Honoring an Outstanding Clinician

Azra Admani scans a fistula patient for One By One's Ultrasound Study

On the 100th Anniversary of International Women’s Day, we want to highlight one woman doing extraordinary work with One By One: Ms. Azra Admani.

Azra is an outstanding ultrasonographer who lives in Mwanza, Tanzania and works at Bugando Medical Center. For the past year, in addition to her full-time duties, Azra has played a critical role on a very exciting research study that we are conducting. Every Monday, Azra spends several hours using her keen ultrasound skills to measure the internal pelvic dimensions of women with fistula and a group of comparison patients. This study will help determine if ultrasound can be used to identify women who are at high risk of experiencing obstructed labor that can lead to fistula formation. If proven to be effective for this purpose, ultrasound may be an important tool for fistula prevention, making it possible to target high-risk women in remote areas and ensure that plans are in place to access emergency care if needed.

Prevention is the key to ending obstetric fistula throughout the world. Azra Admani’s commitment to carrying out this research with great care is making an important contribution to One By One’s efforts to develop innovative and effective prevention strategies. We honor Azra on International Women’s Day for her tremendous work on behalf of girls and women.

A final note: Rep. Carolyn Maloney just introduced the “Fistula Prevention, Treatment, Hope and Dignity Restoration Act”. In her words, this bill would “authorize the President to provide assistance to prevent and treat fistula, including through increasing access to prenatal care, emergency obstetric care, postnatal care, and voluntary family planning; building local capacity and improving national health systems; addressing underlying social and economic inequities such as reducing the incidence of child marriage and increasing access to formal and informal education; and supporting reintegration and training programs to help women who have undergone treatment return to full and productive lives.”

Let’s all thank Rep. Maloney for her commitment to this issue, and support her efforts to persuade the U.S. government to invest in eradicating obstetric fistula worldwide. To echo her call… Spread the word.

Outreach in Rural Kenya

Top Row (from left): Winnie (our translator), Sarah Omega, Emmanuel (the school principal), Heidi, Carolyn; Bottom Row: The school head teacher, Nereah, Catherine

While in Kenya, Sarah took us along on her outreach trip to some rural areas around Eldoret. On our way to a community meeting, we picked up Catherine, a woman that Sarah had met while previously doing outreach in a nearby area. Catherine told us she had heard from a local school principal that one of his students was leaking urine, and had asked us to stop by to see her.

So, we took a detour to Kimilili Deb Primary School, where we met the principal and the head teacher, who introduced us to Nereah, a 17-year old girl with fistula. As a result of her fistula, Nereah has developed a phobia of being around other people. Sarah told Nereah that her fistula could be repaired, something Nereah never knew before. Repair will be life-altering for Nereah as she will be able to sit in class with other students without fear of being ostracized. Thanks to Sarah’s outreach work, we are working with Nereah’s family and school to get her to Eldoret for free treatment.

We then went to the community meeting, where Sarah educated a group of men and women about fistula, and even gave out a phone number where people can reach her, something she does at every outreach event. She told the group that they can call her at anytime if they hear about or find someone living with fistula. As a result, Sarah's message spreads beyond community meetings, allowing her to work through people like Catherine to reach more women who would otherwise never hear about free treatment.

We hope you can join us for our 6th Anniversary Dinner on March 24th to hear more about Sarah's work in rural Kenya. Don't forget to RSVP, if you haven't already.

One By One Community Book Discussion Success!

One By One hosted its first Community Book Discussion focusing on the book Cutting for Stone by Abraham Verghese. Over 40 individuals attended this wildly successful event. We opened the night with Ethiopian-sourced fair trade, organic coffee from Pura Vida (buy Pura Vida through our website and a dollar from every bag of coffee sold goes to One By One!), and wonderful Ethiopian snacks provided by a local Ethiopian caterer, Konjit Fekade.

As the room filled with guests, we started with small group discussions on the book. The room was a-buzz with lively and engaged discussion on Cutting for Stone, Ethiopian culture and society, fistula and maternal health, and One By One’s work in Ethiopia.

These small group discussions were followed by a panel featuring Lydia Assefa-Dawson, a representative from the Ethiopian community who spoke beautifully about her experience growing up as an orphan in Ethiopia; Dr. Laura Hart, a urologist and volunteer fistula repair surgeon who provided her medical expertise from her experience working in the field; and Heidi Breeze-Harris, One By One Co-founder and Executive Director, who spoke about One By One’s programs in Africa. Much like the small group discussions, a lively and varied panel discussion filled the air.

It was inspiring to see the diverse group of community members join in on the discussion and connecting with One By One’s work.

One By One thanks those of you who participated in our first Community Book Discussion and for making it a huge success. For those of you who were unable to join us, we are hoping to plan similar events in the near future, so please stay tuned!

Maternal Deaths Decline

For all of us who care deeply about the rights and well-being of girls and women across the world, it is rare to wake up to good news on the front page of a major newspaper. But on April 13th, this remarkable headline appeared on the cover of the New York Times: “Maternal Deaths Decline Sharply Across the Globe.” So accustomed are we to hearing about the persistent lack of progress in reducing maternal mortality globally, I’m sure that many of us did a double take.And then devoured the article. It describes the new findings, published in the highly regarded scientific journal The Lancet, as “challenging the prevailing view of maternal mortality as an intractable problem that has defied every effort to solve it”, and demonstrating that “money allocated to women’s health is actually accomplishing something.” This is very good news, indeed.

Those of us in the One By One community should be especially heartened by the fact that one of our critical investment areas – increasing the availability of trained birth attendants – is identified as being of one of the key factors responsible for the decline in maternal deaths. We have chosen to support training of birth attendants because we know that they play a vital role in both ensuring that uncomplicated deliveries are clean and safe, and in identifying and supporting women who need to be transferred to a facility that can provide emergency obstetric care that will prevent fistula and save lives.It is great to see the importance of this work being highlighted in this high profile article.

While this long-awaited decline in maternal mortality demonstrates that important progress is being made, there are still hundreds of thousands of girls and women dying each year due to preventable pregnancy-related causes, and vast numbers of others develop devastating childbirth injuries such as fistula. There remains an urgent need to work towards ensuring that all girls and women have access to basic and emergency care during pregnancy and delivery. As Richard Horton, editor of The Lancet so aptly concludes, “ This is a moment to celebrate – and accelerate.” Thank you for supporting our acceleration to end fistula.

Infibulation – a practice of female genital mutilation and how that affects obstructed labor for affected Afar women and girls

Fatuma Abubacker’s story of surviving obstructed labor in the Afar is harrowing but not unique. Afar women give birth often with little skilled assistance and in extremely rural conditions. The women may be very young, malnourished or have had many pregnancies in quick succession making their uterine muscles less capable of moving the fetus into the right position at birth. Additionally many women in Afar culture are infibulated, which is one of the most extreme forms of what we call female genital mutilation or female genital cutting. Women, like Fatuma, in the last story, have their genital areas sewn nearly entirely shut when they are infants or at age six. There is a tiny hole left through which they can urinate and through which they can have intercourse, though often painfully. Infibulation can cause additional health problems and the process of infibulation itself is very painful.

When women who have undergone infibulation go to give birth, the traditional birth attendant arrives, as Fatuma’s story goes, with a knife, the blade of which she would heat up for sterilization. The traditional birth attendant would then cut the laboring mother’s scarred vulva back open so that she might give birth. In Fatuma’s case, her closed vagina was her obstruction. Her labor ended with a deceased child and with a fistula that was too complex to ever permanently repair.

This practice is changing as a result of the grassroots work of many dedicated groups on the ground. One of One By One’s fistula prevention program partners, the Afar Pastoralist Development Association, works within their own community to educate about the issues that the Ethiopian Government calls “Harmful Traditional Practices” which include the practice of infibulation. From the standpoint of obstructed labor, infibulations, for the communities that practice it, is an important area of intervention to save the lives of mothers, babies and an important way to prevent obstetric fistula.

Our grants are going to educate the first midwives that will serve the Afar people. These newly trained Afar women will be placed at the Barbara May Women’s Health Center in Mille, which is a new hospital, that is in process. The midwives will supervise and support the newly trained birth attendants who will have more tools at their disposal to assist women in labor. Enhanced birth education for birth attendants, new midwives, and education on harmful traditional practices are just a few of the incredible grassroots programs operating out of ADPA’s Loggia office. One By One is a proud supporter and with your help, more women and girls can survive and thrive in the Afar region!

All photos courtesy of Heidi Breeze-Harris, (c) 2009

Listen to my interview with Valerie Browning: http://www.youtube.com/watch?v=Dl_UeCsovVU

http://en.wikipedia.org/wiki/Infibulation

An Afar fistula survivor in her own words

My trip to work with our partners this past November took me to both Tanzania and Ethiopia. This entry is about a night I spent in the Afar Region of Ethiopia in a town called Loggia. Loggia sits on the main road that runs from the port in Djibouti to Addis Ababa. Although it is only two lanes wide and often has a 6-7” drop-off on either side into soft sand (not the soft shoulder one wants to drive into at 75 miles an hour) the road feels anomalous in many senses. It is a paved road through land that can sometimes look like the moon. It is one of the best roads in the country - a very important trucking road. Giant blocky trucks, many with Chinese on them as that country has many development projects here, cruise with incredible speed down this two-lane highway. They race up to one another’s bumpers and pass each other just when I would think one might want to exercise caution….you know, like when a head-on is about to happen or a blind curve. And so you can imagine the accidents are frequent and fairly dramatic. (In all truth, I did nearly meet my end twice on this road so I do indeed have a good feeling about what a very very near head on with a Chinese dump truck feels like.) As the road rushes by, the bones of many past accidents, poking now out of the sand and dirt that covers them, look like prehistoric sites ready for excavation. All this big machinery flies past the slow and anachronistic lives of the Pastoralist Oromo people and the Afar people with their lovely and simple houses of sticks, blankets and such. Pastoralists watch trucks rumble by as they graze their goats, herd their camels or try to wave a truck down for a ride.

I drove to Loggia, a good thirteen hours from Addis, Ismael and Valerie to work on our partnership with the Afar Pastoralist Development Association. (Valerie and Ismael, husband and wife, are two of thirty-two founding members of the organization Afar Pastoralist Development Association that work on improving myriad components of Afar people’s lives. We are proud to be working with ADPA on ways to improve maternal health in the Afar region where women are at great risk for childbirth injuries like fistula. In a future posting, I will write further about them in particular.)

My goal today is to relay the story of Fatuma Abuacker, an Afar fistula survivor. Fatuma is a beautiful woman around thirty years old who lives with Valerie and her husband Ismael.

I admire Valerie and Ismael greatly. They work effectively and tirelessly not only for the Afar people as a whole but they also help individuals with equal vigor. When I stayed with them a short while this past November, I met numerous people who live amongst them in their family compound. Valerie and Ismael have taken these folks in, in many cases, as they needed very particular help and would not have received it from many other sources.

The story included here in pink writing is an interview I did with Fatuma just before we all went to bed one evening. She was brave to tell me her story so frankly.

I am proud to have worked with a young man named Mohammed Saleh Mohammed who was my translator for this interview and who ultimately transcribed Fatuma’s words into the writing you see here. Mohammed is a young man with a leg injury who is also being helped by Valerie and Ismael. He aspires to be a journalist so he can tell the story of the Afar people to the world. I send my deep appreciation to Fatuma, Mohammed and of course Valerie, Ismael and all of ADPA’s amazing staff who bring a perfect mix of compassion and pragmatism to their important grassroots work for the Afar people.

In case you cannot read all of the pink handwriting, I have slightly edited Mohammed’s translation of Fatuma’s story here but I do believe his actual handwriting and choice of words are quite beautiful in their unedited form.

Fatuma Abubacker, fistula survivor’s story, as translated and written by Mohammed Saleh Mohammed on November 26, 2009

“My name is Fatuma Abubacker. I am 30 years old. I got fistula from my first baby and I had no more babies. I had pain or suffering for ten years because of the traditional circumcising they did for me. Also sewing the vulva was very small to give birth normally and safely. Also because of under age marriage and my womb was very small. The baby died. I suffered with this disease in my body for ten years without having any treatment and there was nobody to stand beside me to get to hospital or what I deserve.

When I was very close to give birth the woman who is the traditional midwife or birth attendant was there and she was not ready to use traditional tools as we have in our tradition. To use the fire for the knife.”

[Heidi’s inserted note for clarity in case it is useful: For women who have been ‘infibulated’ or sewn shut, the traditional birth attendant heats a knife blade and at the time of birth the laboring mother has her scar re-opened so that the baby may be born. Without this cut being made, the baby will be unable to pass through and out of the vagina.]

“It was getting dark, no light. It is far to the village and because of that people were getting upset. They were running here and there. Despite the circumstances I became two. But my life was in between and my relatives had no hope. The consequences were very bad. I was not any more productive for the society and dependent.

After that Maalika [Valerie’s Afar name] came suddenly and took me to Addis Ababa to go to the fistula hospital. They gave me a surgery and they told me my kidneys were damaged. That is why they gave me a mechanism outside of the body. I urinate in a plastic bag.” [urostomy bag]

“I was very lucky to be saved by Maalika and Ismael. I still stay close to them and get support emotionally, mentally and physically. I would like to give them endless thanks for everything they did for me.”

After Fatuma told me her story, she kindly pulled out a cot for me to sleep on and all of us, perhaps ten or more in the compound, slept on different cots and bedrolls under the innumerable stars that had little electricity with which to compete to show off their brilliance.

Fatuma and Mohammed, I am excited to see you both and all those stars again soon!

Men who stand up for women, and the importance of community voices in access to emergency obstetric services

I feel a great honor to be connected to, supported and mentored by an amazing group of people. One of my mentors is Ms. Maggie Bangser, the founder and former director of Women’s Dignity Project in Dar es Salaam, Tanzania. Maggie is also the visionary who helped to start the fistula treatment ward that is now within Bugando Medical Center in Mwanza, Tanzania, one of One By One's long-term grantees.

On my very first day in Tanzania on November 10^th, I had the honor of interviewing Maggie. One of the stories, from her days at Women’s Dignity Project, was about a courageous young man named Abdallah Sadiki Aziz, a farmer from the southern area of Songea and a village secretary of his area in 2005 when this story takes place.

Abdallah’s story, below, is important for many reasons. It illustrates the obstacles women face when working to seek care during childbirth.

Additionally, I wanted to highlight this story because it shows amazing courage and resourcefulness on the part of a man on behalf of a young girl in labor and in need of emergency assistance.

During my recent trip, I met some incredible men like Abdallah in the story below – men who fight for women and their rights. I am very moved by these men, many of whom risk ridicule, community pressure and sometimes even their lives to stand up for women’s voices, health and rights. As I update this blog, I plan to introduce you to some of the great folks I met.

A special thanks to Maggie for telling Abdallah’s story to us and a thank you to Christine Matovu, the Executive Director at Women’s Dignity Project in Dar es Salaam for the permission to share this story with you all.

One Man’s Courage to Speak Out Helps Save Pregnant Women and Children

By Women’s Dignity Project – www.womensdignity.org

In March 2005 a young girl Teresia, from a small village in Songea got pregnant. She was not married and had not intended to have a baby so early in life. By the time she was nine months pregnant and ready to give birth, Teresia was only 14 years old. Because she was very young, the nurses at the ante-natal clinic had advised her to travel to Songea town to give birth at the regional hospital. But because the family did not have enough money, she was unable to do this. However, Teresia and her family did manage to save funds to pay the 30,000 Tanzanian Schillings (Tsh) ($20 USD) ambulance fuel charge to transport her to Songea Hospital.

On December 14^th, the day Tanzania elected a new president, Teresia’s contractions started. Her mother went to the health center to summon the ambulance, but when she got there she was told that the cost had increased to 38,000 Tsh due to the recent rise in fuel prices. No matter how much Teresia’s family pleaded with the Clinical Officer-in Charge of the health center, he would not release the ambulance until the full 38,000 Tsh was paid. Although the lives of Teresia and her baby were clearly at risk, he did not relent. He rudely criticized the family for waiting too long to take Teresia to Songea. “It is your responsibility if she dies” he told her mother.

Teresia spent the night in labor. The following morning the family contacted Abdallah Sadiki Aziz, a neighbor and the village secretary, asking him to plead with the Clinical Officer, or to help them raise the outstanding money. Realizing the urgency of the situation, Abdallah put up his bicycle on bond and provided the remaining 8,000 Tsh ($6 USD) for the fuel. Teresia arrived at Songea Hospital that afternoon. She immediately received a caesarean section, but it was too late to save her baby. She, too, was in grave condition. She remained in the hospital for another month, and when she was brought home in January, she was extremely weak and could not walk. She died three weeks later.

The man who attempted to save the life of his neighbor and her unborn child was Abdallah Sadiki Aziz, a 38-year-old father of three. He is a farmer and the village secretary; he also gets called on to settle family disputes. When Teresia’s family called Abdallah about her situation, Abdallah pleaded with the Clinical Officer to take the pregnant girl to Songea, 80 kilometers away. “When I got to the health center and realized that the clinical officer would not give permission for the ambulance to travel, I found someone who took my bike in return for the last 8,000 Tsh.”

“I traveled to Songea with Teresia, and when she was in safe hands at the regional hospital, I asked the ambulance staff if I could travel back with them. To my surprise, the accompanying nurses asked around for other people who needed a lift, and they charged seven people 5,000 Tsh each for the transport! When I returned home to the village I went straight to the ward Councillor to complain. How can the clinic staff deny a desperate young woman transport for the sake of 8,000 Tsh and then make a 35,000 Tsh profit on the return journey?

“The Ward Councillor suggested I talk directly with the District Authorities, as he did not think they would listen to him. After hearing this, I was discouraged and I thought there is nothing I could do.”

“For two years the health center staff continued to charge everyone the enormous ambulance fuel charge, and there was nothing we could do about it. One lady in the village died in childbirth. She didn’t even try to ask for the ambulance, since she knew she could not afford it. Then one day some people from Women’s Dignity came to our village. When we discussed the health services, I stood up and told the story of Teresia. After I finished, they invited me to speak during a meeting they had planned with the District Health authorities. I told them the same story, and the District Executive Director promised to take immediate action.”

“The Clinical-Officer-in Charge at the health center was transferred a few weeks later, in September 2007. The new Clinical Officer has made sure that the ambulance is free for emergency cases involving pregnant women and small children. The villagers are happy with the change, and many have come to thank me for speaking out about the problems we had.”

A few weeks after the transfer of the Clinical Officer, Abdallah spoke at Tanzania’s first ‘Popular Tribunal on Girls and Women’s Lives’ in Dar es Salaam. He was interviewed by newspaper journalists and spoke on national radio. People across the country learned what he had done and the ways in which girls and women face threats to their lives on a daily basis.

Abdallah remains modest: “I do not want to draw too much attention to myself, but I was glad I got a chance to tell District officials about Teresia’s case. I enjoyed speaking at the Tribunal because I learned a lot about human rights, things I didn’t know before. I will use this knowledge to tell others in the village. But I don’t want people to think I am a trouble-maker, especially not the health center staff. My wife, my children and I rely on them when we are ill. However, if a similar problem happens once more, I would certainly speak out again, for the sake of women in our village.”

We at One By One are proud to learn from Women’s Dignity Project and their years of experience helping to coordinate partners in the National Fistula Program in Tanzania. Meetings like the one they held which inspired Abdallah to tell his story are crucial to helping community members witness and believe that their voices can indeed create change. Emergency access to care is a critical element of fistula prevention. And as Abdallah’s efforts for Teresia show, there are many varied obstacles to women getting proper care. From a community education and outreach standpoint, we have seen our grants with Kivulini Women’s Rights Organization create important community dialogues regarding getting pregnant women and laboring mothers to care in time. After visiting our programs and partners, it is clear to me that outreach and community education remain critical adjuncts to the technical and infrastructure related aspects of emergency obstetric care.