Nou La

Midwifery students and their teacher, Marthonie

Nou La is we are here.

Tomorrow is our last day in Hinche. I feel like the time has flown by. I feel like I haven’t posted enough. I feel less of an observer, recorder than the two previous visits. We are in the groove with life in Hinche—St. Therese at night, the orphanage during the day; bumpy rides in the pink jeep, halting Kreyol that makes me feel like I am tripping over myself when I open my mouth. Dina says this is not true and she is impressed that I am speaking in “paragraphs.” Dina tells jokes in Kreyol, so we are even.

The first two births of last night’s shift came within 15 minutes of our arrival. Two healthy babies. Then, I slept. Earlier in the day, I had travelled to Port Au Prince with Genette, the young and inspired clinical director who I am trying to bring to the MANA conference. We left Hinche at 4am to arrive in Port Au Prince by 6:30. We went to the US embassy to try to get her passport. It is always by appointment only at the embassy. Even so, there is a long line that you need to wait in. I had come along, hoping that I could speak on her behalf and confirm her reasons for travel. But, I didn’t have an appointment. Either did Genette. Her appointment had been last Friday, the day that the “hurricane” was supposed to pass through. The day they closed the embassy. She had heard on the radio that all those with Friday appointments needed to arrive on Wednesday for their rescheduled appointment.

I worked my way up the line for Americans and simply told them that I had had an appointment on Friday that was cancelled and that was why I didn’t have an appointment for today. They let me through the security gate and I passed onto American soil.

The American embassy is a solid-looking structure compared to all the other cement and rebar buildings in Haiti. It looked like the outside was granite and the doors were heavy glass. Inside it was air-conditioned, clean and electronic. Each person hoping for a visa needs to get in line to speak with one of the cashiers. The cashiers sit on the other side of a glass window and speak to you through an intercom. It is here that I learned that today’s rescheduled visits were only for Immigrant visas – not the kind we were looking for for Genette.

I told the cashier my story: that we had come a long way; that I am leaving on Saturday; that I want to be here for the appointment. Isn’t there some way that she can be seen today? No. You will need to send us an email to try to expedite her appointment. But who receives those emails? Can’t I just talk to them today? No. You will need to send an email. Can I speak to a supervisor? Oh, you were supposed to have an appointment on Friday, the day of the hurricane? Then, you will need to send an email. You see where this was going.

Strike one. Not out yet though. Genette never even made it through the security gate. To take advantage of our trip to PAP, I asked Genette’s brother Gito, who had driven us to PAP, if he could show me the Neg Mawon. It is a famous statue outside of the President’s palace in Petionville. The Neg Mawon symbolizes the freed slave who was now marooned on this tropical island. It is a symbol of strength and commitment for the Haiti people. 

 

I also saw the damaged presidential palace. 

After a small bite to eat, we headed home. When I arrived back at Maison Fortune, I sent an email.

Needless to say, I was tired that night, and, after our first two births, I slept for 4 hours. Soon after I woke up, a woman came in with a small hand peaking out of her vagina. This was not good news in any way. She was only 30 weeks pregnant, dangerously premature. The baby was thought to be in a transverse position, but as the baby began it’s descent to be born, the hand retreated and a small rump appeared. The staff midwife and the students could not find a heart beat, so the baby was presumed dead.

With a stillbirth in a breech position, the students know that the best thing is patience and to let the birth proceed at it’s own pace. The baby’s limp and lifeless body slowly emerged. There is always a point in a breech birth that looks odd because the body is out and the head is still inside the mother. With a complete lack of muscle tone, the baby’s body slowly crumpled in a small heap as we waited for the head to be born. Then, a small convulsion of the baby’s body. Was that for real? Is this baby alive and fighting for life? It happened again. Yes, this was a faint sign of life in a baby that we thought was no longer living. But truly, this movement was only a reflexive action of the baby’s nervous system. There was no muscle tone, no reflexes, when the baby was finally born, no breathing effort.

So here was the flip side of the coin of our experience with the baby, Miracle. Was this baby in need of a massive resuscitation effort that couldn’t be sustained and that would ultimately not save the baby’s life? Was a day or two of living worth the effort? This baby was unresponsive, not breathing, unconscious, but had a slow heartbeat. Without words, we all knew that this baby wouldn’t make it. It was too early, too difficult a delivery, too far gone. We were the ones who had to suffer through the 20 minutes of its short life. Who gets to decide who lives and dies? Is a massive, heroic American effort to resuscitate a baby the right thing to do when there is absolutely no ongoing care here for premies? Even if the baby were to live, the risk of brain damage is great. Is it fair to ask an already impoverished family to take on child that will always be a burden? The answers are impossible to know, so instead you go with your gut. For me, I knew that this baby wouldn’t make it and that instead, it might be better to have the mother just hold the baby for the few minutes of its life. Except in Haiti, most mothers don’t even look at their babies that are born healthy and alive. The mother declined the offer to hold her baby.

We wrapped the baby in a small, blue surgical towel, giving some semblance of comfort. The baby lived for 20 minutes and never made a breathing effort except for its spasmodic, occasional agonal breaths. Later, the mother stood in her white mesh “culotte,” unsure of the next steps when you are leaving the maternity ward empty handed. It was her first baby.

The next, and final, baby of the night was born healthy, if not full of drama. The mother was reluctant to open her legs and was quite loud in her travail. The mother’s name is Darling and she named her baby girl, Guerline. She smiled when I asked to take a photo of her and her baby. A moment of pride.

Just a few photos.....

at the end of a long day. We went out on the mobile clinic in the morning, interviewed Magdala after lunch, met Genette at Maison Fortune, and had another dance party with the girls. I'm tired!

Mobile clinic

Hurricane Isaac Means Get Your Soap

August 23, 2012

Brother Harry is wearing a sweater this morning. I celebrated the weather as well and put on my one long-sleeve, travel shirt. The central plateau in Haiti never really gets the full effect of a hurricane because it is surrounded by mountains. The mountains break up the pressure system enough so that Hinche lives in relative weather security.

Yesterday as the hurricane began, we had a full 15 minutes of spectacular rainfall. The prepubescent boys stripped off their clothes and splashed around the outdoor basketball court. Others soaped up underneath a cascade coming from the roof drainage system of our two-story guest house and administration building. The soccer field flooded which was an invitation for two boys to slip around playing Frisbee in the rain. Nearly as quickly as the rain had started, it finished. Was that it?

 

We awoke in the middle of the night to fierce winds. Dina and I got up and took the clothes off of the line on the veranda. This morning it is cool and breezy with a light rain falling. The girls are wrapped in small blankets as they venture out of their dormitory. Maybe it is 70 degrees.

My second shift at the hospital was a constant barrage of births and medical crises. At one point, a pre-eclamptic woman gave birth unexpectedly in the antepartum room. Her premature baby lay lifeless on her chest when Ami joined the other midwives attending to the scene. No one seemed to be paying much attention to the baby. Ami immediately grabbed the child in a torn sheet and brought her into the labor ward to resuscitate her. I joined her in the effort.

We worked on the lifeless little one for at least 20 minutes. She was unresponsive and limp but her heart beat never faltered. She could have been that way because of the Magnesium Sulfate given to the mother for her pre-eclampic condition. The little girl looked to be only about 3 pounds, 36 weeks by dates but looking like a 32 or 33 weeker. At some point in the resuscitation we knew that we couldn’t just ventilate her forever. At some point, you just have to decide that you’ve done enough and see if the baby will breathe on her own. We let her try a couple of times, only to begin the resuscitation again. Eventually, however, she held her own tentative breathing pattern. Still, she had not responded to stimulation and her eyes were glossed over.

We watched her for over an hour before we started to think about bringing her back to her mother. Would the mother want to spend time with her baby who might have only a few hours to live? Would the baby survive a disruption of her stabilized state? Ami and I agreed that the baby was stable enough to move and that the mother should get a chance to see her alive and decide for herself what to do next.

The mother was lying emotionless on her cot in the antepartum room. We brought in the tiny child and lay her down next to her mother. The baby was snuggled inside a receiving blanket and just her little face was visible, her eyes were closed. The mother barely looked at her. When we discussed her daughter’s tentative vitality, she placed her arm over her eyes, hiding her response. We asked her whether she would like the baby to stay with her, or whether she wanted us to take the child back into the labor room with us for observation. She wanted us to take the baby away. We did and simply watched and waited to see if the baby would survive.

Within a couple of hours, it was clear that our little one was holding on and that she could safely stay with her mother without observation. Of course, this is all relative because in the states, this baby would have been in the NICU for weeks. We brought the baby back to the mother and they both slept. Whenever I went in to check on the baby, she was still breathing. By morning, she was opening and closing her eyes and moving around, just a bit. Without ongoing care, this one will have a hard time surviving the first week, the first month. But she survived through the night and that says a lot. In Haiti, one of the greetings is “N’ap kenbe” – we are holding on. Against all odds, the littlest Haitians embody their country’s affirmation of life.

The rest of the shift was a steady stream of mostly first timers. Two babies were stillborn and 3 babies were healthy. Honestly, I can’t exactly remember how many births we had that night. At one point, I took a 2 hour nap on the hard cement floor; the rest of the night was busy.

 At the orphanage, we have been learning Creole with Kenel, the young man who is full of hope and potential. He just passed his 12^th grade state finals which means that he is officially a high school graduate. We celebrated at a night club in town where a live band was playing Kompe music. He said it was his best night out ever.

Oday

During one of our Creole lessons, our favorite little boy, Oday, sat in with us which he is want to do. Distracted from the Creole lesson, Oday had figured out how to use the flashlight that hung from Dina’s belt loop. She said that she hadn’t known how to turn it on continuously and was glad that Oday had figured it out. Mind you, he’s 6 years old. He returned with the following question in Creole, “Pou ki sa ou te achte yon ti flach e ou pa konnen kijan ou kapab itilize li?” Why did you buy that little flashlight and you don’t even know how you can use it?

Postscript, Sunday August 26, 2012:
Our little one, that we affectionately named "Miracle," lived for about 30 hours. We walked up to the hospital yesterday during a break in the rain to check on her condition. The midwife on duty told us that the baby had died around 6:00am. The family hadn't told the mother yet, only saying that the baby had been transported to a better hospital. As far as we could understand, they will tell the mother about the death once she is at home. Perhaps they are looking for some privacy to break the news. We told the mother's cousin that we had done everything that we could do, but that the baby was just to weak and little. We told her that we would pray for them.

First Shift at St. Therese

Ami and I worked in the hospital last night with 3 students: Suzette, Marie Rose and Sonis. I was surprised at my reaction this morning as we finished up our shift. I felt speechless and overwhelmed. In contrast to my ease with the orphanage and the flow of Haitian life, I felt despondent and discouraged at the familiar hospital scene. Three women gave birth in the wee hours of the morning after a slow start to our shift. With each one, I felt moments of regret; this shouldn’t be happening like this.

The first mother to give birth was a young, first timer who accidentally gave birth in the antepartum room. Antepartum, postpartum and post-op are large rooms with 12 beds, one woman to a bed. The rooms were completely full all night. The other two women who gave birth through the night had to stay in the labor ward because we had no empty beds. The young mother gave birth almost painlessly. Her sister told us that she was sleeping when the baby started coming. The mother looked no more than 17 years old, although the midwife claimed she was 22.

She gave birth in the antepartum room, without opportunity for privacy or modesty. We had to clean up the baby and mother without the simple luxury of a partition or sheet to separate her from the other 11 women in the room. Thankfully, the baby was gwo e asante (big and healthy). As the midwife in charge rubbed the baby to a hearty cry, the mother looked away, disconnected and masked. Her face gave no hint of what thoughts lay within. This is a familiar response to birth in Haiti. The mothers seem overwhelmed and disconnected to their babies. The only explanation that I proposed my first year here was that there is so much infant death. Still birth, infant death, children not reaching the age of 5. Giving birth risks her own life as well. With such odds, mothers bond tentatively and slowly, too familiar with the pain of loss.

It is also poverty. I have no idea what it may mean for a mother to have a child here. We so rarely witness joy as a reaction to birth. A baby means another mouth to feed, school and clothe. An already impoverished family may not see a new baby as a blessing. My first year here, I tried to emphasize each healthy birth. We encouraged the mother to speak to and touch her child. “This baby is so big and healthy,” we would exclaim. “Look, how beautiful, a girl, a boy.” Could we possible teach a mother how to bond?

The other two births this morning also produced healthy babies. One woman had been literally wailing for what seemed like hours. She had been coming to the hospital for the last 5 days; a long, early labor that was possibly indicative of a posterior baby. At the peak of her labor, the midwife on staff examined her and said she was 5 cms dilated. I was outside at the time, trying to nap sitting up in a chair. I finally went in to really understand why this woman was literally screaming. She seemed to be pushing with each contraction. I asked again how far dilated she was and why she was pushing at 5 cms. The staff midwife, a student from the prior class, seemed disinterested in the pushing effort in front of her. I told them I wanted to do an exam. Sure enough, the woman was completely dilated and the baby was minutes away from being born. I felt disturbed by the lack of competence and follow through that ultimately led to a chaotic rush to prepare for the birth. This shouldn’t be happening this way.

When the woman actually gave birth, meconium-stained amniotic fluid flooded the floor and the top of my sneaker. The baby needed to be suctioned with a DeLee, which the students had never seen used before. I was glad to show them a new skill. Sonis did a fine job suturing.

The third mom was rushed also; a general understanding of preparedness will be our teaching theme for the week. Ami and I walked home at 6:30am, grateful for the 3 healthy babies, but not without noting the small, taped up cardboard box on the counter all night that stood sentinel to the truth that neonatal mortality is a constant tragedy here in Haiti.

*************************************************

Watson is a 7 year old orphan boy at Maison Fortune. His nick name is Wa Wa. Here is the letter that he “sent” me yesterday:

Kreyol Lesson

There's Blood on the Floor

Yesterday was our first day working at St. Therese, the regional hospital in Hinche where Midwives for Haiti is headquartered. Things have seemed so familiar this time around; WE are the ones who are less wide-eyed than before. So, of course, it was death that met us at the door. The first and only birth that we witnessed Monday morning was a 24 week stillbirth. The baby had a genetic defect that undoubtedly contributed to his demise. Ami helped with this birth while I worked with the other midwives. We had many women in labor that morning. Each shower-curtained stall had a woman in it. Some women were accompanied by family, most were being cared for by one or two Midwives for Haiti students in their signature pink scrubs.

I was assigned to work with Marie Rose for the morning. She is an older woman, perhaps in her 50s, which is unusual. Most of the students are young women in their late 20s or early 30s, eager and willing to work hard and upgrade their knowledge and skills. Marie Rose is more old school. She is set in her ways that are sometimes incorrect. I soon learned that if I just showed her the correct way, she was totally competent. She thrives on the small tricks of the trade. If I can follow her for the two weeks that I am here, I hope I can bring her up to speed with the rest of the class.

The majority of students are competent and sweet. They have learned how to place IVs, treat pre-eclampsia, deliver babies, rub a woman’s back in labor. Yet, it still seems that there are cultural and professional differences in the Haitian way and the American way.  Most of the work space is untidy, simple wrappers from hypodermic needles and gloves strewn about. Medicines are in disarray. The blood is still on the floor as the next woman comes into the stall to deliver her baby. We observe, we teach, we wonder how much will be retained.

When the steady flow of laboring women eased, I cleaned and organized the supplies. I remember this from last year. Modelling, I am hoping, is the best way of teaching. 

It is always the orphanage that allows us moments of pure joy here in Haiti. Last night as we went over to the girls' compound, Dina and I were immediately swarmed by 20 or 30 girls, no exaggeration! They were so excited to see us that they began chanting our names, "MA-REE-A, MA-REE-A, DEE-NA, DEE-NA!" We had to squeeze up the stairs to the third floor with two girls on each arm, many in front and back. En masse, we slowly made our way up and up until we reached the small room where we showed them photos of themselves from 2010 and 2011. We handed out piwilis (lollipops) and the atmosphere was animated and energized as the girls saw photos of themselves and their friends. One little girl, Joska, glued herself to me, at times rocking back and forth as we stood watching the show. I sense a loss of adult nurturing; most of the girls have to be independent and take care of themselves from such a young age. Of course, the girls (60 in all) take care of each other. But if there is a substitute mother around, many of them take advantage of a cuddle or hug to soothe a wordless ache. I feel lucky to experience a moment of tenderness with any of them. They fuel my  resolve for a better experience for the Haitian mothers and babies.

Matthew 25 and Maison Fortune

We arrived quite smoothly into Port Au Prince yesterday morning. The 1 hour and 45 minute flight was quicker than it took for us to get from Port Jefferson, Long Island to LaGuardia airport. Upon arriving in PAP, we needed to gather our bags and make it through the aggressively eager porters to find our ride. This time, it was surprisingly calm and uneventful. We were met at the doors and whisked through the travelers to an awaiting Matthew 25 vehicle and Ricardo, a familiar face. Within 20 minutes, we were at the traveler’s lodge.

Matthew 25 is the place that I wrote about 3 years ago. A tent city was erected in the soccer field next to them that at one point, immediately after the earthquake, hosted 2000 people. Today it is being used for a different purpose – the local soccer championships! So wonderful to see life back to normal.

Nancy, our friend at Matthew 25, says that the big success story here is a young girl named Reginette. She lost part of her leg in the earthquake and was part of a video that Dina made our first year here. You can see the video here. Today Reginette works at Matthew 25 as part of the housekeeping staff. She is a straight A student and says she wants to become a journalist. Most importantly, when she started working here, she was very shy and reserved. She was 13 when the earthquake struck. Today, Nancy says that she plays Uno and Sorry with the staff and is coming out of her shell. She was all smiles for us as we showed her the video of herself.  She uses the money that she earns at Matthew 25 to pay for her school books and to support her mother at home. 

Having arrived a day ahead of our departure for Hinche, we did some much desired exploring of Port Au Prince. We went to the outskirts of the city where they make the metal art that is signature Haitian. We ate at a local restaurant – fritay, which means fried. They sell fried meats, plantains, potatoes covered in pikliz, which is their spicy coleslaw. We also stopped at the Italian hospital, St. Damien’s, looking for my friend Esther. We found Anise instead and chatted in our very rusty Creole.

Today we arrived in Hinche at Maison Fortune. The girls remember us and remember my name!! Dina, Ami, and I went over to the girls compound and were immediately swarmed by children. We were surrounded by about 12 girls each. Ami ended up being covered in glitter and admired for her tattoos. Dina started writing down the girls’ names and pretending to be their teacher. I practiced my Creole, while the girls told me their names in English. I showed them photos on my iPhone which prompted them to gather even closer. If I have your photo on my iPhone, you were a star in Haiti today. I called Dina to rescue me when my swarm was nearly on top of me.

We are so happy to be here. The children are a year older, they have learned more English, we have learned more Creole. We can already see the power of continuity on their smiling faces.

Donating 10 pairs of shoes to the orphanage

Ayiti Anko

Genette

Dina and I are careening toward our Haiti departure date this Friday. We spend our time weighing baggage to make sure we don't go over the 50 pound limits, buying last minute items like lollipops, beef jerky and Imodium D, calling airlines who won't waive our baggage fees even though they've done it before. Genette emailed me and knows that we are coming soon. We leave for Miami on Thursday night so that we can be in Florida for a 7am departure to Haiti on Friday morning. I'm getting excited.

Magdala

This year will be a continuation of our work with Midwives for Haiti. We will follow up with Magdala who is the lead midwife for the mobile clinics. She also runs a school for 600 children, has taken in 12 orphans, hosts a cholera encampment on her land and works her shifts as a midwife at St. Terese hospital. We were hoping to find her a major donor to help with her dreams of building an orphanage on her land but so far we haven't found the right funder.

Genette is one of the clinical instructors for Midwives for Haiti that I am trying to bring to California for the MANA conference. The visa interview was delayed until August 24th. That is problematic since by the time we even know if they approve the visa, it may be hard to get airline tickets for a mid-September visit to the US. I am hoping that my presence in Haiti when she goes to the interview will lend legitimacy to her proposal and that we won't have any snags. Haiti logisitics are always tentative and unpredictable.

As usual, we will try to blog live from Haiti using a personal hotspot from my iPhone. As long as it is all working, you'll be able to follow along with our trip. In the meantime, be sure to check out Dina's videos on my YouTube channel. Here are the links:

2011 Midwives for Haiti Update

2010 Midwives for Haiti Update

2010 Port-au-Prince Tent City