Clinic Day

School children watch as the midwife listens to a baby's heartbeat.  

I love the drive  along the sea and up into the mountains of LaGonave. I study the soil and how many domesticated animals people have.  I notice if children are in school or walking along the roads.  I notice the location of the central market and how far it is form the village we are visiting.  Was World Vision once serving the community and is there now a hole in past services?   I notice these things as we pull into a lovely cluster of school and well and church.  It flat and the soil is a rich, dark color with well tended crops.  The churches large and all the buildings are well cared for.  This village has a strong partnership back in the United States and so perhaps this is the result of  long term care and support.

The ajan sante greets us.  There is no sign of the matrons and I wonder why.  We set up the church, pulling a series of shower curtains on a rope across the church.  They are sue to mobile clinics and know what to do. This is not true in our next site.  But it is always the same process sod setting up and turning any available site into a clinic while women sit on steps or under trees.

The midwife provides prenatal care on a school room floor.





The mobile clinics see about 25women on their first day. The plan is for the midwives to return once a month.
For the entire island to gain access to care it would require about 20 mobile clinics visiting villages once a month.  If each village had 50 women who needed care ( prenatal, postpartum and family planning ) it would cost about $2500 per village or $50 a woman.  With the ability to choose pregnancies and to gain reasonable assurance that they and their children would survive pregnancy and birth, families can begin to build strong futures. That women can choose when to have a baby and can have a chance not to die in birth is a human right.   What we need is 20 groups to adopt one village and to have that process run by the women of LaGonave; by the midwives and agent santes and mothers.   This seems pretty basic, right?   Its about like saying, there will be no rocks on the roads.  It seems impossible.

Getting ready for the mobile clinics

 I returned in June of 2014 to LaGonave, Haiti and tried my hardest to begin a process of establishing mobile prenatal clinics in remote villages.  Four villages were chosen by The LaGonave Partnership; a group of US churches who support and maintain a relationship with a village on LaGonave.  All the villages are connected by the Episcopal Church that appears to act as the governing body.  Each village has a small church with a lay leader, a school, a school lunch program and an adult literacy program.  All have a community health worker who lives in the village and, in theory, provides day to day health care.  The villages are 1-3 hours from a hospital, over very poor roads. in the event of a matronal emergency, it is unlikely the mother can reach care.  It is uncertain that there is a means to get her to care or that mergence services will be able to care for her should she arrive in time.

Meeting with the midwives, akan santes and matrons to play the new mobile clinics

The goal of the mobile clinics are the following;

1. To prevent, through education, screening and treatment, maternal and newborn problems leading to death and disability.
2. To allow families to build local economies without the additional burden of health care costs, orphaned children and the death of a mother.
3. To identify women who should have their babies in town, closer to emergency services.
4. To provide prenatal vitamin, safe birth kits and other medications as needed.
5. To support the collaboration of the the midwives, ajan santes, lay leaders and matrons.
6. To provide transport in the event of an emergency.
7. To provide safe waiting homes for women presenting with high risk pregnancies.
8. To provide life saving measures and medications to women in remote villages.

Everyone has fun practicing skin to skin birth techniques at a training on preventing postpartum problems for matrons, midwives and ajan santes.

My schedule for the "launch" of matronal/ newborn mobile clinics was intended to be democratic, inclusive and involve the people it would impact most,  in the decision making.  Within hours, if not days, I was made aware that there were no medications, no complete charts, no educational materials, and that the midwives and not been paid in months.  The "ambulance" is the car for the church.   All decisions go through the Father and must wait his approval.  The doctor, who is the medical director, also must ask him for everything; copies, medicines, water.  There is no system of independent, creative problem solving.  While I have worked for over a year to empower these two midwives to be critical thinkers, independent, responsible and caring practitioners, they are part of a large, complicated system that stretches across seas and countries and moves very, very slowly.  Despite this, bags are packed and we go to the villages ties and hold the clinics.   

"The women just die. We cannot get them anywhere."

After a crazy, wet speed boat ride to LaGonave from the mainland, I tumbled into the Episcopal Church where the lay leaders sat in scattered chairs waiting to meet.  I tasted like salt and was still dizzy from the ride.  I had not actually known they were really coming.  I had asked for the meeting but there they were.  The lay leaders are the ministers of small, distant villages who take care of the small churches and schools that are sponsored by the parish.   They are the leaders and had wanted to get  their support and advice in the starting of the mobile clinics.

I ask for their names and villages and what problems women faced in childbirth.  One by one they told me the same thing. Their village is hours from the hospital and mostly they do not try to get women to the hospital.  She simply dies.  It is too far.  Sometime, they said, they carry her on a bed down the mountain but even if they get to the hospital they might not see them.

There is no prenatal care.  Never.  World Vision use to supply some in some places but they left.

I explain that the clinic is sending a team out to work with their matrones and agent santes and that they will come once a month to provide some care.  In time, we hope to send a nurse or doctor who will also provide primary care.  I explain these things.  I tell them it will be free.  I explain that they can come to Bill Rice for free too.

Although the Bill Rice Clinic had been offering free prenatal care since I left, I could tell that no one had told them about that or about the birth center.  It is often too far, it is true, but they were not told.

As they talked about the many mothers who die each year in their villages, I felt  waves of such sorrow and injustice.  

I look at each village on the map and wee how far away they are and how difficult it is to get there.  I listen to what they tell me.  "The matornes have never been trained."    "We have no vehicles at all if something goes wrong."   "They bleed to death."   "They have eclampsia and never wake up."

The Hatien doctor, says each woman needs 3 sonograms in pregnancy.  I look at him in disbelief.  Is he listening?  They have no prenatal care and sometimes no matrone even and no transport in an emergency.  He is a sweet, charming man and he is the director of the program.  He had doubted this was possible but I hope by listening to the stories he feels a deeper commitment.

We have 10 days to set this in motion.   It is not too difficult but it is at the same time almost impossible.  They have to get to me or I have to get to them.  It is hours on bad roads.  The training takes time and yet their is not enough time to train people in skills often reserved for specialists.   We must prepare supplies and try to get a system of reporting and charting organized.

Kenel, who I met at Midwives for Haiti, is translating for me.  I am trying to help him with a farming internship in Oregon. He is starting a Fruit Trees for Haiti Project.  He does a good job and later we walk down to the small port and visit with the people who work there.  It is a warm, lazy evening in Haiti.  Tomorrow is a training with the matrons and agent santes.  I am hoping to build this sense of a health care team in the villages.  We review films and pictures and then I sleep until the church bells wake me at dawn.

Returning to LaGonave - June 2014

Lagonave

June 2014

The waiting area at the Fort Lauderdale Airport is filled with Haitians who happily greet one another. They form small, happy groups who visit until it is time to board the plane.  I let the sounds of Kreyol spill over me and drift back into my heart.   I speak in my awkward version of a language that is meant to be rhythmic and full of life.   My attempts are slow and labored as my brain switches gears and looks for the right words.

The people, who wait with me, have the means to travel back and forth and are a long, long way from the mountains of LaGonave.  They have money and a visa.   I wonder if they know what it is like for so many Haitians. But then someone could say that in my country too.   Do they look at me and think- ah a white missionary coming to save the souls of Haiti?  I say I am not a missionary but a midwife and they smile with a shrug.

I am never sure that the Haitien people would put maternal and newborn health at the top of their wish list.   They are ranked the highest for infant and maternal mortality in the western hemisphere but I suspect that data means far more to those of us committed to global maternal health than to the individual person in Haiti.   I remember the Haitien social year doctor telling me the statistics were all part of a plot against Haiti and were not true.   But then US medical people also gave me articles saying that the placement of the US alongside Cuba was also not true and a plot.   The rankings are suppose to make a country want to try to improve; not dig in their heels and defend what they are already doing.

I doubt myself.   I get sick and throw up in a planter in the airport.   Am I sick or is my body rejecting another plane ride and the wear and tear on body and soul I am about to put it through once again.

I had hesitated to come.   I had said I would return if they ever wanted to get mobile prenatal clinics up and going.  It was an offer in the midst of hopelessness.   Your island and your health care system are so broken there is not much of anything I can do to help but if you ever want to have mobile clinics I think it would help.  I also say that it should have village leadership. I picture small, rural maternal/child health councils where women demand that they not be left to die in childbirth.  My mind drifts and I see the women standing up to the powers to be; marching to Port-Au-Prince and demanding healthcare and transport.   I say it must be a grassroots form of care with the matrons, agent santes and lay leaders. 

My last experiences in the hospital in Henche had left me believing that the village system has to be given the tools of education, diagnosis and transport.  We use to debate, which comes first prenatal care or emergency obstetrical care.  Of course we wanted both.  But, we would say, what if we had to choose. I am a midwife and an educator so I chose the village and mobile clinics.  But it is jus tone part of the puzzle that includes prenatal care, a means of transport, a skilled birth attendant and then good care should you need a hospital.   In LaGonave I have offered to help with the prenatal care and transport plans.

In the days, leading up to me leaving I am not sure that the villages have even heard of the new prenatal mobile clinic system, let alone be involved in the planning and implementation.   They cannot even tell me what villages we will visit.  They say the ones on the list are too remote and we will all get tired visiting them.  I try to explain that this is the exact reason why they were chosen. Emails fly and I feel caught.   The premise for my returning was establishing community based maternal health care and no one seems prepared for this.    I think of my gardens and grandchildren and projects I am working on in Portland.   I think how I might cancel my ticket to Haiti.   I do not want to go down and be a white person arguing with the powers to be for the basic medical rights of women in Haiti. 

My piles of pictorial teachings lie in folders. I make graphic plans of how it all could work.  I look at my countless workshop plans.  I have downloaded films.  My approach was to include the lay leaders, the matrons, the agent santes and the midwives.   I was going to try and build teams that solve problems and work together.     I know that I appear casual in my dress and in my manner but I am a person who cannot live a moment without a notebook to write plans in.  I am a planner and they are not.  I have sent my training plan and they send me back shrugs – we can talk about it when you get here.   I sent the plans months ago and I do not want to go without a plan.  I have ten days for this and want every minute to count.   I have not recovered from the eclampsia and

Cardboard box of dead babies from the last trip.   I need a plan.   Was it too many years as an administrator?  Trainings have schedules, start and stop times and plans.   I cannot, it seems, go in without a plan.  I have tried it before in Haiti but not again. 

 But I consider the woman with eclampsia in the hospital bed; in a coma after a five-hour motorcycle ride down the mountainside. They tied her between two men. She had four other children and after the birth had a seizure.  With good prenatal care and a transport plan this did not need to happen.   It is difficult, yes, but can be reduced.  She is a real mother, being held in her husband’s arms for days while she is in a coma.   I felt powerless and I do not want to return to the world of male decision makers who seem oblivious to these deaths and disabilities.  They say to me, “they will never change.”    Did this woman even have a choice?   They say “women in Haiti like having their babies at home.”   I say but they can do that and still have prenatal care and be screened for risk.  We can do so much. 

My sister takes me to the airport at 6:00 am and I throw up in the planter.  The suitcase is four pounds too heavy and I have to repack on the airport floor.  The small gifts for children pour out and I scoop them into different piles.   There are toothbrushes and crayons and handheld lenses a school was disposing of.   I bring very few pieces of clothing.   My sister puts one suitcase in the other so I have one to leave for a family who needs it for storage.   This is a very good idea but there are small things all over the floor; seeds and baby blankets and old window shades to write on.  I smooth the dirt over my vomit and consider it is something I ate and not my hesitation about the trip.

My body says – maybe this is not such a good idea but I stand and smile; take my boarding pass and walk to the gate where I wait for the plane to Haiti. 

It is a short flight.  It is only an hour and a half.   As we fly over Haiti, I see the ring of turquois water and white sands.  It is a greyish brown but as we get closer, I see a patchwork of fields and houses and rivers.  At a certain altitude it does not look so different.   We glide through white clouds and then Haiti comes into focus; the now empty rice fields and houses only half built, muddy rivers and broken roads.  I begin to see what for one moment, flying at a certain altitude I could almost pretend wasn’t there.  There is music as you enter the terminal; always music. Even after the earthquake there was music.   And with this music I accept that despite my resistance I have come home.

Breastfeeding inequities in their village and in mine

In my village but never theirs....

I had come home from Haiti, wanting to do a few things.  One of them was to look at the many ways that all people share common problems and concerns.  I had wanted to look at the birth practices of my own community. I had wanted to find that common thread and to understand the meaning of "best practices' world wide.  I had wanted to simplify my thinking and in that find some universal truth.

I also undertook the work of taking the 90 hours of lactation education related to Baby Friendly Certification which I have found to be a unifying way of caring for babies endorsed by WHO and UNICEF.  As I watched still another mother and baby struggle to live, I considered that this could be a unifying good for Haiti' mothers and babies as well as the mothers and babies in my own community.

I was only home a few days when the classes began.  They were 9 to 6 and required large amounts of time on the computer.  I jumped from a world with very little electricity to a classroom totally dependent on electricity and the internet.  I went from a world where people sat at sunset and talked to a world where we were suppose to chat on line.   I was still having nightmares about a box of dead babies spilling onto the floor while I was delivering a baby.  I was shaken by that and then by the death of a dear friend.   I was experiencing cultural shock that was exasperated by on-line learning, yes, but something more.

I had helped thousands of mothers bring their baby to breast with no difficulty.  I had considered it part of the birth. I would have no sooner left a birth without the abby nursing than I would have left a placenta in. It was part of the birth.  It was my job as the birth attendant.  Here I was in a world where helping the mother to breastfeed was a whole other vocation.  I was trying to get LaGonave caught up on prenatal care and they are fast moving into a world of breastfeeding so foreign to me; even in my own community.

Through the course, I could see that many babies in my villages do not latch easily or early because of drugs and procedures used in childbirth.  Women in my villages, thousands of them, have surgeries to improve the look of their breasts.  In my country, women ahve the time and money to worry about how their breasts look.

As I move through the course, I can see that there is not much I can bring back to Haiti or any low resource setting.  A great deal was based on electricity, plumbing and computers.   Mother is Haiti rarely have access to lab work, NICU's, and high tech birth.

In some ways, the mothers of Haiti are far more successful.  I am sure their breastfeeding rates are far higher.  Not breastfeeding means almost certain death to a baby there.  In my village they have milk banks where milk is psateurized, tested and cooled.  I think they cannot even do that for cow milk for older children, let alone babies.

We review the metabolic diseases, jaundice, prematurity, low milk supply and I think well, I guess in Haiti all of those babies simply die.  Sometimes I consider still the box of dead babies. I see them all with their arms around each other and the tiny hands.  I find myself trying to determine their gestational age as we are shown slides of premature babies in my villages NICU.  The babies were not that young - perhaps as they say they were late prematures or they were term but no one knew how to care for them at birth.

Some will die of infections passed from mother to baby that are never tested let alone treated.  Some will surely have blood types that cause them to die in the first hours of life.  The inequities of care go on and on and on.  I sit through a 90 hour journey of extreme inequity of global resources.  In my village women have breast surgery, have fertility treatments and keep their babies alive for months in the NICU.

In Haiti. we are happy if they get prenatal care and can get to help if there is an emergency.  Some of us dedicate hard won fund raising dollars to getting care to women through mobile clinics or birth centers. it is not , I tell myself, the women's fault.  My country has created this culture of disparity.

I sit and watch. I do my assignments and try to take part but I am a world away.   I wonder if some children are worth more than others.

I will go back in a few days and help the matrones and agent santes and midwives with breastfeeding complications. I plan a workshop on this topic but I know I will not bring any of the gadgets, pumps, feeders, banked human milk, lab equipment and vast technology of the NICU in the village where I live.  I will bring some pictures.  i'll work with a translator and do the best I can.  There are no lactation consultants.

Many of the reasons women struggle with breastfeeding, in my village, are reasons related to birth, the media and the need for mothers of young babies to return to work.  I try to find the simple truths beneath all I have learned.   I try to think about what it mans to care for the young in any culture, in any place on earth.

It is a beautiful morning. I consider what it means to be born fully awake and alive with no drugs pulsing through our bodies to a mother who reaches down and brings us to her breast.   This is almost always true in haiti and almost never true in my villages.   Our babies are often induced, born through surgery, effected by maternal drugs.  The women in Haiti have much to offer the women in my villages about birth and breastfeeding.  I am angry and confused about all the things they don't have that US women have but then I can see that in many ways they have the most important things to help a baby latch and establish a good milk supply;  a culture that supports and appreciates a breast feeding mama.

"My Mom has died. " Melove in Haiti

In loving memory of Melove's grandmother who loved her family and cared for them though many joys and hard times.  In this photo she is making castor oil from the beans Melove picked.  She sold them in front of the house she shared with Melove and her children.  She had polio as a child and could not walk. I did not know  she had diabetes which led to the amputation of her feet at Justinian.  Despite this drastic measure, she died this week, leaving an empty place on the road to Bois-Camain.  She always welcomed me and any other guests, pulling up a small.market chair for us to sit on.  She was a Seventh Day Adventist and loved her church.  Despite the rocky road, someone would push her to church each Saturday for services.   A warm and welcoming person, I will miss her when I again walk that way and I am so sorry for Me love and her children who depended on her kindness and love for their very survival.  Brave, courageous and gracious, we celebrate the courage and faith in which she lived her life.   She lived through many political changes, natural disasters and personal tragedies.   May the beauty of Haiti wrap he rin their arms and offer peace and comfort.  

Landslides and deforestation; in your village and in mine

Landslides and deforestation;

In your village and in mine

Land slide in Haiti caused by de-forestation

Landslide in the United States caused by de-forestation

One of the things people say to me about Haiti is how they saw a photo taken by NASA that shows the border of the Dominican Republic and Haiti.   The photo shows Haiti with 100% brown dirt and no vegetation and a green Dominican Republic.  

When I traveled between the two countries I did not see any difference in the landscape but I understand that Haiti, like my country, lost most of its original forests.   I live on a mountainside and all of the original trees were cut down a few hundred years ago; the same time Haiti’s were.   The difference is that the trees on my hillside are growing back and the climate in Haiti makes this very difficult. 

When the forests were cut, in their villages and in mine, the small streams and springs were filled in with dirt and animals fled.   Water, which was once absorbed by large trees became floods of water heading down the hill to the river.   Smaller trees and bushes were knocked down along the way.   Thousands of years of deeply rooted and naturally nurtured topsoil was washed to the sea.   Food and medicines and habitat for wildlife was destroyed.   The food chain which fed and clothed people were destroyed.

Although much of this wood was used to build the small towns and farms of Oregon, it goes without saying that the first people of Haiti and Oregon managed to live happily without destroying all the old forests.  It is also true that most of the timber was sold and not used for the basic needs of the local communities.

Later, the forests in Haiti and the forests in Oregon were taken over seas and sold.   Wealthy and powerful people took the trees and the earth beneath them wept with the loss of springs and topsoil.  

Without the complex root system that was part of the mountainside, the land slid down hills taking people, houses and wildlife with them.   Recently in my country many people died and a town was destroyed by a landslide.   It is estimated that 5 million cubic meters of dirt on heavily logged land slide down the hillside after heavy spring rains. When it was suggested that it was caused by decades of clear cutting, the critics were silenced and called disrespectful.   It has taken the dedication of many, many people to protect the forests and streams of my villages.   De-forestation, in my village and in Haiti’s village, cause climate change, a loss of forest food and medicine and yes, landslides. 

When people ask me about the picture of Haiti I answer, “Yes, it was de-forested by colonial powers who sold it to become very rich.  Our forest were logged too and we have very few ancient forests, as well.  This is a problem in all the world’s villages.” 

When we value healthy, sustainable lifestyles for all living things we can help prevent landslides; in my village and theirs.   Beneath rests the question of how rich, is rich enough?   Do some people’s need for wealth justify the poverty of others? 

The line between Haiti and the Dominican Republic is the line we walk each and every day.  It is the divide between rich and poor,  between walled communities and borders between nations.   Somewhere,  someone left the ground bare and scorched; in my village and in theirs.   The impact of deforestation and land slides on families is significant.  In my villages and theirs, families morn the loss of friends and family. Homes are destroyed and lives are forever changed.  Mothers need solid ground, clean water and top soil to help their families grow.  These are the things we all need; in my village and in theirs.