Just for today - a poem for midiwives

Today I need  to remember
 the mothers who lived;
the ones
tended at birth by a million
sisters and mothers and neighbors;
Unschooled but not unskilled
called by their God to
sit
and wait with mothers
whose names can not
be written but are
never lost.

Just for today
I want to remember the mothers
who lived;
I want to look at the stars
and count the ones they
saved and not
the ones lost

Just for today,
I want to remember
The whole of earth
born and wrapped
in ancient prayers

Just for day,
before the work begins
of saving mothers lives

I want to consider
the ones who lived;
 the ones
high above me
in the mountains
and across the sea
and in the midst
of war
who still and always
sit beside women
and wait

Unschooled but not
unskilled

There is time later,
 to
consider eclampsia,
and bleeding and
babies who do not
breathe

But today,
I open my
door, listen to
dawn's first  birds
and  count the ones
who lived.

Today
I want to
hold onto the
angels;
to the small
 miracles
of life

the ones
that exist
beyond living
the ones that
cannot be contained
by death.

The Donkey

The Donkey

The donkeys are on my mind, more than I want to admit.  I cannot help it.    They always look sad and I am not sure what they are eating and they cannot be getting enough water.  Their bodies are covered with scars.  The way they bray sounds so sad like they are calling for someone, anyone to help.  I think of the boys in Pinnoccio being turned into donkeys and wonder if a person is trapped in there.  They work way too hard and are everywhere.  They are too tired to be dangerous or to even much run away.  

On the other hand, I enjoy a landscape  full of animals and the ease with which farm animals and people live together.  Sometimes I think the children are so fortunate to run and play with animals all around.  I know mothers, in my village, who go to great trouble to have the goats and donkeys that roam  rural Haiti.

But it is not a hobby in Haiti.  The donkey is a tool for survival.  It is not a pet or a 4-H project.  It is how one gets water, food and fuel.  Mostly they do not even ride them as they have to be used for carrying loads.   

My thoughts go everywhere.  This is a good life.  It's better than many kids who are inside all day playing video games.  Then I think, its not fair that they should be so vulnerable.  It is not equitable that some children depend on a donkey while others have multiple cars and turn their water on each morning with no thought of where it came from.   

The children can not imagine the children's life in the United States and they can not imagine theirs.    It seems they are happy until they are grown and have to earn a living and do not want to be farmers with a donkey.  They want a job in the village but there are none so they go to another city or another country where a donkey, so familiar a part of their childhood, does not exist.  

I work on making a birth center and the women laugh and say, "I cannot ride a donkey  in labor."  

I consider that Mary was suppose to have been riding a donkey when she was in labor with Jesus but don't say anything.  It doesn't seem like a good idea, I admit.  I understand that birth may not always be safe in their homes with an illiterate midwife but it is safer, they feel, than riding a donkey in labor for an hour or two.  One in forty- four women will die of a pregnancy related cause but getting healthcare on a donkey's back seems, they feel, to up the odds beyond reason.

Children play with a donkey near the soccer field.  There were no motorized vehicles in the area where I was living.  In the case of an emergency, a person with a moto or machine would need to be called and travel some distance to help with transport to the hospital.  Children helped with the care of the family donkey, assuring that this important resources was well fed and given water.  

Women and young girls are most often responsible for getting the household water and taking produce to market.  Owning a donkey can make this work far easier and is a much needed asset in rural communities.  Women with a donkey could load water on a special saddle and bring it from the pump.  

In the place where I lived in LaGonave donkey's were an ever present part of the landscape.  Their braying were the first sound I heard in the morning and often the last I heard before drifting to sleep.  There were parking lots of donkeys with young boys watching them at the weekly market.   It is estimated that there are 44 million donkeys being used for work and transportation world wide.  There are at least 210,000 in rural Haiti.  In areas where a donkey is a families only means of transportation, a woman must depend on walking long distances to get prenatal care. In the event of an emergency, the community must use a donkey to travel many miles for emergency care or find a motorcycle.

George is getting ready to ride his donkey up the mountainside to help his aunt  return from a busy market day.  The donkey first came to Haiti on Christopher Columbus 's second voyage to Haiti in 1495.   It is believed that they were first domesticated some 5,000 years ago on the African continent.

George's mother has died.......

George’s mother has died.

George and Rosette's mother died a few months ago of breast cancer.   She had no access to screenings or treatment, leaving her two young children to be care for by a cousin.

I watch him and his younger sister, set out into the world without her.   A cousin has taken them in and I can see that they go to school and have food. But ever since I came to his village, George has tapped on my window or knocked on my door and called for me.  The other children say, “Mamma dead, papa dead.”   It is how they define him.  George is the boy whose both mother and father have died. The children who say this, do not  live with  both of their parents. Their parents live in different cities or even countries trying to find work, trying to find a better future.  They wander too but with the hope that one-day the unknown parent will return and they will be a family once again.   No one says, “Mamma dead. Papa dead.”   There is an occasional phone call or a gift or even a visit.   Even in this hamlet with many parentless children, George and his sister, Rosette, are unique in their lonliness.

George’s mother died of breast cancer.   By the time she sought medical attention it was swollen and abseced.  It was beyond hope.  In my village, we try to find a cure for breast cancer.  They say cancer is cells gone wild.  I think of a gang of teenagers and someone saying that they have gone wild.   A bunch of adolescent cells dividing and growing and taking over the town with no sense of how to behave; no sense of order.  You want to say, “If you keep this up, something really bad is going to happen.  You are bad cells gone wild.”    They use to say some children were just “bad seed.”  It was just a bad crop and noting much could be done about it.  The next year, the next child will be better.   There was a mold n the seed or not enough rain or to much rain.  It was just bad seed gone wild.  

George’s family had little, if any, knowledge of cells, let alone cells gone wild.  No one explained the disease.  They keep saying it was a breast infection and I think how could George’s mother have died of a breast infection but it was cancer which, at the end, looked like an infection to those who cared for her.  They sent her, on the crowded ferry, to Port-Au-Prince but it was too late.   They are grinding corn in a large wooden pestle and mortar as they try to explain why George has no mother. They keep pointing to their own breasts and showing me how large it grew.  

George’s  sister eats a bowl of rice all alone.  She tries to join a game but she cannot. She is frozen.   I begin to notice that love is defined by how tight your braids are, how many there are and if they are tied off with ribbons or brightly colored barrets.  It is defined by someone sitting  down and taking the time to yank on your head and pull the hair tight and braid a hundred small braids that are shiny and black with red and yellow and white ribbons.     Rosette and the other children, living without mothers do not have braids.  

They say, in Haiti, 1 in 44 mothers have a chance of dying in childbirth.  Most of the babies will not survive if their mother dies.   There will be no milk and no one can afford formula.  But George’s mother survived childbirth and nursed him and his sister.  She got them that far.    In a country where so many children never reach their first birthday, this seems like an accomplishment worth noting.  

It is dusty and they are most often covered, like me, in a fine layer of red dust.    It collects in our hair and on our clothes.   Sometimes I look at George and the other children and we are all bathed in the earth.   We try to wash it off but it is not easy.   The water must be collected and poured over you.   Once I gave George a bar of soap and he took his clothes off in one second  and washed.   I had not meant the soap to be an order to bathe but only a small gift.   I think of his mother handing him soap and telling him to bathe.   Dis he see the soap as an order or was he just so exited to use it.   Did he have, even for a moment, a mother who cared if he was clean?

In my village, in the United States, mothers die too.  I have watched beautiful, young, talented.. loving, funny, smart mothers die.   Mothers who ate well, took good care of themselves and devoted a large part of their lives to being a parent.  I knew women who mothered everything they saw and shared their mothering arms with every child they saw, die too soon.   I am ashamed to find myself thinking their deaths are worst; not just because I knew them but because mothers in my country are not suppose to die and deep inside, death in Haiti is not such a surprise.   I can blame poverty, colonialism and the rich elite for George’s mother’s death but here I am forced to accept a mystery.  I am fighting it.  There is no one to really blame and why do I want to blame anyone at all.   It was so sudden, so unexpected, such a rare disease, an accident.  

Their children have the same look in their eyes as George.  I can see it when I run into them.    I sit in the sun watching the sea.   I watch the waves come and go; the shorelines shift and change.   I want to scream, “ I know, I know” but I do not know.   I only see the faces of the children whose mothers died before they were grown..   George’s mothers death was preventable and with early screening, curable.    Maybe other deaths were preventable and curable but how can we prevent everything.   An inner voice tells me I am not being reasonable.  I argue. I am not trying to defy death or believe everything can be prevented.   I am only asking for a moratorium on mother’s dying; on children growing up without mothers.

 I can tell it is too much to ask.    I am brought to my knees by the latest death of a loving mother.    I feel her warmth and radiance around me.   I watch soap bubbles blown into the air; small rainbows that drift until they land and return to the earth.     I want to see her again.  I want the baby to cling to her legs as she talks to me in the hall of the school.   I want to listen, once again, to her hopes and dreams.  

She climbs up on the cliff where I am sitting and George’s mother finds her way there too.    “You two have met?”  I ask.  This seems impossible.  They did not know each other.  They lived in vastly differently countries.    I think they are trying to explain the work they are doing and how there are many ways to mother.   I can see that there are many things I do not understand. I tell them to go away and just let me put my head in my hands and be sad.    Let me paint my body with clay and mud and make a fire and sing all night until I am worn down by grief.    I am not interested in understanding.

I see George and his sister and all the children who lost their mothers.    I want to shake the world and free them from this loss.  I want them to  wake up and discover it was a dream and not true at all.    Are we united by our losses as much as by what we gain?

By morning, the tides have changed and the seas have covered yesterday’s footprints.   On the mountains above me stand the nations who sing their own death songs; their own songs for mothers, for the first words spoken and lost to children taken away and sent to boarding schools.   I know death takes many forms for mothers.

Sometimes I ask my own  motherless children from Cambodia and Vietnam to try to remember their mothers; to think back on any small memory.    I remember a relative saying, “She didn’t try hard enough to live.  She gave up.  “    Another says, “She gave the food to the children. “      I want to keep their mothers alive, for them, but I cannot.  

I think of the last Star Wars movie with Obie One and Datthe Vder and Yoda altogether in the sky, offering love and encouragement to all the world below.  And then I see the mothers; the ones who passed away before their children were grown.   I know they are counting on us to raise their children.  I can see the world they are hoping for. I feel their prayers drifting over all of us all like the cherry blossoms on a windy day.

Later we walk to see an ancient  tree.  I try to explain how the mother tree fell down and began to die but also to make a bed for new, baby trees.  We call it a nurse log because it gives its last bit of life for the next generation.    Although the tree has fallen, it continues to nurture and inspire its young for many, many more years.    And in time they too will lie down and make a bed for the young to grow in as it has been done for all of time.  

I would like to say that I found peace there by the ancient tree but peace comes and goes.  I dive into acceptance and come back out in depression, despair and denial.    They say that the mother who has died had a rare disease that had no cure.  I can see that I have not accepted that as possible.   I take my sad heart out of my dreams and try to work on a plan for mobile, prenatal clinics in rural Haiti.   I think of  the sunrise in Haiti and Vietnam and rural Cambodia.  I look out on my world. I try to understand how I can live within the mystery of death while working hard to prevent the needless deaths of mothers in Haiti.     In these raw early morning struggles I am left only with a faith in a goodness beyond understanding, beyond borders, beyond history, beyond death.    I close my eyes and feel the loving presence of the mothers who died when their children were young and know that I cannot see the world as they do or fully understand.    I only can go out into the world with love for each child; with a vision of the world that honors their life and their children.

The children and the wheelchair

I met this woman and soon found out she had not walked for most of her life.  The children brought her a wheelchair that was donated to Bill Rice Clinic.  They also sang her a song and she cried for joy.  Life, at that moment, seemed so perfect and filled with limitless joy.

After English class, I said "Let's bring a wheelchair to someone who can not walk."  I started to push it but soon all the boys picked it up and ran down the road singing "We are the World. We are the children."  I could hardly keep up with them as we made our way down the road to another small hamlet.

We came down from the mountains; a story of eclampsia

“We came down from the mountains”

A father holds his wife and newborn baby in his arms as he waits for his wife to recover from  a coma like state caused by eclampsia.  She had no prenatal care and lived a four hour motorcycle ride from the nearest hospital.  The effects of an extended hospital stay and the long tern disabilities will be devastating to this family.   It is a terrible disease that with prevention, early diagnosis and referral can have less of an impact of women and their families.  

The husband is holding his wife in his arms in what could have been one of many hospitals in Haiti.   I have come in the post partum room to see a baby I had delivered but I am quickly drawn to the bed that is next to the nurse’s desk.   Something is not right.

The mother is draped over her husband’s body and is showing no signs of life.  She is in a coma like state and her baby is sleeping on a sister’s lap.   The IV bags are empty and unmarked.  The catheter bag is full.   There is no sign of a nurse, midwife or doctor.    

I gather her story from her husband who looks on powerlessly.  It is her fourth baby; a girl after three boys.  After the birth, she had a seizure.  He had to run around the small village finding a way to take her to the hospital four hours away.  They stuffed a rag in her mouth and put her between two men on a motorcycle and drove four hours on mountain roads with her seizing.   By the time I meet her she is quiet and comatose.  Her blood pressure is still dangerously high and the baby has not been given anything to eat for over 24 hours.  I look around.   When a nurse finally drifts in I write her BP on a slip of paper and point to the empty IV bags and full urine bag.  She had been my student in a unit I taught her midwifery class on the immediate postpartum.  She goes over and looks at the bag and sighs.   “Mwen ap achte pou medikama” I try to say in my broken Creole.  I will pay for the medicine.   She waves her hand and goes to get the supplies and care for the mother.   I wonder what would have happened had I not drifted by.

Another US midwife and I try to let the family know that she can still nurse the baby.  She has to nurse the baby. I pull back the dress of the heavy, unconscious woman and squeeze her breast.  There is still milk.  I show them all.  Her arms, legs, body are all heavy and unyielding.   I hold the baby to the breast and thankfully she nurses.  We hold her there for a long time as she empties both breasts and the family sees and understands what we are doing.   I know if the mother does not survive, the baby has little chance and if she does survive, the baby will need her mother to keep up her milk supply.   Formula is not a possibility but I look at the mother and wonder how she can ever survive or be normal again.  My new friend tests her reflexes and we peep into her closed eyelids.   The husband strokes her forehead and begs her to wake up.  

 The next day, I would listen at a regional meeting of healthcare providers ,as doctors made fun of village men searching despretly for transport for wives who were seizing or bleeding.    ‘Why would they ask us?  They don’t even have a way to the hospital.”

Their scorn drifts over the table.   “Our cars are for our work.”   I wonder if the man they are making fun of was the father in the hospital; the family I had gotten to know.   I want to say that whoever donated money to your NGO, expects you to give people who are dying and inured and sick a ride to the hospital.   A kind doctor persisits, “But if you are going that way anyway, can you take a patient.”   The doctors of the well funded NGO,  reluctantly agree it might be possible.   It is unlikely but might be possible.  They explain that their  program is for AIDS  and not, I reflect, for postpartum mothers with four children to care for.   I want to ask what if she is a postpartum seizing, bleeding mother who may also have HIV but has never been tested.  How do we even know if she has HIV and qualifies for a ride in the expensive new vehicle.  The conversation is beyond reason and goes on for sometime as we drink cokes and shuffle in our seats.   

Two men are dominating the conversation; one is from the government and one is from a well funded NGO.  The kind rural doctor persists. 

“We need ambulances to bring people to town. This year can the government get us ambulances. “

“Ask your NGO. “  Everyone laughs.   There is not one ambulance system for everyone who  may need it.  There are cars and trucks, paid for by school children and middle class donors in the USA and Canada, that are used as private vehicles for employees.  

There is, I can see, a class system within the established healthcare system.  Some people have vehicles and some do not.  We are there to coordinate our efforts.   We are like the father with his seizing mother standing in the road trying to get help as the “ambulance” goes by.   I am tired of the circular arguments for doing nothing.  I am developing an after lunch bad attitude.  

After the long ride back the town, I go and check on the mother and baby that I have adopted as my personal post partum patients.   I unwrap the baby and make sure she is fed.  The mother has opened her eyes.  They say she can not see but when she asks why there is a white woman there, we all laugh and are happy because we know she can at least see that well.   The IV has come out of her arm and is poking her.  The urine bag is full and her BP is still high.   

The nurse tells me she is waiting for a doctor but at last gets up and fixes the IV but it is still empty.   I wonder how long it will take her to recover, if she ever does, with this care.   In the delivery room, a pediatrician sits and visits with the midwives and nurses.   I count six.   There is a medical team from the states but this is not their exact job.   They are both on the verge of death but it is not anyone’s job to take care of either of them.   I persist.  I am only one woman in a sea of people who need care but I persist with this one woman and baby.  I had watched a baby starve to death in that same room a year earlier so I was not giving up.   I had watched children orphaned by eclampsia so I was not giving up, even if it was only to put the baby to the breast, take her BP and bother the staff enough to make them respond.  

We are having many discussions, at meetings and in the guest house about mothers and families like the ones I am watching over.   This is the question, “If you have limited money, where is the care most important.  Is it more important to do mobile prenatal care, provide transport or focus on the hospital?”

This hospital has a grant for a new NICU and a new c-section room.   There are many volunteer medical teams and a great deal of financial support.  Staff are paid by US based NGO’s but no one believes it is their job to make sure this mother and baby do not die.   She does not qualify for the NICU as she is in the postpartum room and is alive.  It is too late for a c-section.   The father has worn the same shirt for a week and has no food or water.  The mother, when she slowly wakes up, has no food or water.   We give him a few dollars for food and water.

Back to the discussion, I vote if I must, for mobile prenatal care as the most important.  They are all critical but it seems the hospital has the supplies and staff to provide emergency care if they want to.  

The mother had no prenatal care and none was available to her.  There is no way to know if she had a high BP in her pregancny and that if, with identification and treatment, she might have been saved this ordeal.  She says a few words but she is clearly on a long road to recovery and may be disabled for the rest of her life.  Had she been identified she could have come to town to give birth in the the hospital and could have been given medications to prevent eclampsia.   The condition she is in was preventable.   Her other children are somewhere and they can not contact nayone to know how they are .  The husband is not working.  The mother cannot take care of her self, her baby or the other children.   The whole family system is entering a crisis.  The older children may have to leave school and suffer malnutrition.  

I vote, if I must, at this point in time, for prevention and prenatal care.  Then I vote for safe transport.  Most woman have their babies at home with their traditional village midwives and it will  be like this for some time.  At the rate, Haiti, is training skilled birth attendants , it will be decades before women have access to skilled car at birth.  They are  living in remote areas with poor roads.   

I go everyday.  She smiles at me.  I cannot tell what she is thinking or doing.  Her BP is high but better and she has taken a few steps with assistance.   They are preparing to send her home on a motorcycle.   She will most likely not receive anymore care.  

If there was a mobile prenatal clinic with postpartum agent sante’s someone could check on her baby and her, when they arrived home but instead she will slip into the mountains and not be heard of again.   No one will know how they survived or if they survived.   I try to explain ecalmpsia and to say that it was no one ‘s fault and how sorry I am. The father nods.  Perhaps though the nieghboors will consider it a curse or a punishment for some unknown bad behavior in the past.  Without village by village preantal care and education, who knows.  

A translator tells me its epelepsi and is caused by being crazy.  I tell her this is not true at all and she must translate what I say word for word and not say things like that.   I can tell she does not quite believe me or that maybe there is eclampsia in the United States but in Haiti it is epelepsi and caused by being crazy or cursed.  She does not believe I understand Haiti at all.  She says sometimes its better for people to die than to be crazy and have siezures.   “Its how it is in Haiti.”   I suggest that perhaps the mother an dher family do not want her to die when it was not necessary.   She shrugs and checks her cell phone as I rub the mother’s legs hoping I can somehow bring them back to life before the long mot ride home.  

Back at the discussion table, if I must have an opinion, pick one over another I vote for mobile prenatal clinics and transport over more hospital staffing.   I vote for education and care during and after birth but none of it is an easy decision for small NGO’s with limited funds.   

We are midwives. Midiwives can sit with the matrones, high up in the small, rural villages and offer education and care and help sort out who needs to go the hospital and who is most likely to deliver safe at home.  The midwives can walk to homes with post partum agent santes and check on nursing babies.   This is the walk of midwives; heart and hand and woman by woman.  I am not sure what the large NGO’s will choose to do with million dollar grants to make the hosptials better, should women need them but in the mean time I vote for midiwferey care, village by village in the rural coummunites of Haiti.   

As we sit and talk, the family I cared for, is heading home and soon so will I.   In the village I come from we do not have small, local midwifery care before and after birth either.  We too have placed our healthcare dollars into the new NICU and not into the communities women live in.   We focus on high tech care and not prevention; in my village and theirs the understanding of the role and possibility of midwifery care is compromised.  In Creole they say, SageFemme or “Wise Woman”.   They are not meant to be bored nurses acting as the arms for overworked doctors.   They are the entry level to care that is preventative, heartfelt and educational.  They belong in the neighborhoods and villages with soft serhcing hands and voices helping women to have safe, healthy births long before they end up, as this woman did, in a coma and most likely disabled for life.  

   

A grandmother walks a baby to sleep In Haiti

The matrone's grandfather

The matrone’s grandfather

Matrone is the affectionate term for the people in the community who help with the birthing of the babies.  They live in the small, remote villages that are tucked into the mountains that surround us.   Sometimes people walk over to their house to give birth and sometimes they go there.  It all depends.  They are both men and women. 

A matrone comes  and sits with me for a little while.  She tells me her grandfather taught her to be a matrone when she was sixteen and she has been one ever since.  Actually, he taught all his grandchildren to be matrones and pretty much all of the people delivering babies in the area are his relatives and learned from him.

She caught her first baby when she was sixteen and went on to deliver twelve more babies for that family.   I give her a bag with some educational pictures in it; things h she can show the women in her village.   There are pictures of babies in various forms of fetal development on a metal ring with educational drawings on the back.   There is a small, handmade book of anatomical drawings related to reproductive health.   She looks at them and nods.   She has been doing this a long time without such drawings.   I am not sure if I foolish or helpful.   She is training her nieces and she says they will like them and she, of course loves the new bag they are stored in.

 She proudly wears a badge that indicates she has had some training through the clinic.   After she leaves I figure that she caught her first baby around 1964; around the time the United States government started supporting Hatien dictators out of fear of communism.   She caught babies under the watchful eye of Papa Doc’s secret police and then in the background of Aristede’s liberation theology.   Governments would come and go as she walked these familiar paths and watched babies be born, grow, walk away never to come back, and have their own babies. 

I ask her how many births she does. She both smiles and looks weary.   Then laughs,

“anpil” which means many.    I think of a grandfather training all of his grandchildren to deliver babies and the legacy he left here amongst the rocky places where goats and children climb and play as the adults sit in the last light of day around the three large rocks of the cooking fire. 

When the singing stopped

When the singing stopped

A man was brought to the clinic and stayed the night.  I know he is an older man  because  many of the children from my English class tell me their grandfather is there. They say he has a fever. They hang around my room and draw pictures for my art wall.   At dusk the family gathers in greater and greater numbers and begins to sing.   Mothers, wife, sons, daughters, children, cousins and friends; they all sing.  There are solos and times when they sing in unison.  I go to sleep to this song.  It is so tender, so sweet, so heartbreakingly sung for a beloved grandfather.  The music softens and someone prays.  I go to sleep to this; the singing and the prayers.  

The next day three more people are admitted with the same fever.   The nurse tells me its typhoid fever.   We also have a woman in labor.   Once again they begin to sing.  The laboring woman is draped in her sister’s arms and all around us is the singing.  They begin to pray with a deep devotion that almost sounds like speaking in tongues.  There is singing and then prayer.  It is becoming more and more powerful; the contrast of sweet, tender melodies and rhythmic prayer.    The woman’s contractions and the songs and prayers; the being born and dying working in unison. 

Then a person of authority comes down the hall, enters the room and after a few stern words, the singing stops and does not return.   The silence is a heavy thing all around me the rest of the afternoon and into the night.

Note

As I write this, they have started singing and praying again.  Perhaps it is a new shift of relatives or perhaps they answer to a higher authority.   It is dark and the singing is as sweet and tender as always and the prayers most deeply prayed.   Sometimes the singers are background music to the prayer.   The music is like the wind and rain and sea and sun. In it, there is no suffering or hardship.  There is only beauty and a love for God that is tender and all encompassing.   It does not blame God for all they haven’t had or even beg for more.  The song seems to rise above the earth and bless us all for that is good and beautiful.