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Step by step, door to door, district by district, Hamlin Fistula Ethiopia’s new Project Zero aims to find and treat every woman living with obstetric fistula in Ethiopia. It is an ambitious yet achievable goal, writes Carolyn Hardy, CEO of Catherine Hamlin Fistula Foundation.
For 27 years, Abebech* hid herself from the world.
Her obstructed labour, at home and without medical assistance, lasted five days and resulted in a lifetime of loss. Abebech suffered the grief of her child being stillborn, and her birth injuries left her with lasting physical and emotional pain.
Leaking urine and shunned by her local community, she said: “I was afraid to go outside. My neighbours covered their noses when I went out.”
She withdrew from society completely. For decades.
The Hamlin Model of Care
Abebech was eventually discovered by a Hamlin patient identification officer. She was brought to the Hamlin Fistula Hospital in Yirgalem and her obstetric fistula was repaired with surgery. Our world-renowned Hamlin Model of Care supported Abebech as she began to heal from the psychological wounds caused by her birth injuries and years of social isolation.
Dr Catherine Hamlin developed the Hamlin Model of Care and it remains core to the organisation today. It considers the whole woman with respect and compassion, treating the physical, psychological and emotional effects of fistula. In addition to surgery, the Hamlin Model of Care includes physiotherapy, nutrition, counselling, vocational training, and support for reintegration back into the community.
Today, Abebech’s health, dignity and confidence have been restored. She no longer needs to hide from public view.
While obstetric fistula is rare in Australia, women in Ethiopia like Abebech continue to have their lives devastated by this birth injury, even though it is both preventable and treatable.
The progress achieved so far
Thanks to the pioneering work of Drs Reg and Catherine Hamlin, a cure is available. Together, they established Hamlin’s world-famous Addis Ababa Fistula Hospital, and Catherine went on to establish five more fistula hospitals in regional Ethiopia to ensure rural women had access to treatment and care.
Every year, Hamlin-trained midwives graduate from the Hamlin College of Midwives also founded by Dr Catherine Hamlin. As the health care system in Ethiopia has strengthened, the rate of birth injuries suffered by women is slowly reducing over time.
In 2016, the Ethiopian Ministry of Health estimated the rate of obstetric fistula was around 0.42% of all births (ie, around 15 500 obstetric fistula cases per year). Given the continued improvement in maternal health care, the Ministry of Health have constructed a statistical model that suggests that the annual rate reduced to 948 new cases by 2020.
Despite this progress, we have continued to face a significant challenge in eradicating fistula entirely. How do we find and treat women like Abebech, who are so often concealed behind closed doors? How can we ensure women, particularly those living in remote areas of the country, are aware that help is available?
Project Zero
To overcome these challenges, on 4 February this year, Hamlin Fistula Ethiopia launched Project Zero, a nationwide program that will accelerate the eradication of obstetric fistula across all regions of Ethiopia, step by step, woreda (district)by woreda.
With up to 1000 new obstetric fistula injuries occurring each year and an estimated 31 000 women living with historic untreated fistula injuries, the goal of Hamlin’s Project Zero is to reduce these numbers to zero. This is an ambitious program, but one we believe is achievable.
In a country of 118 million people, most of whom live in rural areas, ending fistula requires a systematic approach, and Project Zero has been designed with three fundamental parts: identification, prevention and education, and will be implemented woreda by woreda.
Identification
During the identification phase, Hamlin-trained Project Zero teams, made up of health workers and patient identification officers, will undertake community outreach and household surveys across the woreda. This will allow Hamlin to find women living with a historic fistula injury and transfer them to hospital for treatment.
Prevention
To reduce and prevent the number of birth injuries across the country, Hamlin’s Project Zero will expand the health care services available to women. Our goal is to establish at least one midwifery clinic in every woreda which does not yet have maternal health services.
Professionally trained midwives play a crucial role in reducing birth injuries. By identifying pregnancy complications, they can prevent obstetric fistula from occurring in the first place.
As part of Project Zero, Hamlin midwives and Hamlin-trained teams will also implement a comprehensive antenatal program to track pregnant women within each woreda to ensure they deliver their babies safely and birth injuries are prevented.
Education
Education is the third component of Project Zero. It is vital that women across Ethiopia have the knowledge and tools to give birth safely and understand that help is available should they suffer an injury during labour.
Our community education campaign will highlight the importance of seeking professional medical care during pregnancy, labour, and after birth. Additional training for existing health care professionals will also be rolled out across the country, so they have a deeper understanding of birth injuries and can advise patients of treatment options.
A fistula-free Ethiopia
The first pilot of Project Zero is now underway in Ale woreda in south-western Ethiopia. Hamlin staff are working alongside health professionals from the local government health bureau as well as other key stakeholders. The pilot is on track and we hope to declare Ale woreda as fistula-free by the end of 2023.
Key learnings from this pilot will inform Project Zero implementation in other woredas around the country. In each district, Hamlin teams will also provide longer term support to ensure that Project Zero interventions are embedded and that change is sustained.
Ending obstetric fistula is not just a maternal health issue but a human rights issue. On top of their physical injuries, women like Abebech face a lifetime of isolation, poverty and discrimination. This suffering is needless given that treatment is readily available in Ethiopia.
With Project Zero as our road map, Hamlin will ensure that all Ethiopian women living with obstetric fistula today are treated and given back their lives, and that we can minimise the risks of childbirth for the women of tomorrow.
Eradication of obstetric fistula is within reach. We are more determined than ever to make Dr Catherine Hamlin’s vision of a fistula-free Ethiopia a reality.
Carolyn Hardy has been Chief Executive Officer of the Catherine Hamlin Fistula Foundation since 2016. Prior to that she worked in senior leadership roles at UNICEF and UN Women.
For more information about Project Zero https://hamlin.org.au/what-we-do/project-zero/
*The patient has given consent for their information to be shared, and their name has been changed.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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