1. Reproductive health Over 25000 women and girls die each year More than 500,000 Ethiopian women and girls suffer from disabilities 0.3% of all deliveries (8000-9000) develop obstetric fistula

2. Obstetric Fistula It is a hole that forms in the vaginal wall communicating with the bladder (Vesico- Vaginal Fistula) or the rectum (Recto-Vaginal Fistula) or both, as a result of obstructed labour, beyond the reach of medical help.

4. Usual features of fistula patients:- Young peasant girls Married in their early teens Given heavy tasks in the household Not having an access to any health institution during labor (long distance, no transportation) Labor prolonged and obstructed (average 3.8 days, range 1-10) These young women often helped by women of the village Baby dies in uterus Head collapses and dead baby is expelled

5. Usual features of fistula patients:- Few days latter a new horror wakes them up- incontinence Often whishes they died with the baby, many commit suicide Soon deserted by their husbands, ostracized by their village friends, excluded from their old social life They exist without friends, without hope, bearing their sorrow and suffering in silent shame

7. Patient distribution by region Amhara 39.7% Oromo 28% Southern 17% Tigray 6.4% Harar 0.6% Benshangul 0.3% Somalia 0.3% Others 4.0% AA 2.0% No information 1.2%

8. Age profile <16 5% 16-20 38.4% 21-25 23.6% 26-30 16.5% 31-35 8.1% 36-40 5.8% 41-45 1.3% >45 1.2%

9. The Addis Ababa Fistula Hospital The second fistula hospital; Founded in 1974 A free charitable hospital Operated more than 25000 patients Operates 1200-1300 patients/year Trains doctors On the process to establish 5 outreach centers Six gynecologists

12. The Addis Ababa Fistula Hospital 12 nurses and more than 40 nurse aids A village for fistula patients with conduits Have school and physiotherapy department where they exercise for the crippling injuries

14. Cause of Fistula Obstructed labor Obstructed transport Reginald Hamlin

15. PROBLEM AREAS A- Problems directly related to the three delays: Delay in decision making Delay in transportation to health institution Delay of care in health institution B- Other socio-cultural problems (contributing factors)

16. Delay in decision making -Low status of women (Low involvement of women as decision makers) -Illiteracy -Inhibitory socio-cultural practices -poverty -poor information on health issues (both to men and women

17. Delay in transportation to health institution -Distance - Poor roads - Transportation system, not existing -No means of communication -Poor referral system -Poverty

18. Accessing EMOC was difficult, because:- Distance 28.2 Economy 13.6 Poor knowledge 9.8 Referral 4.7 Distance and economy 23 Poor knowledge +Economy 11.3 Poor know +distance 2.3

19. Accessing EMOC was difficult, because:- cont Dista+ economy+ poor know 5.2 Referral +poor knowledge 0.9 Referral + economy 0.5 Referral +distance 0.5 Total 100

20. Delay of care in health institutions -Financial accountability (resources, supplies, etc) -Health staff motivation (lack of commitment, urbanization, etc) -Managerial accountability (Budgets underutilized) -Manpower inadequate - Restrictive laws

21. Other factors -Illiteracy -Harmful traditions -Poor access to other reproductive health care services

22. Interventions Access to information Access to EMOC Quality EMOC

23. Access to information School enrolment Community education IEC/BC

24. Access to EMOC Road Transport Communication (link) Affordability “Those mothers who failed to access road to EMOC will easily access road to death or disability’’.

25. Quality EMOC Capacity building -training -equipments and supplies sustainability Affordability/free of charge