The Midwives of Lagonave
The two midwives, I am here to support, are from the island of LaGonave. Before going to school in Henche, last year, they were community health agents. Last year, they left their homes and families to learn how to serve their small, rural villages, as midwives.
They attended the midwifery school, Midwives for Haiti; an intensive program that trains two year nursing graduates in the skills of prenatal care, normal labor and delivery and post partum care including family planning. The midwives I worked with at MamaBaby Haiti were graduates as are the two new midwives here in LaGonave.
These two midwives did not go to nursing school first but were rather agent santé or health workers. I was not a nurse before becoming a midwife either. There is a great international debate about this situation. In Canada and most of Europe you do not become a nurse before becoming a midwife. It is largely a product of the United States health care system and thus adopted, like many things, by Haiti’s institutions. The two midwives here, who I will call Rose and Anie, are not part of the elite and could never have gone to nursing school. There are no nursing schools on this island and they could not afford to live and go to school on the “mainland.”
They are intelligent, kind and eager to do well. They had already, as health agents, given shots, done vital signs and helped with malnutrition. They were public health workers. What they had not done was worked in Haiti’s large, crowded public hospitals. They had walked the time worn paths that connect the many villages that make up their island. They have come “home” to a place where 99.9% of the women give birth at home and 99.9% have never had prenatal care. Their challenge, and the one I am here to help them with is getting basic prenatal care to the many women living in remote villages and offering them a place to give birth should they choose.
The challenges are many. The villages are about a one -hour walk apart with some being hours from the clinic. The women have never had prenatal care and do not necessarily connect maternal and newborn deaths and disabilities to preventative healthcare. The pregnant women do not often have money to spend on healthcare. The women have 7-8 children. These are all significant enough barriers but there is one more.
There is one that I was not expecting. The clinic is a well funded, institution where roles are defined and things are done as they always have been done. It is overseen by a pastor in town, funded by churches in the SE United States and run by a director who has good intentions but is not often present. In the absence of the pastor, the churches in the US and even the director, the midwives are left to the informal systems of governance. In this system, there was no need for midwives. There was an absolute resolve that pregnant women did not need care, were not having any problems in childbirth or wanted family planning. A line was drawn and so if we were to reach the thousands of women at risk during pregnancy and childbirth, the new midwives had to be accepted as people and in be seen as a much needed resource.
Having just been in Cambodia, I saw how they effectively trained one -year midwives and got them out into rural communities as fast as they could. They trained women from the communities, as the partnership here did. I could see that training women in the city and then expecting them to go to rural centers is difficult. In my own state, they have difficulty getting doctors to work in very rural communities. Here, there and everywhere there is a call for skilled birth attendants who can quickly get prenatal care, education and life saving measures to women and babies. There is not time or money to send rural women to years of nursing and midwifery school. These communities cannot even commit to sending young people to high school.
And so one of the greatest obstacles they face, in getting care to the thousands of women who need it, is the age-old barrier of discrimination, class, privilege, access and acceptance. Is the education system intended to create, diverse democratic communities in which all people have a right to healthy, sustainable lives or is it here as it is my own village, a ticket for some to maintain wealth and privilege?
These two midwives, from modest backgrounds, have worked hard but the medical hierarchy, so devoted over thousands of years to undermine midwives, looms large even in this small, isolated and resource starved island. I like to think that when the World Health Organization called for more skilled birth attendants to solve the problems of maternal health, they understood this barrier and so defined it to welcome the Rose and Ani’s of the world, as vital links in their village health care system. Although I knew this, I had not fully grasped it. The reason why so many women and babes, are dying worldwide is this very barrier. If Haiti wants to reach its rural women, they will need to applause this model and in this model change the lives of families in Haiti, one village at a time.