For almost a decade, I have been enamored of the advanced fistula care being delivered in Ethiopia. My interest in fistula care first arose after I read a 2003 article in the New York Times by Nicholas Kristof regarding the famed Hamlin hospitals. I was a junior in a five-year Nursing and Wharton joint degree program at the University of Pennsylvania and was beginning to think about avenues in health care to pursue after graduation. This article spurred my burgeoning curiosity about obstetric fistula.

An obstetric fistula occurs when a hole develops either between the vagina and the bladder or the vagina and the rectum and most often results after prolonged childbirth, usually in communities where proper health care services are not present; it is estimated that over 8,000 women in Ethiopia develop new fistulae each year. As I began researching the condition, I was surprised to learn that fistula services were not heavily integrated into maternal and obstetric care in developing countries that were pursuing the Millennium Development Goals.

This research fueled my desire to find post-graduation employment at the Hamlin hospitals, and when I was unable to do so—after earnest inquiries by email, telephone, and even the postal service—I decided to pursue a nursing position at UCSF Medical Center in 2005, never quite letting go of my desire to witness first-hand the work being done in Ethiopia to reduce fistula. After five years of working as a registered nurse, I was accepted to a two-year master of science program in global health and population at the Harvard School of Public Health (HSPH) and was able to revisit my interest in fistula care services through coursework and, in particular, a very recent field experience.

Last September, I learned that Ana Langer, a reproductive health specialist, a physician, and a professor at HSPH, was organizing a field experience in maternal health in which HSPH students would be matched with maternal health organizations around the world. Naturally I applied and cited my interest in fistula services, particularly those provided in Ethiopia. The rest, as they say, is history.

In December 2011 and January 2012, I was afforded the lucky opportunity of traveling to Ethiopia in order to assess the work on Fistula Care, a global USAID-funded project led by EngenderHealth and managed in Ethiopia by IntraHealth. Given that the project is slated to end in 2013, my role was to assist the project team in deciding which activities could be transitioned to the government to manage.

While in Ethiopia, I had almost four weeks to learn as much about the Fistula Care model as possible and to deliver recommendations on which components were ready to transition. At this time, the model involves a community component of volunteers who disperse information in their respective regions about prevention, identification, and treatment; a clinical component of four pre-repair units (PRUs) where fistula patients receive physiological and psychological care before and after their fistula repair surgeries; and lastly, fistula mentors who are experienced and specially trained nurses who provide and coordinate both these components in order to increase rural populations’ access to fistula services.

As part of my work, I visited the four PRUs and interviewed the four fistula mentors. The fistula mentors play integral roles as caregivers to PRU patients, instructors to district and health officials, and partners with members of the community in terms of identifying women who are seeking services. I attended a half-day sensitization workshop in Sekota, which included a host of stakeholders including women's organizations, religious leaders, and regional health bureau officials. I also interviewed a variety of project staff and project partners as well as examined models that countries with comparable maternal mortality rates were utilizing. 

After an intense four weeks, I submitted my report and included recommendations based on my own observations along with those shared with me by interviewees. Some examples include the following:

• Encourage health centers to lead and manage joint supportive supervision (JSS) meetings. Currently fistula mentors travel to health centers quarterly to conduct JSS visits where they discuss challenges the health center staff encounter in providing services and review performance data such as uptake of partograph use by staff. Fistula mentors could review the meeting reports rather than traveling to the health centers to attend the meetings.
• Integrate the PRUs with the health centers, and make the fistula mentor a mobile force who would travel between the centers.
• Aim to decrease transportation costs by reducing IntraHealth van-provided return trips from the Hamlin hospital to the PRU to the community and explore how best to support women to use public transport.
• Quantitatively measure the hospital length of stay as well as post-surgical outcomes of patients who arrive at the Hamlin hospital directly from the community versus those patients who arrive from the PRUs in order to illustrate any differences between the two populations.

I loved my experience in Ethiopia and even had the unexpected blessing, despite warnings, of avoiding gastric upsets. I am scheduled to graduate from HSPH this spring, and I am interested in pursuing employment where I am able to tackle documented maternal health problems and design interventions to address them. Ideally, I want to pursue such work while living in the countries facing those problems. The people I met in Ethiopia, both through the project and through serendipitous encounters, were unequivocally gracious and generous, and if I were given an opportunity to return, I would do so without hesitation.