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.
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."