29th March 2004
Ten years ago I attended the United Nations Conference on Population and Development. Brendan Howlin was Minister for Health at the time. He had been extremely important in influencing the European Union's attitude to the conference and to the eventual declaration. The Irish position on abortion, that it could not be considered a suitable method of family planning but the consequences of back street abortions could not be ignored, was adopted as the EU position and, indeed, went into the final declaration.
The Cairo declaration is very broad, however. It is not just about family planning but about the rights of women and children the world over. There is so much talk now about HIV/AIDS and so much money promised to prevent and treat it that maternal and infant mortality seem sidelined.
Two and a half years ago I went to Ethiopia with some other Irish parliamentarians on a visit sponsored by UNFPA to look at the provision of family planning facilities there and the position of women. They asked us to go back again this year to see what progress we felt had been made. This we were very glad to do because, apart from the fact that the maternal and infant mortality figures there are some of the worst in the world, Ethiopians are very nice people and Ethiopia is one of Ireland's priority countries for development co-operation.
Nearly fifty per cent of Ethiopians live six hours walk from an all weather road. It is easy to see how badly this can affect access to health care. The average Ethiopian sees a health care worker, not necessarily a doctor, once every four years. Seeing that those living in towns have much better access to health care, their country cousins may get some professional help once or twice in their lives.
Between early marriage - girls may be betrothed at nine or ten but not have sexual intercourse until after they menstruate - and lack of care by anyone with training in obstetrics, the maternal mortality rate in parts of the country is well over 1,000 per 100,000. This gruesome figure is made up mainly of those who die in obstructed labour, through haemorrhage and from illegal abortions.
The Government has set up a Health Extension Programme to try to improve the situation in the country. Health posts are to be set up and staffed by specially trained workers from the community. They will all be women and will focus particularly on preventative medicine such as immunisation and family planning. What we would call home economics are also to be promoted so they will have their hands full because each pair of workers are to deal with about twenty five thousand people. The only curative medicine they are to carry out is first aid and all the training they will have will take place within one year.
Curative medicine will take place in Health Centres and we visited the model one they have set up south of Addis Ababa and it did look good.
The obstetric problem will still be a big problem, however. Back street abortions account for 50% of the maternal mortality figures but these have been reduced in Addis Ababa, in particular, where family planning clinics not only give advice but also provide emergency contraception.
The last time we were in Ethiopia the death rate of teenage girls who had had back street abortions was further complicated by lack of facilities for vacuum extraction of septic retained products of conception and no antibiotics. This time both seemed available thank goodness because it must be truly demoralising for staff to lose so many young girls.
The last time we were in Addis Ababa we did not get a chance to visit the Ghandi Memorial Hospital, the tertiary referral hospital for maternity cases. Of all the hospitals I have seen in the developing world this was the worst. With a budget of 6 million bur a year (about 550,000 Euro) 5,000 patients with the most complicated of pregnancies and deliveries are cared for and gynaecological cases are treated as well. The equipment is so meagre that electrolytes cannot be measured in the laboratory.
The medical director was extremely open, showing us the hospital figures for the previous month. While the month in question had been good over all, the death rate in the hospital is 7%, that is about 350 patients each year die. Destructive operations seemed common, too, so many were admitted in obstructed labour.
UNFPA is assisting in the training of non-obstetricians but medically qualified personnel to carry out Caesarean sections in the country. The famous Fistula Hospital is setting up satellite clinics in four parts of Ethiopia and these units will be able to carry out sections, too.
It was cheering to see improvements in Addis Ababa but the lot of rural women in Ethiopia is very hard. Delaying first child births and encouraging longer intervals between children seems to be all one can do for many of them and it is certainly what they want. Injectable contraceptives are very popular because they are needed only once every three months. With the lack of choice these very poor women have it was depressing to meet the American administrator of a hospital who was teaching women and worse still Ethiopian midwives that injectable contraceptives made African women sterile. No evidence was produced to show that this was true and many of these women have no choice over whether they will or will not have intercourse. She did teach a modified form of the Billings method which, I suppose, was something.
To end on a cheerful note. The World Bank held a competition amongst groups in Addis Ababa for a project to help the city. A group of 600 women, handicapped in some way, wanted to put in a proposal that they would refurbish and maintain the public lavatories (if you saw them!). Our Ambassador, Ms. Pauline Conway, had the imagination to give them a small amount of money to make a professional proposal. They won the competition and now with two thousand dollars they are about to start. The first lavatories they are going to work on are in the markets area. This should be looked on as one of the best preventative medicine projects ever because the disease transmitted there must be enormous.
Senator Mary Henry, MD
