Dr. Bereket Alemayehu

I’ve always felt that the glamorous life associated with doctors having multiple jobs is overstated. In fact, having multiple jobs comes with unique challenges. However, one aspect I appreciate is that it opens your eyes to different experiences, each offering a unique perspective. I have two jobs: one at a maternity and child health (MCH) specialty medical center in Addis Ababa, and the other at a non-profit organization established to help women suffering from obstetric fistula. I’ve noticed a significant divide in the experiences of mothers at these two jobs, and I wanted to share it.

At the MCH center, a typical mother comes in very early in her pregnancy. Most are in their late twenties to early thirties, educated, and earning a good income. Sometimes, the husband accompanies the mother because the well-being of the mother and child is a priority for the family. From then on, her pregnancy is regularly monitored by experienced professionals who combine knowledge and skill. Problems arising during the pregnancy are almost always detected. Before the delivery date, the parents are often well-prepared. They come to the hospital when labor begins and are admitted into a fully equipped labor ward. At any given time, senior midwives and obstetricians closely follow the progress of labor.

In contrast, at the civil society organization, I encounter very different groups of people. Usually, these young girls become pregnant in their late teens. They come from extremely poor backgrounds and have not received any form of education. Moreover, the women in these communities occupy the lowest societal strata. Once pregnant, they rarely receive any antenatal care. Often, there isn’t a healthcare provider nearby, but even for families with some access to medicine, medical care for pregnant women isn’t seen as a priority. Complications during pregnancy are often not identified, and complications during delivery are not anticipated. Parents are often ill-prepared for delivery. A young girl may begin labor, and it could take days for her labor to be taken seriously. When attention is finally given, a local birth attendant is summoned. Naively or perhaps arrogantly, it’s assumed that labor will proceed smoothly even without professional intervention.

These two settings result in starkly different outcomes. At the MCH center, labor is closely monitored throughout. The mother is presented with several options to lessen her pain and delivers her baby in a clean, fully equipped delivery room. Even if labor progresses abnormally, three fully equipped operating rooms are just a few meters away, ready for an emergency Cesarean Section.

On the other hand, the scenes of home deliveries are harrowing. The mother endures agonizing pain, more intense than regular labor pain, because the labor is obstructed. While it’s difficult to say whether the fistula patients are lucky, they are certainly those who narrowly escape death, as obstructed labor can be fatal. Often, they are surrounded by people who cannot alleviate the pain or manage the labor. The girl survives but develops obstetric fistula. The baby is almost always lost due to the labor. A few days later, the young girl realizes she is now leaking urine or feces through her vagina. She notices that others are bothered by the smell, but it’s hard to imagine anyone else being as bothered as she is. The girl, already in a precarious situation, faces inhumane treatment. Her husband and community shun her, and she shuns herself.

This divide is enforced by complex social, economic, political, and institutional systems. At the MCH center, several managers are dedicated to ensuring the hospital is clean, pleasant, appropriately equipped, and staffed. When mothers are discharged, they are asked to fill out a satisfaction form, and those with serious grievances usually have a sit-down with the managers. In the stories of patients with obstetric fistula, I see individuals who deserve accountability for their actions. Sadly, these women have been treated poorly for so long that they see it as naturally ordained. The illness makes them feel ashamed, so even though they have been wronged in many ways, they direct the guilt towards themselves. They suffer in silence and impose further punishments on themselves to hide their symptoms.

The question of health equity becomes more apparent whenever I reflect on my two jobs. It’s a disturbing realization that the location where a girl is born can so deterministically affect her fate. This is completely unacceptable. It is up to us to demand health equity, as those who are treated poorly may not even realize they deserve better.