MEKELLE, Ethiopia — Dima Yehea's two-year-old son has large brown eyes and a sweet, carefree smile. He sits on his mother's lap wearing only an old T-shirt. Dima, dressed in a loose hospital gown, looks at me with intent, studious eyes. Her baby turns towards her, grabs her left breast with both hands and nurses for a few minutes. As the baby focuses on his meal, Dima concentrates on me, a Westerner in Ethiopia.
Dima also wears a big smile on her face. Her hair has recently been styled, pulled back in tight braids, in preparation for her departure from the hospital and trip home to her rural village.
A young woman living in a country with one of the world's worst health care systems, Dima has experienced needless, preventable pain and tragedy. Yet she appears happy to share her story. To an American, it is a story of the poor state of women's health care in Ethiopia. To Dima, it is a story of triumph and hope.
Dima was 15 when her family prepared a wedding ceremony and married her off to a man she had never before met. Soon after getting married, her husband forced himself on her.
"Did you understand what he was doing?" I ask her.
Dima's smile slips away. She slowly shakes her head. "I was a kid," she says through a translator. "I didn't know what was happening."
The sex was painful, but her husband did not stop.
Dima soon became pregnant with her first child. She was living in a rural village called Late about 145 kilometers from Mekelle, the largest city in northern Ethiopia.
Like 94 percent of Ethiopian women, Dima went into labor at home without access to a skilled birthing attendant. Too young and undeveloped to be giving birth, Dima's body could not handle the labor. The baby's head pushed down on her pelvic bone, not yet wide enough to let the baby pass naturally, for 48 hours.
Dima eventually gave birth, but the baby had died during the protracted labor. Plus, the prolonged pressure caused the tissue between her bladder and vagina to die. A hole called an obstetric fistula formed.
Obstetric fistulas are practically unheard of in developed countries because women give birth at a later age and therefore have more developed bodies - plus, even more importantly, they have access to medical care. If a woman has a complication during pregnancy, like about 15 percent of women do, she can have a Cesarean section.
Dima had no such luck.
In Ethiopia, where such surgery is rarely an option in the rural areas where women like Dima live, obstetric fistulas plague about 100,000 women, says Karen Beattie, the project director for Fistula Care, a project managed by EngenderHealth and funded by USAID. The exact number of women living with fistulas — like the exact maternal mortality rate — remains unknown due to lack of good population-based statistics, she says.
About 2 million women in the developing world currently live with untreated fistulas, according to the UN Population Fund.
"The whole problem lies in detection of difficult labor and appropriate referral to emergency obstetric care," says Dr. Melaku Abriha, an obstetrician and gynecologist who runs the Mekelle branch of the Hamlin Fistula Hospital.
The hospital's facility in Addis Ababa opened in 1974 and has treated more than 32,000 women, according to public relations officer Feven Haddis. The Mekelle branch opened in February 2006 and has operated on around 600 women from rural villages surrounding Mekelle. Ninety-one percent of the surgeries have been successful, Dr. Melaku says.
Dima's fistula caused her to leak urine at all times. The uncontrollable discharge left her uncomfortable and smelly.
Still just a teenager, Dima became so embarrassed of herself that she stopped seeing her friends.
"I felt like they were talking about me behind my back," she tells me.
Dima told her husband that she did not want to have sex with him. She felt unhealthy and uncomfortable. But he insisted. After having a second child, the little boy now sitting on her lap, Dima began refusing to have sex. Her husband divorced her and married another woman. Dima moved back home with her parents.
Her baby stops nursing and turns to watch me. Dima's bare breast rests on top of her gown. She explains that she stayed at her parents' house, without any contact with the outside world, until a local non-governmental organization visited her village and found her. The group, Relief Society of Tigray, helps women who have developed fistulas. They brought Dima to the hospital in July, and Dr. Melaku performed surgery on her to repair the hole between her uterus and bladder. The surgery cost about US$400 and was paid for by the hospital.
The surgery was successful, and Dima will return to her village the day after I meet with her.
I ask Dima how she feels now, and the joy returns to her face. Her eyes open wide, and she starts talking fast and loud. "I am happy!" she says, pounding her chest with her clenched fist. "I will start to talk with the neighbors and community. I will look for a new job, and I will start a new life."
She says that she cannot return to farming because after living with a fistula for six years and undergoing surgery, she does not think her body will be strong enough for the intensive work. In general, women who undergo fistula surgery can return to farming once they have fully healed, says Karen Beattie of Fistula Care.
Dima also no longer has a husband to help her with the farming. Instead, she says, letting out a laugh, she will become a businesswoman.
"My plan is now to change my life," she says. "I will do business and earn some money for me and my baby."
It is unlikely that the number of fistula cases in Ethiopia is decreasing. However, more places like the Hamlin Fistula Hospital are opening and serving more women, says Beattie. Furthermore, increased attention by the international aid community over the past 10 years on the issue of fistulas has led to greater awareness about the problem of both this medical condition and women's maternal health in general.
Despite the gains, only about a third of the 9,000 fistula cases that occur in Ethiopia each year get treated, according to the UN Population Fund.
"Fistula is a marker for what is happening for maternal health more generally," Beattie says. "It has shined a light on the need for more access to emergency obstetric care."