Footsteps to Healing: Healing Childbirth Injuries in Ethiopia

Woman in hospital bed holds smiling child
Photo by Joni Kabana

Imagine being in labor and unable to deliver because of your baby's size or position or your pelvic size. Here in the United States, experts and hospitals are trained and ready to help you deliver safely. But for a woman in rural Ethiopia, her baby could be trapped for days, often resulting in its death and severe injury to the tissues of her pelvic floor.

Women who have experiences like this are much more likely to develop fistula, a hole that leaks urine or stool uncontrollably, or pelvic prolapse, a condition where the uterus falls out of the womb due to extreme nerve and muscle damage. Worse, in Ethiopia where poverty, social stigma and lack of access to care are extreme, woman may endure pain, isolation, shame and an inability to work or do physical activity for the rest of their lives.

This dire need for care inspired Rahel Nardos, M.D., a urogynecologist at OHSU's Center for Women's Health to found Footsteps to Healing. The program began as an annual trip to Ethiopia to provide life-changing pelvic organ prolapse surgeries. In the past four years, it has evolved into an ambitious capacity-building partnership.

Founding Footsteps to Healing

Between her residency at Washington University in St. Louis and her fellowship in urogynecology at OHSU, Dr. Nardos spent a year at the Hamlin Fistula Center in Ethiopia, treating and performing surgery for patients with obstetric fistula.

"The experience was a turning point for me," says Dr. Nardos. "The stories of these vulnerable yet resilient women are what move me to do my part."

When she arrived at OHSU, she was eager to do more and the Center for Women's Health's obstetrics and gynecology department supported her in setting up Footsteps to Healing. Anesthesiology, nursing and operating room teams at OHSU became ongoing partners.

The team quickly learned that even though they could provide 50 surgeries every time they went to Ethiopia, it wasn't enough to meet the incredible need. An estimated 250,000 women in Ethiopia suffer from pelvic floor injuries and conditions.

"It became clear that the best strategy was to build capacity. We could train doctors in Ethiopia to provide the care themselves," says Dr. Nardos.

Expanding the Program

She built a partnership between OHSU, the Worldwide Fistula FundHamlin Fistula Ethiopia, and Mekelle University Hospital in Ethiopia. The partners worked together to create the first urogynecology fellowship in the country at Mekelle University. Now in its second year, the program has two senior fellows and two junior fellows. All are fistula surgeons who are receiving comprehensive training in pelvic floor reconstruction surgery.

The impact of this strategy is already clear. When a trip planned for February of this year was indefinitely postponed due to political unrest in Ethiopia, that didn't stop the senior fellows at Mekelle from using their new skills to care for women.

"They recruited 40 women and did the operations themselves under the oversight of their fellowship director, teaching their junior colleagues as they went," Dr. Nardos says. "We will no longer have to tell patients to come back next year when we return, because they now have providers who can take care of them."

Dr. Nardos has expanded the scope of Footsteps to Healing to meet a variety of the needs faced by Ethiopian women. Recent OHSU team members who have gone to Ethiopia to provide care and training have included intensive care unit doctors, breast radiologists, and hospital management specialists.

An especially important need at Mekelle was for biomedical engineering training. "We had situations where a machine wouldn't work and that would mean no surgery that day," says Dr. Nardos. OHSU biomedical engineers have accompanied the team to work with their counterparts at Mekelle on fixing and maintaining machinery needed for surgery.

The impact for women in Ethiopia is clear, but OHSU's doctors, fellows, residents and students who go on the trips are also impacted. For the surgeons, they are able to gain experience performing surgeries that are needed only rarely in the United States.

"More importantly," says Dr. Nardos, "their world view expands and they think of other people and health care in a new way." It is common for participants to say the experience made them realize why they went into medicine in the first place.

Dr. Nardos has big plans for the future of the Footsteps to Healing partnership. "Women's health is so much more than urogynecology," she says. "My big vision is setting up a center of excellence in women's health at Mekelle University Hospital, a center that can be a model for Ethiopia."

Learn more about Footsteps to Healing or support its work on our website.

Rahel Nardos and team visit a patient during rounds