most popular method of protection for women in Ethiopia is the injection.
Ms Yihunie said, “Most women do not tend to use condoms, especially if they have already had children and they know that their husband or partner has no sexual disease, than they opt for the injection. It is better for them.”
The injection lasts for about 12 weeks and is 99% effective, it is simple to administer. The key advantage for the women here in this health centre is that they do not need to worry about forgetting to take it.
Sister Hirut Kintu, a midwife mentor at the centre believes that these consultations have created a revolution amongst the people. “Women have more freedom to say what they want, it’s a choice that they have and this is powerful,” said Sister Kintu.
Data has shown that contraceptive prevalence rate in Ethiopia has doubled since 2005 and is now over 30 per cent. One of the reasons for this increase in prevalence could be down to the Government and the strong commitment it has placed behind ensuring women are aware of what is on offer to them.
Government Minister for Women and Children Abey Eframe said, “We are encouraging and empowering women to take control of their healthcare this includes helping them to make the choice on what is the right contraceptive method for them.”
Sister Hirut Kintu said, “It is not easy for a rural woman to know if the injection is better than the condom. We place pictures on the wall which show them what the contraceptive looks like, this is important.”
Many women visit the health centre each day, some attend for antennal checkups, whereas others visit to know what contraceptive method is right for them.
A further reason for this contraceptive revolution in Ethiopia may be connected to the awareness of what is on offer at the grass roots. More women in the cities and rural areas of the countries are becoming aware of the options available to them.
Mr Eframe said, “It is not just about educating the health care professionals it is also about informing the people. Women want to know what they can have, how they can protect themselves. This is critical.”
The women in the health centre ask questions of the midwives, speaking in their native language, they are curious to find out what options are available to them. One lady questions the length of time that the injection lasts for, while another wants to know how long they have to take the emergency contraceptive pill.
Knowledge of contraception in Ethiopia is changing, with this increased awareness many believe that it will reduce maternal health care problems and prevent child or infant mortality.
Ms Yihunie, “We have some way to go, but the women know now what is available to them and that is good.”