In many families, Christmas comes with the long standing tradition of reading a Christmas story. Midwife Without Borders set the tradition to end the year with an awe-inspiring midwifery story. Last year, we took you to the concentration camps of occupied Poland. This year, we will take you along on Ethiopia's fistula pilgrims' road to healing.
Softly, chants echo through the night from the many churches in the Ethiopian landscape. Shepherd's children watch over their flocks as their parents attend the Christmas celebrations. In the Eastern-African country, Christmas - even in the cities - still largely is a Christian feast, and pre-eminently a family event.
For approximately 10,000 Ethiopian girls and women however, Christmas is a moment of great desolation. They live their lonely lives in ragged little huts, away from their families and communities, sometimes for decades on end. Perhaps someone will bring them a portion of the Christmas meal, but attending church is something of times gone by.
Urine, and sometimes also feces, is continuously leaking down their legs. Often, they are covered in sores or have been crippled. These are the tragic consequences of a traumatic delivery, often in young age and almost always without the attendance of a midwife.
The Calling at the Pub
It is 1958, and Australian physicians Reg (1908-1993) and Catherine Hamlin (1924) respond to an add the Ethiopian government put in The Lancet in search for someone to set up a midwifery school. They were well suited for the job, as both had specialised in the fields of obstetrics and gynaecology and had extensive work experience. And what is more, they had started to realise that their Sydney jobs might not give them the fulfillment they were seeking.
In her autobiography The Hospital by the River, Catherine writes: “We could not spend the rest of our lives living in a suburban house when we had so much to offer people in a less privileged part of the world.” Since the add in The Lancet combined Reg Hamlins two great interests - midwifery and teaching - it seemed a done deal… save for one question, that still bugged the couple: would Ethiopia be good place to take their six-year-old son Richard to?
One day, Reg Hamlin sits in a pub, pondering this question over a beer, when the bartender asks him what’s the matter. As Hamlin tells him, the man next to him at the bar sets in and shares his experience of living and working in Ethiopia, where he had just spent three years. “It’s a marvellous place”, he says, and as for taking children along: “My boy went and had no trouble getting into a good school when he got back to Adelaide. He’ll love it. Just go.” This settled everything.
Pioneering in Ethiopia
The Hamlins arrived in Addis Ababa in 1959, after a stomach-wrenching local flight. To them, setting foot on Ethiopian soil felt like coming home, as they “breathed a familiar scent, a mixture of dust and eucalyptus - the smell of the Australian bush”.
When they started their obstetric work in Ethiopia, however, they soon found that not everything was like home, and they had to deal with circumstances that are quite different from what they were used to. They were faced with “dreadful complications because of lack of medical care” and “horrendous pathology”.
A frequent, life-threatening complication in obstetrics is a hemorrhagic bleeding, a condition that is even more challenging in a country where at that time there was no blood bank and “blood was scarcer than gold”. The Ethiopians were not accustomed to the idea of donating blood, so the Hamlins often found themselves rushing to one of the embassies in Addis Ababa and convincing foreign staff to donate blood to safe the life of a patient. Even more inventive and rigorous was their idea to filter a patient’s lost blood and transfer it back into her, which at least helped to overcome the problem of incompatibility of blood groups. Later, they started to import frozen plasma from abroad, and a local blood bank was set up.
The Fistula Pilgrims
In Ethiopia, they were also confronted with a complication that so far had only been a paragraph in their college textbooks to them: the obstetric fistula. Catherine recalls how the fistulas at first “seemed like a minor curiosity” in the “whole gamut of obstetrics and gynaecology” they were hired to do. The words of one of their colleagues however - “The fistula patients will break your heart” - would soon turn out to be “prophetic”, as the first of these patients came knocking at their hospital’s door.
Obstetric fistulas are a largely unknown phenomenon in the western world, were the problem was rooted out over a century ago. Worldwide however, even today around two million women suffer from them. Soon after their arrival, the Hamlins were confronted with women who bore the scars of being married off as a girl and getting pregnant at a very young age.
Because of their immature bodies, the physical consequences of malnutrition and a devastating shortage of midwives across the country, the delivery often becomes an agony of days or even weeks. Not seldom, the young women give birth to a stillborn baby and are left with a fistula, an opening of the bladder or rectum leading to continuous incontinence. With no water or money to buy some rags to keep themselves clean, many are left by their husbands and shunned by their community, and spend their days in loneliness and poverty.
The Hamlins immediately started to work towards a solution for these patients, and succeeded in developing a successful surgical treatment. Eventually, they decided to dedicate themselves entirely to the ‘fistula pilgrims’, as Reg called them. Their specialised Addis Ababa Fistula Hospital opened its doors in 1974. Nearly every day new patients arrived from across the country, often barefooted, dressed in rags and without any possessions. Some begged for years to collect the money for their journey, others are carried by their father or a brother.
For the Hamlins however, to care for these patients means much more than to just cure them. Up to this day, the hospital staff tries to continue Reg Hamlins tradition of greeting all women who just arrived. They want their patients, who have known nothing but rejection, loneliness and humiliation for so long, to be able to feel human again. “It was touching to see”, says Catherine, “how often this humble ceremony caused a smile, and eyes to sparkle, as hope was born again in the patient’s heart. Just to be loved and cared for means so much to these women who have suffered rejection and isolation.”
All fistula pilgrims receive free treatment and remain in the hospital until fully healed. As different as they may be, they all share the same symptoms - and the same hope of being cured. Many of them are not only restored physically, but also spiritually. Catherine describes how cured women “emerge like a butterfly from the chrysalis” and feel they have received a new life. To mark this, all women receive new clothes on their discharge.
The hospital by the river is in many ways an oasis to the fistula pilgrims, surrounded by a well kept garden. Trumpet like blooms spread a wonderful scent, almost as if announcing the new life the pilgrims will receive. Patients and staff members also point out the special atmosphere and nursing spirit, which makes the hospital more than just a place of physical healing. Women are treated “as human beings first rather than just as patients”.
Holistic treatment is the focal point. Both the emotional and the surgical needs of the women are met and the staff is well aware of the need to make “each patient feel valued, respected and loved”. Catherine Hamlin recalls how staff members who had left the hospital, “would often come back and wistfully tell us that we didn’t know how lucky we are”. Doctors who visit the hospital often mention that the “deep concern” shown “for each individual patient” strikes them.
Finding the money to run a hospital that offers free treatment is of course not easy, and Reg Hamlin had a rather unconventional way of raising awareness for their work. This is probably best illustrated by a note he once wrote to the chairman of British Petroleum, hoping to get BP to support the hospital: “While you have been drilling holes in the Middle East and making a profit, we have been mending holes in the Horn of Africa and making a loss.” Although it didn’t result in an official sponsorship by BP, it did convince the chairman to contribute out of his own pocket.
The Hamlins considered themselves “professional beggars”. During trips to the US they tried to “tap into America’s wealth” and “to break the heart of millionaires, as they are always well shielded from beggars”. It is truly miraculous how the Hamlins have always managed to find - often in the nick of time - the resources needed to continue and expand their work.
They often found the stark contrast between the American way of life and life in Ethiopia confronting. Catherine writes that in “America everyone seemed to be in a hurry, the fevered activity mostly centred on making money” and that “The family seems to spend very little time together”. Ironically, it’s partly that American wealth that made their work possible. Especially after Catherine appeared on The Oprah Winfrey Show an impressive amount of money allowed her to take her work to the next level.
Although their commitment to the fistula patients is generally praised, both inside Ethiopia and far beyond its borders, there were definitely also voices who contested their work and approach, particularly in the West. “Some doctors gave us surprising advice”, Catherine writes, “advocating birth control to solve all the problems of obstetric fistulae. Others suggested that we should sterilise our patients after the repair operation to prevent it happening again, as in any case, there were too many babies being born in the developing world.”
These, she says, are “sweeping statements” which rather “reflected their ignorance about the patients need, even if well meant”. She emphasises that “these people were just thinking of the American society and they didn’t understand the position of women in Ethiopia”. Her husband used to summarize the life of a recovered fistula patient, who can marry again and become a mother: “For these girls, the wheel of fortune has turned full circle. They (now can) have what every woman wants, a live baby in their arms.”
Stay or Go?
In the more than five decades that Catherine Hamlin has been living and working in Ethiopia, the country has seen war, political violence and destructive famines. Leaving the country, however, was and is not an option to her. Reg and she simply “got terribly involved and fell in love with the patients”, and besides, she says: “How could we turn our backs on so much need?”
She recalls a political turbulent moment when she was sitting at home and the headmistress of the English school called to check whether she still felt comfortable about staying. “We feel safe here”, she replied, “and in any case I do not wish to leave our patients.” To answer the phone, Hamlin had risen from the couch. “Just at that moment a bullet came through the ceiling and lodged in the cushion where I had been sitting”, she recalls, and she laconically told the headmistress: “...you may have just saved my life”.
The Crowning Achievement
The Hamlins had initially moved to Ethiopia to set up a midwifery school, something they were very passionate about since they saw the value of having midwives available even in the remotest areas of the country.
After their first group of students had graduated however, the Ministry of Health decided that nurses could be midwives as well and gave up on the idea of a specialized training program. Later on, the government changed policy and provided a midwifery program again, but the Hamlins felt it didn’t adequately provide midwives with the skills and knowledge needed in rural Ethiopia.
Most government trained midwives ended up in cities, instead of in the far away provinces where they were needed most. The dream of opening their own midwifery school had never left the Hamlins however. Setting up the Hamlin College of Midwives in 2007, became Catherine’s crowning achievement.
A Midwife in Every Ethiopian Village
The Hamlin College of Midwives provides a midwifery training of 4 years. There is a strong focus on clinical training and gaining experience in doing deliveries: graduates have done at least 100 deliveries, but the curriculum also teaches them “to show love and compassion to the women in need”. The College believes that this is the only way to prepare midwives for the many obstetric emergency situations they might encounter when working in remote areas.
The first 11 ‘Hamlin midwives’ graduated in 2010, and by 2016 that number had risen to 80. From 2010 to 2016, these midwives accounted for around 225,000 safe deliveries. There is a high demand, which is witnessed by the fact that some of them do more than 100 deliveries a month.
Maternal mortality rates and fistula incidence have dropped significantly in areas where Hamlin midwives work. In order to eradicate obstetric fistulas entirely, however, many more midwives are needed. Ethiopia currently has about 7000 qualified midwives who serve a population of around 100 million people. In other words, the number of midwives is still precariously low, and far from what Catherine Hamlin envisions: “I dream of a midwife in every village of Ethiopia.”
Midwives on the Front Lines
The importance she attaches to having enough well trained midwives in Ethiopia, was also clearly illustrated in her speech to the first graduated ‘Hamlin midwives’. She told them: “You are embarking on a great and ancient career. Midwives are mentioned in the first book of the bible. You are a key person in the struggle to eventually eradicate fistula injuries, or even death, from obstructed labour. You are indeed on the front lines of the battle to prevent fistula. We have confidence in your ability and devotion to the hard task ahead.”
Mothers are of Priceless Value
What started with a three years contract in 1959, has become a life’s work. In around five decades, the passion of one couple for helping the fistula pilgrims overcome their injury, the shame and the suffering, has helped a family-led NGO grow into an international organisation. For Catherine and Reg Hamlin, this was not just a job, but rather “a labour of love”. As christians, they believed that circumstances do not simply happen at random. They felt that they were led to the Horn of Africa, to work with these “brave Ethiopian mothers” who were so “tragically damaged”. Almost up to her 90th birthday, Catherine Hamlin still regularly operated, until her health forced her into retirement. On the 24th of January, she hopes to celebrate her 94th birthday.
The Hospital by the River ends with the hope that the torch the Hamlins lit “for the fistula pelgrims of Ethiopia, and indeed of the world, will burn even more brightly and that others will become inspired out of this long-neglected and shameful maternal tragedy”. Reg Hamlin used to say that “a mother is a family’s richest possession, a being of priceless value”, and so it is.
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I wrote an article on the work, deeper drive and motivation of Reg and Catherine Hamlin for the Christmas edition of the Dutch weekly Katholiek Nieuwsblad. You can find the article here. A review of Catherine Hamlin's book, The Hospital by the River, can be read here.
Dr. Catherine Hamlin with John Little. The Hospital by the River. Updated edition. Monarch Books: Oxford. 2016.