Last week we conducted our 26th rural facility assessment at the Abawuram Health Center. We agreed that this was definitely one of our favorite days in Ethiopia, not only because we got to see the lush countryside, but because it brought to life in a fresh way many of the challenges the health center faces in trying to provide services for the rural community.

We drive south from Gondar, and within one hour we were faced with a river crossing that was impassable by car. Our driver threw up his hands and looked to us as if to say “what are we going to do now?” So we put on our sneakers, and set out to walk the remaining 10 kilometers to the Abawuram health center. The hike was beautiful – small river crossings and vast, green farmland. We frequently encountered local farmers and shepherds, asking them directions to guide our way on the crisscrossing trails, sometimes barely visible, through the meadows. The local residents were surprised to see ‘firenges’ (Amharic word for foreigners); curious to know where we were going and why we were in their community. We arrived at the health center in just under 2 hours, sweat dripping down our backs and eager to retrieve our water bottles. Walking the distance ourselves put into perspective the reality community members face in trying to access healthcare.

For us the hike was lovely- we had optimal conditions, such as transportation to the very end of the road and sunny but cool weather. But we could see how in the rain, or dark, when a family member is suffering or dying, the trail could be nightmarish. It is not uncommon for local women to walk much further than 10 kilometers, facing extreme rain or harsh sun during different seasons. Given these circumstances, merely arriving at the health center is a feat in and of itself.

The head nurse, Gebeyehu Kassie, greeted us warmly at the health center. He proudly showed us the maternity area and helped us gather the data we needed. When we took his picture, we asked his permission to post it on this blog, and he obliged, with one caveat.

“Please tell people what our challenges are here. They are three.”

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As we anticipated, the first challenge was transportation. As the clinic head, he described how the long walk to the health center often left his patients exhausted upon arrival. But the problem didn’t end there. Because Abawuram is inaccessible by road, the clinic is often unable to keep a constant supply of life-saving medications in stock. It is nearly impossible to transfer new materials and equipment or build infrastructure.

We asked, “What do you do if a woman has an obstetric emergency and needs to go to a hospital?”

He described how they carry patients in a homemade, wooden stretcher the 10 kilometers to the nearest road. The midwife travels with the patient, trying to stave off further danger during the treacherous journey. In the best case scenario a woman would access emergency medical care in 3 hours.

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The second challenge was running water. On the day we visited Abawuram, the health center did not have any water on its premises. Nothing in the delivery room- not even a bucket. There was a water tank in the corner of the facility, but upon further investigation, we could see that the tank was empty and the pipes were not connected to anything. When we asked about the water situation, Gebeyehu Kassie shook his head. The nearest water source, he said, was a borehole, a 20-minute walk from the health center. Staff traveled with a donkey to the community borehole, to fill up containers with water and then walk 20 minutes back to the health center. Given limited staff and resources, what this meant practically was that they often provide health services without clean water.

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Delivery room sink, which hasn’t seen water in years

And the third challenge was electricity. The Abawuram health center has no electricity. In the evenings, they are forced to provide services by flashlight, whether that means delivering a child or simply looking for a medication. The picture below is of the delivery room, taken on a sunny afternoon, yet it is still quite dim. We could not imagine delivering a child in this very room in complete darkness, with only cell phone flashlights and one solar-powered light to assist, yet the dedicated staff at Abawuram do just that.

Additionally, lack of electricity impacts the health center’s ability to sterilize instruments. They use a kerosene-generated autoclave and charcoal-generated boiling water to clean medical materials. Given Abawuram’s remote location and their dependency on kerosene, having clean, safe tools for delivering a baby rests precariously on their capacity to carry this fuel in by hand, overland.

After hearing Gebeyehu Kassie describe the difficulties of operating the health center, we told him that yes; we would tell whomever we could about the obstacles faced at Abawuram. It reminded us that improving maternal care typically involves both push and pull factors. Community leaders can promote safe delivery and encourage women to come to the health center, but if the health center is not equipped with even basic supplies, or is impossible to reach, women may still opt for home birth, unsafe as it is.

The dim delivery room

The dim delivery room

For both of us, this was a beautiful day in Ethiopia, with the opportunity to spend time outdoors hiking with good company in a beautiful landscape, completing meaningful data collection, and engaging with local health professionals. However, we realize that if our roles were shifted, we would feel quite differently. If we were health care providers at Abawuram, the constant stock outs and lack of essential materials would be endlessly frustrating. And if we were seriously ill or in labor, this ‘beautiful walk’ would be an incredibly challenging, life-threatening journey.