Outline of my workshop with photos

Workshop outline with photos

Training in the Russian Hospital in Phnom Penh

Objectives:

To create a cross cultural dialog about maternal and newborn health

To reinforce the maternal and newborn health polies of the World Health Organization as a unifying multi-national norm.

To reinforce the millennium goals of the United Nations regarding maternal and newborn health as a multi-national norm.

To demonstrate curiosity and respect for traditions related to childbirth; to reinforce the concept that many cultural and historical practices may not be harmful and can be continued.

To teach the curriculum of Helping Babies Breathe

To teach the value of skin to skin contact after birth

To teach the value of early initiation of breastfeeding and exclusive breastfeeding for 6 months.  

To help make health centers aware of The Baby Friendly Certification as a unifying mulit-national goal.

To discuss and answer questions regarding things that may cause a baby not to breathe.  (Position of the mother, drugs, shoulder dystocia, breech)   This is based largely on concerns the midwives generate.   Shoulder dystocia was brought up many times.

To answer questions about birth in the United States and discuss topics based on their interest (C-section rate, support people in the room, position, water birth)

To give each birth center an ambu bag kit.

To interview traditional birth attendants/ midwives and document their stories; to thank them for their work.  

At the end of each training the health center was given new supplies from Helping Babies Breathe.
These supplies were made possible by the donations of friends and family

Teaching materials

Picture of a midwife at Angkor Watt to demonstrate traditional birth practices in Cambodia.

Helping Babies Breathe Materials – NeoNatalie Dolls to practice with ambu bag and suction.

Films from utube when possible 

Demonstrations with a cloth baby, placenta and pelvis

Newborn baby stomach kit ( showing the size of a newborns stomach)

Demonstrations of maternal position and role plays 

Practicing how to help a baby breathe with an ambu bag
Breathe- two- three

Workshop set up

If possible, gather in a circle with the babies and birth equipment on a table or on a mat on the floor.  

Wear pants for ease in demonstrating positions during birth

Pass pictures and teaching aides around the circle

Arrange for refreshments and travel funds as appropriate

Give certificates and breastfeeding education kits to each midwife

Create several stations for practicing with the ambu bags and Neo Natalie

If possible , arrange for short films of natural latch, skin to skin, kangaroo care

Introductions

Introductions, followed by a  simple hands up activity  for a  large group. In a smaller group we simply introduced ourselves and shared our experiences and training as a midwife.

Raise your hands if

You are a midwife

You are a student

You are a doctor or medical student

You are a nurse

Raise your hands if

Have practiced for 1 year, 2 years, 5 years, 10 years, 20 years

If someone in your family was a midwife ( let them share )

If you were born at home

If you live near by

If you ever had a baby yourself

Raise your hands

If you ever had a baby not breathe at a birth

If you ever had a baby be born prematurely

If you ever saw a women with eclampsia

If you ever had a woman bleed too much

I raised my hand for all of these.  

 Share the agenda.  

Statistics

 Share global statistics as well as in country statistics including under 5 data.  I share United States statistics, highlighting the problems with prematurity, high c-section rates, low 6 month exclusive breastfeeding rates and high induction rates. These can be found on line. I let them know we all have work to do to make the lives of women and children and society better.

I let them know that midwives are so important in any country and thank them.  I encourage them to ask their own birth story and to talk with traditional midwives in their community.

Ancient Akgor

In Cambodia I passed around a photo of a woman giving birth from Angor Watt and the midwives.  It is powerful because she is squatting and being very tenderly cared for by many women.

Setting up for a birth

 Demonstrate, with the midwives help, setting up and being prepared as in the HBB Curriculum.  Most birth rooms do not have the right ambu bag, one that works, or it is in another room or building.   

Normal birth/ routine care

This takes about an hour and is a good time for films, if possible.  Most health centers and hospitals suctioned, took the baby away and encouraged bottles for the first few days.   Given the high under 5 and under 1 mortality rates, I devoted time on the first 30 minutes after birth as a way to prevent some of these early deaths.

Skin to skin for 30 minutes

No suction in a baby that is breathing

Natural latch

Letting the cord pulse for at least 3-5 minutes.

When the baby does not breathe

I tried to go on a tour of the birthing rooms before the workshops so I could see the set up and practices.  At this time I also inquired about the protocols around babies who do not breathe at birth.   I ask how often the midwives are trained in NRP and what they do.  I ask about the centers statistics.

Helping Babies Breathe

I flowed the HBB curriculum with an emphasis on the Golden Minute and practice.  My groups were far too large.  They suggest 1:6 ratio of instructor and learner and I sometimes had 50 midwives.   This photo was taken at a training at a district hospital in Cambodia.   The lead midwife actively assisted the new midwives in learning how to use the ambu bags.   They have asked for 50 of the new suction devices and their won teaching materials.   The head midwife is responsible for many  rural health centers.

Concerns

After practice I let the midwives ask questions about the USA or birth problems they encounter.   They often had concerns about shoulder dystoria and I was able to show two positions that have good results.  

Thanks, photos and certificates

We often ended with photos and kind words and in two cases I was quickly ushered into births to show them what I do.  This was difficult but I did the best I could, emphasizing skin to skin and trying to get the woman up off her back.  It would take some time to model such things but I tried with the rooms bursting with all the participants.

Follow- up

Many were interested in future workshops.  

Things I would do in the future

Expect more participants than planned

Bring business cards to give out

Pass out helpful internet links

Bring more teaching sets

Give each midwife the baby’s stomach set and some teaching cards

Future workshops

I came away feeling that Vietnam and Cambodia were both eager for training opportunities and that government officials were supportive.   This is what I would suggest to myself and others:

Work with a whole district on a set goal such as being a Baby Friendly Hospital with UNICEF recognition

Bring more trainers.  Make sure the trainers have time to learn about the culture and some language before working.   Train these trainers. 

Work on a district level to train the trainers. Leave them training material

Work on a health center level to train the midwives and model if appropriate.

Model postpartum home visits as part of breast feeding goals

Teach family first aide in small villages

Bring midwives small gift bags with baby stomach models and teaching cards and a small gift.

Embed history and culture into the visits.  Ask the midwives to teach something too and pay them.  They are all great at stitching and giving IV’s.  

Nathan and the elephants of Cambodia

Nathan

Nathan is the second son of my only daughter.   Fourteen years and two days after he was born, we said good -bye to him in the emergency room of a hospital.  He had shot himself with his father’s unlocked, loaded gun.  They landed a helicopter in his father’s suburban yard and flew him to the city.

At the hospital, everyone is crying and screaming.  My daughter cannot stand.  Somehow we must get from the room where we are waiting to where he is lying.  She says, ‘It is like the war all over again.” 

He had already died.  They were just keeping him warm and breathing so we could say good-bye or perhaps in the hope we would donate his eyes or organs.   I am sorry we could not have thought more clearly about this.  I am sorry he is not out there some where, even if it’s a liver in another body I will never see.   In Cambodia, they would have a party to honor him but we have just gone to the mountain for three days together and do not do anything.  I spend the days between his birthday and his death day suspended in a quiet desperation.  

In Cambodia, no one told his cousins he had died.  They say, “Where is Nathan?”   I say,  “Nathan is dead.”   The cousin sits with me for many hours trying to understand why he killed himself and why no one told him.   They say suicide brings shame to the family so no one can talk about it there.  It is a secret.

I tell the cousin that hatred, pride, war and greed kill people everyday; that Nathan’s death was caused by these things.  I explain that the effects of war never really end and that we feel the suffering for many generations; even if we cannot name it.   There is not much evidence of the war in Cambodia.  There is the Killing Field Monument and a museum of the prison but really not much for the younger generation to hold on to.  They all seem to blame the Vietnamese.  I say that won’t do anyone any good.  Its just creating more hate and that gets us nowhere at all.  

In the United States, Nathan’s Dad beat his very young wife and teased Nathan.  Nathan’s father was the spoiled youngest child in a large Cambodian family that prided themselves on being Chinese. Even after all they went through with Phal Pot, they cling to illusions of class.  He tells me he beat my daughter because he was beaten under Phal Pot.  I say many people came out of the war and did not beat their wives.  When she finally left him and married a loving, healthy man, Nathan was already torn apart, tossed around, used as a negotiating chip and sinking fast. 

He came into the world peacefully and then grabbed on to it with all his tiny might.  He laughed easily and was enraged at small injustices.  He was a bolt of fire across the sky.   This exuberance turned into depression as he became a teenager.

The end of my marriage, Nathan’s death, the unraveling of the school begin to grow into one aching beat within my heart.   I did not trust myself to keep things alive. 

In Cambodia, I look for little boys with curious minds and a twinkle in their eye.  I watch them with so much longing and joy.   My daughter and I see such a boy and smile and say, “Ah there goes a child like Nathan” and feel some happiness in this.

In my country, in my school system, he was one more second -generation child of a refugee.   He told me, “ No one has ever heard of Cambodia.  They thought he was Mexican or they called him ‘China Boy.”   He was teased at home, at school and in the community.   In his school district, many second- generation refugee children from Vietnam and Cambodia killed themselves.     The post traumatic stress, the expectations, the abuse were too much.

I was Nathan’s midwife and his grandmother. 

After he died, people donated money to buy a well in Cambodia.  The monks said we had to do something like this because he committed suicide.  My daughter suggested I use this money to buy medical equipment for the rural health centers of Cambodia; places where midwives worked and babies were born; places of spirit houses.

Once there were elephants all over Cambodia but now they are almost all gone.  I ask, “When did you see the last wild elephant?”   The old people consider this and say, “Sometime before the war.  They ran away to Thailand during the war and never came back.”

Nathan ran away and never came back.  Perhaps he is with the elephants.

Agent Orange

Nhan takes me to the War Remnents Museum in Saigon.  It is in a large building with a courtyard filled with US war planes and helicopters.    Although Nhan lives in Ho Chi Minh and was a child during the war, she has never been in the museum.  She reads each sign carefully and for a long time.  She has these experiences but they were not connected to the greater political and historical context of the war.  They were a family of 18 children running around trying to survive.


I can see that good fortune, for her, is based on hard work as well as paying respect to ones ancestors who can offer protection and good fortune.   Even the most simple home establishes a place to honor the ancestors and most have an outdoor spirit house for a daily offering of fruit, flower and incense.  Although I ask  for more information about the spirit houses, I could see that they were such a part of their life that my questions seemed foolish.  No one asked why.  It just was.  This was what would protect them.

If the last babies, born to Nhan's mother died, no one questioned why.  The country was suffering from severe drought and famine and  the country was recovering from war.  There was very little healthcare and so a baby born too early and with birth defects would have slipped away without understanding the lingering effects of the war.

In the museum there are rooms full of pictures of children who suffered from birth defects caused by Agent Orange.  Twenty-one million gallons were spread on southern and central Vietnam to defoliate the landscape where North Vietnam soldiers were hiding.  24% of South Vietnam, or an area the size of New Jersey was stripped of all crops and forests.  Two million acres of forests remain without trees today.

The spray, manufactured in the United States, was spread by plane, helicopter and by hand.  The barrels it cam in was later used for water barrels, showers, and barbecues.   It was made of Dioxin, a chemical that was known to cause birth defects.

The Vietnamese Red Cross estimates that over 150,000 children were born withe birth defects. The chemical was also sprayed over Vietnam and Laos.  As I look at the pictures I feel, along with everyone else, deep waves of nausea and grief.  We walk quietly from room to room.

In Cambodia, I talked to a midwife and she told me about these births of conjoined twins and how they were her hardest births. I remember thinking that most people never see such a birth and I am amazed she delivered them at all.  I think this but the I am in the museum and in the Agent Orange Exhibit, I see all these conjoined babies and think of how she seemed to have no idea of its cause.

Service men, who worked around Agent Orange or sprayed it also had babies with birth defects, though it would take make years, many law suits and may public health studies to get the government to take responsibility and provide care.

Aschengrau and Monson of the Harvard School of Public Health conducted a study published in 1990 in the American Journal of Public Health on paternal military service and the risk of late pregnancy outcomes. The scientists reported that Vietnam veterans’ risk of fathering an infant with one or more major malformations was increased at a statistically significant level.

Although the US government has paid $47 million dollars for the victims of unexploded bombs, it has refused to help the many people who need health care and support due to disabilities caused by Agent Orange.  Somewhere in my country there are wealthy families who profited from their stock in Dow Chemical and other chemical companies who made Agent Orange.  Perhaps that wealth has been passed down to children and grandchildren.  

On the news, people range about unemployment benefits but no one talks about all the people who got a hand out from the US government by supplying chemicals that caused the death and disability of children in our country and SE Asia.  

The war in SE Asia was not fought for democracy.  If it was, we would have supported the elections called for by the treaty that divided North and South Vietnam.  We would not have placed a dictator in the place of democracy.  This belief in Democracy, even if some did not like the outcome, would have saved millions of lives.  We fought the war, not for political freedom but for the freedom, for some companies, to make money, regardless of its impact on others or the environment.    

The people in Vietnam, with disabilities caused by Agent Orange, are our spiritual children.  They are the legacy of my country and we have to make amends, both here and there.  The children of the people who owned the chemical companies enjoy fewer inheritance taxes than prior generations.   The money exists but it is concentrated in the same hands that fought so hard to send young boys to spray a chemical they new nothing about.  It is unlikely that the children of the chemical companies ever went to Vietnam.  

Today, women struggle to get pregnant, supporting a billion dollar fertility industry.  Babies are born premature and our schools struggle to care for an increasing number of children with learning disabilities.  In our hearts, we know we are being sprayed, with today's version of Dow Chemical.  We know but it is not easy to see and we do not know how to stop it.  Coal Companies, oil companies and chemical companies spill and toss things not good for any baby into the air.  

I sit at a table, in Vietnam, with mothers who gave birth during the war.  "It was not birth who killed our children. It was other things.  We were not afraid of birth."  




 

My Journey Continues...to Southeast Asia

An Introduction

In 1980, my family grew to include children who had fled the conflict in Southeast Asia.   They made their way to refugee camps in Thailand and Indonesia by foot and by boat and then as, orphans and unaccompanied minors, they arrived aour house in Portland, Oregon.  I was thirty-two years old, pregnant and already a mother to two young boys.  My husband was in medical school.  We felt that love could accomplish all things and were children ourselves of the idealism of our generation.  Our old wooden house would burst to overflowing as we faced, unprepared, the joys and challenges of bringing young people into our community who were sick, frightened, homesick and lonely.  

Thirty-three years later, I made a trip to Vietnam and Cambodia with two of those now grown children. I had been to Cambodia twice before with my daughter but it was my first visit to Vietnam.  I had volunteered as a midwife in Haiti and Gahanna and wanted to spend some part of my trip with midwives.  They had grown up with a midwife- mother and knew this to be my particular and peculiar passion. 

I was interested in how Vietnam and Cambodia’s midwives had managed through bombs, famine, genocide and years of conflict.  I wanted to know how they became midwives and who helped them along the way.  I wanted to know how their new governments had made the transition from war to peace while improving the maternal and newborn mortality rates of women and children.   I wanted to know the situations in which my own children were born; of the practices and women who helped them take their first breath and survive.

I had wanted to offer the midwives of my children’s countries some small gift and so

before leaving, I had decided to offer training in newborn resuscitation through Helping Babies Breathe.  I packed training materials and 40 ambubags to give to local birth centers.  My children helped me to make contact with many local clinics and others I found through NGO’s working in the countries.   Through them I gave many workshops, observed birth in a variety of settings and had an opportunity to meet many midwives. 

I had become a midwife in the post  Vietnam war years, when many of us struggled to create a way of life that would eliminate the causes of war.  During this time, we formed food co-ops, schools, community gardens, and some of us were drawn to birth.  I was working in Head Start and saw the harm of drug and alcohol use on the unborn child.  I saw the need for parenting to begin long before my four- year old classroom.   A co-worker asked if I would go to her teen age daughters birth classes and birth.  It was my very first birth and I sensed then that in that place I could find, for myself, the moment where heaven and earth touched.   After so much conflict from war, the civil rights movement and protest I felt a possibility of healing and peace.

I began my journey, as a midwife, slowly but without hesitation.   In Cambodia, a midwife told me she was woken by a dream that told her to go and help a neighbor in labor.  We are all perhaps, offered these dreams but it is often hard to get out of bed and follow them.

This is how it was for me, both as a midwife and as a mother.  Once I knew that children from the refugee camps needed homes and families there was really never any turning back.   Once I began to listen to the story of birth there was no choice but to listen.

While women in my country were making connections between war and corporate control over every part of our lives, the women in Vietnam and Cambodia were struggling to heal their communities and their families.   Over and over again the women and the midwives told me that it was not birth that killed them or their children but war and famine.  Most women had many children during this time and all, that I spoke with, lost several to starvation and a lack of basic medical care.  I was reminded over and over again how deeply war impacts women and children and their ability to survive and protect one another. 

In these stories, I try to capture the impact of war but also the resiliency and courage with which women preserved their families and their communities.   As the guide in My Lai said, “It is hard for your generation of Americans to come to Vietnam.”  It was often very painful and full of heartbreaking memories.  Coming face to face with the lasting harm of Agent Orange on newborns left me sobbing with embarrassed, powerless, pent up tears.

Years ago, I had stood in silent vigils  asking for the war to end.  It felt right, no matter how difficult, that I make this vigil and stand beside the women and midwives of Cambodia and Vietnam.  I tried to feel peace and to let my heart, so broken by the actions of my own much loved country, heal. 

I am forever thankful to my children’s families who fed me, introduced me to older midwives and helped me find my way from place to place.   For all the cups of tea, laughter and nights spent sleeping together I am grateful.  To all the midwives of the world who deliver each and every baby with a silent prayer for peace in their hearts.  For all women who deserve to give birth in peace and to raise their children with enough food, a free education, health care and a clean environment.

A photo of my children who came from Cambodia and Vietnam as adults.