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.

Friday, May 30, 2014

10 Things I learned in Haiti

10 things I learned in Haiti-

  1. Life for women in developing countries is incredibly hard. Finding water, making a fire, cooking food and washing laundry takes hours each day.  Women who have no “time-saving devices” work hard just to keep their families fed and clean. That means there is little time to read, to create art or to do more than try to survive.
  1. In Haiti relationships are the source of happiness.  Most Haitian families have few material belongings.  Conspicuous consumption is not possible in Haiti.  Only a tiny fraction of Haitians could find self-worth in what they possess.  When you do not have things, cannot shop when you are depressed, do not have more or less stuff than most of your neighbors then it is your relationships that define the richness of life.
  2. Even the simplest of medical procedures can be life-saving.  Routine procedures like taking a blood pressure or measuring the amount of protein in urine can save a life.  These are things we do every day for our patients in the U.S. and I lost my sense of their importance until I went to Haiti where most pregnant women are not receiving prenatal care.  Without these simple tests women can develop life-threatening high blood pressure.  They will not know they are desperately ill until it is often too late to save them and their baby.
  3. Education is the most valuable treasure a country can have. In Haiti it is very prized by children and adults and is seen as the only hope for change. At night you will see children reading under the only street light in their neighborhood or in the dim light that comes from a window at the back of a store. They walk miles to school and have great pride in their uniforms and books. To get their children into a school may be a parent’s greatest dream.
  4. Taxes and government are under appreciated in the U.S. If you don’t have a functioning government and an adequate tax base you can’t have the public infrastructure that supports private enterprise.  You don’t have paved roads, clean water, sewers, garbage collection, free public education, trusted police protection or an honest justice system.  If you believe your taxes are too high and that “government is the problem” go to Haiti and you may decide that for all its flaws American government works pretty well. 
  5. When death is common your view of life changes. Here we live in denial of the inevitability of death. Because death is a common experience in Haiti, Haitians have a stoicism, resilience and an ability to carry on with life after a tragedy. They have the same pain from the loss of a child as we do. They are just as sad and grieve the same but they have accepted that death and life go hand-in-hand.  I believe this attitude changes what they value and how they treasure each other.
  6. In Haiti people still remember that they are descended from slaves and they retain a proud connection to their past. Here in the U.S. we often have a sense we are living in a unique time of our own making and have lost the realization that the world we live in is a consequence of those who have gone before us, those who have worked for hundreds of years to make our lives better.  We owe a debt to our pioneer men and women, a debt to be paid forward.
  7. For every task you want to accomplish in Haiti there are unpredictable barriers. To get anything done in Haiti you have to have perseverance. For every organization that is succeeding in making good changes for Haitians there are twenty that just gave up.  A friend once gave me very valuable advice, “There are so many problems in Haiti that the only way you will succeed in solving one of them is to put blinders on to all the rest and concentrate on spending your life-time solving just one of them.” The problem I chose to focus on was the lack of skilled care for pregnant women.  And I think even that has been too broad at times.
  8. The midwives who come to Haiti to volunteer believe midwifery is a calling. They are not there for the money, the fame, or the fun. They are there because they believe deeply that midwifery is a special gift to women all over the world. They know medical interventions can save lives but bringing compassionate care and dignity to childbirth is equally important to them.
  9. Compassion is the universal language.  We may not understand the medical jargon or barely grasp the detailed explanation the doctor is giving us but we intuitively know when someone really cares about us.  If they care then we trust.  With unrushed attention and a caring touch midwives speak a universal language of compassion to comfort their patients, whether they be American or Haitian.  Haitians recognize when someone is genuinely interested in helping them get well, get the best care, get to the bottom of the problem.  They are truly grateful for the compassionate care given to them. For some it is their first taste of compassionate health care.  I still get teary eyed when I think of the story told by one of our volunteers about the 16 year old soon-to-be-mother she help through a birth.  That young woman told her she wished she had something to give her in return but she had nothing to offer but her thanks and the words, “you have been kinder to me than anyone has ever been in my life.”  Little did she know how her words were treasured.   

Tuesday, April 8, 2014

"Thoughts on above, feet on the ground"

April 8, 2014

I was looking through Cheryl Hanna-Truscott's pictures from her recent trip to Haiti. My heart cried looking at this picture from both the simple joy on this girl's face as she sang a welcome to the "blans" visiting her school and from seeing that most of these children have that orange tinge to their hair that indicates long-term malnutrition and lack of protein (Kwashiorkor).  I also fear for this girl's future - as many girls do not stay in school or have to move to the city to get further education. In the cities, these girls face unwanted pregnancy and rarely finish high school.

Recently, on a Sunday morning at the church I attend in Haiti, the young women's choir was singing a song that included the chorus, "Thoughts on above, feet on the ground.."   I thought about the girls who were singing in much the same way I thought about this girl. What lies ahead for them? When they hope for the future what do they have to hope for?

I wondered, as the Haitians sang, if they do not have a better understanding of "feet on the ground" than we Americans do. We manage to escape from the more difficult things of life like hunger, lack of clean water, washing clothing in the river, bucket baths, dirt floors, and no educational opportunities or hope for better times ahead. Instead we comfort ourselves with our food, our drink, our clean and lovely floors, our modern kitchens, our heated and cooled cars, workplaces and homes. We live in constant denial of our own death, the death of our loved ones, and the misery that most of the rest of the world deals with daily. We watch TV and read Facebook and constantly escape in computer-land so we can forget that life is fragile and precious.

My work in Haiti is as necessary to my spiritual being as it is to the Haitians our program serves. It keeps my feet on the ground and better prepares me for facing the hard things in life. The fact that I was born in the U.S. instead of in Haiti is an undeserved gift. Those of us who can easily keep our thoughts on above because we are so physically comfortable owe it to the majority of the rest of the world to walk with them as they have their "feet on the ground" in a way we do not begin to comprehend.

This girl's feet will see much hardship. I hope someone's feet will walk with her and give her hope.

Wednesday, March 12, 2014

The Long Way Around

Saltadere is the name of a community 2 hours east of Hinche near the border of the Dominican Republic. The poverty is deeper there- evidenced by mud huts instead of brick and thatched roofs instead of tin. There are women there who have never had money pass through their hands and the majority of them have never had contact with any health personnel. Children are lucky to have one outfit to wear and their hair comes in orange from long-term malnutrition.

When our mobile clinic goes to Saltadere once a month 60-90 women come for prenatal care in one day. Some walk for hours to get there. Some are so sick with complications of pregnancy that we transport them to the hospital that very day. Severe anemia and preeclampsia are common. 

We have the funding for starting a birth center in Saltadere and the first year of its operation. Having a birth center there would mean that women would get prenatal screening much sooner and that instead of birthing alone or with an untrained matrone, they could have skilled care in a place that would have emergency medications and equipment. We could treat the anemia and the causes of it. We could educate the women about the foods they have that give the most nutrition, about family planning, and about breastfeeding exclusively for one year to increase the infant survival rate.

We have never run a birth center- even though that is where most of our graduates end up working. So this past weekend we hosted a symposium on birth centers in Haiti to learn from the organizations that we know are operating these centers across Haiti. We addressed issues about level of care, level of training of employees, protocols for emergencies, and disposal of waste. Fourteen organizations were represented and we learned some valuable things. Some organizations charge a fee and some do not, believing a fee is sometimes a barrier for the people who need it the most.  

Today we met with Father Illrick to learn what needs to be done to the building before we put equipment in it. Plumbing and electricity will need to be installed. The community will need a survey to make sure they will use it. The midwives will have to be interviewed and protocols reviewed and written. We are short on committed money because of a security wall that will need to be built.

Father Illrick ( beard) and Dr. Larry Hoffman (black shirt) of St. Thomas Aquinas

From my experiences in Haiti there will be no direct road to this birth center. Not only is the road to Saltadere a rough one for vehicles, we will go over many bumps in the road to open this birth center. If there is a long way around, we will need to be willing to take it. If I sound pessimistic it is caused by the seven years of working in Haiti. Nothing has been simple or cheap or easy or straightforward. 

When we left Verettes, Haiti yesterday morning we could not drive "as the crow flies" to Hinche. Because of where the mountains are, we had to drive south to get around them and then north once we reached Mirabilais where the road goes through a space between mountains.

It is a metaphor for everything we try to do in Haiti. There is no straight line of tasks to get something done. There are twists and turns and obstacles at every turn and everything we do takes more than twice as long as we predicted. It seems that everything conspires to make sure we have to take "the long way around."

What is it that drives those of us who ride this road? It's the faces of the women we see who walk for miles to make sure their baby is ok, the women who are recovering from a seizure in the hospital (today one woke up from a two-day coma), and the sweet babies that ride home with their mothers on the back of a motorcycle. They will never have hot showers and a vacation at Disney. They will be lucky if they learn to read. Their mothers have no books to read to them at night. 

They are all worth taking the long way around.

Saturday, February 15, 2014

Jenna and Brittany are holding the dossiers of  the 16 students who will get the call that they have been admitted to our training program this year. Sometimes it is mind-boggling to think how this will change their lives and the lives of their families. The sad thing is that 109 applicants have to be turned down.

Why do we continue training skilled birth attendants even after the government midwifery school  reopened last fall? There were several things that helped us decide to continue to train. One is that we think it will be a long time until there are enough graduates from the government program to meet the need for around 1600 skilled birth attendants in the country.

Another is the history of brain-drain.  Every nurse-midwife we have hired to teach has left the country within one to two years. We do not think it is the nursing degree that got them to Canada. It was the money. Anyone who makes enough money in Haiti dreams of going to the U.S. or Canada. So the drain will continue to happen.There are only about 100 obstetricians in Haiti. And around 100 nurse-midwives. More than two-thirds of the obstetricians and midwives have left the country. That leaves a total of 200 skilled birth attendants left to deliver about 250,000 babies a year in Haiti. So most women do not ever see a doctor or midwife or even a nurse.

Another is that we are uncertain of the willingness of others to work in rural areas of great poverty for the same income that our graduates work. Most will want to work in the urban areas where food is less work to produce and entertainment and friends are nearby. Well, wouldn't you chose a place with electricity over one without?

The International Confederation of Midwives has decided that nursing is a necessary ingredient in the education of midwives. Because so many countries do not have a high quality nursing educational system they have recommended at least a three year program for students with no nursing background and 18 months for nurses.

Because of the recommendations, although Midwives for Haiti is the name of our organization and we accept only auxiliares and infirmieres, we mostly use the terms "skilled birth attendant" when we talk about our educational program and training. The "Core Abilities of Skilled Birth Attendants" are defined by the World Health Organization and the International Confederation of Midwives and include both the abilities to care for normal pregnancies and skills to treat and care for complications and emergencies that can occur in the childbearing year.  So even though we refer to our graduates informally as "midwives", the ICM would not approve of us using that term.

Currently our mobile clinic offers the same testing that is available at most government facilities for pregnant women. Plus education about signs of danger, breastfeeding, nutrition, dehydration, etc. And we will add Tetanus vaccinations this year. So far our graduates are working at 10 birth centers and two hospitals in Haiti.

So the most important reason we will continue our educational component one more year is that currently 49 graduates of our program are doing over 60,000 prenatal visits a year and over 11,000 births per year . Until there are enough skilled workers to take over their work with the poorest women in Haiti we will keep training. And who cares what they are called? Not the women who walk for miles to see them. Not at all.