The tragedy of Queen Henhenit -- The human obstetrical dilemma and its consequences -- The conquest of obstructed labor -- Dr. Sims finds a cure -- Structural violence and obstetric fistula : the Hausa case -- Deadly delays : deciding to seek care -- Deadly delays : getting to a place of care -- Deadly delays : receiving care -- Compassion, respect, and justice -- Hamlin fistula : a vision realized -- Epilogue : lessons learned and the way forward
In November 2020, the federal government of Ethiopia invaded its northern region of Tigray, in collusion with the Government of Eritrea and ethnic Amhara militias. The invading forces pillaged the schools, destroyed the transportation infrastructure, burned crops and killed livestock, and looted the health care system. Thousands of civilians were killed, often in extrajudicial executions. Thousands of Tigrayan women were raped. Tens of thousands of Tigrayans fled to Sudan as refugees. Hundreds of thousands face famine and millions more have been internally displaced. The region is under a total communications blackout. The banking system has collapsed. The federal government has harassed external aid workers and imposed a de facto blockade on all medicines and famine relief. A man-made humanitarian catastrophe unlike any in recent memory is unfolding. The world medical community must speak up. The madness must stop.
Obstetric fistula, a devastating complication of prolonged obstructed labor, was once common in the Western world but now occurs almost exclusively in resource‐poor countries. Although much has been written about the surgical repair of obstetric fistulas, prevention of fistulas has garnered comparatively little attention. Because obstetric fistulas result from obstructed labor (one of the common causes of maternal death in impoverished countries), this study assesses the obstetric fistula problem using a framework originally developed to analyze the determinants of maternal mortality. The framework identifies and explicates three sets of determinants of obstetric fistulas: the general socioeconomic milieu in which such injuries occur (the status of women, their families, and their communities); intermediate factors (health, reproductive status, and use of health care resources); and the acute clinical factors that determine the ultimate outcome of any particular case of obstructed labor. Interventions most likely to work rapidly in fistula prevention are those that have a direct impact on acute clinical situations, but these interventions will only be effective when general socioeconomic and cultural conditions promote an enabling environment for health care delivery and use. Sustained efforts that impact all three levels of determining factors will be necessary to eradicate obstetric fistula.
Abstract Background In developing nations with fragile healthcare systems, the effect of war is likely to be much worse than it would be in more developed countries. The presence of COVID-19 will also likely exacerbate the war's impact. This study set out to determine the effect of armed conflict and the COVID-19 pandemic on health service utilization at Ayder Comprehensive Specialized Hospital, in the Tigray region of Ethiopia.
Methods An interrupted time-series study design was used to analyze patient visits over forty-eight consecutive months (from July 2017 to June 2021) at inpatient, outpatient, and emergency departments. Data were analyzed using segmented regression analysis with a defined outcome of level and trend changes in the number of patient visits. In addition, negative binomial regression analysis was also used to estimate the impact of both COVID-19 and the war on patient flow.
Results There were 59,935 admissions, 876,533 outpatient visits, and 127,872 emergency room visits. The effect of COVID-19 was seen as soon as the Tigray regional government imposed comprehensive restrictions. Immediately after COVID-19 appeared, all the service areas exhibited a significant monthly drop in visits; [-35.6% (95% CI: -48.2%, -23.1%)] for inpatient, [-60.6% (95% CI: -71.6%, -49.5%)] for outpatient, and [-44.1% (95% CI: -59.5%, -28.7%)] for emergency department visits. The impact of the war became apparent after a lag time of one month. Controlling the effects of time and COVID-19, the war led to a significant fall in inpatient visits [-44.3% (95% CI: -67.2%, -21.5%)], outpatients [-52.1% (95% CI: -82.7%, -21.5%)], and emergency-room attendances [-45.0% (95% CI: -74.8%, -15.2%)]. An upward trend in outpatient flow was observed after the war [1,219.4 (95% CI: 326.1, 2,112.8)].
Conclusions The present study has clearly indicated that the war and COVID-19 have led to a large reduction in admissions, outpatient attendance, and emergency department visits. The evidence from this study suggests that due to this double catastrophe, thousands of patients could not gain access to healthcare, with probable negative consequences. Governments and organizations should implement measures to buttress the healthcare system to maintain pre-war status of service.
