In Ethiopia, pregnant women and young children face a serious problem: most of them live in rural areas, far from health care facilities. Usually they must travel for hours on foot to the nearest clinic, only to receive marginal quality treatment. For many pregnant women, even that is a luxury.
A model maternity clinic
Mondays are busy at the Fufa village maternity clinic in south western Ethiopia. Mothers from near and far come to this clinic, the first of its kind within a 100 kilometer radius.
The hospital has a delivery room, basic equipment and trained professionals - luxuries compared to what was available in the past.
Gebremariam Ayele, a clinical nurse who has been working in the Fufa area for decades, says prenatal care was a much different experience before the Fufa clinic was built.
"We were limited in what we could do. [Before the clinic was built], we sent two health care workers to the villages on foot. They provided vaccinations and antenatal care to mothers," Gebremariam says.
Challenges to rural healthcare
Most pregnant women do not get to proper clinics like the one at Fufa, says Gebremariam. Many are forced to travel long distances on foot to seek medical treatment, or to forgo it altogether.
The effects are devastating. The UN reports that Ethiopia's infant mortality rate is 86 out of every thousand, compared to about 6 out of every 100,000 in the United States.
Lack of care can also be fatal for mothers who go through difficult pregnancies or labor. Those who survive have to deal with the emotional scars and physical complications. One of these complications is fistula, a childbirth injury where fluid leaks through a hole between the bladder and cervix or rectum. It can be caused by prolonged labor.
Mark Bennet is the CEO of the Addis Ababa Fistula Hospital, where women who suffer from birth injuries get free treatment. He says fistula often happens in rural areas because women don't have access to healthcare during delivery.
"They live a long distance from a place where healthcare can be provided, so getting transport, getting to a health center in time and getting to a health center that actually has the facilities or the professional staff that can give some assistance takes a long time," Bennet says.
According to Bennet, it will not be easy to improve access for women in rural areas.
"Ethiopia has a big challenge. Building roads to connect rural communities to locations where health care can be provided, that is a big challenge," he says. "Providing education to rural communities is a big challenge. And providing health care professionals to a rural community that is so large is an enormous challenge. Educated people do not want to work in the countryside."
Often, educated doctors choose to leave Ethiopia altogether for better-paying jobs overseas. The government is training health extension workers to meet the growing demand in the country, which has Africa's second largest population.
Health extension workers are low-level professionals with some months of training. Midwife Mekdes Kassahun says these workers can still make a big difference.
"Health extension workers and mobile clinic workers teach mothers about basic nutritional needs during pregnancy," she says.
According to Mekdes, the biggest challenge is raising awareness in rural communities, and health extension workers are helping bridge that gap.
"They grow cabbage and carrots for sale at local markets to buy grain. We advise them to eat vegetables during pregnancy. We also consult them about possible birth complications, vaccinations and PMCT [Prevention of Mother to Child Transmission of HIV."
Clinics like the Fufa hospital also focus on PMCT as a big component of prenatal care.
At another maternity clinic, in the town of Durame in southern Ethiopia, farmers Amenech Haylemariam and her husband Desta Tsienew came to visit a patient. Amenech said she is likely to be four or five months pregnant, and intends to go regularly to the clinic.
The government says health extension workers will help out in efforts to expand healthcare access for millions of Ethiopia's rural women, but there is no quick fix in sight. Poor infrastructure and a high population growth remain formidable challenges.