May 18, 2013

It has been a different kind of week - but every week here in Haiti carries its own surprises, joys, and frustrations. Today I was cooking on the stove and listening to our cook sing a hymn while she peeled carrots on the back porch. The medical team was back from Bonabite and recuperating from seeing many patients in the country-side. Dr. Ken was draining a cyst from a midwife's arm that she had had for 27 years and she was happy she was finally going to be rid of it. Mirline, one of our teachers, was studying placenta previas and acretas at the classroom table. I thought about all the lovely souls in this place- from the laundry lady to the volunteer midwife from New Hampshire that puts her heart into teaching our students.

The stories of the patients break our hearts sometimes. Both Sarah and Maribeth have worked hard to find a place for a 19 year old who birthed last week and has not talked since she was raped at age 14. Her sister says she has been raped repeatedly since then and that is why she also does not feed herself and is incontinent. Maribeth is being persistent in trying to find an alternative to her going home to a certain fate of more sexual abuse. There is actually a social service department here in Hinche but the resources for dealing with this woman are not here so there seems to be no solution to where to put her for care.

Maribeth's persistence is what Jesus meant by caring for "the least of these". As women, we cannot fail to fight for our sisters who are oppressed or we will lose our very lives and souls.
Sarah's continued return to Haiti to teach midwives and care for Haitian women with gentleness and love is another example of someone whose soul is rich and vibrant. Dr. Ken's listening ear and love for the Haitians who need medical care is legend here so they wait at the gate for him to see them.

I am blessed to know these servants.

Nadene Brunk

The cure for "anesthesia of the soul"

It is 4:45 on Friday afternoon in Hinche, Haiti, and downstairs there is lively music playing as Brittany continues Carrie's tradition of taking dancing lessons. Outside the volunteers are doing a lot of laughing as they take Kreyol lessons from Kenel Pierre. I am trying to recuperate from the busy day by setting on the porch in a rocker, enjoying a cool breeze, and looking at the trees. 

For the end of June, the temperature has not been as hot as I expected and the late afternoon rains cool the air - so sleeping is not a problem- along with the fans, of course.
My Mac says that back in Richmond it is 91 degrees so sitting outside on the deck at home right now would probably not be comfortable.
We are all over-the-moon jubilant because one of our dear translators finally got his visa approved to come to the states with the goal of becoming an OB/Gyn. I called Wendy Dotson, who with her husband, Greg, will host him while he goes to school to give the good news. The meaning of what this opportunity will make for his life is overwhelming and brings me tears to think of it.

It is a time of enormous activity for Midwives For Haiti in Hinche. Right now we have 23 students and hard-working teachers and preceptors. Our mobile clinic midwives care for around 250 women per month in surrounding remote villages. We have an ongoing outreach program for the matrones in the Central Plateau. We continue to support the midwives at the hospital here with salaries continuing education and volunteer work support. They handle around 150-180 births per month and their reputation is high in the community. 

Although it is easy for me to just see the problems, I am continually inspired by the stories of individual women who are blessed and saved by the care they receive from our midwives. There is the baby that is too tiny to eat but getting breastmilk because of a donated breast pump. There is the mother of 6 who would have bled to death if her matrone would have not seen her high number of pregnancies as a risk and insisted she deliver at the hospital. After 4 units of blood she will go home to mother children that would have otherwise had their own survival rate decreased drastically if their mother would have died. 

Ste. Therese is going to have a NICU by the end of September! Ohio State University faculty and staff will be training and supporting the staff over the next few months. Babies who would have otherwise died or been transported to Cange (which is closing their NICU to move the staff to Mirabilais) will be able to be cared for here in Hinche. Monica Trexor, the neonatal nurse clinical specialist, is here with us.

I started today with a problem-solving meeting with our mobile clinic midwives. The to-do list at the end of it includes getting benches made for the clinics where women wait with no chairs, finding a beach-type tent for the clinics that are held outside, and getting a DVD player so that patients can watch educational videos while they wait to be seen. Figuring out snags in the record-keeping and medication orders (getting Cefexime in this country is difficult) and how to pay the announcers in each village were on the agenda also. With the help of Kathryn Kooistra and her friend, Tracy, we are going to have a new way of getting data from our records so that we can measure our effectiveness

The direction of our program for next year weighs heavy on my mind. Our training program needs continual evaluation of its effectiveness. We are faced with probable loss of two teachers to Canada and the U.S.at the end of the year. I think we have the strongest class we have ever had but retaining good teachers remains a problem for us. (Indeed it is a problem throughout the country. The most educated make the most money and are the most likely to leave the country.)

The town of Hinche has been our center of activity for 7 years. But we are asking ourselves if we should continue to teach midwives here at this hospital where there are so many barriers to evidence-based care and in this area where we have saturated the job market for our graduates. It is exciting to have many of our graduates from sponsoring organizations. They automatically have jobs when they finish. The thought of Vilana and Soislia, Mariette and Vesline going to their rural communities and working to bring skilled care where none has been before affirms that we are doing the right thing, the needed thing in training. 

So we ask: Should we teach in another region, should we teach in two other regions if the opportunities are there? (We are exploring Hospital Albert Schweitzer in Des Chappelles and Hospital Convention Baptiste in Quartier Morin.) Should we take only students who are sponsored and have jobs when they are finished? Should we begin to open and support more birth centers? We really believe that the model of birth centers with skilled attendants referring to more advanced medical care when needed is a model that is the most life-saving and most cost effective for every country in this world- including the U.S. How do we incorporate more birth center experience into our students' clinical experience if most of them will work in birth centers when they complete the program?

As always, the path for Midwives For Haiti is never easy or clear. A favorite saying around here is that the problems and questions we face this year will be gone next year but next year we will have new ones. The really cool thing about our volunteers is that they have such good ideas, help us problem-solve and give us encouragement to keep climbing the mountain of obstacles. That's because they are midwives and medical professionals who are earth-shakers.

I am reading "To Repair the World" by Paul Farmer. In a speech he gave to a graduating class of doctors he warned them of the "general anesthesia of the soul" that can come from being among the privileged of this world. For anyone who is experiencing "anesthesia of the soul", joining us in our work here in Haiti will cure you.

Nadene Brunk

The Landing is Scary

Monday and today I rode a small 3-passenger plane to and from Jacmel. Three of us were in Jacmel to buy art for our art show this summer in Richmond. I am not overly fond of flyng - let alone in 3-passenger planes. But this morning we left Jacmel at 8:30 am and arrived in Hinche 30 minutes later and had the whole day to get some work done. Without the flight we would have had a 5-6 hour car ride and would have lost the day and been exhausted.

Landing in Hinche is always a bit nerve-racking because people, motocycles, goats, donkeys, cars, and children still use the runway to shorten their trip from the road on one side to the road on the other and there is no one to clear the strip before the plane lands. Barbed wire that was placed to create a barrier was gradually stolen. The pilot has to depend on people's ears working well and that they will hear the plane circle and get out of the way before it lands. I pray every time that no one gets killed. There are too many close calls.

During the flight I thought about how lovely Haiti looks from the air. During the rainy season it is greener than usual. It was fun to see places we have been, including the new hospital in Miribilais with its 1800 solar panels on the roof. But the reality of living in Haiti is more like the landing in Hinche - it is risky and scary. It does not matter if they build a new hospital if you would have to walk an hour to get to it and there is no midwife in your village to tell you that your blood pressure is too high and your family has no transportation but a makeshift stretcher to take you there when you start seizures.

Sometimes I feel the same way about our program. It looks good from the distance but in reality we have so many problems to solve before it is truly a model of a way to get skilled care to the women who do not live near hospitals. We have our mobile prenatal clinics but have no birth centers in those villages. Most women we see for prenatal care are still going to deliver without skilled care. We will prevent many seizures, preterm births, and post-partum hemorrhages by the preventive care and screening for risk that we do in these clinics. But the reality for pregnant women in rural Haiti is that the landing, the birth, is scary and risky. In rural Haiti 83% of women will not have skilled care for their delivery- even with a state of the art hospital one hour away.

What good does it do to build a hospital with state of the art equipment and well-trained staff with an ambulance parked outside unless you have established rural clinics around it that screen for risks and teach danger signs? You can offer free care for HIV positive pregnant women but who is going to test the women just down the road and over the mountain unless they walk to the hospital for a half a day or two days for HIV testing?

Research has shown it takes 3 very important things to save the lives of mothers and babies: 1) a skilled birth attendant during pregnancy and birth, 2) transportation when things are not going well to 3) a well-staffed and equipped hospital that can deal with emergencies. Partners in Health and their many generous donors have built the hospital. Now we have to work on the first part- training skilled birth attendants and putting them to work in rural villages. This is where "the rubber hits the road".  Without this mothers and babies will continue to die in rural Haiti.

A Fete in Haiti

The Surprise Fete-

Yesterday around 25 graduates of Midwives For Haiti held a "fete" for me. This was supposed to be a surprise party but I got suspicious when a midwife who works in Port-au-Prince showed up dressed to the nines with no apparent agenda. I changed out of my scrubs into a blouse and skirt because clearly this was not going to be a casual event. Gradually between 3 and 4 pm, more and more midwives arrived and started filling the table downstairs with huge and colorful plates of food. Some of these midwives I see only once or twice a year at continuing education sessions so it was quite exciting to see them so pretty in their party dresses and some of them brought their small children along.

After they rearranged the classroom so that the tables were in a large square, covered with tablecloths, and decked out with red napkins and bouquets of flowers, they invited me and the other volunteers to "chita" (sit down) in places of honor. Val Josette from class 3 was the mistress of ceremonies. There was singing- "How Great Thou Art",  solos- some with improvised words to give gratitude to Midwives For Haiti, and speeches. Volunteers Cara Osborne, Zelda Collett-Paule, and Sarah Taylor were there to enjoy the music, the party, and food.

In one speech, a midwife described how women in her community seek her out for her midwifery skills and medical knowledge. She noted how empowering it is to be able to own property because of her midwifery job, and how empowering it is to not have to ask a man to buy her things.  This inspired another graduate gave a recitation of a poem she had memorized for graduation last year. She apologized to the men in the group before she gave it- our faithful driver, Ronel, one of the male midwives, Frid, and our translator, Emmanuel. The poem was about the power of women, how capable they are, how they are not to be disrespected, how much in trouble a man is if he does not respect the women in his life. While she gave it there were hoots of approval and when she finished, there was great cheering and pounding on the tables. Clearly she had struck a nerve for all of them.

There were gifts for me and Carrie and Steve. Carrie has been such a wonderful addition to our team at Hinche.  The students and graduates know they can count on her to be an advocate for them, to problem- solve with them, to be a laison between here and the administration in the States. And they love that she has learned so much Creole so quickly.

I gave a short history of how Midwives For Haiti came to Hinche, the role my faith has played in the beginning and continuing work of Haiti and the obstacles we have overcome. I know they are some of the hardest working people in the world. Who in the U.S. works 8-10 hours a day in intense heat delivering loving care to mothers in clinics, in makeshift clinics under trees, in understaffed crowded hospitals and birth centers?

They recognized the sacrifices of volunteers, the hard work of our drivers and translators. They know it takes a team effort to make the supplies keep coming, the mobile clinic keep rolling, the patients delivered safely, the education of new midwives to go on for 6 and 1/2 years.

I was blessed by this "fete", the obvious care they had taken to prepare it, the love they brought to me and the rest of the MFH staff. I am so blessed to be a part of this thing that is bigger than me, bigger than each of us, and blesses both Haitians and volunteers each year.

Back in Haiti in April 2013

This morning after coffee and oatmeal, I jumped on the back of a motorcycle to go to the hospital. It felt good to be back in Haiti to keep tabs on our program and see our students, friends, and teachers again. I wanted to check on Zelda, the CNM volunteer from Homer, Alaska, as it was her first day at the hospital and it can be a bit overwhelming, to put it mildly, with all the critical patients mixed up with the normal healthy patients and figuring out who are the students, the teachers, and the preceptors and who is the regular staff. Then there are auxiliare students and nursing students, too, and it can be overwhelming.

Zelda told me a baby had just been born with an emphalacele, which is an opening at the umbilicus that the intestines protrude out of. This baby will need surgery and that means going to PAP and there is a question whether or not the family can come up with the money for both transport and the surgery. The baby also appears to have some other chromosomal abnormalities. The hospital is fortunate to have a pediatric resident from Ireland helping out and she will do the follow-up.

Later in the day, Dr. Alice Hirata came back from mobile clinic with a patient who was 32 weeks pregnant, an unusually large abdomen for the dates, and a suspicious mass in her uterus. After getting a second opinion from Dr. Eads, they decided this woman has a baby with a neural tube abnormality, similar to hydraencephaly where the brain is displaced with an abnormal amount of fluid. So that baby will not live after birth.

One has to wonder if the poor nutrition in the impoverished areas of rural Haiti makes these kinds of abnormalities more frequent. It gives us more motivation to get education about nutrition, multi-vitamins, iron, and worm treatment to more women earlier in their pregnancies.

One thing that stands out to us is the stoic way these Haitian women accept the fact that they have a baby that will probably not survive. It is almost as if they have braced themselves for it ahead of time and they are not surprised. Not like we would be in the U.S. where we see abnormalities less frequently, expect a healthy baby every time, and ask for the answer to why if it does not happen.

It makes me think about the issue of control and how we live in the U.S. with the perception that we can control so much of our lives. Here in Haiti they to do not assume they have control. They are willing to think that curses, voodoo, and God controls their life and seem to have a lot less stress as a result. We worry about preventing cancer and preventing accidents, and want to know what we did wrong when things did not go as planned. They seem to accept that they are not in control. In some ways, I envy their ability to lay the blame anywhere but on themselves.

We also worry about the future much more than they do. They are grateful for food and life one day at a time. This makes problems for us when we think they should do long-term planning. But we could learn from them also that most of the things we worry about in the future we have little control over today. It would add to the joy of our days.

Today Sarah Taylor talked with the students and learned some more traditional postpartum practices that are common here. They believe that pinching a baby's cheeks frequently helps it get dimples, pulling on a baby's penis makes it get longer, and sitting over steaming water after birth helps the vagina heal tighter and smaller. The latter has been the cause of 3rd degree burns so there was some teaching to be done about the harm that some traditions have caused.

I am continually humbled by the fact that there is so much to learn about this culture, that I have so little understanding of their beliefs and world view. It is important for us to recognize that we have much to learn, to stay humble, to open ourselves to learn about how they view their problems. Otherwise, we will throw up our hands in frustration and give up. Lots of NGO's have come to Haiti and have done just that. We are saving lives of women and babies daily so we cannot afford to stop learning how we can be more effective in our work here.

International Women's Day

 

Blog #4

It is March 8, 2013, International Women's Day. Here in Hinche we have a house full of women.

There are the cooks, Diunny and Salomon, who sing while they work, Elliot the housekeeper whose service and smile encourage us everyday, and Monique who does piles of laundry 2-3 days each week by hand in large plastic basins. I think these women represent what most women in the world are doing each day- trying to provide food and clothing and a clean home for their family. Sadly, it means that the one thing that could bring women empowerment and a way out of poverty for their families- an education-is not available to most women in the world. (Thanks to a midwife donor, at least the 14 year old who babysits for the cook is going to school for the first year of her life and glows when she talks about it.)

Right now I can hear the students from Leogane down in the classroom discussing malnutrition and sources of good food for pregnant women. They watched 2 videos on Nutrition this morning thanks to our projector and a donated laptop. There are two teachers here who have a lot of experience and education behind them who have decided that training other midwives for Haiti is the work they most want to do.

This new class of students are here because we had no clinical site in Leogane, which would have been closer to their homes. Since Monday night they have been sleeping on mattresses on the floor and sharing a bathroom here at headquarters until they can find a place to rent together in Hinche. I am amazed how far they have traveled, how many comforts they have given up, how they are willing to be away from family in order to reach this dream of being a midwife.

It is being around these women that gives me encouragement to continue this work when it all seems so hard. They believe in Midwives For Haiti and its mission passionately and are so proud to be students or graduates of the program. So when I hear another impossible request from the medical director of the hospital, wonder how the budget will get us through the year, and feel exhausted from the constant decisions and responsibilities, I just need to be with them, to hear them sing, to hear them thank Jesus for Midwives For Haiti, and I feel so blessed to know them and to be here.

This afternoon the 16 Hinche students will share case studies from their clinical experiences this past week. The Leogane group will listen in and ask questions. Then for the first time all 24 students will end the week together singing, united in their mission to bring health and life to mothers and babies in Haiti. On this International Women's Day, they know they can change the world.

There are not enough hours to waste on worry

 

March 2, 2013

I try not to fret in the middle of the night but it was difficult to find a “letting go” point last night. Tomorrow the teachers and 8 students arrive from Leogane. The logistics of getting them a place to stay, getting mattresses for them, starting classes and coordinating their clinical experiences feels really big. I worry we are going to overstretch our budget and our energy. Some of the restlessness was caused by the events of yesterday when we just crammed too much into one day.

It was one of those non-stop days that left us all in a stupor this morning. The first Friday of the month we always hold Continuing Education classes for all of our graduates that can come. Twenty-seven came in the morning. I had Abby Merryman, OBGyn MD from Dartmouth to help me review partogram use as they are using it very poorly at the hospital even though the hospital administration has done some education on its use.

The most frustrating thing for me about that morning was the realization that although we go to great lengths to have our students think critically about their practices, it is still easier to just do what they are told instead of asking why. So when I asked them why they kept women in bed who had ruptured membranes they did not know except that they were told to do this. Infuriating. Sometimes mornings like this make us feel like failures as educators. I realize this is the challenge of educators everywhere but it seems so much harder in Haiti where everything has been learned by rote memorization and not by thinking through what the research has shown to be best practice.

While the midwives were still here in the morning, seven men arrived from the Church of the Brethren's Haiti Medical team. I had met Dr. Paul Minnich and Jeff Boshart in the fall at a missions conference and they wanted to learn more about what we were doing. They have 3 Haitian doctors that they pay to run clinics in seven areas where they have churches and are looking to expand the services they provide. They have no maternal health component so far. Until I could get free to talk to them, Steve tried to give them information and history on our project while they had cold drinks on the upstairs veranda.

Right after the Continuing Education group left the current students arrived for case study day. Abby stayed to help and observe this and Bobbie Curtis arrived back from matrone training to help also. Students tell of cases they have seen the past week and we all discuss what we can learn from them. This week the cases included a woman who presented at prenatal clinic with extreme fatigue and “poor health” who they sent for some lab work. She had a hemoglobin of 4 (normal is 12-14) and a positive malaria test (a major cause of anemia here.) Her baby measured for small for her gestational age and she received 2 pints of blood and chloroquine.

Another case involved a woman coming to the mobile prenatal clinic in Roysec because she had been told by a doctor near the border of the DR that her baby was too big and would die. Because of her concern, the midwives brought her back to Dr. Celestin at the end of the day for an ultrasound. He found a severely hydrocephalic baby and recommended terminating the pregnancy before the baby's head was too big to deliver vaginally. The baby will die anyway because there is no available surgery for this here in Haiti. (In countries where there are more medical resources these babies would be delivered by C-section at full-term and have shunt put in their head that would enable them to live normal lives.) The woman refused the induction and was advised she must have a C-section if she waits until the head is bigger. Sad stuff for the students to learn.

Once the case studies were over and the students left at 2 pm, I finally had time to have lunch with the Church of the Brethren team and enjoyed hearing about the growth of interest in their project in the denomination that I have been a part of for almost 40 years. They were especially interested in our Matrone Outreach Program and we encouraged them to send someone to our training the trainer program the week of March 18.

Before they left Karen Leichty, CNM turned up to buy some HIV tests and some Albendazole as the medical group from her church in Nebraska that she is working with this week was running low on both. She and a family practice doc had gone to Cabestor with our midwives on Tuesday and she was full of praise for them and our work. She left a contribution for Midwives For Haiti and a promise to come back to volunteer with us.

After the COB group left, multiple graduates wanted to talk to me with various requests. This happens every month. “Could you find a job for me closer to my children?” “I need a new BP cuff.” “Last month I was not here to get the fanny packs you gave out.”

The massive amount of food and drink that goes in and out of our house on a day like yesterday is incredible. Without Carrie and the cooks it would be impossible. By 4 pm I was so very tired when Carrie reminded me it was time for our dance lesson. Let me tell you that living with a 23 year old puts my energy in question. But learning to dance the batacha with our handsome teacher, Fortuna, gave us some good hilarity at the end of a busy day here at “grand central station”.

This morning Gladius helped me with an interview with one of our graduates for a position in the family planning clinic at the hospital. We are receiving a donation of a salary for her. There are still a lot of misconceptions about birth control methods in Haiti – about whether they cause infertility or cancer or make God unhappy. Add that to Haitian men thinking the more babies they have proves their fertility and these poor- and I mean really really poor- women have to be pregnant and risk their lives too many times. Anyway, the graduate has some experience with placing implants and other family planning methods and wants to be able to stay in Hinche with her 2 small daughters so she is thrilled. She is one of those colorful and powerful women who will make it her mission to find every woman who wants birth control and get them to her clinic. While we were waiting for Gladius to translate, I practiced my Creole on her, which caused hearty laughing, and we shared pictures of her girls and my grandchildren.

The truth is that as women we have so much in common no matter our age or nationality. We all want our children to be healthy and happy, in that order. We all want to be loved. We all want meaningful work and the empowerment of an education. That is why we are in Haiti and that is why I did not stay awake long to worry last night. There is peace about our purpose here.