Mothers Of Ethiopia Part IV: Inside A Rural Health Post

MAIANBESSA, Ethiopia — I get into a UN Land Cruiser with the UN Population Fund (UNFPA) staff coordinating my visit to Ethiopia and an official from the ministry of health to visit a rural health post. We leave the northern Ethiopian city of Mekelle, and its Obama Cafe and Obama Pool House, and drive about 25 kilometers along winding roads into the countryside. We pass donkeys with packages strapped to their backs and young boys using foot-long sticks to herd their families' cattle. Other young boys jump and down when they see our vehicle, hoping to sell us a live sheep to buy and then slaughter for the upcoming Ethiopian New Year.

The Land Cruiser zigzags around the uneven terrain, trying hard not to get stuck in the deep pockets of mud. We must also avoid hitting the donkeys and sheep standing in the middle of the roads. According to a common saying, if you hit an animal, you must pay its owner the value of that animal plus the value of seven generations.

Eventually the road becomes too narrow for a vehicle, and our crew gets out to walk the next couple of kilometers.

Yellow stone homes shaped in small rectangles dot the lush green fields. Women sit on the grass sifting legumes to later boil and eat with injera, the traditional Ethiopian bread that looks like a flat circular sponge. Guard dogs stand on the rooftops, which stand only six or seven feet high. A farmer walks by holding a live chicken with its legs bound. Young boys and girls spot the group of foreigners and run towards us in their ripped up T-shirts and beaded necklaces, shouting hello. Some see my Caucasian skin and immediately shout, "Money! Money!"

We arrive at the Maianbessa Health Post and find a group of women lined up on the porch outside carrying their babies in sacks on their backs.

Ethiopia, a country of 77 million people, has 2,085 physicians, according to the health ministry. Of those, there are about 200 gynecologists, according to Dr. Ashebir Gaym, the president of the Ethiopian Society of Obstetricians and Gynecologists. During my time in the country, doctors, students, journalists and non-governmental workers all repeated the same line to me: there are probably more Ethiopian doctors in Chicago than in Ethiopia. The statistic comes from the International Organization for Migration, which estimates that some 20,000 professionals migrate out of Africa each year.

The Maianbessa Health Post serves a community of 5,000 people and typically sees about 10 patients a day, says Malefia Gebretensaye, the post's health extension worker. Malefia is one of 30,000 health extension workers who have been installed in rural health posts across the country as an attempt by the Ethiopian government to address the dire shortage of medical professionals in the country.

"Health extension workers are expected to provide clean delivery services at home and in health posts, along with identifying complicated labors and high-risk pregnancies, and referring them to nearby higher facility," Dr. Kebede Worku, state minister of health in the Ethiopian federal ministry of health, writes to the Huffington Post in an email.

Health extension workers are a quick — but only slightly effective fix — to a massive problem. They receive one year of training and can provide basic primary care such as information on family planning and access to contraceptives, immunizations for children and malaria medicine.

It is immunization day at the Malanbessa Health Post. Inside, a mother holds her infant on her lap as a health assistant prepares an immunization. The assistant grasps the baby's arm and begins to inject the immunization. The baby gives the assistant a look of angry horror and lets out a loud scream as the mother squeezes her eyes closed and turns her head away from the needle.

At a table nearby, Malefia fills out a chart with information on what immunizations the baby has received and when the baby must return.

Like 94 percent of Ethiopian mothers, most of the women in the community give birth at home with the help of a relative or neighbor. If they have a retained placenta, they come to the health post to have it removed.

For all other complications, the health extension worker must refer the women to a health center about eight to 10 kilometers away. About 15 percent of all pregnancies involve complications. For those mothers, UNFPA says they need access to a midwife who can help with minor complications, a district hospital where they can have surgery if necessary and a working transportation system that can get the women quickly from the midwife to the hospital.

The villagers in Maianbessa, like most Ethiopians, do not have access to transportation, and if a mother needs to go to the health center, she must be carried there by stretcher, Malefia says. Four men must hoist the stretcher carrying the mother — who at this point would be in labor — onto their shoulders and walk the 8 to 10 kilometers.

Once they arrive at the health center, the mother is still unlikely to have access to a medical professional who has the skills and equipment necessary to perform surgeries like cesarean sections.

At one such center in Serbo outside of Jimma in western Ethiopia, the health officer told us they cannot handle any birth complications due to lack of human resources and equipment. If a mother has a prolonged labor and her uterus ruptures, she must leave and go to a hospital.

In Ethiopia, where 85 percent of the country lives in rural areas and donkeys seem to have the right of way, getting to a hospital can take days. And for many women, that travel time becomes the difference between life and death.

Maternal health serves as a good measure of a nation's health care system because the entire system — infrastructure, referral services and financial processes and more — need to function properly to improve women's health, according to Dr. Muna Abdullah, a reproductive health officer with UNFPA.

"Maternal health is a litmus test for a country's health system," says Dr. Michael Tekie, another reproductive health officer with UNFPA.

Maternal deaths are also preventable. The three ways to drastically reduce maternal mortality are providing information on family planning to reduce the number of unwanted pregnancies, access to skilled birth attendants and access to emergency obstetric care, according to Dr. Michael.

In Ethiopia, the maternal health statistics suggest that the nation's health care system needs an overhaul. Less than six percent of women have access to a health professional while giving birth, according to Ethiopia's 2005 Demographic and Health Survey. The maternal mortality rate is one of the worst in the world. For every 100,000 live births, 673 women die giving birth, according to the survey.

Progress has been made to reduce global child mortality rates, yet maternal mortality rates have remained stagnant in many countries. Child mortality rates in Ethiopia are still too high — UNICEF reports that an Ethiopian child is 30 times more likely to die by his or her fifth birthday than a child in Western Europe — but since 1990, Ethiopia has seen a 40 percent drop in child mortality.

Maternal mortality has not seen similar progress. Furthermore, for every maternal death, 30 other mothers develop debilitating maternal injuries like fistulas and ruptured uteri, according to UNFPA. Additional related casualties include stillborn babies and the hundreds of thousands of children orphaned because their mother did not have access to proper health care.

"Maternal death is the tip of the iceberg of women's health misery," says Dr. Francois Farah, UNFPA's Ethiopia Country Representative. "That's what we see — a woman dies. What we don't see are the injuries."