“Tell them the truth,” she instructed me. Those were the only guidelines Edna gave me when she encouraged me to write a post for her blog. The task sounded simple, but for many weeks after my return from Somaliland, I could not articulate all that I had experienced. Only now am I beginning to understand the reason behind my difficulty. The truth is that The Truth is much more complicated than anything I had expected as a medical student in Toronto.

On Day 1 of my arrival to Edna Hospital – still jetlagged and disoriented – I watched as both a mother and her baby died shortly after an emergency caesarean section. I spent the next five weeks learning why they and so many other women and children in Somaliland die as a result of childbirth.

Global health’s beloved catch-all phrase of “limited resources” only begins to scratch surface in explaining this phenomenon. Yes, there is a deficit of obstetricians and medical supplies, but the deaths also occur because scar tissue from a previous female genital mutilation can lead to obstructed labor. They occur because an unusually high proportion of pregnant women from Somaliland suffer from dangerously elevated blood pressure and never receive treatment. They occur because many women do not know when to seek medical care for a complicated delivery. They occur because the cost of delivering a baby in a health care facility can be prohibitive. They occur because there may not be any roads that connect a woman’s home to a hospital. They occur because the consent of the husband – a legal prerequisite for any medical procedure – may not be obtained. He knows that a caesarean section may limit the number of children his wife can deliver in the future, and this limitation can be unacceptable in a culture that values offspring. They occur because a scarce number of individuals are trained to work on a surgical team and hours can pass before a team can be assembled. All of these factors (and probably many more that I did not encounter during my brief stay) interact to create the perfect storm.

The good news is that Edna and her hospital are fighting the battle of maternal and infant mortality on all fronts. She is training more rural midwives to cope with minor delivery complications and to recognize the signs of more dangerous complications. She is leading a campaign against female genital mutilation. She is offering an antenatal clinic to diagnose and treat problems early. She is providing perinatal care with sliding scale fees to reduce economic barriers. And she is doing it all with the respect and admiration of Somaliland. Her hospital is the quintessential example of a grass-roots development project done right.

But the battle has just begun, and many obstacles lie ahead. Somaliland’s lack of international recognition and foreigners’ fear of involving themselves in anything that sounds like Somalia are isolating factors for a pursuit that could greatly benefit from collaboration and external support. Firsthand experience has shown me that Somaliland is not Somalia. Somaliland is a country of pride and ambition, constrained by external and internal contradictions. In Somaliland, political stability cannot translate to economic growth. Women become doctors but cannot consent to their own caesarean sections. And the only street sign I saw in Hargeisa read “Sixteen Street,” and no one could tell me what happened to streets One through Fifteen. Yet, despite – or perhaps because of – all of the complexities, Somaliland is a country I hope to return to someday. And that, I can confidently say, is my truth.

(Please feel free to contact me at if you have additional questions. I am happy to discuss either my personal experience or the logistics of volunteering in Somaliland.)

Jessica Duby nurse volunteer

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