The costs of doing good

Last evening I had my 2^nd 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 plantain 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.

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 2^nd 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.