Childbirth injuries continue to destroy thousands of women’s lives in Africa each year. The problem persists substantially because low-resource countries lack medical professionals with specialized training in high-quality emergency obstetric care. Formal training programs with advanced education in specialty areas such as Female Pelvic Medicine and Reconstructive Surgery are not widely available at African universities. Local physicians interested in such specialties routinely leave their countries to seek training abroad. Many do not return home, having established roots in the countries where they have trained.
WFF is dedicated to improving the capacity of low-resource countries to address childbirth injuries by building local medical programs. Through local and international partnerships, we develop high-quality, in-country medical education. Since 2013, our local partner for in-country African medical education programming has been the College of Health Sciences at Mekelle University in Ethiopia. We have several programs designed to increase local medical expertise to prevent and treat childbirth injuries:
Mekelle Medical Education Collaboration (MMEC)
In 2013, WFF began holding annual medical conferences at Mekelle University to provide enhanced obstetrics and gynecology education to students, residents and faculty at the university. For one week each summer, WFF Founder, Dr. Lewis Wall, and guest experts in Obstetrics and Gynecology, Urogynecology, and additional specialties teach enhanced curriculum to benefit local medical professionals. Approximately 80-100 students, residents, faculty and visitors from other institutions attend each of the classes provided.
This collaboration was a vital contributor to the Mekelle University OB-GYN residency program. In December 2016, the first five graduates chose to stay on as Mekelle University faculty to increase the institution’s capacity to train future students while also providing patient care through the university’s Ayder Referral Hospital. The MMEC introduced numerous U.S. and International physicians to service in Ethiopia, many of whom remain engaged and made repeat trips. Guest lecturers at the MMEC have included: WFF Board Members (Dr. Rahel Nardos, Dr. Christopher Payne, Dr. Holly Richter, Theresa Spitznagle, Dr. Lewis Wall), Washington University in St. Louis faculty (Dr. Christina Chu, Dr. Jonathan Green, Dr. Jerry Lowder, Dr. David Schmidt), University of Ghana faculty (Dr. Anyetei Lassey), and Internationally recognized experts (Dr. Linda Brubaker, Dr. Jeannette M. Potts).
Urogynecology Fellowship Training Program
In 2015 and in partnership with Mekelle University, Hamlin Fistula Ethiopia and Footsteps to Healing at Oregon Health & Science University (FH-OHSU), Ethiopia’s first Urogynecology Fellowship Program was launched. The program provides Urogynecology sub-specialty education comparable to Western standards with the goals of enabling graduates to 1) establish clinical centers of excellence to treat women with all types of urogynecologic disorders (not limited to fistula) and 2) develop additional training centers for sub-specialists in urogynecology.
Urogynecology, also known as Female Pelvic Medicine and Reconstructive Surgery, is a specialty focused on the care of women with pelvic floor dysfunction such as incontinence (urinary and fecal leakage), prolapse (bulging or falling of the vaginal tissues) and pelvic pain.
Maternal mortality and obstetric fistula are the most traumatic and immediate effects of unsafe childbirth. Pelvic organ prolapse (POP) is a chronic, more common effect of unsafe childbirth in developing countries. A preliminary, ongoing survey of three regions in Ethiopia estimated that 5,000 to 6,000 women have obstetric fistulas, while over 250,000 suffer from POP. Pelvic organ prolapse can develop when a woman endures multiple, difficult deliveries. Over time, muscles supporting pelvic organs like the uterus and bowel weaken. The organs drop, push against the vagina and sometimes fall out.
Training a New Generation of Urogynecologists
Our partnership with Mekelle Universtiy and Hamlin Fistula Ethiopia allows us to provide both in-country medical training for Africans and to treat local women for injuries beyond fistula through multiple medical centers. Our first four Urogynecology Fellows in training were skilled fistula surgeons with Hamlin Fistula Ethiopia. Fellows are mentored in conducting clinical research and, in addition to classroom instruction; they receive surgical instruction while performing life-changing prolapse repairs. Since the start of this fellowship training program, our Ethiopian fellows have performed over 500 POP and incontinence surgeries. Dr. Fekade and Dr. Melaku, our first two graduating fellows have become the primary trainers.
Dr. Renate Roentgen, an expert in female urology from Germany, served as the first Fellowship Director and as the primary urology instructor. Dr. Melaku, one of our first graduates, succeeded her as Fellowship Director in 2020 and the primary training location transitioned from Hamlin Ethiopia’s Addis Ababa Fistula Hospital to Ayder Regional Referral Hospital at Mekelle University. Dr.Fekade, another Fellowship graduate, is helping develop a Pelvic Floor Center of excellence at Ayder.WFF Board Member Dr. Rahel Nardos facilitates travel to Ethiopia throughout the year of expert instructors from partner institutions to provide our Fellows training and hands-on surgical instruction while performing POP surgeries.
Master’s of Physical Therapy Program
WFF Board Director Dr. Tracy Spitznagle, Professor in Physical Therapy at Washington University in St. Louis, consulted on the Physical Therapy Master’s Program curriculum being developed at Mekelle University in 2013. The university continuously struggled to enlist qualified PT instructors locally and requested help in 2015. Since 2016, Dr. Spitznagle has recruited experienced PT instructors for programming funded by WFF. By sponsoring international PTs to travel to Mekelle, WFF provides the university with top instructors who would be otherwise inaccessible.
Why Physical Therapy?
Pregnancy and childbirth cause changes to the musculoskeletal system that predispose women for pain and incontinence disorders. In developed countries, PT is readily available to assist in the care of women post-childbirth. Unfortunately, the specialized PT services women may need post-childbirth are difficult to find in the developing world. The trauma childbirth injuries cause can be extensive and PT is often needed to work in tandem with surgery for a woman to fully recover. Physical therapy is a critical piece of our holistic care model. In 2018, Mekelle University’s inaugural class of 12 PT Master’s students graduated and 5 chose to stay at the university to support the program.
Critical Care & Quality Improvement Training
While conducting clinical training over the years, our visiting experts realized that the local doctors, nurses and physical therapists did not work well as a team to optimize patient outcomes. In 2017, WFF, Mekelle University, Washington University in St. Louis and Footsteps to Healing at Oregon Health & Science University partnered to begin providing team training in Critical Care and Quality Improvement best practices. Substantial 2018-2019 WFF funding launched a specialized Critical Care training program. Programming highlights that every team member brings value to patient care in high-pressure situations such as complex surgery, childbirth or post-operative complications. It is critical for providers to understand that each discipline plays an important role in helping women heal and recover.
Gestational Trophoblastic Disease (GTD) Center
In 2015, WFF launched development of a GTD Center at the Ayder Referral Hospital of Mekelle University. GTD is a group of conditions in which tumors grow inside a woman’s uterus (womb). Clinical data from Ayder Regional Referral Hospital suggests that GTD is a relatively common problem in the surrounding Tigray region at 1 case per 110 deliveries — one of the highest rates in the world. In a recent worldwide survey, mortality rates for patients primarily treated at a GTD center was far lower than rates for those who received treatment elsewhere. Patient mortality rates were 2.1% at a GTD center and 8% for those who received primary treatment elsewhere. The GTD Center in Ethiopia became fully operational in 2016, and the team was able to cure 65 of 66 women through their dedicated treatment that first year. The program became self-funded in 2020 with approximately 120 women treated annually.
Images courtesy of Joni Kabana