Adet Health Center is only 40 kilometers from the city of Bahir Dar but the road is muddy, narrow, and full of pot holes, so the journey takes an hour and a half. We drive through lush fields of teff and maize and pass through small villages where donkeys, goats, and chickens are tied up waiting to be sold. Children carry babies on their backs and play on the side of the road while women carry firewood for cooking.  Men are building new homes with wood, stones, and mud. Everyone is busy, and I wonder how this land of 80 million people can sustain the never-ending consumption of natural resources.

We arrive at the Adet Health Center, which looks like many others I have seen here. People are hanging around wrapped in their white scarves—men with their walking sticks and women in traditional green dresses, silver crosses, and tattooed faces. Everyone looks thin and tired. The health care workers are seeing patients and filling out prescriptions and record books.

In Ethiopia, health centers provide antenatal care and delivery services, but most women still deliver at home because the health center is too far away or they cannot pay for the services. Only 7% of Ethiopian women are assisted by a skilled birth attendant during childbirth, and they have a 1 in 27 lifetime risk of dying in childbirth. At this center, I ask to see the delivery room, and my colleague cracks the door open. Inside there are three young nurses standing against the wall in bright white, neatly-pressed uniforms. They beckon me inside, where I see two old, rusty delivery tables covered with dirty plastic and a small, blue plastic bowl at the end of the table—I imagine to catch blood. There is a woman curled up on one of the tables with her face to the wall, moaning in pain. Her feet are bare, knarled, and muddy.  She has no blanket or pillow. The nurses tell me that she arrived at the health center this morning after laboring at home for two days. She walked 15 kilometers to get to the health center. The fetus is dead, but its head is visible. The midwife and nurse are discussing what to do. Finally, they decide they will try to vacuum the fetus out, I leave before they begin the procedure.

These are the realities of many women’s lives in rural Ethiopia.

Next, we head over to the obstetric fistula, pre-repair unit—a small, three-room ward with an office. Obstetric fistula is a hole that forms between a woman’s rectum and vagina or between her bladder and vagina as a result of complicated or prolonged childbirth without appropriate obstetric care. Without treatment, obstetric fistula can lead to incontinence, severe infections and ulcerations of the vaginal tract, and paralysis caused by nerve damage. Many women who experience fistula are discriminated against, even ostracized from their communities. However, women who undergo corrective surgery are often able to resume a normal life and regain full bodily function. In Ethiopia, there are an estimated 100,000 women suffering with untreated fistula, and another 9,000 women develop fistula each year.

Like other pre-repair centers that IntraHealth supports, the place is spotlessly clean and neatly arranged. There is only the slightest odor of urine. There is one patient at the pre-repair center today. She is in her 30s, but looks much older. Six months ago, she lost a baby after three days of labor. She has been living with an untreated fistula ever since. An IntraHealth-trained, community volunteer met her and referred her to the clinic. Like so many women I have met with fistula, she looks ashamed and depressed. The woman sits outside in the sun with the nurse-aide, Zanab, a young women who used to be a fistula patient herself. Since undergoing a successful fistula surgery two years ago, Zanab has worked at the clinic. Looking at her, I think she doesn’t look much older than 20, how young must she have been the first time she gave birth? Zanab’s role as a nurse aide is critical because she offers much needed psychological support to patients, explaining to them what to expect at the Fistula Hospital and encouraging them that something can be done for them. She knows first-hand how these women suffer and how this surgery can change their lives. This year, Zanab will finish high school. She tells me she wants to become a fistula-repair doctor herself. I think back to the woman I saw earlier in the day in agony and grief and feel some relief in the hope and determination in Zanab’s eyes.