Monday, February 24, 2014

Prenatal outreach at the market

Prenatal outreach at the market

The midwife helps a mother lister to her baby's heartbeat at the weekly market

I could see, last week that there were many pregnant women at the market.  The question is why none of these women were not coming to the clinic for prenatal care.  It has been my experience, in Haiti, that women like and want prenatal care.  I have seen hundreds of women walk for hours and wait in line all day for care.  The question is why do these women not come to the clinic for prenatal care.   What are the barriers and how can they be overcome? 

I decided that perhaps going to them might help and so we pack up some supplies and head to the weekly market.  We find a tin market table and cover it with rice bags and a sheet.  We arrange the educational charts I made and begin to do blood pressures and hand out a weeks worth of prenatal vitamins.  I find baby heartbeats with a stethoscope and try to let them listen.  There are brochures that say the care is gratis and when it is. 

I watch the pregnant women flock to the table.  The newly graduated midwife, who is from the community and was a health agent, is hesitant.  I know enough Kreyol to know she is not telling them it is free.   They tell the translator they cannot afford to come.  They are far poorer than the women who currently come to the clinic.  She is not telling them to come in a week for more vitamins and a complete check up.  I encourage her and model enthusiasm but she is quiet.   Does she not want them to come in?  Is she shy?   Is there pressure to not have non -paying prenatal mothers at the clinic?   There are lines of women all around us.    The matrons come up and kiss me and introduce themselves.   The midwife smiles at me.

The pregnant women clearly do not know about the clinic and did not know about prenatal care.  Many are eight months pregnant and have never had a blood pressure taken.  They have had no prenatal vitamins, have had no testing for serious diseases and have no emergency plan.   They live in small villages, get pregnant, and have no birth control and no money to pay for food let alone medical care.   They know if there is a serious problem, to go the hospital, which will cost them a year’s income.  

There has been no common understanding of why prenatal care saves lives, prevents long-term disability and disease and why it is a keystone to more prosperous communities.  Orphaned children, motherless children and disabled children are a challenge for any community. The cultural, geographical, historical barriers are many nut there we are.  The new midwife is passing out vitamins, the volunteers can hardly breathe for all the people wanting their blood pressure taken, and we laugh and listen to baby heartbeats.   There is a sweet excitement; a hint of possibility and hope.  

A nurse from Atlanta, Georgia buys two new brooms from the market for us to hang in the new birth room.  In Edwidge Danicott’s Claire book she describes a new broom at the birth of a baby for good luck and to sweep the mother’s belly to help the baby come out.  I had not heard this before, but I love to know these traditions and am thankful for the gift.   It is difficult to set up a room that reminds the mothers of home.    

The volunteers walk around the market looking for pregnant women and watching the heart of the community’s economy.  Someone buys cassava bread. I give the cook $10 to shop for fruits and vegetables.  Another volunteer buys the two brooms.  We pass out vitamins from Vitamin Angels and many blood pressures are taken.   The women laugh, shove, shout and shake their heads.   They listen for heartbeats and the results of their blood pressure.  Life has been hard for the oldest amongst them.  Their life expectancy is about 62.  I want to say that good, education based prenatal care will prolong their lives and make them stronger.  They can watch children so parents can work and their community can grow strong. 

At noon, we pack up and make our way down the mountainside to the clinic, passing small houses, women cooking and children returning from school.  

In the evening, after my English class, I rest on the roof with some children and watch night settles in.  There is no electricity.  Mother’s call and children try to play outdoors for as long as they can.  The burro’s call and the night sky fill with stars.  The children rest and nearly fall asleep on my lap. It has been a long, good day.

Later, I sit in the dark and make a list of why prenatal care is important.   I tell myself, “start over, go back, review, don’t take things for granted, don’t assume, walk slowly, imagine you too never had the possibility of prenatal care, be creative, be patient.”    I wonder at times if I made it all up.  I am sure that it is a standard thing that is well accepted but here I am with a solar lamp writing my list, which is accompanied by thanks for the day and a prayer for the next one.

Why prenatal care

1.     It is an important opportunity to introduce and teach positive health habits.
2.     It is an opportunity to teach women about their bodies.
3.     It allows women to benefit from essential health screenings that may impact their own health, their partners and their children including HIV, syphilis, honoree, chlamydia and many others as cost allows.
4.     It may be their first complete physical exam.
5.     It is a place to get prenatal vitamins which helps prevent anemia and birth defects.
6.     It screens for anemia and helps prevent death or disability from hemorrhage.
7.     It provides women with worm medicine to prevent anemia and malnutrition.
8.     It screens for hypertension and pre-eclampsia, which may lead to death and orphaned children.
9.     It screens for diabetes, which leads to life long health problems.
10. It prevents health problems in newborns.
11. It supports breastfeeding.
12. It helps women create safe birth plans including an emergency plan.
13. It provides malaria screening; a leading cause of maternal death and disability.
14. It screens for possible high-risk birth situations that require a mother to stay with relatives in town such as twins, breech or high blood pressure.
15. It screens for physical abuse of women.
16. It helps parent’s transition into parenthood.

Sunday, February 23, 2014

The teenagers walk to school

It is late Sunday afternoon and I am being picked up to go stay in the guesthouse of the hospital.  I have agreed to do the Helping Babies Breathe training for the nursing staff there.  I sit outside the clinic with various people of the village.  The clinic yard is the town square.  This, the soccer field and the pump are where we gather.

Gathering at the soccer field in the evenings.    There is no high school in the villages so the teenagers must walk down out of the mountains each Sunday and back again on Friday.   Families work to help one child get through high school.  it is not free here and there are books and uniforms and board in town.  If your parents have died there is little chance you will be able to go.

A man has fallen off his donkey and has smashed his leg.  It is twisted and turned and not looking good at all.  Who knows how long it took him to get this far.  I am picked up in the ambulance but the driver does not want to put him in.  Everyone crowds around and insists so in he goes with his frightened daughter and some crutches. Two teenagers climb in as well.

I do not think too much of this at first.  But them it becomes clear. There are  many teenagers  walking down out of the mountain to go to high school in town.  They are walking miles and miles on rocky, mountain roads that are little more than paths.  We fill the ambulance to overflowing but there are many, many more.  They emerge from scrub brush and rock and burning charcoal.  They gather at the last pump and walk past soccer games on dusty crossroads and grandparents making thread from rice bags.  They leave whatever family is left and whatever family survived to make this walk every week for their future, for their families, for Haiti.  They wear back packs with freshly washed uniforms.   They will stay with a relative, a friend, a person who needs help with cooking and cleaning.   They wave to the farmer coming home with his machete and their sisters getting water.  They are the best and the brightest their villages, their families have to offer.  It is for them they cut the trees and make charcoal. It is for them there is never enough food.   It is so they can have the education their parents never had.  It is not free.  Their parents and they must work and then they must walk home each Friday; up the mountainside where they must help their family and study before walking back down.

We  turn a corner and the sea, cool and blue like a postcard calls to us but no one answers.  They are going to school; going to school in the hope that by the time they finish, they can get into college or get a job and help their families.  I watch this brave, beautiful march down the mountain.

I watch this knowing, that in the village I come from, nearly half the teenagers will choose to leave high school; to drop out, to take another path.  Their education is free, the books are free and they do not have to wear a uniform.  They can live at home and are given free food, if they need it.  They are given a ride or a car or a bus ticket.  They have sidewalks, electricity and running water.   But they have lost the journey, are starved for the journey, for meaning and navigation and the belief that the world will be a better place for their effort.

I want an easy way down the mountain for these kids so much I could cry. In my heart, I am cheering like I am at a soccer match.  You can do it.  Don't give up.   And world, please don't give up on Haiti either.  At the end of this walk, they need jobs, higher education and the promise of possibility.  Please make this walk worth making.  

And if you are a teenager in my country, you are a part of the walk too.  I know it is hard to see.  Even with lights and cars and a free education, we have made the road almost impassable for you.  In the name of commercialism, we have denied you the journey.  I am not sure, by the end, what is breaking my heart more.

As we come into town, it is dark.  We drop our students off and they melt into a path, into night fires and dirt streets.  There are many still on the road behind us.  We drop the man withe the smashed leg off and I go to the hospital.

Next Friday they will be back home again.

Gratis - the cost of healthy mothers and babies

The cost of healthy mothers and babies

Prenatal classes for all the pregnant women who visit the clinic.  The posters are made on from materials I buy at Scrap in Portland, Oregon.  After I did it once, the midwives took over
Ever since I have suggested that the prenatal care cannot cost anything, I have head the word “ gratis” passed around in animated voices of disbelief.   The social doctor is vehemently against it.  He says free health care will ruin Haiti and no one will pay him.

I look around the clinic.  Five paying patients a day is not going to support even one of them, yet alone the whole staff.  They are not earning their keep, even with their payment system.   It is not financially viable.   There is a chart person, a lab tech, a pharmacist, two nurses, two doctors, and now two midwives.  There are all sorts of housekeeping and grounds people.   Outside the clinic there are hundreds of women with no prenatal care.   He shrugs.

“How much is a visit,” I ask. 
“About $1 US. “
“How much are they earning?”
“Maybe $4 a week.”
“So ¼ of their total weekly income must go to this visit and this does not count lab work and pharmacy and the four hours to walk to and from the clinic.
“How much to have your baby, in town, at a hospital?’
“It starts at $50 US dollars but you pay more for medicine.”
“Two months of their yearly income. “
“Is family planning free?” 
“Nothing should be free in Haiti.”
“Healthcare is free all over the world.”
“Not in Haiti.  I need to be paid.”
“You are being paid and you got a free education.”
“I need more.”

The debate, over health care, rages in my country as well.  However, even the most conservative politician, understands that prenatal care for all women is a sound social and economic investment in the long -term well being of a community.

 The countries with the best maternal and newborn outcomes provide medical, social and economic support to the newest members of their society.  The yet to be born are nourished, given medical care, and once born given time to be breast fed and provided with a free education.   Mothers are offered an opportunity to choose when and if they will have more children.   Many give mothers paid time off in the last weeks of pregnancy and ample time to care for their newborn before returning to work.  

One of the new midwives providing care
doctors in Haiti and many part of Europe, complete a social year as a gift to their community for a free education.  The social year doctor is pretty much against free care, prenatal care and midwives.

“There are very few pregnant women in this area.”

“But there are so many children.” I reply.

“Well, even if there are pregnant women, they don’t like prenatal care.”  He explains.   “Haitien women do not like prenatal care.”

I had seen women walk miles for prenatal care in other parts of Haiti.  I am confused and the midwives were hired, I thought, to meet an identified need.

“Have they ever had it?”


I always consider the possibility that I am wrong and wrong in another person’s country is even worst.  I walk around on the roof and consider.   If no one comes because it costs, then why have the new midwives?   Is health care a human right or something only a few can purchase?  For my own country, I want health care for all. It is what I want for all women, everywhere.   I toss my cards with every pregnant women needs free health care. 

The young doctor, who is also the clinic director, was born and raised in these mountains.  I am at the clinic for over a week before I see him.  When I do, he smiles and quickly agrees to free prenatal care.  Within two weeks, there are pregnant women sitting on benches, waiting for care.   The new midwives are smiling and doing the work they were trained to do.  I breathe deeply and smile.

Through walking, I learn

Through walking, I learn

A mother and her twin babies I met on my first walk in the villages surrounding the clinic.  There were many pregnant mothers and babies who had never had prenatal care and were happy to hear of the two new midwives from their community.

I have come here to help an organization with the set up of a comprehensive maternal health program in rural Haiti.   Like many clinics, it is contained within high cement walls with an iron gate. There is always a local man who watches over things and that is true here as well.  He has been here for as long as anyone remembers and his sons live here, as well.    

On Saturday morning, I walk with two sons, to the nearby school and church.  I ask where the nearest water pump is and they offer to take me there.  As I am scrambling up hillsides, barely passable on foot, I am thinking of one WHO requirement for a safe birth- “access to a skilled birth attendant.” 

I have grown somewhat accustomed to motos but this does not seem passable even on a moto.  Only one moto passes us  and we never see a car or truck.  I had asked to walk to the nearest pump.  I had not understood how far and how difficult the walk would be.   I walk and walk but still we have not come to the pump.  I can not imagine that they met the second WHO requirement for safe birth “access to transportation in an emergency.”  Even if they could get down off the mountain, the clinic ambulance is kept in town and so it would take an hour and a half, for transport after walking to the clinic.   Women in shock or seizing can not very easily be propped onto a motorscooter and bounced over rocks. 

“Just a little further.”  My new friends know everyone by name and we stop to say hello at every house and sit on stools in the yard as we visit.

We pass small houses with tin roofs that are mostly isolated and not clustered.   There are small, harvested patches of Congo Beans that appear as sticks bare of any currently growing leaves.  They tell me they will replant when the rain begins in a few weeks.  Some houses are blue plywood and show that perhaps a volunteer crew had built them.  Some have outhouses and the earth houses have the added benefit of the rocks for building material.   There are very few animals; a very occasional goat and one cow pen but without the cow.   Most of the historic mangoes were cut for charcoal.  We see a young boy busy with a machete cutting down the only tree in his yard.  

In some places, in Haiti, there are rivers for washing clothes and other household chores.  Here, there is no fresh water at all anywhere that I have seen.  I can see that they do not meet the United Nations suggestion that all people live within an hour walk of a water pump.   This is at least one hour up hill, over rocks and boulders. There are no smaller stores and the main ferry town is an hour the other direction from the clinic.

We pass babies in every yard; mothers, babies and children of all ages.   I wonder how anyone came to live up here, far from the sea and fertile land.  There are caves everywhere; large, craggy caves.  I think, a runaway slave or Taino Indian would have made their way up here rather than being a slave or killed.  Perhaps these strong people are the survivors of Haiti’s genocide; tucked in caves and rocky hillsides making a life for themselves away from mainland Haiti.    

When we get to the village I can see the skeleton of a market but it is Saturday and almost nothing is for sale.  Market day is Wednesday. There is a well made chicken fighting ring, a small Catholic church, a school and a rice mill.  There is a World Vision compound but no one is there.  “They left Haiti” I am told. There are young men, children and a red, clay clearing, which is the town center.  There is a clinic building but no one to run it.  There are no other buildings and most of the small houses are on the outskirts of this village. 

We see a young woman in early labor who slept at the clinic the night before but when she did not have have her baby, returned home.   I consider that there should be a clinic up here every week as well as a small, rural birth center.    Without transport this area is remote, isolated and a dangerous walk to town for a pregnant woman.   She tells me she is far more afraid of the moto ride at night than birth with a familiar and loved matron at home.  She has considered her odds for living and decided home, without any life saving medicine, is safer than the road.

On the way back down, we stop at a “girl friends” home and there is an older woman with a flock of children.  One toddler is on the verge of dying.  I know the signs; the sores, the drooping, wet eyes and lack of any sign of life.  She picks him up out of the dirt and holds him. Another child drops his plain white rice in the dirt and gobbles it up; sure that there is no replacement and that he might have to soon fight off the one turkey.   I ask about MedikaMamba; a program for malnourished children but no one seems to know.  I tell her to bring him to the clinic on Monday but she says she has no shoes to get there.   No one is wearing shoes but I am unable to continue without mine.  I got them for $4 at Goodwill and someone may have them when I leave but sadly not till then.

One in four children, under the age of five will die in Haiti.   I tell the community health agent to go see him and tell her again to come down but I don’t know.   Everyone is running around. His mother has left him with her and he seems mostly forgotten amongst the dirt and rocks.  He is not fighting for rice.  He has given up. 

We make faster progress on the way down the mountain and when I arrive back, I lie down.  I shut my eyes and review the barriers for women and babies, I noticed on the walk:

1.     An inability to get to the clinic for prenatal care or delivery and post partum.
2.     Even a nominal charge may be prohibitive.
3.     A lack of water and food. A lack of topsoil for gardens and farms.
4.     Children spaced too closely together may mean they are not accessing family planning. 
5.     Perhaps a lack of men remaining with the family.
6.     Women leaving children to go work in the city; a lack of jobs.
7.     Communication about the services of the clinic reaching those who need it.
8.     The continued cycle of poor soil, lack of clean water and poor roads caused by the cutting of trees for firewood.

When the solar power goes on, I plug in my kindle, camera and computer deciding the kindle and a book to read was most vital.   I cannot bare not to have something to read. I am in a country with no books and where only 10% of the women can read.   I have just finished Claire of the Sea by Edwidge Danticut.   She always helps me to see.  She helps me to see the song in what I see; to hear the children playing and the women singing.  She helps me to notice the blue sea and the one old mango tree that has been saved.  

It grows dark and someone brings me a mosquito net and hangs it in my room.  They bring me a coke and some ice.  I cannot tell from where these gifts are coming but I accept them with gratitude.   It is getting dark and the solar power has stopped working.   Everyone stays outside as long as they can; talking, joking and maybe singing.   Tomorrow is Sunday and it is a day to shine.

I can help set up a prenatal clinic but there is more; there s trying to understand what the women need to be healthy over the long run.  There is the trying to understand why there is not already prenatal care and if the lack of it impacts lives, in ways no one has identified.   What are the stories that impact health care and what can I learn as I set out for a walk or sit by the road, beyond the clinic gates?