Thursday, February 8, 2018

Maternal death hits home

A week ago tonight after we were in bed awhile, I heard the big metal door slide open and the Land Cruiser leave the compound. I remember thinking, "Who gave permission for someone to take the Land Cruiser- at this time of the night?" I forgot about it until maybe 30 minutes later when there was pounding on our door.

It was Stecy, our volunteer coordinator. She said with urgency, "Dr. Steve, Perrine needs you at the hospital. Someone is seizing." Steve dressed quickly and hopped on the moto with Judnell to go to the hospital. I was thinking that Perrine knows what to do about seizures--MgSO4 injections and hydralazine--- so maybe it is worse than usual and the patient is not responding. But seizures  themselves don't usually kill women. It is the organ failure from the excessively high blood pressure that kills them. The brain swells, the kidneys stop functioning, and the lungs fill up with fluid. I felt that Steve would have good suggestions about what steps to take to reverse these and fell back to sleep.

Some time later, I woke and wondered why he was not back. I heard low voices in the kitchen so I opened my door and saw Steve and Phu sitting at the kitchen table. I walked out to see why they were still up in the middle of the night. Steve looked at me and said, "She died." I could see he was upset. I asked, "Who?! Why?"

The story of the death of our student, Guerline Adeka started way before that day. She was pregnant through most of the last 9 months of the class and due two weeks after graduation. But for some reason, she spent about 4 days the week before this night in the hospital with ineffective labor pains-meaning she was not dilating. So a doctor did a C-section. All seemed well. She and the baby went home. A postpartum visit was done. All seemed ok.

Monday and Tuesday were review days for the class. Guerline did not come but everyone understood. Major surgery 3 days before would not make sitting in class for hours very comfortable. But she did come for the exam Thursday morning at 8 am sharp. She was determined to put a lid on this year's work. Determined to graduate with the exam behind her. Perrine, our clinical director, asked her how she was doing. She told Perrine she felt short of breath the night before. Perrine said to call if she felt worse.

So she did. She called Perrine about 10:30 pm. Perrine took the vehicle and went about 2 miles to pick her up. Guerline was in respiratory distress and kept saying she could not breathe. She was panicking and Perrine stopped on the way to the hospital to get some money because she knew oxygen would be needed and one has to pay for that. Within minutes of walking in the hospital, Guerline collapsed and was gone. Perrine started CPR, anesthesia intubated her so they could get good ventilation. When Steve arrived he could not find a pulse but he helped Perrine do CPR longer. Perrine had the desperation one feels when you know and love your patient and when you are saying, "This CANNOT happen! NO! It did not bring Guerline back.

No one slept much the rest of that night.  As medical people do, we discussed what happened to Guerline. Probably a Pulmonary Emboli happened. Its a risk of any surgery, thankfully rare. And here in the U.S. we also lose mothers after C-sections due to PE's. There was some discussion about heart failure from cardiomyopathy but that probably would not have taken her in an instant like a PE can. And was it a necessary C-Section?

I woke in the morning to wailing. As the students started arriving to review the exam with Cindy, they learned that their friend and colleague had died. I have never heard such wailing by so many people at once. It was heartbreaking. It went on for hours. It was so so sad. We gave hugs, served coffee, held each other. Later in the morning, some students started singing. Mixed with the sobbing, it was sweet and comforting.

I thought about how Haitians know how to grieve. There is no hiding how they feel, no burying their emotions. The grief is there for all to see and hear. I also wondered if the weeping encompassed all the sad things, all the losses, all the injustices they had ever experienced in their lives. Grieving is the only way to get to the other side. And we never quite arrive on the other side. We are never the same when we experience great loss. It marks us for life. It changes us.

One of the most striking things about Haitians that anyone learns when they spend time with them is that they are some of the strongest people I know. They have an incredible ability to feel deeply, to express themselves vividly. They know how to live in joy regardless of their circumstances. They can dance and sing with grace and skill and beauty.

That is why, later in the afternoon, the maestro led the students in practicing their singing for the graduation ceremony. It was a bit more subdued. He could tell it was not easy. But sing they did. Life must go on. They were graduating from a difficult course of study and work. They had spent hours in the hospitals and birth centers learning from women. They had sat through days and weeks and months of classes. Graduation would bring a new life for them and their families.  The work they were called to do will save lives. They know that deeply. They will do it for Guerline.

And they would sing. They deserved to sing. They needed to sing.

This is why I love Haitians. They get me in the heart and soul every time.

Sunday, November 19, 2017

The costs of doing good

Last evening I had my 2nd shower in the 7 days we have been in Haiti. I am a pro at bucket baths by now and can get really clean with very little water if I have soap and a washcloth. I do not take showers for granted so I am thankful even for the cold ones. Last evening the shower was really just cold water flowing out of a high faucet but it felt so good.

As always when Steve and I come to Haiti we are constantly problem-solving with our staff. Haiti is not an easy place to work and probably the most difficult part is that we do not understand the many ways Haitians think differently than we do. Things we take for granted that are not ethical are not seen as unethical at all- “just the way we do things here in Haiti”. We can knock our heads against it constantly or accept that we have to have a lot of supervision and oversight over every detail. When we cannot find the right persons to trust in a supervisory role or cannot afford them we have to accept that frequently we will be “taken” financially and materially.

It is common for Haitians to recommend someone for a job you want done and when they do, they always recommend a relative or friend not necessarily the person who knows how to do the job best or at the best price. So finding skilled workers is really hard. Added to the finding of a friend or relative to do your job, you can bet the price will include a kickback to the person who got them the job. We have some regulations and laws against this in the U.S. but here it is an accepted way of life.

It is easy to slip into a skeptical mode where you trust no one and that can be hard on one’s morale after a time. I think that is why so many NGO’s and overseas relief workers burn out. They just cannot get used to being “taken” and they feel their good will and generosity begin to make the people they came to help develop “entitlement” and “dependency” attitudes.

The problem is that administration and oversight take money and no one wants to see a large portion of a budget going to our administration and less to the actual work of saving lives. And yet all larger and successful organizations have learned that oversight and data collection and evaluation are necessary in order to use the rest of the funds responsibly. Midwives For Haiti grew really fast in the direction of providing a lot of direct care to patients in mobile clinics and the hospital in addition to our training program. We know we have made the difference between life and death for many. But we also hope our donors understand that administration of the programs is necessary also. With the right administrative staff we can teach by rewarding honesty and hard work and put in steps methods of terminating employees that do not do their job or use funds wisely.

Mary Francis is just one of our employees that takes very little supervision. She lives in Cabestor next to our birth center. She fixes the best coffee in the world with a mixture she gets at the market of star anise, cardamom, and cinnamon. And her plaintain soup is so delicious. I do not want to know how much sugar she puts in it. With her we know where our money goes. She buys our food at the market and she cooks it. And her life is so much better because we need to eat when we are visiting the birth center. I wish managing all of our employees was as simple as Mary Francis. But it is not that simple with most of them. Most of them we have to trust to do their work when we are not around and to use our money wisely.

Cold showers are the least of my worries while here in Haiti. I would take a bucket bath every day the rest of my life if I could know we will be able to expand our work, change more lives, and solve the problem of maternal mortality in Haiti.

Thursday, April 13, 2017

A History Lesson about Lovie Shelton

I recently read a book called “Lovie”- by Lisa Yarger, a story of a nurse-midwife who delivered thousands of babies in eastern North Caroline in the 50’s, 60’s, and 70’s, and 80’s - and 90’s! 50 years of being a nurse-midwife!

I was delighted to read references to Frontier Nursing Service and Frontier Midwifery School in the book. Lovie Shelton was a nurse first – graduating from Norfolk General Hospital. Her first job was working with a doctor who did home births and she loved going with him to support women in labor and being in their homes. But she wanted to know more. So she went to North Carolina University in Chapel Hill to get a degree in Public Health nursing. But she was still interested in learning about birth and midwifery. The faculty at North Caroline U. told her about FNU and Mary Breckinridge. So she spent 3 months in the 40’s at Frontier with Mary Breckinridge and the midwives. She was so impressed with not only their maternity skills but also that they did so much primary care in the area completely without the aid or supervision of a doctor.

She knew that midwifery was what she wanted to do so she asked Mary Breckinbridge if she could get midwifery training at her school. Ms Breckinbridge said she had every class filled up for the next four years. (I had not known this happened!) But she told Lovie she could pull some strings and get her into the Edinburg, Scotland school with a scholarship. So in 1949 Lovie went to Scotland for midwifery training and wouldn’t you know- Margaret Myles –yes, the midwife who wrote the Myles Midwifery textbook was her teacher.

You know that after World War 1 the maternal mortality rate in the U.S was between 6 and 700 per 100,000 – like what it is in the Congo or Central Africa right now. And you know that the medical community started paying attention to nurse-midwives when Mary Breckinbridge’s statistics in southeastern Kentucky showed marked improvement over the rest of the country.

Once Lovie Shelton finished her nurse-midwifery training she came back to the U.S. and looked for a place where she was needed. She got a job setting up the health department in Beaufort county in North Carolina. She put out the word that she was a trained midwife and started doing deliveries on the side.  The doctors supported her because they did not want to deliver black women and poor women- before Medicaid there was no money in it. They put her in charge of the granny-midwives and she taught them and supervised them and sometimes took away their privileges if she felt they were incompetent.

Lovie started a maternity clinic at the public health department so that the granny-midwives could bring their patients to that. But even so, most women who came to her clinic were still being delivered by the granny-midwives. But her fame grew and more and more women called her for deliveries. Sadly, she got a lot of flack from her fellow nurses who saw midwifery as a dirty, shameful thing that brought down the stature of nursing.

Over the years granny midwives were being phased out, and Lovie became very busy. She was becoming well-loved because of her skill and because she treated each woman with compassion. She quit her public health job and was on call 24/7. Once she delivered 196 babies in one year. Sometimes she was paid and sometimes she was not.

Lovie always struggled working in a state that had no regulation for nurse-midwives and legally she could do no more than the granny-midwives could do. So she developed a 2-bag system. One was her granny midwife bag- all the clean birth stuff like soap, clean razor blade, gloves, and clean newspapers—and a 2nd bag with her BP cuff, stethoscope and gloves. The first bag is what she would show the doctors. She had respect and support from doctors until Medicaid came along and then they were not happy with her- she had to lay low and be extra careful to take only low-risk moms. She never lost a mom. She did lose some babies, most because she was called too late.

So how does Lovie’s story relate to what I do?

I spend about 4-5 months a year in Haiti in the Central Plateau district where there are 2 hospitals for over 725,000 people.  There are also only around 7 obstetricians for that many people. Calculating birth rate for it comes out to about 18,000 women that are going to need maternity care in one year. I am not certain I have current numbers but there are about 12 nurse-midwives are working in the Central Plateau- these are the university educated nurse-midwives recognized by the International Confederation of Midwives. So guess who is doing over 75% of the deliveries in the central plateau—yes, the granny-midwives, known as matrones, still do the bulk of deliveries in rural Haiti. Even in the towns and cities, women still use matrones because 1) they have no transportation to a facility, 2) they have no money to pay the facility, 3) it is culturally acceptable to birth at home, and 4) they claim they are treated badly at the hospitals and clinics. So the maternal mortality in Haiti is about 350-450 per 100,000 depending on whose stats you look at. And- Currently only 9% of the need for midwives is met in Haiti.

If you look at the State of Midwifery Report from 2014, you can see that the most progress in combating maternal mortality is being made in the countries with several levels of midwives- what the WHO calls task-shifting. What we had here in this country was task-shifting when in 1932, the White House Conference on Child Health and Protection found that when granny midwives were trained, their infant mortality was no worse and sometimes better than the doctors. So, training for granny midwives became standard in public health departments.
We also know that CNM’s, CPM’s and birth centers and the regulation of them has had a rocky history in our country largely because of the financial implications for doctors and sometimes because of genuine concern for safety.

My point is that countries wanting to make progress on maternal mortality need to go through the same process- of starting with training the traditional birth attendants and then educating midwives to differing levels of competence, regulating what each level can do legally, and gradually getting more and more highly trained nurse-midwives. In the U.S. we went through an evolution from the granny midwives- who delivered most of the babies in this country before the 1950’s, to regulation of the granny midwives, to regulation of nurse-midwives- and we are still working on that in some states.

So that is what we are trying to do in Haiti. There are thousands of uneducated traditional birth attendants who need training on when to refer and need a constant supply of clean birth kits. Midwives For Haiti has educated around 200 of them from 6 areas and are being asked to do more. We distribute hundreds of clean birth kits per month and are constantly needing more. We also train nurses who have varying levels of education, to be skilled birth attendants. This means they can do all that the WHO says are the core abilities of a skilled birth attendant. We have trained 124 of them. Haiti does not have a title for them yet. Their diplomas simply say they are nurses with advanced obstetrical training. But the government is taking notice. Unlike the university-trained nurse-midwives in Haiti who have an attrition rate of over 60%, only 2 of our graduates have left the country. The rest are working in birth centers and hospitals all over Haiti and delivering around 9000 babies per year. We are in collaboration with the Ministry of Health who is still in the process of deciding how to regulate them. The Ministry of Health is hiring them because they either cannot afford the nurse-midwives, or they cannot find any nurse-midwives willing to work in rural areas.

An example of how the government views us is that in our current class we have 4 nurses who automatically have jobs in rural clinics working for the government when they are finished. We are in conversation with the government about how to regulate them and what tasks they can do legally.

Just as in this country- a variety of midwives are needed in Haiti to meet the need.

With a rising maternal mortality rate here in the U.S. we are in desperate need of connecting nurse-midwives to the women who need them most. The coming years it is going to be a challenge for the poorest in this country to access the care we are so good at providing.  I challenge all the alumni of Frontier to be pioneers for finding ways to enable the women in their communities to use them for their maternity care from prenatal care to deliveries to postpartum and family planning and their primary health care. Women in the U.S. need us. We may need to rock the boat just like Mary Breckinbridge did and Lovie Shelton did. Let’s not be afraid to do it to save the lives of mothers and babies- whether it is in this country or another. Countries like Angola, Sudan, the Dominican Republic of Congo- they are not on the ICM’s map because they do not have nurse-midwifery regulated. But that should not stop us from trying to train whoever is doing the births- in any country. In order to change lives we may need to do just what Lovie did in this country-  carry two bags. One that is legal and one that rocks the boat but changes the world.

Friday, July 1, 2016

The Servant Heart of a Midwife

Kitty Ernst turns 90 this year. And this is the story she told to new and old midwives in Alberquerque last month.

Kitty told of how when she first went to the Frontier School in Kentucky she had no intention of becoming a midwife. When she learned that the reason most students were there was to become a midwife she wanted nothing of it and planned to leave. The reason she did not want to become a midwife is because she had been exposed to "obstetrics". What she had seen up to that time of obstetrics left her with the image of doctors and nurses standing over suffering women and telling them what to do to get their baby out. She hated it. She was not going to do "obstetrics".

But a wise teacher told Kitty that she should at least see one midwifery birth in a home before she left the school. So very soon she was taken to a home where a woman was in labor. There were sleeping children in the small room where the woman was sitting up in her bed so everyone was very quiet. Kitty was amazed to see the midwife at the feet of the woman looking up to her talking softly. The midwife rubbed her feet, asked her if she wanted water, told her she was strong, and held her when she was in pain.

Kitty had lightbulbs go off in her head. THIS was MIDWIFERY????!!!!! This image of the midwife as a servant to the woman was something that clicked with her core values. She decided on the spot to stay at that school and become a midwife. And what a midwife she has been!

I was not the only one in the room that night that teared up when Kitty told this story. Jessica Jordan and I looked at each other with our blurred-from-tears vision and acknowledged that the story was pretty much pinging on every string of our soul.

One of the things we struggle with so much in Haiti is the culture of class that partly stems from their long history of slavery. In Haiti it is not uncommon to treat anyone who has not received as much education or make as much money as you as a lower-class citizen and worthy of your scorn. So one of the barriers to skilled care in pregnancy and birth is that Haitian women stay away from places where they are talked to and treated as if they are nothing.

We constantly tell our students to treat patients as if they were their sister, their mother, their friend. We talk about compassion, caring, gentle touch, and the importance of listening to women.
But the servant heart of the midwife is the hardest thing to teach. Especially if you have never experienced that kind of caring in your life.

We tell our volunteers repeatedly that if they do nothing else but demonstrate compassion to patients, then they have made a dent in the hearts of the staff and students and demonstrated true midwifery. This year I am thinking of what we could do for our students that would make them feel the compassion and gentleness of unconditional love. How can they show what they may have never experienced?

This picture is of one of our grads pouring water over her patient's head in an effort to cool her. She is being a servant midwife.

Every woman on this earth has experienced suffering in some form. It may have been spiritual, physical, or mental pain. She may have suffered alone or been blessed by caring sisters of the heart who held her up when she was down. The time of birth always hurts. No one can take away all the pain - although in some cases we have the means to come pretty close to painless. But most women in this world birth without access to medications so they rely on their family, their mothers, sisters, and significant others to see them through the deep waters of childbirth.

I try to remember this when I am with strangers in any setting. Here before me is someone who has suffered, especially if she is a woman. The statistics of domestic violence, rape, and trafficking are sobering. Every midwife has heard the stories, cried the tears, screamed inside at the injustices that women endure all over the world. Childbirth is just one time when women suffer.

Whether you are a man or a woman, you need someone to be your servant when you are suffering. I am learning that a lot of midwives get into hospice care when they stop catching babies. Care at the end of life is another form of servant midwifery. Some of you remember Brother Mike McCarthy who was a Xaverian Brother at the Maisson Fortune in Hinche. He was a gentle and sweet soul who let a lot of midwives cry on his shoulder after hard things happened to them in Haiti. When he left Haiti he told me he was finishing three months of training to be a hospice worker. I said, "Brother Mike. you are going to be a midwife to the dying!" He gleamed. He could not think of a greater thing than to join the ranks of all of the "servant" midwives.

This is Beth McHoul and her patient who is in labor. A midwife at Heartline Ministries in Tabarre, Haiti. A servant midwife every day of her life.

This is Rebecca Barlow, student midwife, demonstrating servant midwifery at St. Damien Hospital in Haiti. She is a Frontier Midwifery student.

Being a servant midwife takes emotional and physical and mental energy. What midwives get in return for what they spend is the knowledge that there would be no soul in their work without servanthood. No matter who you are, if you helped someone who was suffering today, you are a servant midwife.

Let's all be a servant to each other. This world needs more servant hearts. Thanks for reminding us, Kitty!

Photo credits:

Photo of Marie Denise by BD Colen, Photo of Beth McHoul by Tara Livesay, Photo of Rebecca Barlow by Maribeth Quinn.

Sunday, April 24, 2016

To be or not to be? To be, of course, but how?

This is a painful thing to write because change is painful and change is inevitable. But change can bring good things, right? Right???

Midwives For Haiti is currently running its annual campaign for the Mobile Clinic Program that serves 600-700 women per month with prenatal care. Other years we had matching funds to help us reach our goal, but the organization that provided those funds has a limit of 3 years on their funding in order to discourage dependency. We understand that but--- what will happen if we cannot support this program after this summer?

It is a painful thing to have to give up something that has been really good and saved a lot of lives because of a lack of funds. Without enough money to run the mobile clinics, the BOD will have to consider the options. We have thought of them before- everything from disbanding the program all together to just reducing the number of villages we visit. There is a lot of fear about any of the choices. Who will get lost in the transitions? Will there be lives lost?

The church I attend meets in a 90+ year old building with a huge sanctuary, incredibly fine woodwork, stain-glass windows, an expansive organ that fills the front of the church, many rooms, and several annexes added through the years that make it a maze to newcomers. Everyone loves walking in those old historic doors knowing that hundreds went before them and everyone feels the responsibility to those who went before to carry on the work of the church.

But the congregation can no longer support the cost of the building, the upkeep, the maintenance, and the cost of heating and cooling such a massive structure. So they are facing some hard choices- namely leasing or renting out a large part of it or selling it and moving elsewhere. A lot of grief is happening and a lot of emotions with fears and hopes are being shared in the "town hall" meetings.

A question in everyone's mind is whether or not the church can remain the same church in a different space, in a different part of town, with different patterns to being together. Spiritual growth and support for it is one thing, but what happens to the projects the church has in the community like the weekend backpacks for the hungry children in the local school, the variety of services for the elderly in the two nearby retirement villages? Can the vision and mission of the church remain the same in a different way? And a big fear- who will get lost in the transitions? Will people we love leave us?

Same questions---If Midwives For Haiti has to stop the Mobile Clinic program can MFH maintain its vision and mission- to increase access to skilled care for pregnant women in Haiti? Can the wonderful midwives who have dedicated their lives to this work be put to work in a different setting? The problem is that anytime you limit a midwife in Haiti to one space you limit how many people she can reach because transportation is a huge obstacle for most women in Haiti. But can we perhaps do a better job  and give more thorough care if we limit the care to a specific place? The vehicle costs are killing us.

What if we just have to bite the bullet and stop the salaries of midwives and drivers?  There will be many family members that will go unfed and their children will have to stop school. And the many women they know need care will go without. Healthcare is just not sustainable work in Haiti.
Or anywhere for that matter. Without insurance a visit to the hospital could bankrupt some of us. In Haiti there is no way most women could pay for the services needed to have thorough prenatal care and a safe delivery. So very few could come up with the money.

And do not tell me they should just not get pregnant. You be the one to issue the decree there should be no more sex. Good luck with that. And even here in the U.S. where birth control is pretty much accessible to everyone- depending on what our elected leaders do next- people still have unwanted pregnancies. And pregnancy can kill women. It does every two minutes in this world. EVERY TWO MINUTES, PEOPLE!!!

It breaks our heart to let Mobile Clinic go. Because we know it saved lives. But there are other lives to be saved. And we cannot save them all. What steps can we take that will bring the most life to the most people with the funds we DO have?

Just like the church at Ginter Park, Midwives For Haiti will jump into this unknown place called the future. But we will do it while holding hands with each other and total faith that we are supposed to DO THIS WORK!! Hold tight!

Sunday, February 8, 2015

The Baby in the Bag

The Baby in the Bag

Three weeks ago Rebecca Barlow and I wanted to recreate Frontier Nursing's "baby in the bag" photo in Haiti. For those of you unfamiliar with the story, in the 1920's to the 1960's Mary Breckinridge established the Frontier Nursing Service in south eastern Kentucky. Small clinics and nursing posts were built in areas where there were no roads. Eventually they were able to refer to a small hospital nearby rather than putting people on boats, mules, and horses to get to a train to take them to Lexington. The clinics were staffed by nurse-midwives who traveled by horseback, and in addition to catching babies, they stitched wounds, gave vaccinations, and brought healing to the sick in the region.

Because the nurse-midwives always carried their supplies in a leather saddlebag that contained their starched white aprons, clean sheets, sterile instruments, cord ties, and gloves, the children of the region came to believe that all babies arrived in these bags. Sometimes they wondered why the babies stayed in there so long after the midwife arrived.
FNU's Baby in the Saddlebag picture

Rebecca is a current Frontier Midwifery student and I am a graduate from Class 8. Right now in the house here in Hinche, Haiti we have midwives Kathleen Lutter and Susan Mitchell, from classes 84 and 85, respectively. Nurse-midwives frequently see how our mobile prenatal clinics operate here in rural Haiti  and draw the lines of similarities- mostly in bringing skilled care to where the people live- between Midwives For Haiti and the work of the nurse-midwives in the mountains of rural Kentucky.

Last year, a colleague of mine from my nursing faculty days, Violet Horst, contacted me. She had found some old leather bags at the University of Virginia's nursing school that were probably used to carry supplies for public health nurses years ago. They needed to be cleaned up and the handles needed repaired. A kind harness-maker from Dayton, Virginia fixed them for her for no charge. Then she mailed them to Midwives For Haiti in Richmond, Virginia. She also fund-raised for BP cuffs, fetoscopes, and other midwifery equipment to put into them.

When they arrived in Haiti, they were given to our mobile clinic midwives. Four of them ride our aging pink Jeep  to sixteen villages around the central, as far away as a 2 hour drive, delivering skilled midwifery care to over 500 women each month. They received 4 of the bags. The other two bags went to Illa and Juslene, the two midwives that Rebecca trained last summer to do thorough assessments of mothers and babies before they leave the hospital here in Hinche.

Putting the bags in the hands of midwives seemed to bring Mary Breckenridge's vision back to us and I really wanted to get a picture of a Haitan baby in one of those bags. We had a professional photographer here for just a few days and the morning before he left we asked him if he could help us get that photo. BD Colen said he would do it so we showed him the Frontier picture.

We decided that for various reasons, going to the hospital to take photos was not wise or practical and that bringing a woman and her baby to us was reasonable as we could provide the vehicle to bring them to the house. We called Illa and Juslene and asked if there was anyone ready to go home that would consent to coming here and having their baby's photo taken. They called back soon and said "Yes, come and get the mother and baby".

When they arrived at the house and Illa helped the very young mother out of the van, she said to us, "She's a little embarrassed to come because she has no clothes." The grandmother was carrying the baby while the mother climbed out of the van holding onto a brown towel wrapped around her body. She had a green blouse on and that towel, nothing else. And she was reluctant to sit because of course, having just had a baby, the back of the towel was bloody.

Haitian women frequently come to the hospital with the only nice outfit they have, get the dress or nightgown or skirt soiled during the birth process, put the soiled things in a bucket to take home and wait for family members to bring them something to wear home on the back of the motorcycle. They use multiple rags in their limited supply of underwear to keep themselves from soiling everything they lie on or sit on.  These rags do not get tossed. No, they get taken home to get washed in a bucket to be cleaned and dried and reused over and over. This mama's skirt was in a bucket back at the hospital.

We have a house full of women and all of us swung into action. Kelah Hatcher, the daughter of a CPM volunteer, offered a pair of underwear, and in that we put a blue surgical towel for padding. I went upstairs to my still unpacked bags and found a blue and white shift I had bought, and because sending it back when it was too small seemed to be more bother than it was worth, had brought to give to someone. We sent her to the bathroom with the panties and dress. She walked out looking regal with a shy smile.
 Because she also looked tired and uncomfortable, we hurried to get our photos. BD worked with lighting and settings in the house, Rebecca kept the baby wrapped well and the little boy just slept through it all. We got one photo with Illa and the baby and many of just the baby in the bag.
 Although Emily said all the volunteer donated baby supplies had been depleted, we scrounged in all of our storage rooms and managed to find one cloth diaper, one onsie, a pink cotton receiving blanket, a blue sheet, a plastic bag for the dirty towel, another clean towel and a baby toy I had brought from my granddaughter. The grandmother is pictured here with the Hospital Albert Schweitzer bag we found to put it all in. It included a few goudes to pay for a mototaxi ride home when she was discharged.

In the end, the pictures were taken and the mother and her grandmother taken back to the hospital to get some last instructions and teaching by Illa before going home. In the end, I was left thinking more about this mother than I thought about the photo shoot. I thought of the home she was taking this baby to- its dirt floor, its lack of running water, electricity, its meager food supply. I thought about the baby's grandmother wanting to help so much but not having much but herself to offer. I thought about how much I love my grandchildren and want them to be happy and loved and safe.

I have also thought about Violet Horst who is a woman who is one of the 3% of people who survive a gleoblastoma, a dreadful brain tumor, for more than a year. I thought of all the love and grace she has brought to her students while teaching pediatric nursing and how her love reached all the way to midwives and mothers in Haiti while she wears electrodes attached all over her head to beat back the growth of the tumor.

In the beginning it was about a picture of a baby in a bag. In the end, it was about women loving and supporting each other through the treacherous roads we travel. In the end, there was so much love in the house it was spilling out and we would never be the same. In the end, we were more inspired than ever to carry on Mary Breckinridge's vision.

Tuesday, September 16, 2014

September 2014

I have been working in Haiti to decrease maternal and infant mortality by increasing the access women have to skilled maternity care. So I have been amazed and dismayed to learn there are actually women in this country who sometimes choose to have their births “unassisted”- without a skilled midwife or doctor close by. It is true that most of the time, with a full-term pregnancy, a woman’s body knows what to do and a healthy baby is born. And it is true that sometimes medical interventions cause complications that would otherwise not occur.

In most cases women in this country who chose to have a skilled birth attendant nearby will not need their expertise. They will frequently just enjoy the reassuring and caring presence of someone who has cared for them during their pregnancy and wants the very best for them and their baby. I know a midwife who knits sitting next to her patients as they labor. But I know she would have interventions ready in a flash if that mother or baby started showing distress.
 Photo: "A woman, as long as she lives, will remember how she was made to feel at her birth." -Anna Verwaal
The reality is that occasionally even women and babies who have had the very best of prenatal care and are in the very best of health have bad things happen during labor and birth or soon after birth. Whether one chooses to birth at home, at a birth center, or in a hospital, having a skilled birth attendant has been proven to make the difference between life and death for mothers and babies. In case you wonder what can go wrong here are just 10 of them:

10 things that can happen to any woman during birth regardless of race, wealth, medical history, or location in this world.

1. The baby may not breathe on its own after birth. This happens about one percent of the time and is more frequent if the baby is premature or has been exposed to certain medications. But it can happen to anyone. It kills about a million babies each year in this world.

2. A piece of the placenta remains in the uterus. This only happens about 4% of the time but can be a cause of heavy bleeding and can happen to anyone.

3. The uterus can bleed too much after birth by not contracting well on its own. It is more common if a piece of the placenta remained inside but it can happen to anyone even if the placenta was completely expelled.

4. Your baby’s shoulders can get stuck in your pelvic bones. This is more common with big babies but can also happen to anyone.

5. Your baby’s cord could prolapse or come out in front of the head. It is more common when the bag of water is broken artificially but it can happen to anyone.

6. You can get an infection. In even the cleanest of situations there are bacteria that you can be exposed to during birth.

7.  Your baby could be stressed by the labor and not get enough oxygen.This is more common if the placenta is not healthy but can happen with even healthy placentas.

8.  Your baby could be in a position that makes it difficult to exit the pelvis well and labor could go very long.

9.  Your uterus could invert- turn inside out while the baby is coming out. It is pretty rare but sometimes happens to women who have had a lot of babies.

10. Your placenta could be retained and not come out at all. This may be because of conditions where it grows into the wall of the uterus or just will not detach on its own for some reason.

Here’s what can happen as a result of any one of these complications and you are a woman in a rural village in 72 countries in this world - or if you are one of the women who wants an “unassisted birth” in this country.

1. The baby could die.
2. You could bleed to death.
3. You could bleed to death.
4.  Your baby could die.
5. Your baby could die.
6. You could die.
7. Your baby could die.
8. Your labor could be so long you and your baby could die.
9. You could bleed to death.
10. You could bleed to death.

So every two minutes in this world a woman is dying from one of these things or one of the things that can happen if they did not get prenatal care such as seizures, placenta previa, and incomplete miscarriage.

And the babies- more die on the first day of their life than at any other time. At least 114 died in the hour I wrote this- the majority from preventable causes that a skilled midwife could have prevented.

Christy Turlington Burns is a model, global maternal health advocate, and founder of the maternal health organization, Every Mother Counts. After a perfectly normal, natural birth, in a state of the art birth center next to a hospital in New York,  she had a post-partum hemorrhage (PPH). Her situation required rapid intervention by the midwife and doctor who were caring for her to keep her from bleeding to death. Soon after, she educated herself on PPH and realized that if she had not had immediate access to care, she would have died. She became passionate about helping more women to have access to skilled care in even the most impoverished situations. She knows about those 10 things. She knows why we do what we do and we are grateful for all of you who know.