"Power of Joy": New Film on Childbirth During Ethiopia's Civil War

For women living in the foothills of Ethiopia's Simien Mountains, medical care is already inaccessible even when it's desperately needed. After the country's violent civil war spread to the remote folds of the mountains, giving birth in a place now completely cut off from the world became even more a matter of life and death.

In her new new short film Power of Joy, to be released on March 7, producer and founder of Healing Hands of Joy Allison Shigo tells the story of Nigisty Gebregziabher*, once a girl with a harrowing childbirth story and now an ambassador for women's health in her community.

In the 10-minute film, funded in part by the Helmsley Charitable Trust, Nigisty gets married, becomes pregnant at 15, and, months later, enters into labor at home. But then her healthy pregnancy takes a turn—Nigisty's labor pains are far beyond the normal pain of childbirth—her baby is stuck in the birth canal facing the wrong way for 12 hours.

Through the trauma of her labor, Nigisty developed an obstetric fistula—a tear through the birth canal and bladder or rectum. Although she survived the ordeal, her baby did not.

According to the United Nations, obstetric fistula is one of the most serious childbirth injuries for women in low- or middle-income countries, with 90% of cases ending in stillbirth. The condition occurs when women experience prolonged labor without access to health treatment. In Ethiopia, where ongoing civil war threatens an already weak health-care system, obstetric fistula is a challenge many pregnant women—as many as 140,000—currently face. According to the film, more than 400 new cases of fistula now happen annually in the Tigray region, versus just 50 cases in 2019.

Obstetric fistula is one of the most serious childbirth injuries for women in low- or middle-income countries

After Nigisty's injury, she was treated like a social pariah for her body's failure to function the same. "People hate you," she says, as odor, incontinence, and the shame of losing a child and—with it—perceived self-worth settle in. That shame drives many women further inward, too tormented to seek health care. Despite this, Nigisty is one of few women from her village who received hospital treatment and recovered.

War Reaches the Mountains

When Shigo was making A Walk to Beautiful in 2007 before the war, her first documentary on women living with birth injuries in Ethiopia, she saw a way to improve maternal care. Years after she first visited Tigray, she returned to found Healing Hands of Joy in 2009 with local partners. The group began expanding health-care access by building rehabilitation centers and educating women on the importance of proper natal care to close the information gap in hard-to-reach places "one woman at a time," country director Meselech Seyoum says.

Women once stigmatized by the mars of fistula were transformed into ambassadors for their communities to encourage pre- and postnatal care and childbirth in a hospital. The organization grew from serving 300 fistula survivors at one location in Mekelle to serving the country's four largest regions and tens of thousands of women.

Healing Hands' women ambassadors reduced childbirth complications so much—to fewer than 50 cases per year—that they had begun to plan their exit in the region in 2019.

In November 2020, however, the region erupted in chaos as the civil war unfurled, the patchwork of small communities, such as Nigisty's, across Tigray becoming the arenas for battle. The fighting disrupted everything. The 50 cases per year became 50 cases per month. "Now, we're starting from scratch," Shigo says.

A woman holds her child as many women like Nigisty are now reclaiming their right to safe births in the aftermath of the war. Photo courtesy of Allison Shigo

More than 3 million people were displaced as they fled the brutal fighting and the rubble of their former lives. Nigisty shows the film crew where she lived in Hagere Selam, near Mekelle, with hundreds of other people hidden in caves. Some women gave birth inside these caves. "We used stones to cut the umbilical cord," Nigisty recalled.

Shigo remarks that she couldn't contact any health workers on the ground for two years. Without electricity, water, or staff, Healing Hands' centers shuttered. Most clinics in the area were destroyed and looted. More than half a million people died in the war, several thousand from lack of crucial health care.

With no safe place to give birth, fistula cases once again skyrocketed. Power of Joy points out another problem: Fighters weaponized women as a tool in their war. More than 120,000 women experienced gender-based violence, assault, and rape. The conflict deepened their need for urgent health care but put it further from reach.

Miriam* was one such woman. She was living with her husband and two children in the Afar region, neighboring Tigray, when soldiers took over their village. Her husband was kidnapped, and she was taken to cook for the soldiers. "The soldiers came suddenly," she recounted. "They only took young women," she says softly, looking down at the ground, "and raped us. . . . It happened over and over again." She redeveloped fistula from two months of unceasing assaults. With no house, no income, and no idea where her family was, Miriam was left to suffer in pain; it took nearly two years before she could get surgery.

When clashes over governance spill over, women's bodies become extensions of the battlefield

The war destroyed all health-care progress. After women had been coaxed into hospitals for safe births, violence pushed them back into their homes. Now, 70% of births in the region are taking place at home, versus around 50% in 2019. Women who suffered from rape or childbirth complications have both physical and mental health complications that are going untreated.

Power of Joy portrays a hopeful exit from the strife, but not without a great deal of work. Shigo has ambitious plans to eliminate obstetric fistula in Ethiopia by 2030. She and her partners have resumed work despite the violence to ensure that women are receiving proper, respectful reproductive care that empowers the community to heal from trauma.

As Ethiopia witnesses a resurgence of armed conflict again in Amhara and Tigray, the future of health care is again at an uncertain precipice. War crimes and fighting continue—with women still facing high levels of sexual violence—despite a peace agreement to end it.

"[Women] are the first victims of war," Healing Hands' Regional Director Senait Tarekegn says. When clashes over governance spill over, women's bodies become extensions of the battlefield.

Although organizations such as Healing Hands offer Ethiopia's women a chance to lift one another up, prolonged conflict has the power to reverse all progress. Their focus on U.S.-Ethiopia collaboration was a keystone in the group's success, a partnership now only increasingly under threat as agencies, such as the U.S. Agency for International Development (USAID), are forced to halt imperative work.

Experts—concerned that conflict is increasingly bubbling up in the region amidst climate change, unresolved ethnic tensions, and frustrations around governance—only highlight the need to pour more attention into equitable women's health care to reach even the remote mountains, as Power of Joy shows.

Hospitals can provide beacons of hope in places like Tigray, but front lines can swallow hospitals whole and stamp it out. It's the work on the ground to build resilient communities before violence strikes, and the wider response afterward, that makes the life-or-death difference.