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.

 

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.

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.

2. 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.
3. 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.
4. 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.
5. 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. 
6. 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.
7. 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.
8. 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.
9. 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.
   
10. 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.   

"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.

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.

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.

End of the year reflections- written December 4, 2013

I recently read that someone asked Mother Theresa how she could see all the poverty in the world and not get depressed. And she replied something to the effect that she just does the work she has in front of her each day. I have been thinking about the implications of that for our work here in Haiti.

I have been told that my face is an open book and I am very easy to "read". Sometimes this is aggravating because anyone can tell if I am sad or uninterested or happy, etc, and I would like to think I am more mysterious. I think everyone in the house had a awareness that I was having a "down" time last week, no matter how hard I tried to hide it.  There were suggestions like, "You need to get out of the house and do something unrelated to work." 

So I did. I went to the feeding center to play with starving children, I played a game of cards with everyone that had me laughing so hysterically I was crying, I had a lovely visit on the porch at the orphanage with the Brothers Harry and Bill. But the relief was temporary. This morning I received an email from a volunteer who saw through it all and wrote a note to me:

Nadene, Thank you for all you do! It is such a joy to be a small part of such a wonderful organization.

There was a meditation that I read yesterday that seemed so fitting for you-

Clearly, the apostolic mission exceeds our own ability and the capacity of any human means. Therefore, we will not put to one side, as if they

were secondary, the supernatural means. We have not placed our trust in our personal talents and energy, or in any of the other means which support

apostolic enterprise. Our hope rests in Divine grace. We can rest assured that God will perform incredible miracles with inadequate means. Let us believe

in the power of His grace and never become daunted by the apparently insurmountable obstacles. Do not let the lack of instruments stop your work. Begin as well as you can. Let us ask Jesus to give us whatever we lack.

 

I so often forget it is not me and that I need help. Your are doing wonderful work. Just do not forget to get help from the source!  (KC Shinners, CNM)

Volunteers KC and Bobbi, who have been here before and truly "get it" about the distance Midwives For Haiti has come in the last few years, were very perceptive. They know from their own life experiences that unless you have hope in "Divine grace" this load is too heavy to carry. I want to believe "that God will preform incredible miracles with inadequate means". Why shouldn't I, when God truly has shown that it is true with the Midwives For Haiti program? The mustard seed has grown into a tree!

Last week Pastor Jude reminded me that the mobile prenatal clinic is the "heart" of Midwives For Haiti because it carries love and skilled care to so many women who need it so badly. Today the Jeep came rushing back from Fonbrun with a woman who has had prolonged and obstructed labor for several days. Without our midwives and Jeep, she would be just another statistic that no one even enters into the books to get counted in the data on Haiti's maternal mortality. Why can't I just find joy in that and not carry the weight of next year's budget and next year's problems on my shoulders? Why do I find it hard to "consider the lilies?"

Bien Aime Guerlie is a graduate of our very first class and now one of our preceptors. She came to me last week with some advice. She is concerned about what will happen to Midwives For Haiti when I die. She suggested we have an advisory board here in Haiti in addition to the one we have in the U.S. She says there are many people who are interested and care about what we are doing and will do whatever they can to help us. 

This is something we have talked about before and is actually necessary if we are going to get official NGO status. So she inspired me to start a committee here. I think it will do two things: 1) We will not feel like we are carrying the load alone, and 2) it will give us some really good ideas and community support for some hard decisions that have to be made next year.

So here's to not carrying the load alone. You and me- we are all in this journey together and we have a Source to lean on. Without it we will fall.