Mothers Of Ethiopia Part I: Zemzem's Journey

Editor's note: Hanna Ingber Win, the Huffington Post's World Editor, was recently invited by the UN Population Fund to visit its maternal health programs in Ethiopia, which has one of the world's worst health care systems. In the U.S., a woman has a 1 in 4,800 chance of dying from complications due to pregnancy or childbirth in her lifetime. In Ethiopia, a woman has a 1 in 27 chance of dying.

This is the first in a five-part series on what she learned on her trip.

JIMMA, Ethiopia -- When Zemzem Moustafa went into labor with her fifth child - at age 30 - she could sense a problem. Living in a thatched-roof hut in Ilebabo, a rural village in western Ethiopia, she and her husband walked to the local health post. A health extension worker there could tell that the baby was in the wrong position, but the worker could not help Zemzem and referred her to the hospital. And so Zemzem's journey began, one that ends in tragedy for thousands of women in Ethiopia each year.

She and her husband, a poor farmer, collected 50 birr (US$4) from their neighbors for the trip to a hospital in Jimma, the closest big town. Leaving at around 4 p.m. on a Friday afternoon, they walked through the fields for an hour until they arrived at a road. Standing at the side of the road, they hailed a rickety old minibus packed with other villagers.

• • • • • • • • • • • • Zemzem Moustafa, 30, looks down at her 3-week-old son at the Jimma Referral Hospital in Jimma, Ethiopia, on September 2, 2009. Zemzem traveled 20 hours, while in labor, from her rural village to get to the hospital in the closest big town. By the time she arrived at the hospital, her uterus had partially ruptured. A resident and health officer were able to save her life and that of her baby.

August is the rainy season in western Ethiopia and the minibus got stuck in the mud. Zemzem, whose contractions became more and more intense, spent the night on the side of the road with her husband and the other passengers. The next morning the men freed the minibus from the mud and the trip continued.

Zemzem and her husband reached Jimma at noon on Saturday, a full 20 hours after the trip began. They drove down the dirt road that runs through the center of the town, past the young boys herding sheep, the donkeys with bushels of hay strapped to their backs and the women sitting on the side of the road selling vegetables.

By the time Zemzem arrived at Jimma Referral Hospital, her uterus had partially ruptured as a result of the prolonged labor. A gyno/obs resident and a health officer operated on her immediately, and they successfully saved the lives of Zemzem and her baby.

"If she [had been delayed] two or three hours more, the baby - and even the mother - would have lost her life," Dr. Chuchu Girma, a surgeon and the clinical director of the hospital, tells me as we chat with Zemzem in the maternity ward.

Maternal health specialists say that there are three ways in which necessary treatment is delayed: when the mother or family first decides to seek appropriate medical care for an obstetric emergency, as the family tries to take the woman to a hospital and faces transportation impediments and once the woman reaches the health institution and faces setbacks in being admitted and getting medical attention.

I am visiting the Jimma Referral Hospital as part of a trip sponsored by the UN Population Fund (UNFPA), which provides support for the government's program to train non-physician clinicians to perform procedures, such as obstetric surgery, traditionally performed by doctors. The health officer who operated on Zemzem is being trained to become one of these non-physician clinicians.

Zemzem is lying on an old metal bed with the paint chipping off, under a heavy blanket that looks itchy and dirty. A used surgeon's glove is tied to the bedpost. The sheet has fallen down, exposing a thin plastic mattress.

When I enter the maternity ward at Jimma Hospital, the stench practically smacks me in the face. The smell, a combination of urine and feces and other bodily fluids, overpowers all my other senses.

Each room along the maternity ward has a sign posted above the door in English and Oromiffa, the local language: "Labor Room", "High Risk Room", "Delivery Room". Zemzem stays in "Septic Room." The Septic Room houses women who have had pregnancy complications like ruptured uteri and fistulas that involve extra discharge.

When Dr. Chuchu and I enter the Septic Room, Zemzem is lying flat on the bed with her baby under the blanket. I ask about the baby, and Zemzem's face lights up. She pulls the blanket back to reveal her newborn. I ask if the baby is a girl or a boy, and Zemzem, saying he is a boy, smiles and laughs.

"They are very happy when they get men," Dr. Chuchu says to me.

Zemzem has remained at the hospital for three weeks because she has an infection. Dr. Chuchu lifts up Zemzem's gown to reveal a large white bandage from the surgery.

Her husband has returned to her village to take care of the other four children, a medical intern says, translating Zemzem's answers in Oromiffa, the local language, into the national language, Amharic, for Dr. Chuchu, who translates into English for me.

Some girls in Ethiopia get married as young as 10 or 11, Dr. Chuchu says, and they then get pregnant before their bodies fully develop. This increases the likelihood that they will have obstructed labor. A ruptured uterus is a very simple, manageable problem, he says. But the girls or young women, living in rural villages, usually give birth at home and lack access to a health professional during delivery -- like 94 percent of Ethiopian mothers.

Without help during delivery and without surgery and a blood transfusion if the mother's uterus ruptures, the girl or woman often dies. In the United States, eight women die during childbirth for every 100,000 live births, according to the UN Children's Fund (UNICEF). In Ethiopia, 673 women die, making the maternal mortality rate 84 times higher. UNFPA considers every single maternal death preventable.

Zemzem's other children range in age from 2 to 12, the intern translates as he gently pulls down her gown to cover up her back.

I bring out my camera, and Zemzem smiles glowingly at her new son.

No one else in the "Septic Room" can empathize with Zemzem's joy. The other three patients all had fully ruptured uteri and lost their babies.

Dr. Chuchu and I stand next the bed of another patient. The blanket engulfs her tiny body, so small it looks like it belongs to a child. An intravenous drip stands next to the bed, pumping antibiotics into the young woman. Dr. Chuchu looks at her chart -- she has lost almost two-thirds of her blood during her operation and now waits for a blood transfusion. He pulls down one of her lower eyelids. The entire eye is white, not a trace of red veins.

"This is a case [where the mother] usually dies," Dr. Chuchu says. If she had been at a rural health post or health center, she would not have had access to a surgeon or to equipment necessary for a blood transfusion.

The woman looks so vulnerable that I whisper in Dr. Chuchu's ear, asking if he thinks she will make it. Yes, she will survive, he says. She will get blood here.

Dr. Chuchu asks the patient where she comes from, but she is too weak to answer. He looks at her chart. She comes from Gatera, 112 kilometers from Jimma. She is 22 years old and has been pregnant four times. This is the third child she has lost. When she arrived at the hospital, her uterus had already ruptured. She therefore lost the baby and had to have her uterus removed.

If she is Muslim, her husband will take another wife to have more children, Dr. Chuchu tells me. He checks her chart. "Oh, she's Muslim," he says. "He will definitely have another wife."

Part II: Escaping Child Marriage in Ethiopia

Part III: Battling Pregnancy Complications

Part IV: Inside A Rural Health Post

Part V: Ethiopian Gov't Looks For Solutions To Dire Shortage Of Health Professionals

Comments

[caalaa]

Hanna thank you for these reporting. Let us not forget that Ethiopia is run by a dictator who care less about the struggle of the public. In many case it is the government that cause the problem, by not providing basic health care.

[MosheDayanHero]

A country that doesn't have effective polcies for cotnrolling population birth control, free abortions, public campaigns, penalties for having more than two children will remain poor and hopeless.
China's one-child policy should be a model for all Third World nations.

[saly]

I am stunned by the commentary’s silly conclusion of society relationship in just one trip. In contrast, these kinds of practice are well known in northern part of Ethiopia among Amahra tribe. You should study carefully before you jump conclusion. Don’t be instrument for 100 years Ethiopian dirty politics. I am Ethiopian Christian who lived among the Muslims ‘whom’ you try to score political game with. A rare incident shouldn’t be your case topic! If you want to write stories go ahead.

[ROSAGrids]

Amen to this comment!

[Mira Kamdar - Huffpost Blogger]

Hanna, you have beautifully conveyed this story, one that is, alas, repeated all over the world wherever women are poor and powerless. I feared when you took us to the bed of the very small woman who'd lost a lot of blood that we were about to meet one of the 10- or 11-year-olds you evoke, and found myself relieved the woman was 22, not that her age makes any difference to her suffering. I look forward to reading the rest of the articles in this series.

[Gail McGowan Mellor - Huffpost Blogger]

Beautiful, compelling work, Hanna. I can see the hospital, smell it, hear it, and feel the tragedy, courage and will to live of the women. The staff is obviously doing an heroic job with very limited resources, preventing even greater death rates from infection. I realize too that these docs are not substituting for midwives during normal births, that without surgery each of these women and newborns would die. Still I wonder....

In the early 1900s in the US, doctors got laws passed and forcibly took over from midwives. In town after town, death rates shot up because the docs were treating a badly infected patients, even doing autopsies, and then without adequate washing, were reaching up inside birthing women. Until docs realized that the germ theory of disease applied even to them, the death rates were appalling. Does the UN have figures or even guesstimates on what aspect of the maternal and neonate death rate there in Ethiopia is iatrogenic: doctor-caused?

The smell that smacked you, that dirty plastic glove certainly raise an alarm. Specifically, I wonder about leaving a newborn and just-delivered mother, plus other women just past hysterectomies, in with fistula patients. Were these fistula patients with just repaired fistulas or were the fistulas still open? What did you observe about staff self-cleansing procedures in between patients? Thanks for any additional light you can shed.

[civilizedthinker]

The baby and the mother would both be at high risk were they to be seperated.

[kitfox]

Hanna, Please don't forget the women of Eritrea! The small east African country received their independence from Ethopia in 1993 and suffer the same horrors as the women of Ethiopia including in some parts genital mutilation.. I rarely read articles written about them.

[girlscount]

Hanna, I know ZemZem had a joyful conclusion to her ordeal, but the story is still so sad.
I understand the problem of maternal mortality and I hope all the attention the issue is getting now(Half the Sky, WRA, and the dinner in NY with all the stars) will end in results and solutions. It must have been overwhelming to see the problem first hand. Thank you for your work! MWheeler

[exhiliration]

HIG94 YUD,

In my experience, people who ask questions such as "why do they keep having children when they cant afford them" like you did are usually speaking out of ignorance, sometimes Bias or simply stupidity. these people have more children because they cant afford birth control and sex is a very strong urge that even poor people in their poverty are not immune to its temptations. most of these women are having babies for their husbands. and irrespective of how the woman may feel in not wanting more children, due to the oppresiveness of her society, has to give in to the demands of her husband. so think before you speak.

[Very Berry]

we must be reading a different article. i can't see hanna asking that question anywhere in this piece.

[anonmouse]

I have recently returned from Ethiopia. It is a beautiful country, but continues to face such severe problems. Thank you for this wonderful series.

[MOregon]

As gut wrenching as this article is, I want to thank you for piercing the bubble we live in that is so far removed from what a good portion of the world suffers. For most of my life I did not know that there were worlds classified beyond third world - even to fourth, fifth and I believe sixth world depending upon the hopelessness of their situations.

Just about everything else is reduced to petty and self-serving when we see family struggles under conditions such as these. I pray we have not forgotten how to weep for others in our nation and let the calling sounds of our tears move us to do something.

[hig94yud]

We need a population control policy for africa. UN should gear its policy toward education about family planning & supply contraceptives. Ethiopians of all people should be educated about family planning (population 80 million, 2nd in africa). Why do they have so manny kids when they can not afford to feed them (ethiopians live on less than a $1 a day). 23 million people in east africa (ethiopia, somalia, kenya, uganda) will need immediate food aid to avoid famine according to the latest report from AP. We can try try to save every baby in africa, but what are they going to eat?

[waterborne]

I was born there, the villagers have as much babies as they can so that they get taken care of when they're old... It is customary to take care of your parents when they're weak and those with no children die a miserable death. The more kids you have that grow up the better off you are (It doesn't really cost much to raise them because the kids help out with the work as soon as they are able to run tending to the animals etc...) This is a huge problem for the government, the people living in the rural areas don't trust the authorities and wild roamers start circulating when they try to start any such programs for birth control.

P.S "population control for Africa" is a scary term, I'm sure you mean well but given the history of the world, it might be better if you use another expression

[exhiliration]

people who ask questions such as "why do they keep having children when they cant afford them" like you did are usually speaking out of ignorance, sometimes Bias or simply stupidity. these people have more children because they cant afford birth control and sex is a very strong urge that even poor people in their poverty are not immune to its temptations. most of these women are having babies for their husbands. and irrespective of how the woman may feel in not wanting more children, due to the oppresiveness of her society, has to give in to the demands of her husband. so think before you speak.

[exhiliration]

In my experience, people who ask questions such as "why do they keep having children when they cant afford them" like you did are usually speaking out of ignorance, sometimes Bias or simply stupidity. these people have more children because they cant afford birth control and sex is a very strong urge that even poor people in their poverty are not immune to its temptations. most of these women are having babies for their husbands. and irrespective of how the woman may feel in not wanting more children, due to the oppresiveness of her society, has to give in to the demands of her husband.

[waterborne]

@hig94yud

Actually I took a look at your comment history, you seem to have something against Africa

http://www.huffingtonpost.com/2009/09/27/beating-death-of-derrien_n_301319.html?page=10&show_comment_id=31778217#comment_31778217

All bias comes out of ignorance, maybe you should visit a country in Africa and get to know some of the people who live there. You might be surprised

[jessicadevyn]

Agreed. I have been to Afrca (The Gambia, Senegal, Ghana, Nigeria and South Africa).

[Very Berry]

are you running as a candidate for the local nazi party? "population control" "having kids when they can't afford them". the shame is on you.