Hospital a beacon of hope in a ravaged land


ETHIOPIA: The dozens of young women with frail bodies and sad eyes are the lucky ones. They made it to the hospital; they will have the operation. Roisin Ingle reports from Ethiopia on the efforts to help women with fistula, acondition caused by difficult births - and which prompts some husbands to abandon their wives.

The newest arrival to the Addis Ababa Fistula Hospital has travelled 300 kilometres to get here. It is five months since Etanesh gave birth to a stillborn baby after an obstructed labour that lasted seven days. Since the birth she has suffered with a fistula - a hole torn between the bladder and the vagina or the rectum during the difficult birth - which left her permanently incontinent. It's hard to comprehend as she sits on a wooden bench, head covered with a black scarf, her eyes scared and unblinking, but Etanesh is one of the lucky ones.

While the specialised surgery available at the hospital offers a cure, the mountainous terrain of Ethiopia ensures transport to the Fistula hospital is a distant dream for many sufferers. Almost 80 per cent of the population live more than two days' walk from a decent road. Fistula sufferers are ostracised by their community and abandoned by their husbands. Even if they could make it to a hospital, it is unlikely the medical staff and facilities needed to perform the operation will be available.

But Etanesh has made it.

"Her husband ran away straight after the birth, we don't know where he is," says her brother, as Etanesh waits to be seen by a nurse. "Faeces and urine leak out of her vagina. It took us five months to get her here because we have no money. She has no appetite and bad headaches. We hope the people here will make her better."

Sunlight streams into the main ward of the hospital. Behind pale blue curtains, rows of frail bodies lie tucked into pale blue blankets. There are dozens of young women with sad eyes. Those who have been operated on smile with relief. Some of them have travelled hundreds of kilometres to get here, on mules, by bus, dressed in stinking rags, some carrying tin cans or other vessels in which to dispose their waste during the journey.

The Fistula Hospital - one of only three of its kind in the world - was founded in 1975 by Australian-born doctor Catherine Hamlin and her husband Sir Reg Hamlin.

Obstructed labour affects 5 per cent of all women in the world but in most cases the problem can be treated immediately by Caesarean section. In Ethiopia, and other places in sub-Saharan Africa, it's a different story.

"The woman gives birth to a stillborn baby after six or seven days and thinks, thank God I am alive," says Dr Hamlin, who has run the hospital since her husband's death in 1993. "But very soon she will wish she was dead because during the obstructed birth a hole developed in the bladder and perhaps another in the rectum.

"She is 16 or 17. She is in a terrible state. Her husband can't stand it, without a baby she is no use. She is a social outcast shunned by everyone. She might be put out of sight in a shed or an outhouse. Her life is ruined".

Around 10 new cases turn up at the hospital each month, treatment is free and patients are never turned away. When they come they are welcomed by hospital workers, some of whom are among the 3 per cent of fistula patients who cannot be cured. With integration back into society virtually impossible for these incurable women, several are trained at the hospital and work there helping other sufferers.

The first thing that happens when a new patient arrives is the urine is drained away with a catheter. In most cases the simple surgical procedure to close the fistula is carried out within days but some patients cannot be treated straight away.

Ethiopian culture encourages new mothers to stay in bed for 45 days after birth. For those with normal pregnancies and births, it is the holiday of a lifetime. But for these young women, sick with a fistula-infected vagina, it is a nightmare. After the birth many sufferers curl up small in an effort to dry the urine. They can stay like this for months or even years and sometimes arrive at the hospital in the foetal position.

"In such cases the women are not physically able for surgery, it might take two or three years to get them walking again," says Dr Hamlin.

There is a small room for physiotherapy at the hospital, where patients make themselves strong enough for the operation. One young woman here is learning to walk again, her bony hands leaning on parallel bars. She was found in the south-west of the country, squatting on a plank. She had been there for nine years.

A group of women stand outside in the sunshine, weaving colourful baskets and smiling at the strangers as they pass by. One explains what it is like to have the condition. "It's disgusting," says the teenager who is living in one of the hostels on the hospital grounds until she is well enough for the operation. There is a constant demand for beds in the hostels but patients don't mind sharing - sharing a bed with another fistula patient is a welcome change from being spurned for their condition in their own communities.

"Before I came here I felt like I was the only one with this terrible affliction. Nobody else understood. But here they don't make you feel bad. At the hospital you are not ashamed and you are not alone."

The women are given bible classes and learn to read the alphabet. They have fresh water and food and sanitation, which in most cases is more than they would have at home. When they leave, cured and most able to conceive again, they are presented with a new dress and told to get to a hospital next time. "We tell them 'When the baby starts walking in your stomach it is time to start walking to a hospital'," says Dr Hamlin. "The cure is complete when they have a healthy baby."

Unfortunately, for women in rural areas there are too few hospitals and not enough midwives, especially in the countryside where they are most urgently needed. But it is not just poor obstetric care that is responsible for fistulas.

Child marriage is still practised in the northern provinces. Girls may be engaged as young as eight, married at 12 and pregnant with their first children at the age of 14. The government recently raised the legal age of marriage to 18. "But still many women are not developed enough to deliver a baby," she says. The maternal mortality rate in Ethiopia is among the highest in the world. And for every woman who dies in childbirth, there are 10 who will develop fistulas.

Catherine Heaney, acting chief executive of the Irish Family Planning Association, was one of the co-ordinators of a recent trip to Ethiopia by the informal All-Party Interest Group on Sexual and Reproductive Health. It comprised TDs Eoin Ryan, Fiona O'Malley, Damien English, Jan O'Sullivan, Simon Coveney and Senator Mary Henry.

"The impact of repeated pregnancies and the lack of adequate maternal healthcare is preventing women from reaching their full potential in developing countries such as Ethiopia," she says. "Giving women the ability to plan and space their own families will result in improved quality of health among women and children, as well as giving women more opportunities to focus on the development of their households, farms and other resources.

"Sexual health education, reproductive health services - including facilities for assisted birth - and quality family planning services will significantly reduce instances of unwanted pregnancies, high maternal mortality rates and conditions such as fistula."

The statistics on sexual and reproductive health and population in Ethiopia are disturbing. Around 23 per cent of the population is of childbearing age, with this figure set to rise sharply as 44 per cent of the population is under the age of 15. The average fertility rate is six children per woman with the infant mortality rate at 97 deaths per 1,000 children. Only 5 per cent of births are delivered at a health facility while only 1 per cent of women and 5 per cent of men used a condom during their last sexual encounter. The 65 million strong population is set to expand to 115 million over the next 10 years. AIDS, already a massive problem in Ethiopia, is set to escalate. According to Dr Benson Morah of the UNFPA, the UN population fund, in Addis Ababa, the key to many of these problems is providing adequate sexual and reproductive health programmes.

Before our visit to the Fistula Hospital, we travelled north, to the Tigray region - an area still ravaged by famine - to see how reproductive health programmes are implemented. Family planning started 36 years ago when the Ethiopian Family Guidance Association was set up.

Now it is a nationwide programme with 130 outreach centres, seven of them operated by young people for young people. Lakachew Walia, branch manager for the Mekele centre in Tigray, explains that religion - Ethiopia is a predominantly Christian society - has been a barrier to progress and planning of these services in the past. "We decided that the two should work together as partners . . . now we have religious people who educate about family planning and distribute condoms. They also have more involvement in educational prevention of HIV/AIDS," he says. "This is a society where beliefs and values are deep rooted, one simple word from a priest can be so influential here".

The Rev Haletom, a wizened, grey- haired man, has become known as the condom priest. He distributes contraceptives to his congregation and can see the benefits. "The people need to know that using condoms can save lives and can make a better future for them and their children. I don't have any moral problems with this. When I distribute condoms the community learns about the issue and hopefully things change," he says.

Supplies are a huge problem, says Lakachew. There are 13 types of contraceptives available but the association has little control over which ones they will have in stock. "Some people come looking for pills and we might only have condoms, or the other way around," he says.

Despite the damning statistics, awareness, especially among the youth, is growing. Asked what was the biggest challenge facing Ethiopia today was, Hirat Andulaem, an 18-year-old student from Addis Ababa, doesn't hesitate.

"We need to minimise the population, we have to use condoms and pills to protect from disease and lower the growing numbers of people," she says.

Standing outside a counselling centre for AIDS victims, she said most of her friends were either abstinent or used contraception. "At this time, most of the young people want to learn about family planning. We know how important it is".

A little boy with big brown eyes and small lesions on his face stands at the gates of the centre. His name is Solomon Worku. He is 10 years old and was born HIV positive. His mother and father both died shortly after he was born and he was raised by an aunt and uncle. But his uncle was never happy with having an infected child in the house and eventually at the age of five Solomon was thrown out. His aunt handed Solomon over to the centre and he was placed with a carer who herself had lost her husband and child to AIDS.

Solomon is happy here, drawing pictures and playing with the visitors who come.

Sister Kate Young from Tipperary is based at the centre. "I find it very emotional, very draining, it is heartbreaking. They suffer so much and have so little. Sometimes we just ask them, what would you really like to eat now. Simple things. When they get too sick we deliver home care three days a week," she says.

His carers say that if Solomon gets a good balanced diet he could live until the age of 20. Nobody is hopeful that he can survive beyond that.

"Many of the problems around Ethiopia's population's health quality and demographics point to the need for improved sexual and reproductive health education and services. The AIDS/HIV crisis alone highlights this," says the UNFPA's Dr Benson Morah.

The level of backstreet abortion, particularly in Addis Ababa, also highlights this urgent need. Of 212,000 illegal abortions carried out in Ethiopia during 2000 to 2001, 15 per cent (2,563) of the women died of complications. The Ethiopian Women's Lawyers Association has called for abortion to be legalised.

"If not," said the organisation's legal aid co-ordinator, Ellen Alem, "then women are going to consult the services of untrained practitioners and that would result in a worse case".

Current Ethiopian law states that if a woman becomes pregnant through rape or inter-family wedding then she can access a legal abortion after proving the details of her case.

However, such legal wrangling takes time. "Getting this kind of case to the court, getting a hearing session and finally getting a decision is something that definitely takes more than three or four months . . . it becomes impossible to perform an abortion," said Dr Yibru G. Hiwot from the Addis Ababa Medical Faculty.

Ireland already makes an important contribution to UNFPA - last year the Irish government contributed €1.84 million - but according to Ms Heaney this contribution needs to increase.

Workers on the ground believe the Government needs to look at how it can work with local family planning projects to ensure that they have adequate supplies, education materials and are in a position to deliver a quality service.

In Addis Ababa, the Ethiopian Family Guidance Association was having problems securing a simple resource such as rubber gloves and this shortage was already compromising the hygiene standards of a valuable family planning service. While these issues have been made more of a priority by the Ethiopian government, they need all the help they can get.

In a lush valley, 70 kilometres outside Addis Ababa, the finishing touches are being put to a Deste Mendes (Village of Joy), a residential community for incurable fistula sufferers and those waiting for surgery.

In the centre of the circle of purpose-built houses, the community centre, the social heart of the community, is almost complete. Up a hill, preparation is being made for a small pond at the foot of a natural waterfall where the women can bathe in seclusion as they recuperate.

Those behind the Fistula Hospital represent a beacon of hope in a country ravaged by poverty, disease, woeful resources and limited access to the sexual and reproductive health services that have the power to improve the lot of this beleaguered nation. "Everyone deserves their dignity," says Dr Hamlin.

Some names in this report are fictitious to preserve the anonymity of patients.

To make a donation to the Addis Ababa Fistula Hospital write to Hamlin Churchill Childbirth Injuries Fund, 5 Victoria Avenue, Halesowen, West Midlands, England B62 9BL; Telephone: 0044-121-422 4164