Powerful Photos of the Struggle to Stop Mothers From Dying in Ethiopia

Tesfaze is 7.5 months pregnant—and feeling good. She had her first child at 28, unlike 50% of Ethiopian women who do so by age 20. Here in the capital, Addis Ababa, she has far better healthcare than the 85% of women in rural areas.

Tesfaze spoke to BuzzFeed as she waited for her regular checkup at a private clinic run by Marie Stopes International, an NGO.

In Ethiopia — an East African country of 90 million — an estimated 1 in 67 women die from pregnancy-related causes, according to Save the Children. The risk is staggering but in context indicates progress: In 2000, the rate of maternal death was 1 in 24.

Most maternal deaths occur during or soon after labor. Common pregnancy-related risks for women include anemia, complications from HIV/AIDS and other sexually transmitted diseases, fistula (tearing of the uterus), unsafe abortions, and extended bleeding. Traditionally in Ethiopia most women give birth at home; an estimated 57% are helped by a relative, and 28% by a traditional birth attendant (not medically trained), according to Save the Children.

Over the last decade, Ethiopia’s government has made it a political priority to reduce maternal and newborn deaths by expanding health and family planning services across Ethiopia’s diverse — and largely rural and impoverished — population.

A woman holds her child at a Marie Stopes clinic in Addis Ababa.

The push has been part of Ethiopia’s efforts to achieve the eight UN Millennium Development Goals — two of which include reducing child and maternal mortality — by 2015. In exchange, groups like the World Bank have agreed to cancel Ethiopia’s debt.

Here, an aunt holds her newborn niece at a private clinic in Addis Ababa. The mother, reclining in an adjacent chair, told BuzzFeed the birth was complication free.

There have been successes: Between 2008 and 2011, Ethiopia’s fertility rate fell from 5.5 to 4.8, the number of married women using contraception rose from 8 to 29%, and the rate of women receiving skilled assistance during delivery rose from 6 to 10%.

A newborn just delivered by Cesarean section at Assella Hospital, Ethiopia. In the last 20 years, Ethiopia has also reduced infant mortality rates by 60%, meeting the MDG. The Ministry of Health places the rates of women giving birth in health facilities now closer to 35%.

But with a highly repressive government that is quick to crack down on criticism, the fight to stop Ethiopia’s mothers from dying from preventable problems is complicated by restraints on basic rights to expression and access to information.

The government owns — and monitors — all Internet and communication networks. Only about 1% of the country is connected to the Internet, which has very poor coverage. A 2009 law made it illegal for NGOs to advocate for rights — making public discussion about reproductive rights and government policy a near impossible task. Here, a doctor and patient walk in the unlit hallways of the capital’s decrepit Black Lion Hospital.

The political taboos of discussing reproductive rights and accessing information are further compounded by daily difficulties, like poor roads and infrastructure, limited education opportunities, and cultural and religious norms that disempower women.

At a private clinic in Addis Ababa, a picture of Ethiopia’s recently-deceased prime minister and Jesus Christ adorn the wall next to family planning posters. Ethiopia is predominantly Christian, with about a third of the population Muslim (mainly Sufi). Child brides and women with genital female mutilation are at a particularly high risk for birthing complications — and both practices (technically illegal) remain entrenched in many communities, especially in the south.

In 2003, the Ethiopian government began to roll out an ambitious “Health Extension” program to expand health care to the majority of Ethiopians living in rural areas as part of its efforts to reduce rates of maternal deaths.

Over the last decade, the government has built over 15,000 health posts, like this one in rural Amhara in the north, and hired 34,000 health extension workers (HEW) in rural areas. The plan is to have two HEWs and one post for every 5,000 people.

The HEW workers are chosen by the government and trained for a year to teach and advise their communities. The government provides the HEWs 16 education packages on issues ranging from family planning to sanitation that they are instructed to teach and implement in their communities. The women are paid on average 1,300 Birr ($66). Each duo of HEWs is also supported by local volunteers, called the Community Health Development Army.

Fasika Menge and Tiringo Alamerwu are HEWs in Mosebo, a small village 26 miles from Bahir Dar in the north. They split their day between serving patients in the post and conducting house-to-house visits and consultations.

Here, the walls of the small post are adorned with graphs charting the community’s vaccinations and health rates. The government plans to have a health post within walking distance for every community; however, in many parts of Ethiopia poor roads and tough climates mean that some must walk hours, with pregnant and young women facing dangers like abduction along the way.

Fasika and Tiringo have seen immense strides in local health over the years; still, Fasika said her saddest moments were when she talked with a woman about giving birth in a health facility — and in the end gave birth at home, where risks are higher.

Mosebo is an impoverished village — but comparatively better off than most others in rural Ethiopia; it is close to a main road and larger town. Fasika and Tiringo’s husbands work for the regional government, providing the women a degree of local protection. Save the Children also helps to support Mosebo’s health post, at a cost of about $100 annually. Still, the community’s conditions and health needs are critical — a sign of how far the rest of Ethiopia must come to mirror this model village.

As part of the plan, the government has also built 3,500 health centers, like this one in Hawassa, in Ethiopia’s southern region. The health centers serve five health posts and provide more specialized care, such as birthing services and safe abortions.

The current prime minister is from Hawassa, making the roads around the city better kept than others.

Zebiba Shikur, 21, is a midwife at the Hawassa health center. In nearby villages, she sees many cases of child brides; they often come to clinics only after starting to deliver and facing complications, too scared or far away to seek health care earlier.

Women with serious birthing complications are often referred to hospitals from health posts and clinics; others who are luckier go to the hospital straight away. Ethiopia has 130 hospitals and the government plans to add 185 more by 2015.

At the capital’s Black Lion public hospital — and others like it — ceilings are crumbling and cockroaches crawl by patients with open wounds. Most Ethiopians use free public facilities; in cities like Addis, about half seek care at (more costly) private clinics and hospitals. Private clinics — many of which receive funds from groups like USAID and Marie Stopes International — are concentrated in urban areas.

At Black Lion’s neonatal intensive care unit (NICU), nurses are overwhelmed and under resourced — and often worried they’ll run out of beds. The head nurse grabbed this reporter’s notebook and began to list all the equipment needed to better save lives.

There are currently about 8.4 physicians, nurses, and midwives for every 10,000 Ethiopians, with higher rates in urban areas. In Ethiopia, the government assigns what profession people study — and is increasing quotas for health related sectors.

Lela Tamam, 19, and Meseret Kebede, 18, first wanted to be pharmacists, a respected job in Ethiopia. Instead, they were assigned to study midwifery at a technical school in Hawassa, where they are now finishing their first year. After completing their three-year diploma, the government will assign Lela to return to work in her small village in the Guraghe zone in the south, while Meseret, who is form Hawassa, will be assigned to work as a midwife elsewhere. Tamam said the biggest lesson she had learned so far as a midwife is how bad FGM, which is practiced in her community, really is for women and reproductive heath.

As part of the health extension, the government is also emphasizing family planning — and urging women to use contraception. From rural health posts to public clinics in cities, more and more women now use contraception to space and limit pregnancies.

Meskem Yonas, 29, waits with her two-year-old son at a newly built family planning center at a hospital in Hawassa. She just received a three-month long contraceptive injection; many women in Ethiopia prefer monthly injections and copper contraceptives that are injected in their arms and last three to five years. (Pills and male condom use remain low.) Contraception costs are low, on average free in public clinics and about 20 birr ($1) in private ones.

In 2005, Ethiopia legalized abortions in cases of rape, incest, physical or psychological harm, and girls under 18. Nurses say previously staggering rates of complications from illegal abortions have plummeted — but abortion stigma and problems remain.

Here, a poster shows women their contraceptive options in the abortion room at a hospital in Hawassa. In 2006, the health ministry released guidelines further reducing abortion barriers; a woman seeking an abortion can say she was raped, is under 18, or a victim of incest (even if she was not) and the presiding nurse or doctor must take her word. In Ethiopia, however, there are no good numbers on the rates of legal and illegal abortions. Abortion rates are higher in cities, though likely in part because unsafe abortions (and maternal deaths from the complications) often go unreported in rural areas.

Tikdim Yohannes, 20, is now among the lucky mothers. She rests beside her husband and firstborn. She gave birth two days ago at this hospital in Hawassa. Bleeding was heavy, so she stayed two nights. Now she and her new daughter are feeling stronger.