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OTI Online
Fall 2008

The Terror of Motherhood in Somaliland
and Women’s Rights to Safe Care
by Edna Adan Ismail


The Safe Motherhood Project at Work
A very distraught old woman came to Edna Adan Maternity Hospital in Hargeisa, Somaliland, appealing to us to help her transport to the hospital a woman who had given birth five days earlier and who still had the placenta inside her. Those of us at the hospital are not sure how this could be possible and we ask her again whether she means five hours. She is sure about the number of days, and quotes the day the woman had delivered which, indeed, was five days earlier. She also tells us that the woman may not be alive by the time we get to her.

We prepared the ambulance, put in our emergency obstetric kit and set out towards the home at the opposite end of town from our hospital. We come to a hut with quite a few neighbors and onlookers standing around.

Before we get to the patient, we could have been guided to the woman by the smell coming from inside the hut. We find a woman who has bled for several days, is very infected, febrile, dehydrated, has no recordable blood pressure and a weak, rapid pulse. We cannot understand how she could have survived this long in this condition. Answers to our questions would come later, but right now, we needed to get an IV line going, and once in, we put her in the ambulance and headed for the hospital where blood transfusions and medical care would be ready for her. We also brought along the baby.

Once she picked up, we got the placenta out, started her on high doses of antibiotics and the woman miraculously recovered and went home a week later.

Our burning question was why did they wait for five days before they looked for help when the placenta refused to come out after the baby was born?


Edna Adan Maternity Hospital in Hargeisa, Somaliland

The unfortunate answers were: (1) We thought we would wait and hoped that it would come out later. (2) When it took too long to come out, her husband suggested that they try Somali Traditional methods to get the placenta out. (3) When this failed, they tried spiritual chants and prayers. (4) By the third day, they feared that if they report this to the hospitals, the old woman who had attended the delivery would be denounced to the government. (5) Finally, the woman became so ill that they feared they would not be able to afford the cost of the medicines she would need to treat her.

Luckily, they got the courage to come to us and we were able to treat her free of charge, although we had our conditions for this free treatment: the woman who had attended the delivery would have to agree to spend five days at our hospital to be shown how to conduct a normal delivery and to know which conditions to refer immediately. To this, she agreed, and hopefully, this situation never will be repeated.

This was just one example of what practicing midwifery in our part of the world entails. My theory is that women in Somaliland die because of ignorance on their part and on the part of those assisting them. Poverty is a strong factor that prevents women from seeking help because they convince themselves that they cannot afford the cost of modern medicine and would rather consult the local traditional healer who often causes more complications.

Women Still Dying of Maternal Mortality

In 1945, diplomats representing the countries of the world at the end of the Second World War gathered in New York and proposed the formation of a global health organization. In April 1948, the constitution of the World Health Organization was passed, with its first article stating, “Health is a fundamental Human Right.”

About the Edna Hospital, Hargeisa, Somaliland

The health of the people of Somaliland is among the worst in Africa, with one of the highest maternal and child mortality rates in the world. Every year, one baby in eight dies in infancy while nearly 4,000 Somali women die in childbirth. This tragedy can be attributed in large part to the long civil war which brought about the death or departure of nearly all of the country's trained health care professionals.

Somaliland is in the Horn of Africa. Edna Adan Maternity Hospital seeks to fill not only the urgent need for health care but also to provide -- in collaboration with the Ministry of Health, UNICEF and WHO -- training for a new generation of nurses and midwives qualified to provide Reproductive Health Care throughout Somaliland.

Edna Adan Maternity Hospital opened in 2002 and now provides a much higher standard of patient care than is available elsewhere in Somaliland. In addition to services and facilities relating specifically to maternal and infant care, the hospital has diagnostic laboratory facilities and an emergency Blood Bank; and provides diagnosis and treatment for sexually transmitted diseases including testing for HIV/AIDS. The hospital makes available facilities for carrying out medical research, studies and counselling with particular attention to the health problems associated with female genital mutilation.

Sixty years later, that noble declaration seems to have had little effect on the maternal mortality rate of women in the developing countries. The women continue to die of causes that have been eliminated in countries where efficient, safe and adequate health care have been made available for their women.

As far as African women are concerned, we seem to have very few rights, particularly in the area of safe reproductive health care. We fare the worst compared to women in other continents. In my 48-year experience as a midwife, I see very little improvement in the conditions under which our women progress through their pregnancies and childbirth. It’s a situation that shocks me even more today when I witness the advances that have been made in medical care elsewhere during the past half-century.

Why Africa Falls Behind

What leads the women of our continent to their graves during pregnancy and childbirth? As I describe below, the reasons fall into six categories: nutrition, education, high fertility, female genital mutilation, improper care at delivery and inadequate health facilities.

Nutrition: Sub-Saharan countries are affected by increasing degradation of the environment -- which we commonly call desertification -- due to frequent droughts, cutting down of trees, soil erosion and poverty. Superimposed on this are frequent wars and instability that cause displacement of peoples and which negatively affects the nutritional status of those living off the land.

While little girls are the mothers of tomorrow, we all know that they are fed the leftovers from whatever the family is eating. If lucky, she occasionally gets a bone to nibble at. During her childhood, who thinks about the growth of the bones of these little girls? Does anyone worry that her growth may become stunted because of chronic malnutrition and anemia? That she might develop a contracted pelvis? What will happen when she gets married and her narrow pelvis cannot permit the passage of the babies she will be expected to bear and produce? How many women have access to a health facility that can perform a Caesarean section to save the lives of the baby and its mother before the labor becomes obstructed?

Education: Quite often, when a family has to decide which of their children can be sent to school, it is often the girls who are left behind. We find that illiteracy affects the health and survival outcome of women. The lower their education level, the higher their risk of health problems, including those associated with their reproductive life.

An illiterate woman is not able to seek her rights because she is not even aware that she has any rights at all. She considers herself “owned;” first by her family, then by her husband and later by his sons.

High Fertility: Once the girl is married, immediate and frequent fertility is expected of her without taking into consideration whether or not her body can take care of the baby she will conceive. Our women, therefore, produce as many children as they can to ensure their place in their new home. In my work, I often witness women having baby number 9 or 10, and also some having baby number 12, 13, 14, 15 or 16 and, once, baby number 21!

FGM: As if all her other misfortunes were not enough in themselves, harmful traditional practices such as female genital mutilation (FGM) are performed on them and affect the health of women and children in many African countries, including mine. FGM affects and damages the perineum and the pelvic floor muscles of women and is a major cause of laceration of the perineum during childbirth, as well as damage to the urethra and rectum resulting in fistula formation.

This is among the most tragic situations and has shocked me so much that I became the first Somali woman to publicly cry out against FGM in 1976, well before those who would like us to believe that they are fighting against a new enemy that they have discovered. Thirty years later, even though umpteen campaigns have been held and many have joined the struggle, millions of little girls continue to be cut, mutilated and affected.

To show the extent of the problem, I developed a study at the Edna Adan Maternity Hospital on the status of women who come to our clinic and FGM. Regretfully, and contrary to anecdotal reports stating that there has been a decline in the practice, we discovered that 97 percent of the women attending our prenatal clinic have some form of FGM, and 98 percent of them have the most severe form of it. I am still working on the final results of this report, but it is clear that there has to be an FGM strategy that is different and more effective than that which has been used in the past.

At The Time of Delivery. Women having babies who are at a time of their greatest need for skilled medical or midwifery assistance are often at the mercy of relatives or other individuals who have received no or insufficient training in the care of women during childbirth. The woman does not know nor seek proper medical care because she does not know that this is her right. Many women die of obstetrical mismanagement with her relatives blaming her misfortune on “evil spirits” or “the evil eye of other women who were jealous of her baby.”

Health Facilities: The health facilities are so ill-equipped and poorly staffed that even if women get taken there, there is very little that can be done for them. More often than not, women arrive at these health facilities when their situation is too advanced and cannot be helped. How can infections be avoided when many health facilities have no water, gloves, disinfectants, sterilizers or dressings?

Charting a Better Path

Delegating women to a second-class status does not necessarily raise men to a first-class status. When when they do, they are denying their sisters, wives and daughters the education, decision-making and the possibility to rise to their fullest potential. In short, men lose when they prevent women from becoming full partners in all the challenges that life brings.

The prevention of maternal mortality is the basic right of all women and must be made a priority in all developing countries. The urgency of the situation warrants vastly heightened attention. Otherwise, the pledges and statements of health as a human right will continue to be words printed on paper made from the wood of the trees that have been cut down -- and thus only contributing to more degradation of the environment, poverty and misery.


Edna Adan Ismail founded the first charity Maternity Hospital in Somaliland in 2002. A Registered Nurse/Midwife by profession since 1961, she helped found Smali Red Crescent Society and held several positions with the World Health Organization. In 1976, she become the first women to be appointed Director in the Ministry of Health in Somalia; served as the Minister of Family Welfare and Social Development and the only female Cabinet Minister in 2002; and as the Somaliland Minister of Foreign Affairs from 2003-2006. She is an activist for human rights and gender issues and, among her many honors, was receipient of the AMANITARE Award for Africa in 2002.

Also See: The Terror of Loving and Losing by Cathy Albisa in this edition of On The Issues Magazine

Also See: Anti Immigrant Fervor Translates to Terror for Women by Melissa Nalani Ross in this edition of On The Issues Magazine

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