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In Ethiopia, Nurses and Midwives Help Mothers Overcome the Pain and Shame of Fistula

Maternal health at IntraHealth International

Women are receiving better care for obstetric fistula after the USAID Transform Health in Developing Regional States project trained nurses and midwives in rural Ethiopian health facilities

Anab Farah, a young woman in Somali State, Ethiopia, thought she was prepared for the birth of her first child. But when she went into labor at her home, she wasn’t able to give birth. For 24 hours, she suffered from obstructed labor. Her traditional birth attendant didn’t know what to do and, after using inappropriate procedures to induce delivery, Anab was told she had to go to a nearby health center to complete her delivery.

When she arrived at the Lafa Ciise Health Center, a midwife helped her deliver a healthy baby boy. The next day, she was sent home without any information or knowledge that she had developed obstetric fistula.

A consequence of prolonged or obstructed labor, obstetric fistula is a hole that forms between the vagina and the bladder and/or rectum. It happens when a baby’s head or other body part presses too long against the soft tissue in the mother’s pelvis and cuts off the blood flow. Within three to ten days, the tissue may die and create an opening. The mother will then suffer chronic urinary and/or fecal incontinence.

Anab is one of the over 70% of women who give birth in Ethiopia without a skilled medical professional. This leads to an estimated 36,000 women in Ethiopia who live with obstetric fistula, and over 3,000 new cases occur each year.

Anab did not know why she was in pain and was ashamed of her incontinence, so she kept it secret and began hiding, afraid to spend time around other people or use public transportation.

“It was hard for me because my child on my back and I both couldn’t control when we urinated,” she says. “I would wash both our clothes constantly and I felt like child.” 

Finally, she went to another clinic for help, but they sent her home with antibiotics, which didn’t work. Anab realized she had to tell her husband. When he learned what she had been going through, he took her back to the Lafa Ciise Health Center where midwife Fardawsa had recently been one of 36 health workers trained by the USAID Transform Health in Developing Regional States (T-HDR) project to identify obstetric fistula and help mothers manage it.

IntraHealth International works with lead partner Amref Health Africa as part of USAID T-HDR, which works in Ethiopian regions primarily populated by pastoral and agro-pastoral communities whose health outcomes lag behind national targets.

Together with our USAID T-HDR partners, we’re helping women like Anab and reducing maternal, newborn, and child mortality by strengthening the health systems of these regions. This includes training health workers to prevent and identify obstetric fistula and pelvic organ prolapse and to assess cases and provide referrals for clients with obstetric fistula and prolapsed uteri.

"Now, obstetric fistula screening is part of our daily routine at the health center."

Thanks to midwife Fardawsa’s training, Anab was able to get the repair surgery she needed at a treatment center and she is now completely healed.  

“Today, I am so happy to see Anab happier and healthier than when I first saw her,” says Fardwasa.

After her treatment, Anab became an ambassador for better maternal health in her community. She now works with USAID T-HDR to support other women who face similar experiences. She is a peer educator, participates in case identification, and helps other mothers who’ve been cast out because of their obstetric fistula reintegrate into their communities and receive support.

After Anab’s experience, Fardwasa presented her case to the Lafa Ciise Health Center management team and they agreed to implement new policies and procedures such as creating advocates in the community for obstetric fistula services, recording and reporting all cases, and referring all cases to the appropriate treatment centers.

“As a woman and midwife living and working in our marginalized pastoralist communities, I was really afraid to hear the word ‘fistula’ before I took obstetric fistula training,” Fardwasa says. "The T-HDR project gave me the knowledge and skills to prevent, identify, and refer obstetric fistula and pelvic organ prolapse. Now, obstetric fistula screening is part of our daily routine at the health center because referrals can turn despair into happiness for women with obstetric fistula.

Transform Health in Developing Regional States is a project funded by the United States Agency for International Development.

Berhane Assefa, Ahmed Ibrahim, Eftu Ahmed, and Wondimagegn Tekalign contributed reporting for this piece.