Notes from Ethiopia June 2018

Traveling to Ethiopia fills one with gratitude for all that is possible through physical therapy. In June of this year Rebecca Stephenson and Tracy Spitznagle traveled to Mekelle, Ethiopia. The trip was twofold, one to participate in the medical school collaborative and the second, to provided education to the third cohort of master’s student at Mekelle University.  This was GWHI’s second trip to educate master’s level physical therapy students.  They both presented to the Sixth Annual Mekelle Medical Education Collaborative. The conference was sponsored by the College of Health Sciences, Mekelle University and the Worldwide Fistula Fund.


Dr. Rebecca Stephenson did four days of education for the master’s students on Obstetrics. During the sessions the graduate students learned about anatomical and physiological changes in the pregnancy and postpartum periods, modification of evaluations, differential diagnosis amongst many other topics. The students were challenged with labs and testing as well as visiting the labor and delivery floors to see some of what they learned in action.

During the same time there was the Annual Mekelle Medical Education Collaborative conference going on with Urogynecologists from across the USA visiting and presenting to the school’s faculty. Dr. Spitznagle presented the most recent research on the kinematics of intra-abdominal pressure and the associated effect on pelvic organ prolapse. In addition, she provided culturally related cases on Ethiopian women and the effect that their specific functional activities creates along with the potential for pelvic floor impairments.


Dr. Stephenson presented on the ripple effect that has occurred with providing education on pregnancy and postpartum physical therapy with in the Mekelle Medical school. As part of the presentation Belay Adugna PT, MS presented his masters thesis plan associated with teaching obstetric physical therapy associated with pregnancy and postpartum to practicing physical therapists within Ethiopia.

This program is designed to build capacity and awareness for the management of pregnancy related musculoskeletal conditions and to optimize women’s health in Ethiopia. The awareness of obstetric care providers towards the role of physiotherapy in the management of common physical complaints of pregnant and lactating mothers in Ethiopia is very low. Awareness of women about the existence and importance of physiotherapy services is also very poor.


The availability of proper physiotherapy treatment for complaints during and after pregnancy is currently a need that is not met. The general objective of the project is to address health problems and improve women’s quality of life thorough prevention and treatment of pregnancy related musculoskeletal conditions, using trained physiotherapists in Ethiopia with a multidisciplinary team approach and a referral system development.

Watch for more news on this exciting GWHI project.

Highlighting Obstetric Fistulas

Hadiza Soulaye is a young woman from Niger who shared her experience with an obstetric fistula with the New York Times2. She was married off by her parents before she even began her menstrual cycle. Soon she was pregnant. Her labor was obstructed and lasted three days. By the time she was able to get to a center for a C-Section she lost the baby and had a fistula causing her to leak urine. Hadiza’s husband threw her out of the house. She heard about the Danja Fistula Center and journeyed there to get a repair. The medical professionals repaired the fistula and she was educated on the recovery process. However, Hadiza’s husband quickly discovered she was no longer leaking urine and took her back. What choice did this young girl have? He tore open the repair and again expelled her from the home. Hadiza returned for a second repair and vowed not to return to her husband again. 

Fistulas are abnormal passages or tunnels that form in the body. Obstetric fistulas occur between the vaginal canal and rectum, the vaginal canal and urinary system, or both. These obstetric fistulas are a result of prolonged and difficult labor which can lead to incontinence of urine and/ or fecal matter. The prevalence of obstetric fistulas has decreased in more developed countries, however, they still greatly impact women in developing nations. 

The impact for these women is wide ranging. It alters a woman’s acceptance in her community, with her family, and ultimately challenges her mental wellbeing. For women with obstetric fistulas this condition can be debilitating and isolating without proper treatment. The average surgical cost to treat a fistula is $5681. For every one woman who receives medical intervention for her fistula, 50 more women are untreated1.

1. Fistula Foundation. Help Give a Woman New Life. Published 2018. Accessed May 19, 2018.
2. Kristof N. Opinion | Where Young Women Find Healing and Hope. The New York Times. Published July 13, 2013. Accessed May 25, 2018.

Osteoporosis Around the World

Osteoporosis is characterized by bone becoming more brittle leading to increased incidence of fracture. These fractures most often occur in the hip, forearm, and spine. Of the 9 million osteoporotic fractures in the year 2000, 51% occurred in Europe and America. The other 49% happening in Southeast Asia and Western Pacific regions. These osteoporotic conditions develop most often in aging women after menopause. Approximately 200 million women have osteoporosis throughout the world. It is estimated that one of every ten women in their 60’s have osteoporosis, one of every five women in their 70’s, two of every five women in their 80’s, and two of every three women in their 90’s. These numbers in more developed countries are estimated to increase by four times by the year 2050 with more individuals living longer.

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There are many factors that contribute to the development of osteoporosis include: body mass, alcohol use, physical inactivity, poverty, and exposure to sunlight. The incidence of osteoporotic tissue development and fractures is higher in caucasian populations. Once an individual develops a fracture they are 86% likely to develop another fracture.

To decrease risk of developing osteoporosis early intake of calcium as a child, vitamin D, appropriate nutrition, and physical activity should be utilized. Weight bearing exercises help to develop increased bone mass. Osteoblastic activity which encourages increased bone mass peaks between ages 25 and 30 in long bones.  


1.  Johnell O and Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 17:1726.

2. Kanis JA (2007) WHO Technical Report, University of Sheffield, UK: 66.



5. Kanis JA, Johnell O, De Laet C, et al. (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375.



Celebrating International Women's Day!

“I alone cannot change the world, but I can cast a stone across the waters to create many ripples.” - Mother Teresa



Happy (belated) International Women’s Day to all of the women creating a ripple and impacting the world! Your work is important and perpetually creating change.


In celebration of women around the world, we highlight Tracy Spitznagle’s recent trip to Mekelle, Ethiopia. Partnered with the Worldwide Fistula Fund, Tracy spent time with Physical Therapists and Physical Therapy students in Mekelle, educating and promoting women’s health physical therapy. The Ayder Specialized Hospital affiliated with Mekelle University started in 2008 and has seen substantial growth over the years becoming the largest facility serving the Tigray region in Ethopia.


While at Mekelle Tracy helped to educate practitioners on prolapse and postoperative care. This trip was an interdisciplinary education trip with a team of people that included physicians and a nurse along with Tracy. A highlight of the week for Tracy was a day spent in a simulation lab with Ethiopian midwives, nurses, and physical therapists participating on three ob-gyn related cases. Some of the goals of the simulation lab was to demonstrate how physical therapy can be a part of the team in a hospital for labor and delivery in addition to starting communication amongst various disciplines within the hospital. The three ob-gyn cases included a post-surgical abdominal pain case (where it was found that the catheter was kinked), a post-surgical DVT case (which allowed the team to work together on their communication within multiple disciplines) and a postpartum bleed. Tracy states of her trip that it is “very empowering to be able to do the teaching knowing that the goal is for all those clinicians to continue to work with physical therapy”.


Tracy also spent some time with a new clinician, Hanna, who is a new graduate interested in women’s health. She was able to take that opportunity to connect Hanna with Tsega, a clinician at the hospital, who is eager to mentor her.  

Zero Tolerance for Female Genital Mutilation

February 6th marks a day of zero tolerance for female genital mutilation (FGM) worldwide. 

200 million women and young girls are currently affected by female genital mutilation. It is thought 3 million more are added to this current number each year (1). 44 million of these individuals are less than 15 years old (2). It is most common in countries in Africa, Asia, as well as the Middle East.  More than 50% of these individuals live in Indonesia, Egypt, and Ethiopia (1). 

There are four subtypes of FGM (3):

Type 1: Clitoridectomy

Type 2: Excision of labia minora, majora, and clitoris, or a mixture of the removal of these aspects of this anatomy.

Type 3: Infibulation which is the narrowing of the vaginal opening. This seal is created by the labia minora and majora while the clitoris is removed.

Type 4: All other procedures to the female genitals deemed harmful and non-medical in nature. 

These procedures do not have any medical benefit. They are painful and can cause bleeding, scarring, infection, shock, and even death. Ultimately, they can have long-term outcomes as well. Individuals can experience urinary changes, vaginal changes, challenges with menstrual cycles, dyspareunia, anorgasmia, difficulties giving birth, as well as psychosocial effects from the procedures (3). 

Female Genital Mutilation is tied to cultural beliefs about transitioning to womanhood and marriage. In these cultures there is social pressure to participate in order to be accepted into society. It is thought to decrease the likelihood of premarital sex and maintain purity. Additionally, they are thought to promote femininity and make females more clean in appearance by removing aspects of the anatomy (3). 

It may be easy to think that these practices are happening worlds away, but they too are occurring here in the United States or individuals from these countries may seek treatment in the US. It is important to recognize Female Genital Mutilation and support individuals who may have had any of these procedures performed. The World Health Organization and UNICEF are working on a global campaign to stop Female Genital Mutilation. 


1. UNICEF. UNICEF'S Data Work on FGM/C./FGMC_2016_brochure_final_UNICEF_SPREAD.pdf. Published 2016.

2. Kaplan A, Cham B, Njie L, Seixas A, Blanco S, Utzet M. Female Genital Mutilation/Cutting: The Secret World of Women as Seen by Men. Obstetrics and Gynecology International. 2013. Doi:10.1155.

3. World Health Organization. Female genital mutilation. World Health Organization. http:/ Published February 2017. Accessed  January 14, 2018.

Cervical Cancers Around the World

January is Cervical Health Awareness Month and we wanted to take this opportunity to highlight what gynecological cancers look like for women around the world.

  •  Cervical cancer, a mostly preventable cancer, is the leading cause of death from cancer (approximately 265,000 deaths per year) in women in developing countries.1
  •  85% of cases of cervical cancer are in low to middle income countries (primarily Africa, South America, and Asia).1
  • Endometrial cancers are on the rise in countries undergoing socioeconomic transition, which is potentially due to lifestyle changes.2
  • Approximately 45,000 deaths per year due to endometrial cancer.2
  • According to the World Cancer Research Fund International, “in 2012, the rate of ovarian cancer was more than two times higher in Central and Eastern Europe compared with Eastern Asia.”3
  • 58% of cases of ovarian cancer are in low to middle income countries.3
  • Gynecological cancers are a high burden in developing countries, resulting in high incidence and mortality rates for even preventable cancers, often due to a lack of access to screening programs.4

So what can we do to change these statistics? Knowledge is power! Educating women, creating screening programs and access to treatment are vital in making a change.

1. Smith, E. (2017). World Cancer Day 2017: how to prevent cervical cancer cases around the globe. [online] Cancer Research UK - Science blog. Available at: [Accessed 16 Aug. 2017].
2. Varughese J, Richman S. Cancer Care Inequity for Women in Resource-Poor Countries. Reviews in Obstetrics and Gynecology. 2010;3(3):122-132.
3. (2017). Ovarian cancer statistics | World Cancer Research Fund International. [online] Available at: [Accessed 20 Aug. 2017].
4. Iyoke CA, Ugwu GO. Burden of gynaecological cancers in developing countries. World J Obstet Gynecol 2013; 2(1): 1-7

This Giving Season Consider GWHI

When you help educate someone who has already demonstrated a passion for healing others, your support will enrich countless lives for years to come. Kiflom Negash is one of those who, as master’s physical therapy student at Mekele University in Mekele Ethiopia has demonstrated that passion. He is the president of his class and he and his colleagues are receiving training through the faculty at Washington University in St Louis and with other experts in physical therapy. Rebecca Stephenson, Susan Clinton and Tracy Spitznagle were among the resident faculty at Mekele University this year teaching the master level physical therapy students about how to evaluate and treat pregnant and postpartum women, treat orthopedic conditions and diagnose patients with movement disorders and instruct the students how to create the best exercise programs for those patients. (Story continues below image).

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Kiflom Negash is a masters physical therapy student at Mekele University in Mekele Ethiopia. He and his colleagues are receiving training through the faculty at Washington University in St. Louis.

Kiflom is being sponsored, through grants from the Global Women’s Health Initiative,, to come to the USA to participate in the Combined Sections Meeting and take additional courses to further his education on treatment of women and children. He will take these experiences back to Ethiopia so that he can bring back the knowledge and work toward making sustainable changes to the health care system in Ethiopia. Though his visits to several rehabilitation and acute care hospitals here in the US, he will be able to take those experiences back to his country and help establish care for the many patients that are going untreated now.

Please consider donating to with your end of the year donations so that physical therapists like Kiflom can improve the quality of life in their communities and empower women through better health.

All donations are tax-deductible through our founding partner the Shae Foundation, a registered 501(c)(3) organization.

Female Genital Mutilation (FGM) - A Violation Shrouded in Culture and Religion

There are more than 200 million girls and women in Africa, the Middle East and Asia who have undergone female genital mutilation. This practice shrouded in culture and religion is a violation of women’s rights and a cause for many medical complications. Below is an interview of one of such women.

Dr. Daniel tell us a little about your background

My name is Jovita Ada Daniel, an Igbo of the Eastern part of Nigeria. I am a Physiotherapist, trained and practicing in Nigeria. I started my career at the Aminu Kano Teaching Hospital, Kano Nigeria where I practiced from the year, 1999 to 2009. While at the Aminu Kano Teaching Hospital, I developed an interest in Women's Health.

At what age did you undergo female genital mutilation (FGM)?

The FGM was carried out within the first two weeks of my birth as that was the practice in my hometown at that time. Thankfully, this practice is significantly lower in the community where I grew up. However, there are still some people who hold onto the belief that it is normal and even necessary to carry out circumcision on the 8th day of a girl’s life. They see it as culture and many even believe it is Biblical.

What has been most difficult for you since going through FGM?

I needed episiotomies during my first two deliveries, which I learnt later with increasing experience in Women's Health Physiotherapy, may have been related to being my being circumcised as an infant.

In what way can people be more involved in helping girls who have undergone FGM or to prevent more girls from being circumcised?

I believe that campaign against FGM should be carried into the rural areas and seminars should be organized to enlighten rural dwellers of the implications of FGM. Government and Non- Governmental Organizations need to support these campaigns. It is also very important for traditional rulers especially to be educated on the evils of FGM and be encouraged to speak to their communities since they wield clout with their followers.


Female Genital Mutilation.
World Health Organization website Updated February 2016. Accessed January 18, 2017.


An Interview with a Duke University DPT Student Fundraiser – Taylor Chapman

We are pleased to introduce Taylor Chapman whom has completed a successful fundraising event for the GWHI in Chicago, IL.  Her singular efforts have resulted in an event that raised $1,000 for the foundation. Taylor is an amazing example of how one person can change the world!

Taylor Chapman is a 3rd year Doctor of Physical Therapy Student at Duke University and a Certified Strength and Conditioning Specialist. She is a member of the Women’s Health Section, the SoWH SIG, the Research Section and the Health Policy and Administration Section as well as a PT-PAC supporter. Taylor will present her research on “Comprehensive Primary Care Models for the Management of Multiple Chronic Conditions in Community-Dwelling Older Adults” at the 2017 Combined Sections Meeting, and gave a Poster presentation at the 2016 ACSM Annual Meeting on “Examining differences in movement competency in professional baseball players born in the United States and Dominican Republic.” She recently traveled to Guatemala with the Hearts in Motion organization to administer skilled physical therapy services via pop-up clinics in a variety of cities.
Taylor, how did you get interested in Women’s Health Physical Therapy?

As a Duke University DPT student in the class of 2017 I had a variety of opportunities to be exposed to the specialty through wonderful faculty and surrounding Women’s Health Clinics. I fell in love with the specialization because of the intimate environment and the inspiring passion Women’s Health clinician’s embody. My clinical instructor at ATI Physical Therapy, Amanda Bachman, was very supportive of my passion and assisted me in securing a 12-week rotation that positively impacted my future in WHPT.  I am now in the application process for a residency program in this specialty.

Why did you get involved with the Global Women’s Health Initiative? The GWHI is the perfect model to describe how I would like to transcend my professional career by first creating a sustainable foundation to then evolve and create positive change.  The start-up’s plan to build from the ground up by initially engaging medical professionals interested in the care of women in under-served communities, locally and globally, along with promoting a social medial message campaign that improves awareness of the current medical status in various countries pertaining to the care of women, will allow for a solid foundation to be built. As they evolve these efforts into awareness and support, funding as well as personal and professional efforts will naturally keep the mission moving forward. I have also had the pleasure of working with another wonderful and sustainable organization, Hearts in Motion, assisting locals via pop-up PT clinics in Guatemala.  I was first introduced to sustainable projects from Dr. Landry at Duke University.

The GWHI embodies two of my passions.  1) My ultimate ambition of educating medical professionals on the benefits of pelvic health physical therapy and to improve the public’s uneasiness and general unawareness of the specialty. 2) The ability to work with an organization whose mission is to transcend the public awareness into worldwide support and effort, utilizing service and education, to create systemic change.

Tell us how you created such a successful fundraising event over a short period?
I have always been involved in fundraising and event planning. I have volunteered my services to organizing charity events for the Make a Wish Foundation, planning social networking events with the various medical programs at Duke University, and acting as the Event Chair for my Greek Student Organization at Indiana University. I served on the Events and Dancer Relations committees for Indiana University Dance Marathon and I am currently the Events Coordinator for the Duke DPT Class of 2017.  
I worked with my Chicago connections, IU alumni/friends/family/colleagues, to raise awareness of WH on a local and global level.  I utilized a survey engine distributed via social media to inquire about the general public’s knowledge about WH PT and found that over 50% were unaware of these services.  I wanted to create an event to promote global perspective with an emphasis on education to improve awareness.  I contacted the event planner at State Restaurant, an Indiana University Alumni bar, to honest the event. I spread the word through social media, friends, connections through my helpful sister at Groupon, local companies and colleagues, and the physical distribution of flyers.  I was able to provide information to local universities and student organizations to help increase event attendance. Finally, I created a mechanism to allow for donations on and offsite of the event. During the fundraiser, I offered pelvic health knowledge as a driver and conversation starter.  Educational materials from the APTA Section on Women’s Health on pelvic floor trauma, fistula and prolapse promoted awareness for the physical therapy need in the US and abroad.  My goal was to give a global perspective and the event procured donations through awareness and in the form of raffles and food/drink donation.  I am so grateful to have successfully raised and donated $1,000.00 for this worthy organization.

An Interview with a GWHI Founding Member and the World Wide Fistula Fund Executive Board member – Tracy Spitznagle

Tracy Spitznagle has been involved in the international education of Urogynecologist and Physical Therapists as well as a provider of clinical services for the World Wide Fistula Fund since 2011 She has served in many leadership roles within her profession as a Women’s Health Physical Therapist.  Included in these positions is serving on the Board of Directors of the APTA Section on Women’s Health and Chair of the American Board of Physical Therapy Specialists.  She is also a very busy clinician and educator at Washington University in St Louis and a strong advocate for Women’s rights.  It is no wonder she has committed herself to the work of the Global Women’s Health Initiative both as a Board Member and as a donor!  The GWHI is focusing this time of the year towards giving and has partnered with the World Wide Fistula Fund during Giving Tuesday.  This amazing physical therapist sat down with us to talk about her involvement on the international stage.

What is the Vision/Mission of the World Wide Fistula Fund?
The World Wide Fistula Fund was developed by Dr Lewis Wall in 1995 to help women heal from birth related injuries.  The initial focus of WFF was fistula repair, however, now the organization is also caring for women with pelvic organ prolapse and post-partum dysfunctions.  Prolapse is now a 3rd world epidemic – and for the women of these regions – fistula and prolapse is believed at times to be a “curse” which limits their interactions with their families and communities as well as their ability to obtain education and earn a living.

Tracy, how did you get started with the World Wide Fistula Fund?  
I met Dr. Louis Wall in 2001 while in clinical practice at Washington University.  He was interviewing for a position as the Chair of Urogynecology and I was on the interview team.  At the time of his initial interview, He discussed my possible involvement in assisting women in Africa.  A few years later, The WFF sent me to Ethiopia to teach and observe at the Hamlin Fistula Hospital.

What has been your focus of your work with the World Wide Fistula Fund? 
My focus in the beginning was providing education for the PT staff at the Hamlin Fistula Center in Addis Ababa.  I worked with the staff treating women pre and post fistula surgeries. I supplemented the established rehabilitation program with lectures on lower extremity strengthening and care for foot impairments commonly found in the survivors of Fistula.  Over the years, as my participation grew, I was asked to join the Board of Directors.  After my second year on the Board, I was asked to join the executive council and served as secretary.  Now I continue to serve on the executive council as the Treasurer and the board representative for our Danja Fistula Hospital in Niger.
How has your practice with the World Wide Fistula Fund changed?
During my tenure with this organization, I have moved into al teaching role with the Urogynecology Fellowship program.  I have provided pelvic health lectures for both Physicians and Physical Therapists at the University of Mekelle.  In June of 2016, I was asked to facilitate the recruitment of faculty to enhance the Physical Therapy education for their first cohort of 5 students starting in 2017. Graciously, The World Wide Fistula Fund has provide the resources to cover some of the costs for this program, thus allowing Physical Therapy educators to engage in  capacity building within the Masters of Physical Therapy program at the University.  WFF is aiding in the development of the future educators of the Masters of PT program, thus allowing them to grow the PT program in within the scope of the Mekelle Medical School. A  long reaching aim of WFF is  to support  systemic change and sustainable growth of the healthcare services in the Tigren Region of Ethiopia.

What led you to become involved in the Global Women’s Health Initiative?
Rebecca Stephenson – a fellow inaugural board member invited my participation because of my work within the World Wide Fistula Fund.  Her engaging spirit, and never ending positivity has given me great hope that we can join together to make a change. There is an extreme lack of women’s health services in both 3rd world countries and underserved populations in our country.  I hope to transfer what we learn globally to local engagement, I believe that global is local and local is global. 

My overall hope is that GWHI will create resources to send and facilitate Physical Therapy care in underserved regions of the world. I feel so very blessed to be able to support sustainable programs for development of Women’s Health Physical Therapy on a global scale.

Please consider your own personal engagement; we who have so much can make a beautiful difference to those who have not.