The LaborPayne Epistles

Winter Update

2012-02-17T04:53:00.000-08:00

Well, its been three weeks since the 'pilgrimage' and readers should have an update as to what has taken place. I did go to Mexico, but I did not participate in the walk with my friends. Instead I spent an entire week writing a grant. I finished writing it, but I did not submit it. I plan to submit it in a second round in August. It has been a very strange odyssey. I returned home to hacked email and stolen luggage (all of it!).

However in the weeks I have been home, I have started to lay the groundwork for Uzazi Village, made partnerships in the community to support the grant, and assembled a board for the new nonprofit. I have started a new teaching job (going very well), started the midwife program at KU (loving it!) and applied for a position on a gubernatorial board, and a position as a state-wide breastfeeding promotion coordinator. I also have a book and article deadlines looming. I have also identified several other smaller local grants to apply for and continue to work on the national conference slated for my city next year. I sit for the lactation consultant exam in July, and the certified nursing educator credential in April. Whew.

I have also never been more satisfied with the direction my life is going. Folks are appearing out of the woodwork seemingly to help with the work. I feel a deep sense of peace and commitment to the work I am doing. All the pieces seem to be coming together. Your continued well wishes and offers of assistance continue to be welcome.

Leonora of the Desert

2012-01-25T07:26:00.000-08:00

This trip has not been at all what I thought it would be. I have not participated in the pilgrimage at all, but made the somewhat difficult decision to stay back at my friend's home and complete the grant writing I started. It has been an eventful few days. On the morning I arrived in San Miguel I knew that Michele, my hostess would be waiting for me. Despite the fact that my bus was an hour and a half late and that I was the only passenger left on it- I knew she would be there, waiting for me. I was so glad to be on that bus to greet her. At each stop, I wondered would I get my connecting bus? Would I be stopped at the border? Would I be able to ask for information if I needed it? Would I get the help I might need. I learned later that my friends had forced to pay bribes at the border to get their visas. I need not have worried. The Mexican people have been very gracious with my limited Spanish (which I have been forced to use). As the bus pulled into the station at San Miguel, the first thing I spotted was my friends head. She is about six feet tall and towers head and shoulders above the Mexicans (so do I, and I'm only 5'7"). Peace flooded my soul. I had come to the end of my long journey. I was dropped off at the home of a generous sponsor who allowed me the use of one of the bedrooms in her villa in town. She was out of town, but gracious to offer her home to American pilgrims. San Miguel is full of American and other International expatriots who settle in cozy townships like San Miguel to live out their retired lives. It is not unusual at all to see tall white-haired Americans journeying to and fro on the narrow cobblestone pavements.

Once I settled into my spacious quarters, I took a long overdue shower, changed clothes, and settled down to attend a lecture via the internet. Once that was done, it was time for breakfast. Fortunately for me, here in Mexico, 12:00 is still considered breakfast time. I walked a few short blocks to the town square and found my favorite restaurant, El Correo. I settled in and in my broken Spanish ordered my favorite dish, Migas, Mexicana. That is, scrambled eggs prepared Mexican style with tomatoes, onions, and chilis, with fried tortilla strips cooked into them, served alongside a side of refried beans. This really is my favorite Mexican breakfast. I thought I might get tortillas on the side, but instead was served a large crusty roll with butter and pineapple jam. I washed the entire thing down with agua de mineral con limon. I felt incredibly spoiled. Next I roamed around the town square, half expecting to find my companions who had all arrived several days before me and were staying in different homes. Not seeing any familiar faces, I did my souvenir shopping and visited an internet cafe to check email. Afterwards, I returned to the villa where I was staying and found it overrun with people setting up for a luncheon. It appeared that even in her absence, my hostess had arranged for a fundraising luncheon to raise money for a local cause. I thought it funny that her house would be full of strangers and visitors, her household running as if she was there to run it. About fifty people were expected so there were folks everywhere cooking food and setting up tables. I dodged the traffic and the animals (so many animals!) and sequestered myself in my room. The hostess has a small menagerie of exotic birds, cats, dogs, and two marmosets (monkeys) that chit chatted at me when I accidentally came upon them grooming one another on top of a bookshelf. I missed the entire event-even though it took place in the courtyard right outside my patio door. I closed my curtains and fell into a deep sleep, and when I woke up all the guests were gone, and all the same people were taking the tables down and cleaning the kitchen. It was near time to meet up with my traveling companions, as we had a prescheduled meeting.

I walked again to the town square, and immediately came upon them. It was so good to see them here in San Miguel after so many months of planning and talking. Michele joined us and took us to the home of her friend Carlos, born in Venuzuela, but a true Internationalist. He made us a lovely dinner of vergetarian paella (a Spanish dish of rice, vegetables, and usually seafood). I am very shy around Internationalists, since my travel abroad has been so limited. This may sound funny to some, who think I travel all the time, but I never traveled in childhood. Michele and many of her San Miguel friends and many of the expatriots have grown up abroad, spent their childhoods in many exotic places, and speak multiple languages. I feel quite provincial in their company. Nonetheless, Carlos is a gentleman and engages us all in small talk while we feast on his lovely meal. He doesn't dine with us, but in true Latin fashion, has a dinner appointment with friends after we leave! His dinner won't start until 9 or 10pm! (This is why they still serve breakfast at noon around here.) His home is lovely and the walls are covered in original art and photographs. I relaxed out on his patio with my friends and enjoyed the San Miguel sky bursting with stars

After returning from dinner, a few of us, Morningstar included, pack our bags and leave the town to spend the night at Michele's home out in the country. I have stayed here on a previous visit and I look forward to being there again. I didn't know I would spend the bulk of the trip here. But it is quiet and peaceful and the internet service has been excellent. During the day the housekeeper and gardener are around, but at night I am all alone and have been able to get much work done. I did come to San Miguel to walk, I and still hope that I might, but so far I have made the choice to forego the pilgrimage to complete the grant I'm working on. Yesterday I was mildly distraught to say no to the pilgrimage but today I am ready to accept what is. My dear friend Rebecca, helping me write the grant from 800 miles away wrote this:

I write all this to say maybe you would have been so distracted up here you would not have gotten your grant done. Maybe you just needed a quiet place to be for a few days with nothing to do except prepare for your miracle, your dream to come through. You are where you are supposed to be and doing what you are supposed to do. You will walk when you are done and that may be only a walk to get on the bus.

Embrace your time alone. It could replenish you to prepare for all that will fall upon you very soon.

I think this is true. If some miracle should prevail, and this grant is funded, my entire life will shift. Perhaps this was the miracle I came for and not the one I thought I was seeking at all...

Pilgrimage to Mexico

2012-01-22T03:17:00.000-08:00

While I have participated in this pilgrimage, three times before, this will be my first time to take the bus to Mexico. Two days on a bus is an adventure prior to the adventure. My mind is consumed with two thoughts- completing the grant I'm writing for community peer educators and seeing my San Miguel 'home' again. In Mexico, I am called by a different name. I become Leonora (because there is no "SH" sound in the Mexican alphabet, the Mexicans have trouble with my name, so I simply changed it to my middle name). I can hardly wait to join up with Morningstar and the other women of Morningstar Community to make this walk through the beautiful vast landscape of the Sierra Madres of Central Mexico. I have been training for months, walking, running, and even achieved some small weight loss (though training in Kansas for a walk in the mountains is somewhat deficient). Mostly for the pilgrimage, what is needed is endurance. You simply keep walking until you think you cannot take one more step, and then you take another step. Even in the company of 10,000 Mexicans the landscape is so vast, you can feel completely alone. It is quite a journey. At the end of it (for me 3 days, but for the others 9 days) we will visit the holy shrine at San Juan de los Lagos and present petitions for miracles to La Virgin. My miracle request is well rehearsed: the grant, and then the clinic. In that order. It will take a miracle for either to happen. For the grant I am asking the US Gov. for 3 million dollars to impact perinatal outcomes in the urban core. This involves an intricate three year plan to engage community health workers, insurance companies, healthcare organizations, and governmental bureaucracy, along with community stakeholders. This is a long shot at best. I am untested and ignorant when it comes to mobilizing something like this. Yet, it could change my community. Follow that up with finishing CNM school (which I only started this week by the way) and opening a clinic in the urban core. Again, I am in no way qualified to do these things- yet they are mine to do. I could do with a miracle or two. Even going to Mexico is a miracle of sorts (the miracle of credit!), seeing as I've been unemployed for three months now. I am somewhat astounded by the lengths God will go to, to make something of my life.

Guest Post

2012-01-04T19:52:00.000-08:00

I almost never do guest posts, but I found this essay by another homebirth woman of color thought provoking. I've obtained the permission of the writer to re-post it here for your perusal. Whenever you see Chicago just mentally insert Kansas City- you'll get the picture.

Occupy Childbirth: Will a single-payer system work for us?

December 21, 2011 //

On, Saturday, October 10^th (which happens to be International Human Rights Day), the Illinois Single Payer Coalition along with the IL Chapter of a Physicians for a National Health Program and the Chicago Single Payer Action Network, sponsored a Teach-in at Occupy Chicago. The teach-in not only focused on the overall heath disparities within Chicago, but more specifically on how a single-payer health care system will (or will not) address health disparities in Chicago and throughout the nation.
Community groups and organizers were solicited to join the discussion and were encouraged to provide action steps to move the movement of a national health program forward. I was excited to attend the event as I am familiar with single-payer health care program as a whole but never really sat down to think of specific concerns and or questions as to how this type of system will affect the maternal health & medical industrial complex.
The event began with a brief but truly thorough overview by Steve Whitman, PhD, Director of the Sinai Urban Health Institute, about the history of racial segregation and access in Chicago, health disparities amongst whites and blacks, and his research over the last 28 years. As highlighted in the event announcement on the Illinois Single Payer Coalition website:

Chicago is one of the most racially segregated cities in the country, with one of the worst records on health disparities by ethnicity and economic class. Responses by major public and private institutions have been ineffective at best, and at worst actively sacrifice public health to the interests of big corporations. Wall Street’s demand for ever higher profits for health insurance and pharmaceutical companies exacerbates disparities instead of addressing them.

Chicago has some of the worst health disparities in regards to maternal and child health. With the countless advances in medicine and improvements in technology, the medical industrial complex has continued to fall short in its ability to adequately provide evidence-based, scientifically proven care to lower income and racially oppressed people. According to the research Steve presented, in 1995 many of the 15 health outcomes his work focuses on were equal when comparing blacks and whites. 15 years later, in 2005 when they re-investigated the current data, 11 of these 15 measures were worst amongst Black people; including ones specific to maternal and child health.
Three of the 15 measures used in his research, Low birth weight, infant mortality, and no-prenatal care, were specific to maternal and child health. His research concluded that after the 15 year difference, Blacks ranked highest for all three measures. The most shocking and most well articulated realization that I have ever heard about the criminality of this segregation is, when you look at all of these measures and look at the “excess death” (meaning those preventable deaths due to lack of access) he says about 3200 Black people died 2005. These excess deaths are due to no other reason than racism. If you do the math, that’s about 9 folks a day. Breaking it down even more, 3 Black babies die each week due to this racism.
According to the 2005 publication of The Birth Outcomes and Infant Mortality in Chicago report compiled by the Chicago Department of Public Health Office of Epidemiology, the following data shows how desperate Chicago (and nationally) is for attention to these disparities in birth outcomes.

Out the highest amounts of births in Chicago, Blacks rank #2 after Hispanics*
% of births with no prenatal care; Blacks rank highest at 3.3%
% of births that were premature; Blacks rank highest at 16.1%
% of singleton babies born with low birth weight; Blacks rank highest at 13.2%
% of infant mortality; Blacks rank highest at 14.7%
% of neonatal mortality; Blacks rank highest at 9%
Lastly, there were 4 maternal deaths in the year 2004 and all 4 were Black

Knowing this information and overstanding the need for immediate action to reverse 15 years (really more) of the harm imposed by the medical industrial complex, what is in store for us within a single payer health care system?
In thinking about access, race, and the current state of affairs for maternal and child health care (i.e. birth justice) I can’t help but have a few questions about how this system will support low income, mothers of color.
One of my greatest concerns about a single-payer health care system is how will this program increase mothers of color’s access to those “evidence-based” practices that I mentioned earlier?
How will this system make maternal and child health more accessible to our communities (i.e. low income, POC, limited-no access to services, birth workers, and/or midwives)?
How will it provide options to poor and marginalized women to make decisions about their pregnancy, birth and parenting without the policing of their bodies and/or reproduction?
How will policies change to support birth justice within the medical industrial complex as well be provided to our sisters in the prison industrial complex?
How will a single-payer system allow greater opportunities (including financial) for birth workers (midwives, doulas, lactation specialists, childbirth educators), healers, and practitioners of color to achieve education and/or certification (if they choose) and practice?
How will this kind of health care reform close these gaps in disparities and improve outcomes for Black women thus improving community health?
Will holistic and modestly cost public health interventions and preventative care (i.e. massage, acupuncture, yoga, etc) be accessible and covered under a single-payer system?
To add, will the midwifery model of care and out-of-hospital midwifery practices be seen as an adequate and viable option for consumers or will the “standard of care” continue to be based on profit-driven, insurance company rules and regulations and not based on evidence and research?
Will a single-payer health care system hold space for increased accurate, client-centered, public health promotion and communication around most importantly, breastfeeding, SIDS, nutrition, fathering, postpartum depression, pre-conception health, and accessing prenatal/postpartum services?
Lastly, in contrast, will Obama’s Health Reform fill in any of these gaps and concerns I have mentioned in discussing a single-payer system?

Well, I am waiting… (crickets).

The International Center for Traditional Childbearing, the Midwives Alliance of North America, and Citizens for Midwifery all have statements that include recommendations** for some kind of health reform (mostly recommendations for Obama-Biden’s Health Reform); many of which can be applied to the single-payer system as well.
I challenge the administration to really step up and address the social and economic barriers that directly affect the overall health of Black and Brown people and in addition make the birth outcomes of those disproportionally affected a continued priority.

It’s clear that what we have now is not only broken but absolutely criminal and barbaric.

*Language provided by the researchers
**Resources for your enjoyment:
International Center for Traditional Childbearing President’s “Healthy Babies are Everyone’s Business”
http://www.ictcmidwives.org/newhealthcarereform.pdf
Midwives Alliance of North America’s “Reforming Maternity Care in America: Recommendations to the Obama-Biden Transition Team on Maternity Health Care”
http://mana.org/pdfs/MANARecsToObamaHealthTeamJan09.pdf
Midwives Alliance of North America’s Working Group Recommendations
http://govinfo.library.unt.edu/chc/recommendations/orgs/midwivesalliance.pdf
Citizens for Midwifery’s “Maternity Care: A Priority for Health Care Reform.”
http://cfmidwifery.org/pdf/CfMStatementObamaTeamFINAL200901_doc.pdf
National Association of Certified Professional Midwives’ “Maternity Care and Health Care Reform: Opportunities to improve quality and access, reduce costs, and increase evidence-based practice”
http://www.nacpm.org/documents/NACPM-recommendations.pdf
Physicians for a National Health Program’s “International Health Systems.” Check out the Cuba and South Africa profile, written by me back in 2004.
http://www.pnhp.org/facts/international_health_systems.php?page=all

A Walk of Miracles

2011-12-29T15:51:00.000-08:00

On January 21st I will depart Kansas City, MO by bus and ride for two days to reach San Miguel de Allende, Mexico in the state of Guanujuato. Once there I will join my 8 American companions who make of the "Sisters of the Morningstar". Our peculiar little all female group of sojourners will travel to San Miguel to participate in San Miguel Walk, a total of nine days of walking across the Sierra Madres. I will walk with the group for three to five of those nine days. Our small group will meld into a group of about 10,000 Mexicans who make this walk annually. I will arrive later and leave earlier than the others in my group because of my school/work schedule. I have participated in this walk three times before, but this time will be different. The other times I went for the walk, this time I go for the destination. The final destination of this pilgrimage is a Catholic church in San Juan de los Lagos, in the neighboring state of Jalisco. When I reach this church (I'll be driven the remainder of the way after walking for three to five days) I will do what thousands of other pilgrims do when they reach it- petition La Virgin for a miracle. There are special rooms in the back of the cathedral- walls lined with requests for miracles. Some of the requests are accompanied by letters of gratitude (brought at some later date) for the received miracles. For example, you might see a photo of a bedridden child, and a second photo taken a couple of years later of the same child running and playing.

I plan to bring my request for a miracle, Uzazzi Village, to La Virgin. She is well known for granting miracles and I figure she might just as well grant mine. After leaving my petition, I will return to San Miguel and board a bus for the two day ride back home or if finances permit, I will walk two additional days and then board a plane home. When I return from my walk of miracles, I want to begin the Community Conversations on Maternal Infant Health. From these Community Conversations I hope to find volunteers and donors to fuel the work.

In order to raise funds to cover the costs of starting the 501c3 that will become Uzazzi Village I am offering to carry prayer requests in exchange for your donation. Your prayer request will be transcribed on paper, made into a small scroll, which I will carry in an amulet around my neck for the duration of the walk. All prayer scrolls will be left at the alter upon my arrival in San Juan de los Lagos. No donation is too small or too large, and all donations can request a prayer scroll. Unfortunately, they will not be tax-deductible until the 501c3 is established. None of your donations will go toward my expenses to do the Walk of Miracles, as I plan to cover all those expenses myself. Thank you to all those who are a part of this vision taking shape.

For more information, or to make a donation go to the website: http://www.uzazzivillage.webs.com/

Community Visioning Survey

2011-12-21T12:48:00.000-08:00

It's Ready!

Here are links to the Community Vision for Maternal Infant Health document
AND
a link to the survey so we can get your feedback on the vision
AND
you can schedule a Community Conversation

Community Vision
https://docs.google.com/open?id=0BxG6TJv-guhPNjIxNmFjZGYtMjQ4ZC00NTZhLWI3MDktODhiYjk2Y2M4MTQ1
http://bit.ly/t7vEJw

Survey
https://docs.google.com/spreadsheet/viewform?formkey=dEVIcEZCTkZId2gzRS1rWElWVVlBeXc6MQ
http://bit.ly/vMD5lW

Please read the vision, and then take the survey. We look forward to getting your feedback.

Uzazi Village is Concieved

2011-12-17T07:04:00.000-08:00

The Community Visioning was a great success. Here is the document created after the meeting that summerizes the vision.

Uzazi Village- A Community Vision of Maternal Infant Health

December9, 2011 a community meeting was held at the Kansas City, MO HealthDepartment. The purpose of this meeting was to gather a group ofcommunity stakeholders to come together to create a vision of whatmaternal infant health in our community SHOULD look like. Here issnapshot of the vision that was created specificto zip codes within the African-American community of KCMO:

Current Conditions

Goals

Strategies

Action Plans

infant mortality rates above national average

FIMR mom profile highest
low breastfeeding rates
high rates of prematurity
high rates of cesareans and inductions
high rates of preterm delivery
low birth weight
delayed or insufficient prenatal care
smoking rates increasing
high rates of obesity/
social determinants of health put residents of certain zip codes at high risk of poor health indicators

Infant mortality and morbidity rates at or below national average
infant deaths not concentrated in the urban core
increased rates of initiation, duration, and exclusive lactation among Black urban mothers
infants born at term with adequate weights
decreased cesareans, and inductions
improved access to prenatal care
improved maternal health prior to pregnancy
work with others to improve life overall in the urban core

culturally appropriate care models
midwifery model of care
mother friendly care models
baby friendly care models
collaborative planning and working with all stakeholders
home visiting models of care
community-based solutions
health care delivery models sustainable without government funding
woman-centric care models
affordable accessible care that preserves dignity and respects those it serve

create a series of

“community conversations” to discuss the vision

invite others to share in the vision through donations of time, money, or goods
identify leadership and create a 501c3 to enact the vision
begin to work with existing organizations and community stakeholders to transition the vision to reality
make a positive difference in the lives of women and infants and their families in the urban core by improving health outcomes

Uzazi Village- A Culturally Relevant and Respectful Model of Maternal Infant Health for the Urban Core

Whatis Uzazi Village?

Uzaziis Swahili for birth. Uzazi Village will be a community-basedperinatal care model created by community men and women for communitywomen and infants (and their families) who are at higher risk forpoor perinatal outcomes. We seek to create a model of care that isaffordable, accessible, sustainable, high in quality, is culturallyappropriate, and respectful of traditional/ancestral knowing, thatpromotes a high level of wellbeing and improves overall potential forthe individual and the community to live in harmony in order topursue its full purpose for being.

Whatdoes this model of care look like?

Maternal-infant health Family health Community health

-Peer to peerlearning models -family care/pediatric care -high risk zip codes

-home visitswith 'peridoulas' -male leadership roles - on bus lines

-midwifery care -assumed male involvement -vibrant communities

-lactation supportive -same provider throughout -providers live here

-barteringsystem for pay -school nurse expanded role -linked to other resources

-house calls bymidwives - parish nurse expanded role -community supported

-same providerthroughout -group centered care - decreased medicaid reliance

-personalownership of health -wellness focused care - we did it ourselves

-partner withclients, listen -clients define family -community gardens

Does this sound likea conversation you would like to join?

This document will be dispersed far and wide throughout our community with a survey attached to invite feedback. In addition, we will begin next month attending assembled groups to share the vision for the purpose of finding 'our people'. Those individuals looking for just such a project to work with will hear about us through our "Community Conversations" series. They will help to write this story.

Another interesting development this week: I invited a national insurance company to join me in crafting an application for a federal grant seeking innovation in healthcare service delivery to Medicaid populations. They said yes! We will be submitting a proposal for pregnancy doulas (or what I call 'Peridoulas' ) to follow pregnant medicaid clients from the start of pregnancy to up to a year following pregnancy. I fully expected this insurance company would read my email and hit the delete button. Imagine my surprise to get a call the very next day from the Vice President of Research and Innovation out of Long Beach California! So add to my to do list, crafting a winning grant proposal that is due at the end of January. Even though I accepted two adjunct teaching positions for the spring semester, I am considering turning down one of them so I can concentrate on grant writing (and book writing, and workshop writing, and article writing...not to mention starting CNM school). This should teach me to be careful what I ask the universe for...

A Meeting of Minds

2011-12-03T06:07:00.001-08:00

Next Friday, December 9th, a very important meeting will take place: 'A Community Visioning'. This meeting, hosted by yours truly, is an invitation to all 'Community Stakeholders' to come and discuss a plan for creating community-based maternity care; what it would look like, and what it would take to make it happen. I have been planning this meeting all year long. I don't want 2012 to come without a plan of action in hand. All year long now, I have been looking at the vision board in my bedroom next to my bed. It is the first thing I see when I wake up every morning. A large poster board covered in sticky notes and timelines foretelling a seemingly impossible dream; an urban prenatal clinic, birth center, and midwifery school. All quite heady stuff for a former teen welfare mom. How do I galvanize the considerable resources of this community to make it happen? Well, it will start with this meeting. I have sent out my clever and attractive EVITE invitations. I have enlisted a top notch talented facilitator. I have a state-of-the-art, large meeting room. I have my mother's cinnamon rolls and fresh fruit for feeding the participants. And I have an agenda.

In many ways I have been waiting 20 years to host this meeting. I have agonized over the invitation list for months. I understand that whomever is meant to be there, will be there. I also understand that this is the first step in taking my dream PUBLIC. Oh sure, lots of people have heard me talk about my plans to do this or that, but this is the first time in 20 years that I have invited anyone else into that conversation. Its like leaving your five year old at kindergarten for the first time- it finally hits you that someone else will have influence on the way your little one thinks and behaves. In taking my dream public, there are risks. On the other hand, alone I can only accomplish so much. Already, I have been flooded with offers for space for housing the project. I will be out next week, looking around Troost Ave. for the perfect store front.

I'm picturing it already:
"UZAZI VILLAGE" the sign will read. (Swahili for birth) In small letters beneath it, it will read: "An Afro-centric community dedicated to maternal infant and community health". To start, there will be free pregnancy tests and resource referrals. Childbirth classes (the good empowering kind), and breastfeeding support groups will be a staple. Other classes will be added: parenting classes, finance management, employment preparation, etc. I intend to invite others who are already doing these things to do them at Uzazi Village, not duplicate them. I hope other support groups will spring up; fathering support groups, infant loss support groups, perinatal mood disorder support groups. Again, there are already folks out there doing these things, I will invite them to do an Afro-centric version at Uzazi Village. In this way I expand the capacity of organizations who have already perfected this work (whatever it is). Uzazi Village will be divided into Houses: Umoja (unity) House will be our think tank, leadership, and administrative council (Council of Elders), Kujichacalia (self-determination) House will house job readiness, GED completion programs and such. Ujaama (cooperative economics) House will house a business incubator for nonprofits supporting maternal infant health, and courses on entrepreneurship and nonprofit leadership. Imani (faith) House will house faith-based initiatives and church volunteer groups and hopefully a parish nurse ministry. Kuumba (creativity) House will maintain art programs and community gardens. I will add clinical services as soon as I graduate from midwifery school, unless a practicing midwife or physician wants to offer clinic hours sooner. The Ida Mae Patterson Perinatal Wellness Clinic will thus, be born. Named for my grandmother, Ida Mae, who had 24 babies, but only saw nine live to adulthood, this clinic is the crux of the vision. Clients of the Ida Mae clinic can expect home visitors known as pregnancy doulas to visit them at home and do assessments and education. Hierarchies will be flattened as care providers retrieve their clients from the vibrant and active community room (no waiting rooms) and walk them back to their serene and tastefully appointed, mutual exchange suite (no exam rooms) I hope the place is filled with students wanting to learn: nursing students, midwifery students, medical residents (DO, OB, family practice) etc. As it evolves from an education center to clinical services, I will also add birthing rooms: The Nia (purpose) House. I chose this name because of Morningstar's quote in her book of the Cherokee birth blessing, "May you live long enough to know why you were born." I want every child born at Nia House to know their purpose, to know why they were born, to be an integral part of the community that has welcomed them. I hope there will be tutoring, a community garden, a daycare... I hope it expands to take up the entire block... the entire city... the entire world... I want Uzazi Village to be a sustainable, replicable model of community-based wellness care that supports maternal infant health that radiates forth to positively impact family health, that glows outward to support community health.

Now join me in my vision. What do you see...?

Winter Update

2011-11-21T19:39:00.001-08:00

Much has happened since my last post. I have left my job as a nursing instructor. I am enrolled in a nurse-midwife program, and working on my IBLCE credential (lactation consultant). I have attended the MANA (Midwives Alliance of North America) conference in Niagra Falls and gave my two presentations. I have attended the local March of Dimes conference on Prematurity. I'm just back from the Holy Land for a meeting about a nine day pilgrimage in Mexico in January. Some committments are ending, while new ones begin. Plans are underway for the clinic/birth center it has become my destiny to create.
What has become clear is that I must press on, despite any obstacles. The work is greater than myself and I am only a conduit of God's will and desire. This work has nothing to do with my own resources of lack of them. While in Niagra Falls at MANA, I was priviledged to spend a lot of time with the midwives of color, these were amazing women from all over the United States, Canada, Mexico, and the Caribbean. Spending time with these midwives and birth workers reminded me that I am not alone in what I am attempting to do, nor am I the first to attempt it.

I hope to resume teaching in January. Here are a few projects I am working on for next year:

finding an adjunct teaching position
writing a workshop that I will start presenting next May nationally
writing a book that I hope to publish next year
sit for the lactation consultant exam in July
submit an article for a peer-reviewed journal
take the nurse educator certification exam next Spring or Summer
begin preceptor courses for nurse-midwife program
begin apprenticeship with a local homebirth CPM
work with a design student on architectural sketches for clinic
vie for a seat on the state nursing board
feasibility study for clinic
host community visioning sessions
create 501c3 for clinic
complete training and fundraising for pilgrimage
complete 9 day pilgrimage in Mexico
investigate MPH program (just dreaming here)
increase business training to include ACLS and LPN-IV course
write for some grants
find some partnerships to complete the Mama Love Project

All well-wishes much appreciated.

Autumn Update

2011-09-26T03:59:00.000-07:00

I have just returned from the Autumnal Equinox gathering at the Holy Land in central Missouri. It was a small but mighty gathering of women. We shared our usual drumming and fire circles, walks, and herb gatherings, and meal making and sharing. Sr. Morningstar led us in many healing rituals and conversations. I slept under the September stars in the tipee on both nights, grateful to have it all to myself, and for the peaceful star filled nights. I fell asleep each night to the hoot owl calling from the woods and woke in the morning to whipor-wills and woodpeckers. It was three days of bliss.
For several months now, I have been making plans for the birth center, and becoming acclimated to midwifery school. I am taking a pharmacology class this Fall but begin my core midwifery courses in the Spring. I am also planning to return to Mexico in January to complete the nine day San Miguel Walk with Sr. Morningstar and 8 other women from our spiritual community. It is a nine day pilgrimage over the Sierra Madres of central Mexico, walking about 8 hours per day. I am also preparing to speak at MANA (Midwives Alliance of North America) this Fall in Niagra Falls Canada. I'll be speaking on maternal infant health after a disaster (based on my three trips to Haiti) and cultural competency in maternal infant health. I continue to teach full time, and will soon begin speaking nationally on active learning teaching strategies. Next year I look forward to becoming certified in nursing education through the National League of Nursing (NLN), publishing my first article in a peer reviewed journal and sitting for my lactation consultant credential. I am also working on next year's CIMS (Coalition to improve maternity services) conference, and locating a building in which to house my future birth center. It has been a busy Fall. Next year will be busier.
I am learning to trust my own intuitive knowing, when to seek the advice of others, and when to press on in my own wisdom. My lessons are many, the trials are difficult, but I am confident of my path. I press on.

The Mama Love Project

2011-07-17T17:18:00.000-07:00

A couple of months ago, I was contemplating the problem of infant mortality in my community. This is a topic often discussed in the Women's, Children's and Infant's Health Committee (WICH) of the Kansas City Health Commission. WICH is also the Community Action Team (CAT) of our local Fetal Infant Mortality Review Board (FIMR). The CAT receives reports from Case Review Team (CRT), the other half of FIMR (of which I am also a member). The CRT reviews cases of infants that have died in the most high risk zip codes of our city to determine if their deaths were preventable. The CRT then makes recommendations to the CAT for systems, policy, or protocal change that will have an impact on the number of infant deaths. The CAT is charged with disseminating and if possible, implementing these changes.

If all of this is confusing to you, I was a WICH member for months before I realized it was also the CAT. The bottom line is, both the WICH and the CAT are actively involved in the issue of infant mortality. Nowhere is this issue more pronounced than in the African-American community in our urban core. Nationwide, Black infant die at rates twice that of Caucasian infants. Here locally, it's almost three times higher. I've discussed this topic before on this blog. I've attended conferences devoted to this topic. I've presented at conferences on this topic. I spent a year and a half researching this topic for my master's research project.

It occurred to me recently that as bad as this problem is, it is an essentially invisible social phenomenon. I thought, what if we put a face on Black infant mortality. As a natural born storyteller, I understand the impact of the personal narrative. I use storytelling as a teaching strategy with my nursing students. I thought, why not let the women tell their own stories of perinatal infant loss. What could be more powerful than that?

The Mama Love Project is born out of a need to put a face and a voice and a human presence on an important social and health issue. Months of work on the FIMR, pouring over the death records of deceased infants and analyzing events that led up to their deaths, has convinced me that most of these deaths were preventable.

The women's stories will be filmed and the footage will be made available to agencies working to decrease health disparities in infant mortality and to create public health announcements. What I need now is the women. I'll be setting up a Facebook page titled, The Mama Love Project. I am actively seeking women willing to share their stories. These women must be African-American, reside in Kansas City's urban core (preferably in our high risk zip codes) who have experienced perinatal loss from greater than 20 weeks gestation until 28 days postpartum.

If you or someone you know would like to participate in the Mama Love Project, please contact me at laborpayne@yahoo.com. Perhaps your story can help prevent future deaths, and bring needed attention to a serious problem that remains under the radar screen.

The She Wolf Lodge

2011-06-30T04:37:00.000-07:00

Photos: me giving counsel, a morning fire circle session, a mother and child, young maidens in a hammock, Sr. Morningstar being smudged during opening ceremonies

Sacred images from the Holy Land (Morningstar Community) where I went this weekend for the Summer Solstice Celebration of the She Wolf Council. I live for these: the drum circles, the smudging, the storytelling around the fire circle, the sessions led by Sr. Morningstar, the fabulous vegetarian and vegan feasts (no meat is allowed on the Holy Land). A pure weekend of women who have left their lives to come together for sharing growth, enlightenment, and transcendance. I'm excited to be moving into my crohn years (defined as one year without bleeding), when I can take my place among the other queen mothers and elders and begin to participate in leadership. In the meantime, I look forward to how much I learn about myself each time I attend. The lesson this time was observing my comfort in my own skin and being still in my own knowing. These are blessed discoveries that prepare me for the work ahead. I'll go back again for the Fall Solstice and continue my work on becoming me.

At one point, Sr. Morningstar asked us to describe our perfect day. Here is mine:

I wake up early, as usual, around 5am. I sit in my garden and have my morning cup of tea and quiet time. After my morning routine, I leave my house and walk around the corner to the clinic. I like to be the first one there to open it up. There is an early morning meeting and I bring fresh flowers from my garden to brighten up the meeting room. As the morning progresses, the clinic staff starts to arrive, the meeting begins and ends, and clients begin to arrive. I oversee the workings of the clinic and the staff, and leave midmorning for more meetings. On this my perfect day, all things go my way. Every idea, every initiative is met with a 'yes!' After a successful round of meetings, I meet my beloved for lunch. We meet at one of my favorite restaurants tucked away on a high hill overlooking downtown on the West Side. After a lovely meal and time to connect with my spouse, I head back to the clinic and oversee its finish for the day. There are patients to see, reports to file, emails and calls to return. My administrative assistant has been dispatched to the airport to pick up a group of international students and researchers. They will be staying in the guest house and working in our clinic for a few weeks. When the last patient has been seen, I rush back around the corner to the house to make sure everything is ready for the arrival of the guests. Dinner has been prepared and the house is full of home-cooked smells. I sit down to dinner with my family and enjoy a good meal. Afterwards, I sit and think and reflect on what a wonderful day it has been. I remember, that it is my perfect day.

Now your turn. What would your perfect day look like?

The Checklist

2011-06-12T08:33:00.000-07:00

In the two weeks since I have returned from Haiti, I have been involved in several activites, most of which I will attempt to summerize here:

I queried my story about Dr. Delson to a journal but they turned it down, however they did give me ideas of what type of journal might be interested in the story.

I started teaching my summer classes, one for LPNs and one for RNs and will be teaching through July.

As a part of my committe work, I will be working on the two following projects- 1) collecting and cataloging the stories of African-American women who have lost babies due to preterm delivery or low birth weight,and 2) interviewing the three urban KC hospitals that do deliveries in order to celebrate what they do right and encourage improvements.

My two proposals were accepted by the MANA conference, so now to get started fleshing out the following: Lessons from Haiti: maternal infant care during a disaster from the midwifery model, and Brick by Brick: dismantaling racism in maternal infant care.

I continue planning for the CIMS Forum 2012- currently identifying potential speakers.

My business is expanding to a third state, and I am writing the training manual for new trainers.

I am lobbying for a mayoral appointment to the county hospital board from our newly elected mayor.

I am researching and writing an educational module on preconception care. If all goes well, I'll be traveling around the country presenting it to home visiting nurses and community workers, along with other content.

I am doing my preliminary planning for my profit prenatal clinic and my nonprofit maternity care think tank.

fielding offers to work in my (so far imaginary) clinic

preparing for a Board of Nursing visit at my college where I teach

planning for trip to Canada in November and Mexico in January, and trying to find a way to go to Tazania in December

looking forward to a trip to The Holy Land (Morningstar Community) at the end of the month for rest and rejuvination

kids leave home but keep coming back, now what?

Still waiting and mentally preparing to hear if I am accepted into the midwifery program

gardening daily now and loving it!

The Salvation of her People

2011-05-28T14:00:00.000-07:00

I sit in a cool air-conditioned room of Jennie Joseph's birth center in Winter Garden Florida. Much has transpired over the past three days. I'll begin at the beginning.

On the last day in Dr. Delson's clinic, I awoke to the surprise of three laboring women. I had hoped for at least one birth per day, and it seemed as if I would get my wish plus a bonus. Mother 1, 42 years old, came in during the night, a multip on baby number four, dilated to four. By morning she was at six. Mother 2 was a multip, dilated to 3. She lost a child in the earthquake last year, as did Mother 1. Mother 3, 27 years old, was a primip. They all labored nicely all throughout the clinic day as Monsieur saw a full slate of clients- it was actually our busiest day, even though it was only a half day clinic! He got through them all quickly and efficiently in order to attend the laboring mothers.

He expressed concerns about Mother 1 because she was large for dates. He wasn't sure if she had an extra large baby or an excess of amniotic fluid. He turned his attention to her first. The ladies in general were left to labor on their own with whatever support person they brought with them. They walked the courtyard and waiting room floor, and layed on the benches or on a bed, and in general did not make a fuss. After clinic Monsieur checked all the mothers again, and found Mother 2 and Mother 3 had made some progress, but Mother 1 was still at six. He put her on the delivery table and added 10 U pit to her IV (I didn't mention before, but there was no IV pump- all IVs are to gravity by drip, in case you were assuming there was. I myself had never seen gravity pit for induction/augmentatation and was amazed to see it regulated in this way- though mostly it was a very slow drip, but not at all titrated, only slowed down or sped up to his will.) After a couple of hours, she was still at 6, as she had been since morning (this was now early evening). Monsieur looked uncertain but he decided to act on his instinct to call in his anesthesiologist- from Port au Prince, two hours away. Now I began to see the gravity of his situation. Mother 1 and her baby were in no immediate danger, but to even consider a cesarean as a possiblility, Monsieur would have to plan two hours out. After reaching the anesthesiologist for the surgery, he found that she had sent her own car to pick up her children away at school, she was available to come, but she did not have a way. Dr. Delson immediately dispatched his own driver to pick her up. This added to the time and would now be four hours instead of two for the surgery. He thought this gave Mother 1 more time to labor on her own and push the baby out if she could. I began to appreciate how difficult his job was and how difficult a call this was to make- getting a surgery that might be unindicated vs needing surgery and the option is not available. The anesthesiologist was on call at her own hospital that evening, and would need to return to Port au Prince immediately following the surgery (and she was too- she didn't wait till after recovery, she was dressed and beat the Dr. and I out the door!) After all arrangements had been made with the anesthesiologist and the small hospital down the road where the surgery would take place, Mother 1 was taken off the table and off the pit and placed in a bed to resume laboring on her own.

Mother 2 was by this time dilated to 7 and was placed on the delivery table. She too was augmented to speed things up and get her delivered before Monsieur had to leave for the surgery. I labored alongside her and within 2 hours she was complete and ready to push. Mother two was such a strong woman! She was a big, robust woman who embrassed each contraction and roared with every push! I have hardly seen such strong, effective pushes. She needed no 'coaching' from anyone. She was a fabulous pusher. After about an hour of pushing, she birthed a fine, fat, healthy boy. I prayed she would find comfort from the loss of her other child, and that this child would bring her peace and joy (not that one can replace the other, by any means). With Mother 2 barely off the birthing table and in bed with her baby beside her, we raced off to the hospital.

When we arrived, we quickly changed and entered the operating suite. It was the first time during this visit to experience air-conditioning- not the entire hospital, just the operating suite. (The patient ward was actually sweltering.) When we walked in the patient was on the table prepped for surgery, the anesthesiologist had already done her thing and the entire team was waiting for us. Monsieur introduced me, and everyone welcomed me. There was a scrub nurse, a circulating nurse, a first assistant (also a nurse, I learned later, trained by the Dr. himself- usually the first assistant is another physician, but there was no other physician), the anesthesiologist, and a dedicated baby nurse, who also acted as a second circulating nurse. The team worked beautifully together. The surgery was fast and effecient (it had to be, we had one other laboring patient to get back to!) I found it interesting that the baby nurse was handed and upside down baby, dangled by its feet, which she carried that way out of the operating suite to a nearby gurnee waiting with baby supplies on it. (There were no baby warmers or a fetal heart monitor in the hospital). She quickly cleaned and dressed the infant girl, and then left her there on the gurney (completely unattended!) and returned to finish helping with the surgery. She glanced out the operation room door, window every few minutes (as did I!) to make sure the baby was still safe on the gurney that had been pushed up against a wall. With the last stitch sewn, Monsieur and I fled out, just as quickly as we had come and drove back to the clinic. I thought the anesthesiologist might stay until the patient was out of recovery, but she was dressed and headed out the door ahead of us, even though she was still in the OR when we left it!

Back at the clinic, Mother 3, our youngest, and a primip, was hard at work laboring. She too went to the delivery table and was at almost 8. Even so, it took a couple of hours to become complete and a couple of more hours for her to push her baby out. She was a sweet girl and she really fought her pushes. She not only relished my labor assist, she would grab me around my waist with each contraction and bury her face in my bosom! I think if she could have climbed into my lap, she would have done so. She screamed with each contraction, but would also eventually bear down nicely. As with the other primip we saw this week, Monsieur cut an episiotomy. I thought with the other, the epis seemed a little 'crooked'. This time when he did the epis repair after the birth of a sweet little girl, I came around and stood next to him to watch, and sure enough, he had cut a medial lateral epis. I have not seen these done in a very long time- I winced to think of her recovery in this heat. By the time, she was recovered, cleaned up and tucked in bed, it was 10 o'clock at night. The first clinic patient had arrived around 8 am that morning. It had been a long, and as Monsieur had predicted, a very busy day. Sometime between Mother 3 being complete and pushing, he had returned to the hospital to check on Mother 1. All in a day's work for someone on the front line of maternity care.

I could hardly process all that had happened that day. I had to fall into bed, and be up for a 5 am ride to the airport. I had used snatches of time during the day to straighten my quarters, and pack my things. I went up to the Heart to Heart clinic to say my goodbyes. I wolfed down a dinner that might have been the best one yet. There was chicken cooked in a delicious sauce, that had been strutting around the yard this morning. "Monsieur!" I asked agast, "You mean this chicken was alive this morning?" "Yes," he answered proudly between mouthfuls, "this is fresh, organic chicken." I didn't ask about the details of his demise and preparation, all that I had missed with the busyness of the clinic. I didn't want to imagine Monsieur ringing a chicken's neck in between patient visits. Better to think the old housekeeper did it- she was stick thin, but strong and sturdy and has probably wrung more than a few necks in her lifetime. This 'fresh, organic' chicken was served along side beans and rice, and a Russian salad. This was a salad of cubed roasted beets and potatoes, like a potato salad made with half beets. Stirred together with mayonaisse (?) it made a pinkish unpalatable looking mass, but one taste and I was hooked. It was delicious! the roasted flavor of the beets was perfect with the boiled potatoes. I ate two servings and since no one spoke for the last little bit left in the bowl, I ate that too.

I was up the next morning at 4:30 am, packed, dressed, and ready to go. I used the final 30 minutes of my stay to sit quietly on my balcony and allow the morning to unfold. I took a few snapshots, that won't begin to tell the stories, or capture the beauty... Madam and the driver and I packed into the truck and headed for Port au Prince. I never dreamed it would take so long. We must have hit ''morning rush hour" in the city, because we moved at a snail's pace throught the densely packed corridors. The driver tried his best, honking all the way, even driving up on sidewalks (!) and narrowly missing pedestrians, who share the roadways equally with vehicles and animals. Even so, I missed my flight out to Ft. Lauderdale, and was rerouted on the next flight out, an hour later, into Miami.

My intent had been to rent a car in Ft. Lauderdale, and drive up the coast to Orlando. Arriving in Miami, they did not have a car for me, so I instead booked a flight to Orlando and rented a car once I arrived there. Once I arrived in Orlando, I drove to my hotel, and settled in for the night. I called Jennie Joseph, let her know I was in town, and made an appointment to meet with her the following morning.

Today I met with Jennie and spent the morning and afternoon with her. How can I relay the value of such a meeting? She gave me a tour of her birth center and clinic and we went out for a Cuban lunch. The value of the advice she gave me far outweighs the time and expense it took to get here to receive it. I feel so honored to build my life's work upon the foundation that women like Jennnie have built. I now have a perspective of my work that is not predicated upon my own singular successes or failures, but as a smaller part of a much larger work, much like a quilt where each piece contributes to the greatness of the whole. After what I have learned from Dr. Delson and Jennie Joseph, I return home with greater clarity and resolve to do the work that only I can, and must do.

I am reminded of the book of Esther. Who knows that I have been placed here for such a time as this? This is my time, I've long known it. I have one more day here before returning home. I've decided to make it a day of silence, prayer, and writing. There is much to be done.

Reunion

2011-05-26T06:39:00.000-07:00

Yesterday, I sat on my balcony entertaining two guests. Kicki and Mose. Kicki was my interpreter during my first trip to Haiti last March, and Mose was my interpreter during the October trip. I introduce them to one another and watch a bond form. Like most interpreters, they are in their early twenties, and hope for a better future. I smile watching them converse in Kreyol. While Mose lives and works here in Leogone, Kicki has made the trip out from Port au Prince to visit with me. I have seen Kicki on every trip, he has been generous, keeping in touch. I fuss over them both, telling them how handsome and how smart they both are. Kicki smiles shyly and tells me he is too 'flat' (he means he is skinny!). Mose says his English is not good. "No", I say, "it is very good!" (It is far better than my Kreyol.) We visit for a long while, and I hear about their families. Kicki plans to start college soon. He has been waiting and saving for four years to go. I am thrilled for him. He is torn between studying engineering and architecture. Kicki has written a book and shares it with Mose. He has written two volumes of a book on French to English translation. I look it over and it is very well done. He spells out the pronounciation of English words from a French linquistic point of view. I've not seen anything like it. I have had trouble learning Kreyol from a book because looking at how a word is spelled, does not tell me how it sounds. Kicki has already corrected me for pronouncing Kreyol words with a Spanish accent. (Spanish is the language I know best after English, and it does get in the way of both my French and Kreyol. When I think of a word I want to say, I have to sift through it's English and Spanish counterparts first in my brain.) Kicki is very bright and I know he will do wonderful things with his life. He will make a very lovely man, inside and out.

The theme of the day must be visiting, because after clinic is completed for the day, I walk down the road and visit at the Heart to Heart clinic. There are six workers at the clinic lodging house, four from the US, one from Dubai, and one from Mexico. I enjoy a nice visit with them. They all plan to go to visit Nicole's orphanage tonight. I cannot go because there is a mother in early labor and I don't wish to miss it.

Madam prepared a thick bean soup with beef and plantain (which taken on the texture and taste of potatoes when cooked this way) for dinner. It is delicious. Gigi has dinner with me, and has four servings- in between making faces at me, and shooting me with his finger gun. I feign a hideous death for his amusement. Gigi is such a little ray of sunshine. He plays all day long in between his parents working in the clinic. He can be seen tossing his teddy bear around the courtyard, or riding is toy motorcyle in the waiting room, or landing a toy airplane on the head of the washerwoman as she tends the laundry. The entire compound is his playroom, and all the adults adore him. His parents especially. His mother rarely scolds him, and he brings a ready smile to his father's face everytime he catches a glimpse of him. Wherever I am, I hear his little four year old voice, singing songs, or calling out for his mother. It won't be the same around the clinic when he joins his brother and sister at bording school next term.

Last night I had a full night's sleep. The laboring mother came last night into the compound, but she was still laboring this morning- along with two others! I woke with a start, thinking I had missed the birth, but when I came down for breakfast, I found her and two others pacing the clinic floor in their nightgowns. Monseiur tells me it will be a busy day. I am glad, since today is my last full day in the clinic. I leave at 5am tomorrow to catch my plane in Port au Prince. I will spend the weekend in Orlando discussing birth centers. I am wistful today, as it is my son, William's birthday. I know the entire family will go to Mi Ranchito tonight for dinner, our family tradition. I'm sad to miss it because the birthday person has to wear a rather large sombrero while the waiters sing to him/her in Spanish! We all laugh at the afflicted one, take pictures with our phones and post them on facebook. What can I say? Its a tradition. I'm also a little sad because William will be the first of our children to leave Kansas City after leaving home. He plans to move to Denver in a couple of weeks. I'm not sure when I'll next share a birthday with him.

As my time here comes to a close, I think of how I have fallen into the flow of life here, and its predictable patterns. The Haitians go to bed early and rise early (as is my custom). I am amazed by the humility and generosity of my hosts. The thick, wet heat has not bothered me much. I enjoy the daily afternoon rain shower, and the siesta it brings in the middle of the day. I have not had a drop of processed food all week. I have lived as a Haitian, without the usual worries of a visiting foreigner. All has been well. Thanks to those who read these posts, and give me an audience for my reflections.

Making Do

2011-05-25T06:29:00.001-07:00

One of the many things I have observed while here in Haiti, is that folks know how to make do. They have come up with all sorts of ingenious ways to get what they need with such limited resources. As I sat on the balcony of my quarters yesterday, I observed a little open air, makeshift babershop in the tent city next door. As the customer sat in a chair, the barber appeared to comb his hair with what looked like a comb, but it must have had blades on it, because as the barber 'combed,' the customer's hair came off in little clumps. I have never seen a haircut of this type without an electric razor. The end result was a nice clean shaven head.

Later in the day, Monseiur was almost out of the little squares of paper he used to write his instructions or prescriptions on. I saw him print of sheets of paper with four little squares on each with his name and address centered at the top of each one. I offered to cut each page into four equal sheets for Madam. I looked around for scissors and seeing none, I was about to leave to go to my room and get my pair, but before I could go, Madam grabbed a knife off the shelf and showed me how to fold and then neatly slice through the folded pages to make the little pads of paper.

Later, I was washing my hands in a sink and noticed that someone had made a little sink plug from a plastic bottle cap. A small hole had been drilled in the center, a string passed through and knotted and tied to the faucet handle. The little cap fit perfectly into the opening of the sink.

I think the Haitians must make, "making do" a daily occupation. They are resourceful in a way I am seldom called upon to be. Monsieur holds constant diligence over the electricity that flows into the compound. Nothing will bring him up the stairs of my quarters faster, than if he notices my lights have gone out. "Did all the lights go out?" "Does the bathroom light still work?" " Does the fan still work?" He asks as he turns all the switches on and off. He stands there for a moment contemplating, then calls his hired man on the phone and talks to him very quickly in Kreyol as he heads down the stairs to tinker with his generator. My room, like all the rooms of the clinic are half government electricity, and half generator electricity. There is a backup generator for the delivery and postpartum rooms. The government electricity and whatever it powers is often out. Monsieur tries to ensure that whatever is essential is on generator power. It appears my fan is on one grid, and my light on another, even though they are a unit (a ceiling fan with a lamp attached). I laugh and tell Monseiur I do not mind if my lights are out, but he clearly does.

He devotes time to each day tending to electrical issues throughout the clinic. I see minimal reliance on electricity but he does have an fetal heart monitor for labors and a colposcope and ultrasound for the clinic. His doppler is battery powered. In the clinic is a computer, 2 printer/faxes, a television, a fridge in the family quarters, and a camp stove with 3 burners and assorted small electric kitchen appliances that Madam uses for cooking such as a coffee maker and blender. They appear to try to ease their reliance and something as unreliable as electricity. For a few hours yesterday, both the government power and generator were out and it became very hot in the clinic without the ceiling fans. We were all sweating profusely through our clothing. The back-up generator powered a few lamps to see by. I try to imagine doing my job as a labor and delivery nurse all the time worrying about whether or not I will have electricity. Of course, that is only one of a long list of Monseiur's concerns throughout the day.

Yesterday was a half day clinic which occurs every Tues. and Thurs. When clinic was done I walked down the road to visit at the Heart to Heart clinic I volunteered with on my visit last Fall. I ran into my former interpreter, Mose. I asked Mose if there was a restaurant nearby. My former interpreter Kicki is coming up from Port au Prince tomorrow and I want to take him out for a meal. Mose offers to walk me there so I can see it. We walk a surprisingly short distance to an open air restaurant playing loud "Kistian" music as Mose informs me. We are the only ones there. This does not surprise me- it is 'siesta' time (the hottest part of the day) during which everyone retreats. I'm not even sure the Haitians 'do' lunch. At any rate I ask Mose to try out the menu with me so I'll know what to order tomorrow. We order cold sodas and two 'poulet'. The menu is a white board on which is written: poulet (chicken), cabrillet (goat), poisson (fish), etc. Nothing is written as to how they are prepared or what they will be served with, so though I know we will be served chicken, I know nothing else about the dish. About 20 minutes later, the waitress sets down plates with fried chicken (here it is done with out the skin, without any coating, or without any spices), french fries, picklese (a vinegary slaw made with hot peppers that I love), and fried plaintain. It is a small feast! I thank Mose profusely for showing this place to me.

Later that evening, I enjoy another lovely meal as Madam has prepared fish I ( I don't know what kind- but its flesh was thick and tender and flaky), cooked in the most delicious broth with tender onions and peppers floating in it. The household cats smell the fish and harrass me all through the meal. This is served alongside rice and beans, and fried plantain with ice cold lemonade. I secretly wish for some picklese to go with the fish, but it is a delicious meal.

Just after I retire to my quarters for bed, Monseiur comes up to tell me, that a patient has arrived in labor, but not to worry, she is a primip (first timer) very early in her labor. I was to go on to bed and he will call me when the time is at hand (Monseiur gave me one of his cell phones to keep with me, so that I could reach him immediately in case of an emergency or he could reach me for a labor). So I go off to bed and the phone rings around 1 am. I answer it, but it is too late, the caller has hung up. I think, of course it is Monseiur alerting me to a change in the labor. I rise, dress, and head down to the clinic. I find the patient dilated to six, and Monseiur saying he did not call me at all! It must of been a wrong number. Nonetheless, I am introduced to the patient and without waiting at all, I jump right in and start laboring her on the very first contraction I witness. Monseiur goes back to bed, while Francios and I quickly settle into a labor routine. I get a wet cloth and start fanning her between contractions. During contractions, I apply counter pressure which she quickly insists on for every contraction. Not being able to speak her language, I smile a lot, and encourage her with the little Kreyol I do know. She is in the postpartum bed, since Monseiur expected her to labor most of the night. I want her to get out of bed to try standing for her contractions, but I cannot communicate this concept, and give up after a couple of attempts. When she feels a constraction start, she looks for me and holds out her hand. I come quickly to her and press one palm forcefully into her lower back (only on her left side- she doesn't want it on the right) and with my other hand I gently stoke her leg downward and out. At the same time I breathe slowly and deeply blowing out pursed lips to model how her breathing should be (she doesn't follow!) Instead of my slow deep breathing, she chants the same phrases over and over. I do not know enough Kreyol to know what she is saying, but I know it comforts her. We go on like this for about an hour and a half as her contractions come closer together. Monsieur emerges from his bedroom. He says he heard the change in her voice and he will check her now. She is dialated to eight and we walk her into the delivery room. In another hour, she has delivered a fine boy whom Monsieur strangely dangles upside down by his feet until Madam takes him. He cries robustly in protest the entire time. An episiotomy has been cut, so the repair must be done. After cleaning her, Madam and I stand her up to walk her back into the recovery room where her baby and kinswoman wait. We get about four steps and Francoise faints dead away between the two of us. We help her gently to the floor and call for Monsieur. He comes quickly, she awakens and we put her back on the delivery table. She passes several large clots. More pit is added to the IV bag and oral cytotec is given (though her uterus was always firm) and an internal exam is done. After some rest time, we try again to walk to the recovery room- this time success. I help Madam clean the delivery room. Francois is very sweet and thanks me. I beam at her new baby boy and compliment him profusely. Monsieur walks me up to my quarters because the outdoor light is out and he uses his cell phone for a flashlight. (I think he really wants a chance to flip the light switches in my room off and on again!) I crawl back into bed at 4 am thinking, maybe I can do this nighttime on call thing after all, and I fall asleep immediately.

Big Pharm or Big Phuck?

2011-05-23T17:03:00.000-07:00

Today I spent with Monseiur in his clinic. The patients started early and stopped coming at midday during the heat of the day, then they resumed coming in the late afternoon. We saw two patients today who were coming after self-induced abortions after taking cytotec. Apparently this was not unusual. I asked Monseiur where these women would get cytotec. He said from the pharmacy, they can just walk in and purchase it. I had no idea. I asked him if the women ever had complications from it. He said sometimes he had to do a D&C but not often. I asked them how much they took. The first patient today coming in for this reason had swallowed two pills and placed one in her vagina! (This is a much greater dose than is given for induction or even postpartum hemorrhage, but I don't know the protocols for abortions.) Monsieur did ultrasounds on both women to see if all had been expelled. I asked him later what Haitian women did for birth control, not knowing what answer I would get in such a Catholic country. He said that they preferred birth control pills and depo. We saw several women for prenatal visits and women of all ages for GYN concerns as well. In all Monsieur saw about 35 patients today.

After the postabortion patients, the patients I found most interesting were for HPV follow ups. Monseiur explained that he had particpated in a drug study with one of the big pharmaceuticals that involved screening 10,000 Haitian women for HPV. When the results were returned, the drug company asked physicians to biopsy (take a tissue sample) all the women whose tests came back positive. Monseiur refused. He would only biopsy those who showed abnormal cervical tissue on a colposcopic exam at follow up. He was not going to biopsy healthy tissue. This started a day long dialog about the exploitation of third world women by drug companies, NGOs and even charitible and religious organizations. I knew all too well what he meant. Hadn't I myself many times particpated in the ''treat 'em and street 'em" brand of healthcare both at home and abroad? This company was not offering treatment to the women who tested positive, only a testing of their screening product. This whole conversation got my blood boiling- again. Monsieur told me at length how again and again he had entered into agreements with individuals and organizations that promised this or that but in time, they all leave. Here he remains, carrying on the work that must be done.

My time here becomes clearer as the days pass. Monseiur exemplifies that model of care that I want to emulate: long term solutions rather than half-assed quick fixes. Later that afternoon, during the break in the heat of the day, I walked down the dirt road to the Heart to Heart Clinic. This is where I had worked when I was here last October. In the courtyard under a shade tree, I immediately saw Wilifred, and Mose. I hugged them heartily. I didn't know it would feel so good seeing my interpreters again looking sturdy and handsome. They smiled and hugged me back. Then I went inside the house to say hello. I recognized the cook and greeted her, and then greeted the two individuals at the table. One was a Haitian whose job was to look after the house, the other was Nicole. We had not previously met. I introduced myself, and we each shared what we were doing in Haiti. She and a friend had actually rented a house for a year here in Leogone with the intention to start a charity/NGO to serve the HIV population. I shared my plans with her for my urban birth center. We walked a bit, and I introduced her to Dr. Delson. He made it plain he had no interest in her ideas. I, however, hope she gets to do all that she intends and more.

Dinner last night was a savory blend of rice and beans, green beans, and stewed conch and onions. I had not had this kind of seafood before but it reminded me of squid in its appearance, but was softer in texture. I enjoyed it very much. After dinner the clouds moved in. I was breathing a prayer of gratitude for the rain after a hot dusty day, when I remembered the poor souls in the tents across the roadway. I peeked out my door across at them, but I could see nothing- pitch black- there was no electricity tonight. We had some because of the back up generator, but elsewhere in the neighborhood, there was pitch blackness all around. I tried to imagine what it must be like in one of those tents, with the heavy rains coming down and sitting in the dark. I thought better of giving thanks for the rain, when I was warm and dry and had light to read by.

I stayed up reading for several hours until I heard Monsieur coming up the stairs calling my name. "Oui? Monsieur" I called out, wondering if he was coming to tell me the state electricity was back on. I had been sitting in the bathroom reading in poor light because my bedroom light and fan had no electrical current at all. Better, a woman had arrived in labor! She was dilated to six with baby number three. When I freshened up and arrived in the clinic (thank goodness I had not changed out of my clothes for the day yet), she was already on the delivery table with her legs in stirrups. I was surprised to see he had her laboring in that position. Her broke her water soon after I arrived, it was nice and clear. He ran back and forth, between the mother and his generator (he had workmen working on trying to get more electrical coverage- the delivery room had lights, but he was trying to get the fan going as well) I was able to give comfort care such as it was. I put a pillow under her head, a cool cloth on her forehead, and fanned her with a packet of sterile gloves. I soothed her with my minimal command of Kreyol. Her husband and two kinswomen waiting out in the waiting area, but every now and then, her nervous husband would stick his head in the door to see if she was alright. His anxious face made me smile, surely nervous husbands the world over have the exact same look. I smiled at him as I held his wife's hand to give him some reassurance. I wanted badly to wave him in let him hold her hand instead, but I have not seen this be the custom in Haiti, and I was determined to just observe (though by getting up and helping the mother I had already broken that deal with myself) and see how Monsieur does things without intervening. While I might later suggest this or that (if it is appropriate), for the first delivery I thought it best just to see what actually occurs in the course of a delivery here. The woman actually labored fine before her water was broke, but the contractions became noticably more intense afterward. With each contraction she would grab me around my waist and look into my eyes. I wished I spoke her language so I could comfort her better, instead I just returned her gaze and slowly shook my head yes, as if to say, "All is as it should be, all is well." As Monseiur predicted, she did not labor long. Within the hour after I arrived and her water was broken, she pushed out a fat juicy baby girl with a fat robust cord, wrapped loosely around her neck and a compound presentation as her head emerged along with one arm. I was surprised to see Monsieur dangle the infant by its feet, yet he was gentle and I saw fluids flow from her mouth. He never suctioned her, she never cried. She only looked around wide eyed and alert. Madam appeared to claim the baby. She never bathed her, but wiped her down, weighed her and dressed her in the diaper and clothing the family had brought for her. She was still covered in vernix, but all the blood and fluids had been wiped off. Madam then took the baby into the recovering room where the Father and two women waited. Monsieur had to do stitches and I assisted and observed. There was really not much for me to do since Monsieur was not used to working with a nurse assisting (even though Madam is a nurse- she did not help at all with the delivery and only appeared to care for the baby) so he pretty much did all the tasks I would have done. However, he did explain what he was doing to me. Then Madam came back and cleaned the mother up and we helped her walk into the next room where her baby and family were waiting. It was as calm and as simple a delivery I had seen in a medicalized setting. Madam and Monsieur hardly spoke, except to give a few directives. (Monsieur was actually much more animated about the generator situation.) I helped Madam clean up after the delivery. There was a lot of amniotic fluid, most of which came as baby was pushed out. The mother had recieved 10 units of pit in a IV Monsieur had started when she arrived. After she was in bed, he also gave her a cytotec pill to swallow with water. I asked Monsieur how long they would stay. He said about six hours, that they would leave in the morning. Sure enough, when I came down to breakfast, they were gone.

Chicken Culture

2011-05-23T05:57:00.000-07:00

Last night after the Merisiers returned, minus two children, we had a fine dinner of okra and beef neckbone stew (I had never eaten okra before and in truth may never do so again, but it was quite delicious), and rice cooked with tiny beans (the size of cooked millet or bulgar wheat) that I had never seen before, but it too was delicious. More frozen papaya juice rounded out the meal.

After my trip back from Port au Prince, I have decided to alter my appearance. I noted on previous trips here that I could pass for a Haitian except for one thing: my hair. After studying intently, I have noticed no Haitian women wear their hair as I wear mine, in a short Afro. They have processed hair, or if it is natural, it is in braids or cornrows. I also brought along a head wrap, but I noticed that the Haitian women don't wear updo headwraps as African women might, but lowlying wraps that hang low instead of pile high. I also noticed that my Afro was not faring well in the dust. Typically I can wash my hair once or twice a week and it maintains its smooth shininess and shape. Here after one day it was dull, misshappen and wild. I decided I will be Haitian, and wear braids. I had to borrow a comb from Madam, wash my hair about three times to get it clean, than comb it out and braid it. I'm afraid I am no longer very good at braiding since I have long since stopped braiding my girls' hair. I look rather like one of Monsier's chickens, but I also look more Haitian.

Unlike the sleep of the dead I experienced last night, due to my extreme fatigue, this night was fitful. The mosquitoes nearly devored me. I wonder if last night, I was too tired to feel them biting me. The first night I also closed my front door, last night I kept it open to give me more of a breeze- it only gave me more mosquitoes. I also discovered a trail of ants- making their way over to and into my bag of trail mix. I poured it all out on the bed and shook loose the ants, and rebagged it. I have no intention of going all week without a protein snack. The other disturbance to my sleep was the music. It just so happens their is a discoteque directly across the road from my quarters. The Paradise to be exact. It is really just a walled in compound with concrete slabs for floors and thatched rooves overhead (same construction as the local churches) I'm sure the music and revelers were just as loud the night before last, but I did not hear them. Tonight, I was treated to an eclectic variety of Reggae, American and Haitian hiphop, sad French love songs, and Justin Bieber (?). The music was very loud, but that didn't bother nearly as much as the drunken revelers who became more verbose as the evening wore on. Their numbers had grown so great, they spilled out of the Paradise and into the street directly under my windows. Finally it all stopped, and the night sounds of Haiti took over. While human voices and noises rule the day, animal ones rule the night. Monseiur's seemingly nocturnal roosters, begin their calls around 3am- just shortly after Paradise shut down for the night. How did I not hear any of this the night before? Add to the roosters; dogs barking, and cows lowing and you get a more complete picture of my constant auditory assault. Even so, I did manage to get some sleep, but I woke several times to commit mosquito massacre and spray repellant on my beseiged ankles and legs. I dreamed of malaria all night. On a good note, once morning broke, I sat out on my little balcony to listen to the call to prayer coming from the Sri Lankan camp down the road. It was the sweetest sound of the assault of sounds I had heard all night, and made me once again grateful for the gift of sound.

Before breakfast, I went with Monsieur to feed the chickens. As he fed them, he gave me a primer on chicken culture. He alerted me to the sounds a chicken makes when it has laid its eggs. (He then went through the thicket in search of the eggs). When I saw a loose chicken seem as though it might get into a cage with the hen and chicks, I alerted Monseiur. He simply shrugged his shoulders and said, "He won't go in, if he does she will kill him." He pointed out two young roosters sparing with one another, stretching their necks and spacing out their feathers until the look like ostriches. They never fight, only posture and threaten. At this point, I feel that I have learned more about chickens than I have about women, birth, and babies. Yet the lesson is not lost on me.

We show even less sense than Monseiur's chickens. The chickens know that a hen and her chicks must be left undisturbed. But we bombard our new mothers with unreasonable expectations, from knowing 'instinctively' how to care for her infant, to getting her figure back quickly, to returning to work in six weeks ready or not. We allow visitors to converge on an exhausted mother and expect her to entertain them in her dimished state. We tell her that breastfeeding will come 'naturally' and leave her to find her sorority of mothers as best she can. Professionals offer opposing advise to that received from mothers, grandmothers, and aunts, leaving the new mother bewildered and unsure of whom to believe. Other cultures are far more protective of new mothers than we are. Even chickens understand the importance of this.

Becoming Haitian

2011-05-22T15:15:00.000-07:00

After many mishaps (including a cancelled flight and a 12 hour wait for the next one) I finally arrived in my beloved Ayiti. When I arrived at the airport tired, from a night without sleep (from sitting up in an airport) and being crushed in a small airplane seat for hours, I felt so good to finally touch down. There were my mountains (ever constant!) waiting for me. Dr. Delson and his driver, Francios arrived shortly after I emerged from Toussant L'Ouveture airport into the hot, crowded outdoor waiting area. The hour and a half drive back to Leogone seemed shorter, since I slept through most of it. I thought I might have my old room back again, but Dr. Delson ushered me to my new quarters, a small second floor apartment that was being built the last time I was here. I entered my small neat quarters with an attached bath and saw how hard the Merisiers had worked to secure my comforts. Dr. Delson pointed to a self standing air conditioning unit in the corner of the room. "It doesn't work" he apologized, "not enough electricity to run it." He had purchased two of them and installed the second in his and Mrs. Merisier's bedroom, but without electricity enough to run either. In truth, I was glad. Though the heat was oppressive to some visitors, I handled it well enough. After all, the hot wet heavy air is reminiscent of my midwest home. "Dr. Delson", I assured him, "When I am in Haiti, I will be Haitian."

Upon my arrival, I greeted Madam Merisier and the three children and gave them all gifts. Madam recieved sturdy cooking utensils, the oldest boy of eight I gave a toy airplane, Delshawna, the six year old girl got a purse with a stuffed cat in it, and to four year old Junior, whom everyone affectionately called, Gigi, I presented a pack of tonka trucks. I also handed Monsieur the money for my room and board for the week, which he promptly handed (without counting) to Madam.

On the ride back from the airport, Francios produced a bag of sandwiches. I was hungry, but disappointed to see the bag held a hamburger and fries (the Haitian version of which is far from palatable). I was hoping for some Haitian delicacy. I munched a couple of fries to be polite, and downed a bottle of water instead.

However, after arriving at the clinic (serving as the family temporary home as well), I showered, changed and came down to dinner to a real Haitian meal. Madam Merisier did not dissapoint. She served rice over which was generously poured a rich, succulent bean gravy. This was served alongside a hearty stew of carrots, greens and beef. I can taste it, even as I write. This was the stuff for feeding a weary sojourner. Alongside was served a cherry drink, made from the Merisier's own cherry tree, that was thick and delicious and had the consistancy of a slushy. This theme of consuming what they themselves had grown, or raised and slaughtered was to continue.

After dinner, Monsieur (Dr. Delson) asked if I would like to accompany him on his favorite end of the day activity. The children followed along as we walked a short way up the road to the plot of land where is house once stood. He unlocked and pushed open the gate, and an entire HERD (yes I know chickens come in flocks, but they came at us like a herd!) of chickens came clammoring towards us. Monsier laughed and said, "They know it is time to eat." There must have been about 50 chickens in the yard. A small white chicken even jumped into his arms, not waiting for him to lower the bowl of feed to the ground. Monsier smiled again, "She always does that." I watched as he went patiently about, feeding his chickens and telling me how he had figured out to breed chickens so successfully. He kept the hens with chicks caged at all times, because he found left loose at night, they were killed by 'rats, snakes, and mongooses'. He also discovered that given them medication at certain times of the year kept them from succombing to infectious disease. At night, all the chickens retreated to their pens to be locked in for the night, and the four dogs living on the property, were let loose (as they were penned by day), to discourage theives or mongooses who might try to get at the chickens. There was also a tom and hen turkey among the chickens. Monsier, had hoped for some baby turkeys, but the latest nest had, 'gone bad'. The hen turkey was kept penned so that she would not return to sit on the doomed nest. Monsier grabbed the tom turkey and put him in the pen with the hen, saying, "Now, go to her" betraying some wish that soon there might be a new nest.

Afterwards, we walked to the back of the property to feed the goats. I did not know the property went back so far (the foliage is so heavy) but as we walked, we passed not only the eery tangled metal remains of the Merisier house, but two other houses as well! "Monsier," I asked, whose houses are these?" They belonged to his brother and sister, 'for retirement' as they both live in the United States. I marvelled once again at how much he had lost and yet he remained resolutely upbeat. I was learning more about Dr. Delson in one day on this trip, than I had known the entire week previously.

I began to ask him about his practice. He said he was the only OB in Leogone, but that he had lost much business since the earthquake when the NGOs and missionary clinics came and served the women for free. He said this matter of factly without malice about the loss of income. He said that before the earthquake, he had a pediatrician partner (the clinic was two floors then) and they had planned to practice full service maternity and pediatrics together. After the earthquake he not only lost his newly built two story home (completely built but not yet painted), but his partner went in search of other opportunities elswhere. He told me Leogone has always been his home and that the need is great, and that someone must stay to serve. When I expressed astonishment at all he had lost, he shrugged his shoulders and said, "I am glad to have my life, that and my family's."

After feeding the goats, he showed me the fruit trees on his property, mango and papaya mostly. Then he asked me, "Have you ever heard of breadfruit?" "Yes, I've heard of it, but I've never eaten it." "This is it." He held out a strange roundish spikey green thing, presently pulling it open with his fingers to reveal its pulpy flesh. I picked some up and almost put it to my mouth but the youngest child laughed at me. "Here is the part you eat," Monsier quickly showed me as he held out a round hard pingpong sized seed pulled deep from within the flesh. "Oh, you eat the seeds?" I asked. "When they have been boiled." Then he pulled several breadfruit from the tree and we all retrieved the 10-12 seeds from each one. "These are small ones," he said, "the larger ones can have up to 50 seeds in them." When we had walked back to the clinic, he gave the bowl of breadfruit to his wife to cook. "You will have them for breakfast," he said to me, "then you will be just like a Haitian."

He told me at one point (while I was devouring his wife's cooking), "We are family now" and I believe that we are. At one point he mentioned that he had never done an abortion even though he had been asked to many times. "Why is that?" I asked, thinking it had something to do with the Catholicism of the island. "I just cannot do it," he finally said after trying to explain. I understood, I could not with my own hands either. The conversation turned to brighter things as he told me about how he had lowered the rate of preeclampsia in his community and helped to stem the flow of maternal deaths. "Dr. Delson," I said, "I shall make a study of you." "I want to write about what you do here, and publish it in a medical/nursing journal if I can. "

This morning, I enjoyed a breakfast of fresh bananas, and mangos, papaya juice (again frozen and slushy and delicious, and made from their own papayas), breadfruit and Haitian coffee. Now when I saw the coffee, I did not want to have any because I am not a coffee drinker. Besides, it looked blacker than American coffee which I took to mean it was even more bitter in flavor. I poured a cup to be polite, and much to my delight, the stuff was delicious! Sweet, smooth and more flavorful than I can tell. I drank two cups! The breadfruit, alas, did not fare as well. They had been boiled and peeled, and did indeed did have a flavor reminiscent of bread. The texture was soft and fleshy, but the flavor somewhat stringent and unappealing. I ate several, again to be polite, and chewed them alongside the banana to mask the flavor.

Francois took me back to the airport to retrieve my missing luggage (Monsier's luggage to be precise, it was his medical supplies). That done, I returned to my upper room retreat to nap away the hottest part of the day. The Mercier's had gone for the day to a party in Port au Prince and to return their two older children to boarding school for the week. I look forward to what the rest of the week holds. Monsier said he has four women due anytime, so perhaps that fates shall shine upon me.

Sex Slave

2011-05-03T05:29:00.000-07:00

Yesterday, I was following a lactation consultant as a part of my studies. She was doing her usual round of seeing new mothers and helping them get their babies on the breast, when we received a page to go to the pediatric clinic. This was not too unusual. She often received pages from the pediatricians in the clinic when they had new moms back for baby weights or infant exams and there were breastfeeding issues. So we finished up with the patient we were seeing on the unit, and headed down to the clinic.

When we arrived, I immediately recognized the patient as someone I saw last week, when she was still an inpatient. I remembered her well because she had had a fourth degree tear and could not sit without discomfort. This time the father of her baby was with her, and I immediately began to get 'a dark and sinister vibe'. The young mother, in her early 20s was obviously from some eastern European country from her accent, and the 'father' was in his late 40s, early 50s, American, and from a part of town known mainly for its gross of per capita meth labs. If the whole look of it didn't freak me out enough, the young girl was visibly shaking the entire time we were in the room. I've seen lots of nervous new moms, but her hands were visibly shaking with fear as the lactation consultant helped her nurse her baby.

Horrible, terrible thoughts went through my mind. Thoughts like, "Where is this girl from and why is she with this old man?" "Is she with him willingly?" "Has she been forced?"
But it got worse.

After the visit, the lactation consultant responded to my many questions. The girl appeared to be a 'Russian mail order bride" except there were no wedding rings (I looked) and I didn't believe she was from Russia (Belarus or Romania perhaps). The couple had an open social service case due to 'perineal bruising' discovered during prenatal care. Nursing staff had charted her unusual appearance when she came for care: pigtails with cropped tops and short shorts in advanced pregancy. All this information made me sick to my stomach. I wish I hadn't asked.

The lactation consultant thought the girl was to be discharged to a women's shelter when she left the hospital and was surprised to see her going home with the father of the baby. She made another follow up appointment to 'keep an eye on her' though the breastfeeding was improving. I'm still shaken by this encounter. Horrible thoughts about this girl invade my mind. I know help has been offered, but she has yet to take it. The pediatric visits will soon end, and so too may the social service case. If help doesn't come to this girl and her baby soon, it may not come.

I know a little about human trafficking because my son did a summer intership with an organizations that works to eradicate it. I also know that I live in a medium sized city with a very diverse population and that its location is a crossroads for the entire country. I know that drugs move through my city at an alarming rate, and that there are people here who are poor and desperate. What I didn't know was that during the course of a regular work day, I would cross paths with a woman who was very likely a victim of human trafficking in the sex trade- and that I would feel so helpless as to what to do about it.

For more information on this topic, go to : humantrafficking.org

Mwen renmen an Ayiti

2011-04-24T06:29:00.000-07:00

I am very involved in my preparations for my return to Haiti next month. Last night I attended a fundraiser for Glory House Services, a local organization of Haitians helping Hatians as they resettle here in the Kansas City area. It is headed by Idalbert Joseph (pictured), a boundless bundle of energy and enthusiasm topped by an infectious smile. Mr. Joseph teaches English to his Haitian expatriots, and Haitian Creole to Americans. He has been a true ambassador for his homeland here in our area. Last night's fundraiser was to raise money for school teachers salaries for a school that Glory House supports. The primary schools in Haiti are almost all private and parents must pay to send their children to school. The school that Glory House supports is free of cost to parents except for uniforms and books. I met Mr. Joseph when preparing for my trip to Haiti last Fall. His group was so supportive of my efforts to build a local bridge between Kansas City and Haiti. For this upcoming trip, Idalbert has made himself my private tutor for learning Creole (Kreyol). He tells me I will be conversational in two or three lessons, and that Creole is very easy to learn. I remain skeptical, but I do have my high school French to help me out. Like every other Haitian I have become personally acquainted with, Idalbert thanks me frequently for my service to Haiti, and he tells me often that 'mwne renmen an Ayiti' (I love Haiti).

It is true, I do love Haiti, and I yearn to reach her shores again. I wish to see Dr. Delson and follow him on his rounds, taste his wife's excellent cooking, bring gifts to his children, and even see how the family of new kittens is faring. Just across the road from the maternity clinic is a small tent city named 'New Jerusalem' (according to the hand painted sign someone hung up). The children would run out when they saw us relief workers and follow us asking for something to eat. I'll be sure and bring enough granola bars and candies to last for the week, so that everytime they see me, I'll never be empty-handed. I hope to visit the Medicine Sans Frontiers (Doctors without Borders, France) Hospital just down the road, and Dr. Delson will take me to the small private Catholic hospital where he transfers patients run by European nuns. I hope to see Mose, and Innocent, our interpreters from before. My beloved George (our main interpreter) is here in the US (New Jersey) in college studying law. I will miss seeing him. He was the second Haitian, after Dr. Delson, who invited us into his home. George was so eager to show us the real Haiti, and not just what we saw in clinics and through our host organizations. I will also see my interpreter from my first trip to Haiti, Kickolito. He will meet me at the airport and I will bring him a gift of some sort. I would love to bring Kicko here to go to school. It is a private dream of mine. He wants to be an engineer. The Haitians are such a lovely people. I'm glad I will be making a trip to be with Haitian people and not through a mission organization this time. This will be Sr. Morningstar's (my spiritual mentor) ideal. When she goes to serve a people, she is determined to live as they do, eat what they eat, wear what they wear, and be as they are. This time I will have the opportunity to do the same.

Here is a list of items Dr. Delson has asked me to bring (and I added a few items). Please let me know if you have these items to donate or if you have leads where I can acquire them. Your assistance is much appreciated.

OXYTOCIN
SUTURES (CHROMIC 2-0)
SYRINGUE 3 OR 5CC
IV FLUID like RINGER LACTATE, D/W 5 %
Sterile Gloves (8)
Chux pads
maternity pads
baby blankets
diapers

Dead Babies in the Heartland

2011-04-23T04:39:00.000-07:00

In the past month, since I've last posted, I've attended a breastfeeding conference taught by Dawn Kersula, and an ICAN conference, featuring Poppy Daniels, Geradine Simkins, Pam England, and Henci Goer, among others. I have presented in Wichita at the Kansas Govenor's Public Health Conference on the subject of Lactation in the African-American Community and at the Doulas of Kansas City meeting on the topic of Birth Practices Among African-American Mothers. In the past month I have sat on several committe and board meetings discussing materal infant health, including the Kansas City Health Commission, the Women's, Infant's and Children's Health Committee, Kansas City Midwives meeting, Missouri Midwives Association Meeting, the Kansas Breastfeeding Committee, the Fetal Infant Mortality Review Board, and most recently, the Mother and Child Health Coalition, which yesterday, brought Tonya Lee Lewis (wife of Spike Lee, seen in photo) to town to talk about infant mortality in the African-American community. All this talk of Black folks, babies, breastfeeding, birth, and death has got me thinking...

The problems that plague my community are so endemic, so deeply entrenched, that I've lost faith in the current system of health/maternity care to fix them. Not many seem to be terribly bothered that the infant mortality rate of the African-American community is twice to three times of that of Caucasian Americans (something I discovered three years ago while researching my master's research project). There are those who see the problem, but feel powerless to know what to do about it. I sit on the local FIMR board with the obstetricians who run the county hospital that sees the bulk of city women on Medicaid, and while they are knowledgeable and wise, they are also weary worn from years in the trenches and too busy on the front lines of care to innovate (or better yet, prevent) problems from occurring. When I worked as a labor and delivery nurse in this same facility several years ago, even I became numb to the number of dead babies I saw on a routine basis.

Infant mortality is the number of infant deaths per 1,000 live births prior to the first birthday. The major causes according to the Center for Disease Control are congenital malformations, prematurity and low birth weight, SIDS, and complications of pregnancy. March of Dimes has gotten involved on two of these: prematurity and low birth weight, because these are so often preventable and iatrogenic in nature (meaning hospital or provider caused). Inductions and non-medical cesareans are frequent causes of prematurity and low birth weight. These NICU-bound babies don't have to be. Healthcare providers and maternity care advocates need to take a much stronger stance against inductions and non-medical cesareans. Breastfeeding is also tied to mortality, when NICU babies, already compromised, don't get the immunological protection of their mother's milk. The CDC listed several NICU complications that lead to mortality (sepsis, necrotizing enterocolitis, respiratory distress syndrome) which might be positively impacted by the introduction of mother's milk. African-American babies die at greater rates because Black women are the least likely to breastfeed and the most likely to have the risky interventions (inductions and cesareans) that lead to infant morbidity and demise. Black women suffer more pregnancy complications, are more likely to have poorer health in general as well as preexisting conditions that complicate pregnancy. Black infants are more likely to die of SIDS.

Kansas fares even worse, boasting the highest infant mortality rate for Black infants in the nation. While the national average hovers between 6-7 deaths per 1,000 births (for all babies) and about 12 deaths per 1,000 for African-American babies, in Kansas the figure is around 7-8 for the state and a little over 19 (!) for African-American infants. Why is Kansas (my current state of residence) so bad? No one seems to know. However I happen to know that in Wyandotte County, the poorest county in this southeast part of Kansas, hospitals have closed and access to prenatal care is limited to one or two hospitals and no community clinics offer prenatal care. Public transportation is an issue in this county and the economic forcast is bleak at best. So the zip codes with the fewest resources have the poorest outcomes. I'm sure this scenario is repeated throughout the urban and rural counties across the state. Infant mortality in Kansas is so bad, that two years ago, the govenor convened the Blue Ribbon Panel on Infant Mortality. This group has lit a fire under this issue, and has recently published a list of recommendations. These recommendations led to the formation of the Kansas Prematurity Panel, which I look forward to being a part of in the near future.

One of my nursing students asked me yesterday, how many committees, boards, and organizations I actually belong to. I told her I've never done an exact count, but there are a lot. I attend these meetings to learn, to discover answers, to find allies, to engage my community. Even though there are many professional organizations to which I claim membership, there is one more that I look forward to joining. I believe these folks understand the nature of the problem in much the same way I do. The International Center for Traditional Childbearing is devoted to a cultural approach to increasing lactation, and decreasing infant mortality. A local Missouri chapter is starting up later this month. Finally, a community-centric approach to the problem. I'm not belittling the wonderful efforts of so many outside of my community- thank God they have taken notice of the problem and have enough concern to act. I'm putting the heat onto myself and other African-American professionals and maternity care advocates to look for home grown solutions within our own communities. Almost daily I write out my ideas and vision for what good maternal infant health looks like in my community. Last night Idreamed about preconception care and how to create a model that was culture-specific. I'm still trying to find my place in all this. My journey toward midwifery is still in its infancy. There is so much work to be done.

This is a clarion call to all others who would join me, but especially to those of my own community who want to become part of a solution. We need radically new ideas, radical new models of care that are woman-centered and culture specific. To this end, a travel phase of my journey will begin. Next month, I'll return to Haiti to spend time with an obstetrician in private practice. Dr. Delson Merisier is making an earnest attempt to deliver quality maternity care in the face of terrible medical deprivation. I met him on my last trip to Haiti last Fall, and was impressed by his tireless efforts to care for the women in his community. I will be living with him and his wife and three children in his maternity clinic (their home was destroyed in the earthquake) for a week. On the return trip, I will stop in Florida to visit Jennie Joseph. She is the British midwife who pioneered the JJ Way prenatal care model to improve prematurity and low birth rates (the two leading causes of infant mortality). I am looking for other culturally specific pioneering models to learn from. I intend to take what I learn and put the best parts of it to work to improve maternal infant health in my own community.

CIMS- Day Two

2011-03-15T20:38:00.000-07:00

Day two of CIMS started with a session titled, "Building a Woman and Family Centered Medical Home" I was enthralled by this presentation given by Warren Newton MD and Adam Zolotor MD, two family physicians offering evidence-based, humanized care with a practice model that most midwives would find enviable. They described a practice that included a midwife/lactation consultant, a second nurse practitioner, a social worker and a centering prenatal model. They provided ample proof of why we need more primary care physicians and fewer specialists.

Michele Laura MD, presented on the consequences of Near Term Birth. I can't get enough of this topic. It is so critical to get the word out that near term is not term. These babies look fine but they aren't fine. Healthcare consumers need to know the true risks of medically induced preterm delivery. The talk was followed by the viewing of a video created to warn moms of the risks of preterm delivery. I thought great, here is a teaching tool I can use. The video was well made but left me with an uneasy feeling. It featured two moms who went into preterm labor through no fault of their own, who ended up with babies in the NICU. This is not quite the same as moms electing induction without a medical reason. It felt a little preachy to hear on OB telling women to stay pregnant for at least 39 week (why not 40?) especially since physicians started this whole thing by selling women on inductions and making them think there were little to no risks involved. You can view it and judge for yourself: www.NNEPQIN.org Even with my reservations, this might be an adequate tool for those trying to stem the tide of social inductions. We have to start somewhere.

The next session was one I had been waiting for: Michigan Health and Hospital Association's Keystone OB by Morgan Martin, and Tami Michele, DO. The Keystone project is an obstetrics collaborative piloted in 16 hospitals in Michigan intiated by physicians to prevent preterm birth, lower c/s rates, introduce low dose pit, and other measures of decreased perinatal morbidity. I love physician driven models as they appear to be the ones that work. Since this model of practice change is initiated by physician champions and backed by administrative policy changes, it presents some real hope to the problem of harmful obstetrical practices. Tami Michele is a midwife in physician's clothing and a hero to our cause. She used to practice here in my city but relocated to her home state: our loss is Michigan's gain...
www.mhakeystonecenter.org

I was excited to hear Robbie Davis Floyd's presentation on MotherBaby Childbirth Initiative (IMBCI) in which she described her upcoming demonstration projects in Quebec, Brazil, Austia, and Mozambique to introduce mother-friendly concepts into current practice. Robbie never disappoints. www.imbci.org

Representations of breastfeeding was an interesting presentation featured three mini presentations on how long term breastfeeding and breastfeeding of older children has been featured in the media, the public perception of lactation consultants, and replacing negative frameworks with positive ones. All very interesting stuff and good food for thought.

CIMS- Day One

2011-03-12T03:48:00.000-08:00

Yesterday was the first full day of the Coalition to Improve Maternity Services conference, here in Chapel Hill North Carolina. This is my first CIMS conference. I was recently elected to become a member of CIMS Leadership Team. I am honored to sit among such esteemed grey heads and not so grey heads of the movement as Michelle Kendell, Barbara Hotelling, Tami Michele, Victoria Macioce-Stumpf and Ruth Wilf. We had a day of board meetings on Thursday followed by a birthday party for Ruth Wilf to celebrate her 80th birthday! (That does it, I'm staying young and vibrant by keeping active and involved in my work- Ruth is my model for aging well. At 80 she is vibrant and engaging and shows no signs of slowing down. She still works as a midwife!) Last night I enjoyed a lovely Thai dinner with Robbie Davis Floyd, author of 'Birth as an American Right of Passage' and many other anthropological books on birth and midwifery. Its been great rubbing elbows with leaders in the field of maternal infant health and lactation advocacy.

For those who are unfamiliar with CIMS, it is a coalition of MCH groups that work toward the standard of 'mother-friendly' care here in the United States and abroad. If you don't know what that is, pop over to the website and check it out at http://www.motherfriendly.org/ This is the standard of care for childbearing women that we all should be striving towards. It will serve as the undergirding philosophy of care in my own birth center some day.

Yesterday I attended the following workshops:

Eugene Declercq, PhD, MBA, Professor and Assistant Dean for Doctoral Education, Boston University
Dr. Declercq spoke about improvements in maternity care initiatives over the past year. He talked a lot about all the good things happening with lactation and how we can apply some of the things the breastfeeding folks have done to maternity care. He spoke of the importance of having a unified message and being united among all our groups. He presented lots of research findings such as the uptick in homebirths, the decrease in VBACs, the increase in cesareans, and how childbirth is invisible in public policy. Overall, his presentation gave us some good news, some bad news, some ideas for improvement, and the importance of engagement- a good overall view and a nice start to the conference.

Lori Dorfman, DrPH, Director of Berkeley Media Studies Group
Dr. Dorfman spoke on how breastfeeding is currently framed and how those frames limit conceptions of what needs to change in soiciety to support breastfeeding. She basically says that telling women about the health benefits of lactation won't increase rates, but rather we need to systematically remove barriers that in hospitals, home, work, school, indeed in society that keep women from being succesful in lactation continuing for as long as they wish. She also framed lactation as a health equity problem. This lady was so right on. Her talk made me proud of my work on my local health commission where we tackle these exact types of barriers within healthcare systems and on a policy making level within city government.

Danielle Riggs and Bettina Lauf Forbes, from Best for Babes spoke on giving breastfeeding a makeover and showed examples and images from their breastfeeding PR campaign to make lactation more socially acceptable. They had some interesting ideas. I'm not sure if this is the makeover lactation is looking for or not. (Very slick, polished, model thin, body beautiful images, and slogans all nicely done, but appear to me to add to myths and misconceptions about women's bodies.) However all great deal of thier campaign is dedicated to many things Dr. Dorfman spoke about in removing institutional barriers which they call, 'beating the booby traps.' Check it out and decide for yourself at http://www.bestforbabes.org/

Barbara Morrison, RN, CNM, FNP, PhD Professor, Frances payne Bolton School of Nursing, Case Western Reserve University- Kangaroo Care for all and all for Kangaroo Care
Barb did a great job standing in for Susan Ludington when she discussed the benefits of skin to skin for term babies. I actually bumped into Barb the day before the conference when we rode in on the same airport shuttle. We discussed all things skin to skin (to the chagrin of our driver, I'm sure.) This was an informative session especially since folks tend to link Kangaroo Care with preemie care.

Geredine Simkins, CNM, MSN, President Midwives Alliance of North America
What Matters to Women, Matters to Midwives
This session was such a treat! We got a sneak peak at a soon to be published anthology published by one of my favorite people in the birth movement. This book is a collection of stories from 25 seasoned midwives. If the standing ovation Gera received at the end of her talk is any indication, this is going to be a fantastic read. Written in beautiful prose, Gera weaves the stories through such themes as courage, compassion, activism, and self-determination. Order an advance copy (like I intend to) at www.wisdomfrommidwives.com.

Hot Topics: Turning it Around
This session was a hodge podge of new developments in maternity care advocacy. Topics included legislative efforts for MOMS for the 21st Century Act www.thomas.gov/cgi-bin/query/z?c111H.R.5807: homebirth promotion at the state level via the MAMA (Mother and Midwives in Action) campaign www.mamacampaign.org We heard from Choices in Childbirth www.childbirthconnection.org and The Big Push for Midwives www.thebigpushformidwives.org

All in all this was a jam-packed day with so much good information I could hardly process it all. I so wanted to sneak away for an hour's nap but each session just seemed so tempting to pass up.

Preparations

2011-02-15T04:51:00.000-08:00

My days have been filled with much activity. I'm taking three classes to complete my masters in May. I'm planning my return trip to Haiti, along with two national conferences to attend this year. I'm planning a nine day pilgrimage in Mexico next January. I have two speaking engagements to prepare for. I have been invited to sit on two more boards. I'm applying to a midwifery program to start next January(and praying it won't conflict too badly with the pilgrimage). I'm visioning my urban birth center. I'm just back from a romantic weekend getaway with my husband. I'm searching for a Parent's Day Out program for my 4 year old. I'm managing the schedules of 4 busy teenagers. I'm underwriting the college education of a nephew in whom I see potential. I'm reading Robers Rules of Order to be a more effective chairperson of whatever committee I happen to be chairing. I'm preparing for the next class I have to teach. I'm learning Spanish- and French Kreyol (Creole). I'm enjoying the dozen red roses that are sitting on my table. I'm contemplating a future of advocacy work, policy setting, clinical service, and teaching, and learning. I recently sat at the feet of my guru, Sr. Morningstar, to acknowledge my fears, failures, and successes, and purposed not to allow them to hinder the work ahead. I vow to be open to my own life... and to make more time for blogging.

Haiti Trip III

2011-01-18T05:23:00.000-08:00

Plans are well underway for the third return to Haiti. I have applied for a two week stint at a birth center in Cap Haitien, Haiti. If accepted, I will work with Mama Baby Haiti living and working in their free standing birth center. I am planning this trip 1) to serve women and babies in Haiti, 2) as a reward to myself for graduating from my masters program in nurse education, and 3) to check out the facility as a possible option for my student midwifery preceptorship (I've also applied for midwifery school to begin next January) and 4) to begin to form my ideas about what my own birth center for my community will look like. I do believe that healthcare should be socially appropriate and fit the environment it is superimposed on. To that end, I will also be visiting Jennie Joseph in Florida (en route to Haiti) to personally experience the JJ Way system of prenatal care. The next two years will be filled with preparation and study for me. Stay tuned for more information about the Haiti trip. I don't plan to take a group this time- just me. However if others want to go concurrently with me, they can apply to the same birth center for the same time period. Also visit my Haiti website for updates on the trip.

Lactation Consultants

2010-11-14T06:06:00.000-08:00

I made the recent decision to become a lactation consultant. In 2012 the required criteria will change to become more stringent. I decided now was my chance to do it. I had most of the requirements already, save one. I need 500 hours of clinical time with a lactation consultant, following her, learning her trade. I need to complete those 500 hours in six months, the deadline for the lactation consultant exam. That's 80 hours a month, 20 hours a week, to eek out of my already packed schedule. I'm up for the challenge. I had my first full day last week with Charlene Burnett, a long time friend and lactation consultant. In one eight hour day, I followed Charlene as she taught two breastfeeding classes, one to inpatients, and one to outpatients. She was called to the pediatric clinic twice to do on the spot consultations with moms having breastfeeding troubles. She did morning and afternoon rounds on all the breastfeeding inpatients, consulted constantly with the staff nurses on their patients' status, and conferred with the quality improvement nurse on gathering breastfeeding statistics to document all her efforts. She also oriented me to the unit, processes, procedures, and culture of the floor. I've know Charlene for many years, but I've never seen her in her element. She was like poetry in motion, zipping from one place to the next, swooping in to save the day (or sore nipples as the case may be) her white coat standing in as her superhero cape. It was all so impressive seeing an expert, high functioning lactation consultant at work. I was actually brought to near tears, as I watched her work with an African-American young mother back in the Pediatric clinic with her week old infant. The young woman's mother hovered near by taking in every word, with a look of concern for both her daughter and infant grandson. Charlene asked the young woman questions to gauge her concerns, then asked to see her breastfeed her son. Charlene watched the woman nurse for a minute or so and asked more questions. The entire time in a low soothing tone, she also spoke to the infant, giving information about breastfeeding basics (of course this information was intended for the mother and grandmother, though she was addressing the infant- very cute). After asking permission to touch the woman's breast (as she was careful to do all day with every patient), she showed the woman how to more effectively position both her breast and her baby to prevent sore nipples. She had immediate positive results and you could see the relief on both the mom and grandmother's faces. She ended the visit with a few positive encouraging words. The entire visit was no more than 10 or 15 minutes, and yet this young mother had turned a corner. I had no doubt that that short visit would reap benefits in keeping this mother nursing her baby for a longer duration. She was more confident and empowered than the worried, anxious mother we had met when we entered the room. Charlene had even convinced the skeptical grandmother that her daughter could give her grandson adequate nutrition. Leaving the room with mother and baby happily nursing, we stopped at the desk for Charlene to give her report to the pediatrician. She explained in a few words what the problem had been and the tools she gave the mother to manage the situation. The pediatrician looked at her with gratitude and relief, and thanked her. She garnered respect from all her peers, it was clear that everyone saw the value in the service she offered. We quickly moved on to the next task at hand. During the outpatient class, three new moms sat around a table nursing their babies of varying ages and chatting excitedly about how their breastfeeding had evolved from the previous week. After each mom had shared, Charlene asked about their difficulties and then worked with each mom individually on her particular nursing issue while I chatted with the others about their baby's progress and development. She ended the class by giving each mom a gift before sending them on their way. (She had written a grant and used the money to purchase breast pumps, nursing pillows, fancy burp blankets, etc.) Later that same day, I watched as Charlene gave instructions to a Latina patient in Spanish (!) on getting her newborn on the breast. I loved getting an up close personal view on the impact an LC can have on the families she serves and her work environment.

Though I have no plans to work in the hospital setting, I'm looking forward to being able to provide this level of guidance and assistance to those who need it. My plans for my LC credential include educating staff nurses on breastfeeding basics, and breastfeeding supportive behaviors, and creating research to measure educational effectiveness for nurses. My research and experience has shown me that staff nurses in labor and deliver, nursery, or mother/baby are often the weakest link in the breastfeeding support chain. I'd like to dedicate my efforts to strengthening that link.

IPV

2010-11-09T03:40:00.000-08:00

- A sweet young couple are laboring nicely for hours, until the husband leaves the room to go to the bathroom, whereupon, the woman clutches my hand, and pleads with me in a desperate whisper, "Please help me, he's threatening to take my baby from me."
-A refugee woman is slapped and pulled from the bed by her hair by her husband, just hours after giving birth.
-A young woman labors all night with premature labor, induced by a kick to the abdomen she received from her boyfriend. Though the baby is rushed to a high level neonatal intensive care nursery, he dies early the next morning.

These are just a few of the cases of Intimate Partner Violence I saw personally during my stint as a labor and delivery nurse. One of the things I found most shocking about my job, was how often I would interface with violence. It was not something I expected to encounter as a labor nurse. I quickly learned that if I was going to work with women, I was going to encounter occurrences of violence.

Intimate partner violence is defined as: violence that occurs between a victim and perpetrator who are current or former spouses or partners. The Center for Disease Control (CDC) recognizes four types of intimate partner violence:

physical violence-the intentional use of force involving hitting, punching, kicking, etc.
sexual violence-the actual or threatened use of force to compel a person to submit to sexual acts against their will, attempted or completed sex acts with a person unable to avoid participation, communicate unwillingness, or understand the nature of the act, and finally, abusive sexual contact
threats of physical or sexual violence
emotional abuse-use of humiliation, name calling, deliberate embarrassment, controlling their activities, isolating from family and friends, controlling or withholding resources including financial
coercive control and intimidation- acts perceived as threatening or violent

The CDC website declares that "all women are at risk'' of intimate partner violence no matter their socieconomic status, education level, age, religion, ethnic or racial group, etc. In other words folks, you can't tell by looking. My experience taught me that. My biases had me keeping an eye on the refugee women with their submissive social structures and missing completely the educated middle class couple with the controlling husband. To become better at detecting IVP and intervening with needed resources, I had to learn that no one is 'risked out' and that every woman in my care should be screened for domestic abuse.

For maternal and fetal health, the consequences of undetected IVP can be grave:
-miscarriage (less than 20 weeks gestation)
-infant injury or death from maternal trauma (more than 20 weeks gestation)
-maternal stress and depression
-self medicating with smoking, drug use, alcohol (all linked to poor infant outcomes)
-decreased or delayed prenatal care (also linked to poor outcomes)
-maternal injury and death
-child abuse or children witnessing abuse

Unfortunately the cost of intimate partner violence doesn't stop there. The Women's, Infants, and Children's Health Committee that I co-chair recently published a report on the literal costs of domestic violence in our city. A 'point in time' survey was sent out to law enforcement, healthcare agencies, shelters, the courts and other agencies to determine the services and fees provided related to domestic violence in a 24 hour period. The total estimated costs of domestic violence for one day in our city was $61,000, or an estimated 2 million dollars a year! About 94% of the funding was provided in services to victims, the other 6% in perpetrator expenses. Of those receiving services for violence, about 6% were pregnant. This cost of IPV snapshot was quite eyeopening.

When I attended the obstetrical complications workshop last week, Ms. Otemba reviewed the following information important for nurses who are on the front lines of assessing for IVP.

Cues to IVP
- delayed prenatal care
-noncompliance to therapeutic regimens
-frequent ER visits
-controlling partner
-somatic complaints (headaches, pain, fatigue, stress)
-fearful, evasive affect
-characteristic injury pattern (head and neck, torso, different stages of healing)

Assessment
Appropriate assessment means universal screening for every patient. Let the patient know that you ask every patient these questions and they should be asked in private without any family members presents.
"Within the year, have you been hit, slapped, kicked or otherwise physically hurt by someone? Since you've become pregnant? Has anyone forced you to have sexual activities?"

While these questions are appropriate to ask every patient, to get patient disclosure we have to create an environment where it is safe to disclose. Privacy, brevity (the abuser may be lurking near by), trustworthiness, nonjudgmental attitude, acceptance are all a part of what we have to offer patients in order to facilitate disclosure. Most healthcare providers may have discomfort asking these questions, or may not know what to do if the answer is yes. It is important to have a plan.

Supportive Intervention

You ask your patient with suspicious injuries if she has been beaten, and she answers, 'yes'. Now what?

-Emergency management: It's imperative to know your community resources. Here in my city, we have the Bridge SPAN (Safe Patient Advocacy Network) program. Our local shelters work closely with the hospitals so that through Bridge, with just a phone call from the nurse (or any staff member) a shelter counselor will be dispatched to the hospital 24/7 to offer shelter, police protection, orders of protection, counseling, case management, and child protection and other needed emergency services.
-Validation: "You do not deserve to be afraid, controlled, threatened, or hurt." The patient may need repetitive validation to understand that it was not her/his fault and that they do not deserve such treatment.
-Evaluate the severity: There are many tools available. In our area, agencies are encouraged to use the Lethality Assessment Program to determine the level of danger a patient might be in. This will help to determine the appropriate interventions.
-Education: often control has been establish by lies and deceit. Patients need to know the facts about their situation and what their rights really are.
-Referrals to ongoing community care and support such as legal services and support groups.

Recently, I met with a woman who has left an abusive relationship after many years. Her abuse was revealed to me during care provided for one of her pregnancies. When she felt it was safe to do so, she planned an escape that was two years in the making. When the opportunity came to flee safely, she took her children and left, with a well executed plan in place. They have remained safe from their abuser for a number of years. Talking with her about her situation reminded me, that there is hope for a life beyond the violence, if we are all willing to do our part.

Center for Disease Control: Intimate Partner Violence in Pregnancy. Retrieved 11/8/10. http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/sld001.htm#10

Otemba, J. (2010). Complicated Pregnancies; implications and management. PESI healthcare. Workshop presented on 11/5/10 in Lenexa KS.

Kansas City Health Commission. Estimating the costs of domestic violence in the Kansas City area: a report on the 2009 domestic violence, point in time survey for the greater Kansas City area. Women's, Infant's, and Children's Health Committee, and the intimate Partner Violence Subcommittee. Approved and issued on 10/1/2010.

Solving the Mystery of Preeclampsia

2010-11-06T02:59:00.000-07:00

As a storyteller myself, there are few things I love more than a good story, even more so if it is a good medical mystery. I recently attended a day long continuing education seminar on pregnancy complications presented by Jamie Otremba CNM. I found both her style and content very appealing, but my best and juiciest learning came during the segment on preeclampsia (the segments on domestic violence and late pretermers were very good also). Ms. Otremba gave me my money's worth when she wove an intriguing tale about a bright young nephrologist whom about a ten years ago noticed something very familiar looking about the kidney lesions he noted in the pregnant women with preeclampsia that he treated. His investigations led him to discover the pathogenesis of preeclampsia. Ms. Otremba regaled us with the story of his adversity as he tried to get attention for his very important discovery- outside of his specialty area. So intriguing was the tale of Ananth Karumanchi that I decided to do a little detective work of my own. I started with the article in New Yorker magazine that Ms. Otremba mentioned.
A physician and staff writer by the name of Jerome Groopman published an article in 2006 in New Yorker magazine finally giving Ananth Karumanchi broad exposure to his work. Theories about preeclampsia abounded, but the true cause continued to allude the scientific community. For those who are unfamiliar, preeclampsia is a disease of pregnancy that manifests as high blood pressure (greater than 140/90) and proteinuria (protein in the urine). Edema (swelling) and neurological changes such as visual disturbances and hyperreflexia (brisk reflexes) can also occur. If left unabated, preeclampsia can lead to seizures (a condition called eclampsia) and liver damage caused by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). The only known cure is removal of the placenta (delivery of the infant), at which point, the symptoms quickly reverse, and the woman gets better (if no permanent organ damage has been done to the liver or kidneys). If preeclampsia manifests late in pregnancy (as it most often does), a preterm infant is delivered. If it manifests in early pregnancy, the fetus may have to be sacrificed for the mother's wellbeing.
It was known that the placenta was the crux of the problem, but how? Groopman details how Karumanchi's careful research isolated two anti-angiogenic proteins (they prevent blood vessel growth) made by the placenta. These proteins, serum fms-like tyrosine kinase 1 (sFlt1) and soluble endoglin (s-Eng) are made by the placenta to control placental growth, and counteract the effects of pro-angiogenic proteins, vascular endothelial growth factor (VEGF) and placental growth factor (PIGF). In preeclampsia the sFlt1 and s-Eng overwhelm the maternal blood stream and cause blood vessel damage throughout leading to widespread vascular permeability and increased vascular resistance. The sFlt1 ultimately causes the hypertension (high blood pressure) and the s-Eng is responsible for the decreased platelets and liver damage seen in the more severe forms of the disease. The amount of these substances increase over time which explains why this is mostly a disease of late pregnancy. It appears to come out of the blue, but in fact the placenta was damaged from the beginning.
Following conception when the fertilized ovum (egg) is a blastocyst (about 100 cells) and starting to imbed itself in the uterine wall (the decidua) small fingerlike protrusions called trophoblasts (precursors of the placenta) grow into the decidua and reorganize uterine spiral arteries in order to set up a good blood supply for the developing fetus. In preeclampsia, this invasive network of trophoblasts and spiral arteries is incomplete, and sets in motion the abnormal release of anti-angiogenic factors leading to ongoing placental insufficiency for the fetus, and vascular insufficiency for the mother, both of which manifest increasing damage as the pregnancy progresses.
Karumanchi after several attempts, was able to publish his findings (increased levels of sFlt1 and s-Eng in the blood stream of women with the disease) in scientific journals and now heads a prestigious lab at Beth Israel Deaconess Medical Center in Boston, complete with government funding. Dr. Karumanchi and his team are now hard at work on what seemed impossible 20 years ago, a treatment for preeclampsia. His research also has implications for cancer treatment interestingly enough, since tumors, like fetuses are dependent on diverting and establishing rich vascular networks.
Preeclampsia and eclampsia continue to plague African-American women at higher rates along with diabetic women and women with preexisting hypertension, obesity, or previous preeclampsia. Those older than 35 and younger than 18 (of all races) are also at a higher risk. No one is sure why, but theories abound. There is still much about this disease that is a mystery.
Last week, my friend Dotty's daughter-in-law delivered a baby boy at 36 weeks due to induction for preeclampsia. She was not in any of the high risk categories. I assured my friend that for preeclampsia, induction is often indicated. Dotty remarked on the small placenta, and the feeding difficulties that are typical for late preterm gestation (more on that in a later post). I am delighted to see inroads being made. They are looking not only at methods of treatment, but early diagnostic tools as well (though the discovery was made 10 years ago and there are still no medications or biologic markers on the market, but I understand that these things take time). I suppose we are all still waiting for the happy ending to this story.

Narrative Report of Research Activities in the Karumanchi Laboratory

Role of angiogenesis in the pathogenesis of preeclampsia (PE) (currently the major focus of the laboratory): Our laboratory has identified sFlt-1, an antagonist of circulating vascular endothelial growth factor (VEGF) and placental growth factor (PlGF), from preeclamptic placentas and has confirmed that it is released into the blood stream in vast excess in patients with preeclampsia. Exogenous administration of sFlt-1 into pregnant rats reproduces the phenotype of preeclampsia, namely proteinuria, hypertension and glomerular endotheliosis, the classic lesion of preeclampsia. These observations suggest that excess circulating sFlt-1 contributes to the pathogenesis of preeclampsia. We have also demonstrated that circulating sFlt-1 and PlGF levels can be used for the clinical diagnosis and the prediction of preeclampsia. Work is in progress to understand the regulation of sFlt-1 production by the cytotrophoblasts of the placenta. We are also testing the effects of antagonizing excess sFlt-1 with growth factors and small molecule compounds in our animal model of preeclampsia with the goal of finding novel treatment options for this disease. Additionally, we are currently characterizing other gene products that are elevated in preeclampsia and which may be synergistic to sFlt-1 in the pathogenesis of preeclampsia and may serve as biomarkers for the early diagnosis of preeclampsia. This project is part of our interest in studying the contribution of endothelium in the pathogenesis of proteinuria and other vascular diseases.

Groopman, J. (2006). The preeclampsia puzzle: making sense of a mysterious pregnancy disorder. The New Yorker.

Karumanchi, S.A., et el. (2008). A longitudinal study of angiogenic and anti-angiogenic factors in normal pregnancy and patients destined to develop preeclampsia and deliver a small )for gestational age neonate. The Journal of Maternal-Fetal and Neonatal Medicine. 21(1). 9-23.

Levine, R.J., Qian, C., Maynard, S.E., Yu, K.F., Epstein, F.H., Karumanchi, S.A. (2006). Serum sFlt1 concentration during preeclampsia and mid trimester blood pressure in healthy nulliparous women. American Journal of Obstetrics and Gynecology. 194(4). 1034-41.

Silasi, M., Cohen, B., Karumanchi, S.A., Rana, S. (2010). Abnormal placentation, angiogenic factors, and the pathogenesis of preeclampsia. Obstetrics and Gynecology Clinics of North America. 37(2): 239-53.

Staff, A.C., Braekke, K., Johnsen G.M., Karumanchi, S.A. (2007). Circulating concentrations of soluble endoglin in fetal and maternal serum and in amniotic fluid in preeclampsia. American Journal of Obstetrics and Gynecology. 197(2). 176-8.

Welcome to the new and improved LaborPayne Epistles

2010-11-05T20:17:00.000-07:00

Welcome to the new look and mission of the LaborPayne Epistles. While I am in graduate school and preparing for the IBLCE exam, I will use this blog to discuss maternal infant health issues relevant to current practice and culture. My goal is to stimulate thought and discussion on topics that impact patient outcomes, through weekly postings of selected topics. I invite your thoughts and ideas.

Day 8- Operation Haiti

2010-10-04T05:00:00.001-07:00

We are back home after and exhausting entire day of travel. I will write when I have had some recovery time. The five of us talked a lot about the trip during our plane rides and were able to spend time processing the entire event and what it means in each of our lives. It's good to be home.

Day 7- Operation Haiti

2010-10-04T04:59:00.000-07:00

Today we all got up early and headed off to the Bel Aire Clinic in Port au Prince. I have gotten a better look around the neighborhood here in Petionville and it actually is full of gorgeous mansions. The neighborhood is nicer (ie cleaner) and I see more businesses that are transnational chains, more restaurants, more nightclubs, more grocery stores etc. Here is evidence of the class distinction. So far I had only seen poor and poorer and poorer still. I still don't know any Haitians who live in these mansions. However I have met far too many Haitians who are intelligent, and civic minded who are unsure of what the future holds for them. Many of or interpreters such as George, Innocent, Mose, Reginald and many others are bright and energetic young men with unlimited potential, but very limited opportunities. Their is no clear cut route for them to attend college (especially now when many schools were lost in the earthquake). Haiti seems poised to lose its best hope for the future if there are no educational opportunities for these young men (and women). I cannot say what will become of them. If the potential of this generation is not fully exploited, that will be the true tragedy.

The Bel Aire Clinic is housed on the second floor of a church. We had four physicians this morning seeing patients. My students, Rebecca and Sr. Marie did triage, I worked with two nurses in the treatment room (patients came into us to get shots, private exams, wound care, or other special treatments. We had a constant flow of patients. Three other nurses worked the pharmacy including Chris who teaches pharmacology. He really worked hard during the week and got the Bel Aire pharmacy organized and cleaned. I helped, remove a rock from a child's ear, cleaned and redressed some pressure ulcers, dressed a burn, did some bandage changes, assisted with a GYN exam, and cleaned and organized the treatment room, labeling and organizing supplies. I should not use the term room since there are no walls on the second floor and room divisions are by function or walled off petitions. As usual, you make do with what you have. My work to day in the the clinic was my most enjoyable clinical experience. After we finished we went shopping for souveniers. We stopped at two separate market places and purchased paintings, boxes, wall hangings, and Haitian flags. Some of the more adventurous (ie younger) folks then went out to eat at a restaurant while the rest of us came home. I had a nap and got back to the business of blogging. Its been a busy week, We take the plane out in the morning and will take 12 hours to reach home. I wish I had down time to 'recover' but first thing Monday morning, I start teaching again and I have a test to take, and a second draft of my thesis due. No rest for the wicked I suppose.

Day 6- Opertion Haiti

2010-10-04T04:57:00.000-07:00

Today we took the road into Fondwa. What an amazing day! It started early as our tap tap arrived from Petionville with Chris and Rebecca, and Jessie ( the rest of our little party of five, that had remained in Petionville). They were going to make the trip to Fondwa with us. We climbed into the back of the caged truck and headed up and into the mountains. It was an hour''s drive into the most spectacular mountains. The entire trip was worth the view of those mountains. However. The trip was death defying. Imagine (if you will) a two lane paved highway weaving in and out and up the mountain. On the highway are vehicles of all types and sizes going at speeds of their own discretion, ox carts, tap taps with passengers sitting on top and hanging off the side, pedestrians, bulldozers, whatever, you name it. The view was magnificent- if you didn't look down. Once we all arrived (safe and sound) we set up clinic at a 'clinic in a can' . We had 75 patients already waiting when we arrived. We had two docs, and three nurses, and two nursing students in our group, along with Rebecca and Sister Marie (who came along to visit. the orphanage at Fondwa). Two nurses went to work in the pharmacy, and I did triage with the two students. We got through about 50 patients before we had to pack up and leave. Because I was in charge of the triage, I personally had to turn away folks and say no, Madam, no doctor, after they had been waiting all morning- not a pleasant experience. I felt like a captain leaving people off the life raft.. I had to decide who of those remaining would see the doctor. I went between the rows looking at their intake sheets. I decided my criteria would be, febrile infants and children, hypertensive elderly, and obvious skin conditions. All the rest I had to turn away. One of the nurses thought it would be a good idea to pass out bottles of pedialyte as "consolation prizes". It wasn't. Mass chaos ensued. Its never a good idea to have a mass giveaway in Haiti. Crowds will swarm. The giveaway quickly ended as we finished seeing the last of the patients, and got on the truck and headed to the Orphanage for lunch. We had to be out of Fondwa by a certain time to avoid the afternoon rains which could leave the road undriveable. The sisterswho ran the orphanage were all in Port au Prince for a retreat. We didn't get to see much of the orphanage at all, but I understand that they lost all their buildings and there was loss of life among both the nuns and the orphans. I t appeared quite a dismal place from what I could see, but at least in the mountains there was clean air to breathe. Down in PaP all the kids had crappy lungs full of who knows what from breathing in very polluted air. Lunch was prepared for us anyway and served by the ladies that work at the orphanage. It was a beautiful feast. There was fried chicken, beans and rice, a corn and pea salad, fresh tomatoes and plantains, a chopped vegetable salad, and green beans. It was both beautiful and delicious. I may have made a critical misstep by drinking the water placed on the table. I didn't want to go out to the truck to get my water bottle, and I could taste the bleach in it used to purify it. Even so, I drank two glasses. Time will tell if I get Toussaint L' Ouverture's revenge! The drive out of Fondwa was marked by stopping for crews to remove dirt off the highway from frequent dirt slides (horrors to think if it had rained while we were there- mud slide anyone?) You really can see the work of deforestation in the mountains. It is still lush and green and beautiful to behold, but it is also obvious that it would be a lot more lush and green if so many trees had not been removed. I'm sure the road is out many times with fall out from mud and rock slides that without tree growth permit soil erosion. The trip back down the mountain was just as death defying. It did not rain, but the clouds moved over the landscape as if it would. You really feel like you've accomplished something if you survive the trip to Fondwa! We stopped in Leogone to get our suitcases and say goodbye to our hosts. I will miss George and Dr. Denton and the family of kittens, and the Dr.'s three little ones, and the Dr's wife's good cooking, and my big queen size comfortable bed. We get back into the truck and head for Petionville where we'll spend the rest of our time. Unfortunately we hit Port au Prince at evening rush hour coming back into town and it takes us nearly five hours to do a drive that normally takes about two hours. We move at a snail's pace through the Friday evening traffic in which the Haitian's obviously aren't in a hurry to get anywhere. Of course, it doesn't help that things such as lanes, traffic lights, rules of the road ect, don't exist here. You move along when you can, where you can. Back at the air-conditioned mansion in Petionville with almost reliable internet and almost reliable electricity seems a luxury. Back in Leogone we lost electricity on Tuesday and got by the rest of the week on Dr. Denton's generators! We kept thinking the 'state run electricity' would come back on, but it never did. The house in Petionville has its own backup generators as well. Its now nearly 11:00 and time to head to bed. We have a half day of clinic in the Port au Prince clinic and then shopping at the market and a happy hour. For me the hour will be sad, because it will mark the end to this remarkable journey. We leave for the airport at 6am on Sunday.

Day 5- Operation Haiti

2010-10-04T04:56:00.001-07:00

Just when I think I've seen the most poverty possible... When we went out to clinic today, we went to another remote area waaaay off the beaten path, in fact it was off any real road. We jumped into our rented tap-tap (a taxi truck with benches in the back that we ride on) with our suitcase pharmacy and headed down the paved highway, then turned off onto a cobblestone street, then onto a mud road. The road (and I use the term loosely) led us through a low lying area that must be flooded ankle deep a good part of the year, as it was today, and yet people were living there. Walking around in the ankle deep muck and carrying on their daily business. The houses were mere shacks and more pieced together tents. I couldn't imagine living under such conditions. Water from an overflowing river mixed with what ever was in the open sewers and all was carried along in a constant stream of fluid slush. The people don't drink the water but they do use it routinely for both bathing and toileting. This is a natural breeding ground for disease. We kept driving to a point where the road literally led into the river. We stopped on the side and watched as vehicles just drove right across the quickly rising river and as one enterprising entrepreneur made a quick business of carrying people back and forth from one side to another on his back. People would drop small coins into his and and then leap on his back as he shuttled them across. Others would just remove their shoes, hike up their pants or skirt, and move briskly through the swirling rising brown water. Our driver contemplated for a few minutes if his tap-tap would make it, and we contemplated if we would be safer riding across the river or walking! I thought about paying that guy to carry me! (He would have charged me double!) Finally we all got into the tap-tap, said a quick prayer, and whoosh, down a steep embankment, across the river and up a second steep embankment where the road continued on undisturbed. Undisturbed for a mud road full of deep pits (the term pothole does not apply here). Drivers in vehicles, motorcycles, bicycles, horses, ox drawn carts (whatever!) zoom quickly from one side of the road to the other avoiding the million pedestrians also crowding the road as well as the mud and water filled pits and the other drivers. Whew. I get tired just recalling that drive. The mud road continued on leading us to a little village I have dubbed, "scabiesville" (since almost every child I saw today had track marks on their arms and legs where the little critters burrow under the skin). This was the most impoverished place I've been to date. How they eek out a living in this remote mud encrusted place I don't know. As at home, rural poverty trumps city poverty, and it broke my heart to see children living this way. We set up our clinic in a 'church' really just a tin roof over a concrete slab with open sides and lots of wooden benches in it. As they came through my triage station, I made them 'balloons' from my latex gloves. Word must have got out because soon even children who weren't being seen came to the entrance of the church and looked at me slyly until I blew up a glove for them. Again, we saw lots of sick babies with fevers and lots of elderly with sky high blood pressures. I saw one elderly woman with a blood pressure of 240/120. It would not go down after even two doses of antihypertensives (prolanolol). She hobbled away with her baggie of medication after being told to return in two weeks when the clinic returns. We finished quickly seeing everyone amid reports that the river was rising. Not wanting to be stranded in scabiesville, we packed up and headed once more across that river pretending to be a road. Sure enouygh the river was moving faster and the trip back across was even worse! George, our interpreter thought it great fun and wanted to do it again. George, I said, do you want to drown me in the river, or have me float out to sea? We arrived back home safe and sound with the most exciting thing about today being the drive to and from the clinic. My colleagues are out seeking adventures but I am content to nap after our return and journal, and waiting for what I'm sure will be another delicious Haitian meal.

Day 4- Operation Haiti

2010-10-04T04:55:00.000-07:00

Today, my four colleagues went out to do a community clinic, while I stayed at the clinic in the can, just down the road a few feet. It was a routine, uneventful clinic with the Haitian doctor. We saw about 30 patients, mostly sick babies, and elderly with chronic conditions. There is so little we can to about the chronic conditions, but because the clinic in a can (a trailer building, built in China and 'mailed' here to it's current location), is more/less permanent, folks can come back to get refills on their high blood pressure medication (lots of hypertension and heart disease). Today was a very eventful day, however, not because of the clinic. We finished up around 1:00 and I headed home to the maternity clinic for lunch. Soon after, my peers returned from their clinic as well, and we also decided to take a walk with our interpreters, George and Mose. George and Mose are 21/22 years old, the typical age of interpreters, young, strong, handsome, and outgoing. As we walked, nurse Linda told me about her most challenging case of the day:

Linda saw a pretty, petite Haitian young woman of about 20 years of age. She administered a pregnancy test to the girl and it was positive. When she found out she was pregnant, she became upset because her parepnts would be angry with her. She said that she would seek an abortion. When Linda tried to talk to her about it, she would not be dissuaded. Even the interpreter told her the girl was determined to do it. Linda gave her birth control information and discussed other options, but in the end gave her a course of antibiotics and made her promise to take them after the procedure was done. Hearing this story was heartbreaking, and Linda was obviously still shaken by the encounter. I'm so glad Linda thought to give her antibiotics. The greatests risks with abortion are hemorrhage (which will kill you quickly) and infection (which will kill you slowly). In a country like Haiti that is very undeveloped and very Catholic, I think she will have a hard time finding a safe practitioner to give her an abortion. Most hospitals are owned by religious organizations which won't offer them. She told Linda she would do it herself if she had to, by pills or by 'other means'. I teach about abortion as a part of my OB lecture so depending on how far along in her pregnancy, pills won't do the job after between 9-12 weeks gestation. If she uses an instrument on herself she is at very high risk of hemorrhage or infection or both. In other words, there are no good forseeable outcomes for this young woman. Attempting an abortion could very well be a death sentence for her. A very sobering thought indeed. Tomorrow I'll ask Dr. Denton (our host) about this. I'd like to know the frequency of abortion here and what options she has to get it done safely.

As our walk continued,we wound our way around the 'neighborhood'. It was quite unlike the view from the road in a tap tap. As we walked we saw up close and personal how people lived. Even after a previous trip to Haiti, I found it shocking. People living in tents and shacks along side their cattle, goats, and pigs. How they lived this way was inconceivable to me. No electricity, no running water. I felt as if I were seeing the real Haiti for the first time. All the people came out of their houses to see the 'Blancs' walking by. No doubt very few whites/westerners ever see what we saw. George and Mose greated all their neighbors graciously and if I smiled and said "Bonsua" they smiled and said it right back, We passed lots of new wooden small shacks that various organizations had come in and built, they were tiny little houses but far superior to a pieced together tent. George took us to his home to meet his family which included a grandmother, a cousin and her three children and another cousin, sister to the first. George's mother died when he was young, and he lost his father in the earthquake. George and his cousins and grandmother lived in a tent outside their home which had sustained lots of earthquake damage and was being repaired by several men walking around and hammering on the roof. 'The men climbed into the trees to get us coconuts, which George's cousin slashed open with a machete and we all drank fresh coconut milk and ate the coconut out with spoons. We stayed about an hour and George and I talked a long time. He wants to go to school in the US and study law and then return to 'do something great for Haiti'. I believe that someday, George will do just that.

We had other adventures on the walk, including seeing an abandoned sugar cane factory, that George says will open in October and employ 2,000 Haitians (may it be so). I lost a flip flop during the walk, and could not continue, so George hired a motorcycle to drive me the rest of the way back to the clinic. I was very nervous, (folks use motorcycles for taxies here, and it was not unusually to see four or five people on a bike zooming by in one direction or another) but as I was the only rider on a privately rented bike, and Mose did the driving (the driver stayed behind with our group) and he headed my admonishments to 'GO SLOWLY MOES" it went pretty well. Remember there were no paved roads where we were, only dirt and rock streets (that's why my flip flop didn't hold up) and of course full of huge holes! So there was Mose driving slowly with me on the back, while he weaved in and out of traffic and gigantic pot holes. That was my adventure for the day. I got back in time to wolf down dinner (a potato, carrot, and greens stew, flavored with meet of an unknown origin, and served with (you'll never guess) beans and rice. All delicious. Then I accompanied Dr. Denton to the hospital to visit a post op patient, which I will write about tomorrow.

Day 3- Operation Haiti

2010-10-04T04:54:00.000-07:00

Today saw another early start, as four of our small group took a short tap-tap ride to the beach and set up a clinic under the palm trees. We saw about 50-60 patients, some we could help and as always, some we could not. After we had seen every patient, my colleagues took a dip in the ocean while I enjoyed the scenery (I'm not a swimmer). We rode back 'home' to our little maternity hospital and I took a nap until dinner. Tonight we were served a potato, yam and beef stew and white rice with a pureed bean sauce. I've since spent 3-4 hours reading homework (I have a pathophysiology test when I return home) and am finishing a long day with my journal. I'm short on detail because I'm tired and in need of sleep, but it has been another amazing and thought provoking day. We had great discussion over dinner processing what we are seeing: the nature of health and wellness, the geopolitial and socio-economic basis for health, the upheaval of Haiti, the nature of family, the meaning of hope and happiness. Sometimes it is all too much to take in at once. Thank goodness for interludes of blessed sleep.

Addendum: Now with some sleep, I'm ready to reflect upon a couple of events yesterday.

Most interesting case: We saw a boy of 12 years yesterday with severe cahexia (not just lack of fat, but lack of muscle- literally skin and bones.) He was with his mother and younger brother and sister all of whom were well nurished and looked fine. His mother stated that he had been sick for two weeks and had no appetite and diarrhea, but his severe state looked like it took a lot longer to produce than two weeks. He was flaccid and lethargic (not surprising- we produce our energy (ATP) in our muscle fiber and he had very little) and had a very flat affect. He was given a referral to the hospital for follow up care. He was heartbreaking to behold, and difficult to even look at. I felt this child might be dying and there was so little we could do. We talked about him long after clinic. We have no diagnostic equipment to diagnose so we can only guess at what the problems are based on clinical manifestations. Did he have severe and prolonged intestinal worms? Was it neonatal transmission of HIV/AIDs? Did some combination of opportunistic infections tax his immune system to the point it wasn't fighting back? Sadly, there is no way to tell. Worse still, no way to tell if his mother took him to the hospital. You need money to pay for healthcare up front. Without money, they'll be turned away, no matter how dire the situation. The hospitals here do turn people away for all kinds of reasons. I can only hope that emaciated boy with the haunting eyes gets the medical attention he so desperately needs.

Most interesting observation: In Haiti everyone breastfeeds. It is a given. However, based on my observations, they don't breastfeed nearly long enough. Now they do nurse their babies for the first year, maybe two, but in this healthcare environment it is not nearly long enough. The reason I say that is the sheer number of sick and compromised babies I see once they are weaned from the breast. If ever anyone doubted the immunological benefits of mother's milk, they should come to Haiti. The minute these babies are deprived of their mother's milk, their immune systems struggle to handle the daily assault and onslaught of disease bearing pathogens. Breastmilk is their best protection, and once deprived of it, they become ill, very ill. I heard one of the nurses say that doctors are telling Haitian women to wean earlier, like at six months. This would be disasterous. I asked why would anyone do such a thing and she said because of the risk of HIV/AIDs transmission. This set my blood to boil. Not only are the benefits of lactation proven (if anyone would bother to read them) but the who relationship between lactation and AIDs is still up for debate. To deprive these infants of their best immunological defense seems, well, indefensible. I make a note to ask every mother of a baby if she is still breastfeeding and encourage her to continue if she is.

Day 2- Operation Haiti

2010-10-04T04:53:00.002-07:00

Today was our first full day in Haiti. Two of us, Pam and I got the coveted spots to Leogone. Chris, Rebecca, and Jessie remained in Petionville to work in the Port au Prince clinic. I say 'coveted' as tongue in cheek. To get these slots we had to get up at 5am, take a very long 2 hour drive up into the mountains and work in an outdoor clinic in the tropical heat. Pam and I are part of a group of 5 (1 resident, 3 nurses, 1 nursing student) selected to spend the week here in Leogone, a small impoverished mountain town. From Leogone we will visit other villages on other days to do one day clinics. We are hosted by a local Haitian physician that has a small maternity hospital. Dr. Delson and his wife and three small children lived next door to the hospital, but their house was demolished by the earthquake, and now they live in the hospital. The have given us quarters in their hospital. The other four women share a large sunny room with four beds, but I got a private room with an attached bathroom! Quite the luxurious accomodations! We worked in a 'clinic in a can'. This is a trailer buidling delivered here by Heart to Heart. It is airconditioned and has three rooms in it, a pharmacy and two exam rooms. Pam and I triaged patients in the courtyard, while the two docs saw patients in the exam rooms. Everything went very smoothly and it was a great clinic day. Our most interesting case today was a man getting follow up wound care after being in a motorcycle accident two weeks ago. We tentatively romoved his bandages to find great looking granualation tissue- a sure sign of good healing and no signs of infection. Pam and I worked triage today. We did weights and vitals on each patient prior to their seeing one of the doctors. The clinic was well organized and everyone was seen by 1:00. I took an afternoon nap while the others walked to a gas station to buy beer and soda. We were served a delicious dinner of savory stew made with pumpkins, and beef and lots of varieties of beans served over (guess what) beans and rice. It tasted so good, we all had seconds. I plan to spend my evening studying (I have a test the day after I return). Tomorrow our group of five subdivides again while some stay behind to work in the clinic in a can, and the others of us will go further up into the mountains to more remote villages. We have to pack up our pharmacy and take everything with us. If we don't carry it in, we won't have it. I'm eager to learn how things are going for Chris, Rebecca, and Pam back in Petionville. I hope their first day went as well as ours. Looking forward to more of the same tomorrow.

Day 1- Operation Haiti

2010-10-04T04:53:00.001-07:00

We made it safe and sound! I can't believe that am once again in Haiti. It all seems so familiar, like another home. After foregoing sleep last night and catching a 6 am flight, we arrived intact after 3 uneventful flights. Our courier met us at the airport and took four suitcases of diapers and pads, and infant clothing. Kicko, my Haitian son, also met us there and I presented him with a refurbished laptop and an I-phone. It was so great to see him. He looked great- maybe a little skinny. Our host was also there to meet us and we all piled into the tap-tap (along with Kicki- we gave him a lift- he lives in Petionville where we happen to be staying). We arrived at a lovely air-conditioned mansion to a lovely dinner made by the Haitian cook. We had a meeting to decide who would go to Leogone in the mountains for the week and who would stay here in Port au Prince and work. Our team was split in half. Pam and I will go into the mountains tomorrow morning. Rebecca and Jessie were dissapointed to be left here (in the air-conditioning) but they will have a busy week here as well. I'm off to bed, very much sleep deprived, and am hoping for internet in the mountains so I can keep up this blog. Haiti is beautiful. Her people are beautiful. I remind us all that we are here to not only give, but to receive- the love of the Haitians, the beauty of the land, and the ceaseless grace of our creator.

When in Haiti...

2010-09-30T15:01:00.000-07:00

I am keeping a blog of my trip to Haiti but blogger won't let me copy it into here, so you must follow my link to Operation Haiti to read it.

Haitian Donations

2010-09-18T06:03:00.000-07:00

Eights days until my return to Haiti. I look forward to seeing Port au Prince again, and also traveling into the mountains to Leogone (the epicenter of the earthquake). I don't know what to expect, so I have no expectations. I know things will not be very different from what I encountered before. Our final team includes two students, one other nursing instructor, a photographer, and myself. We are small but mighty. We will be delivering medical supplies to our hosts (Heart to Heart International), and cloth diapers and cloth sanitary napkins to a courier who will take them to Maisson de Naissance, a birthing center several hours outside of Port au Prince. We also will bring gifts of clothing to an orphanage. If I raise enough funds, I will also take a refurbished laptop to my former interpreter, Kicki, to use as he grows his cyber cafe business. The outpouring of support for this trip has been phenomenal. A group of ladies in central Missouri has hand sewn all the sanitary napkins for us (Thank you Womb Room). The Phi Beta Kappa of Brown Mackie held a fundraiser all of July and purchased 300 cloth diapers for us to donate. We held a big fundraiser party with drummers and dancers and donated Haitian food (thanks Women of the Drum, Lon Lane's Inspired Occasions, and Josie's Sweet Treats) and raised $500. Between our fundraiser events and our individual donation solicitations, we have raised over $4,000 for this trip. We have also made wonderful new friends. Joseph and Glory Idalbert are Haitian Americans who run a local nonprofit to assist their fellow Haitians with adjustment to American life. They offer language classes and job training. We reached out to their organization, Glory House Services, and found our local link to the Haitian community of Kansas City. Joseph and Glory accepted a donation of 3 large crates of infant and children's clothing that we could not carry into Haiti due to the limits of what we could carry. We hope folks will be content to know that even though their donations didn't make it to Haiti, they will benefit Haitians. I also met Captain Jose Belardo of the Public Service Corps. I visited with him before my March trip to Haiti and now he will make a presentation to our group to prepare us for the diseases we will see and how to treat them. It has been an amazing ride, preparing for this trip. I didn't know we would impact so many- and we haven't even left yet. I was asked to prepare a presentation for a meeting of college presidents of all the Brown Mackie Colleges around the country. I made a plea for service learning to be incorporated into all the nursing curriculums. We are planning a joint party with Glory House Services when we return to share our experience and everything we learned. Never could I have imagined that a single thought I had while in Haiti back in March (to bring my nursing students back to Haiti with me) would yield such a response. If you want to keep up with the trip as it happens, visit our website where we post daily at http://www.operationhaiti.webs.com/ It is a fitting present on my 48th birthday today, to reflect back on what has transpired over the past seven months to make this trip happen. I just love to see vision made manifest.

Clinical Lactation

2010-07-31T07:33:00.000-07:00

It's official. There's a new journal in town. It was revealed last week at the ILCA conference by Kathleen Kendall-Tackett. Clinical Lactation is a new peer reviewed journal specifically geared towards lactation consultants. I am honored to have been selected to be on their Editorial Review Board. Clinical Lactation becomes the second of its kind after the Journal of Human Lactation (another favorite read of mine). I'm excited about this new adventure in my life and look forward to receiving my first article for review. Thank you to Kathleen and the other editors for this honor.

Team Haiti

2010-07-20T04:18:00.000-07:00

The return trip to Haiti is well under way. It is not as I envisioned it at all. It is better. I don't have a final head count yet as to who all is going, but there will be about 6 student nurses and 4-5 nurses and maybe a physician on our team. We are being hosted by Heart to Heart International. We will work for a week in their clinic and stay at their house in Port Au Prince. They will provide room, board, transportation to and from the clinic, and interpreters, all for $25 a day per person. We have many organizations collecting (or making) items for us to take with us to give away such as diapers and vitamins. We also have a couple of fundraisers underway and a grant pending. I put up a facebook event page and started a website for the trip. (operationahaiti.webs.com) The project has grown so big, it has taken on a life of it's own. I'm very excited to be a part of this project, and of course I can't wait to return to Haiti. Students are putting together their applications to submit by the end of the week. I'm working on a book signing fundraiser event with a local author and a superb caterer. It's so much fun to put this all together and watch it happen. The best part will be to see lives transform through international medical/humanitarian service.

Scenes from the Holy Land

2010-07-19T04:46:00.000-07:00

I spent a recent weekend in seclusion at my friend, Morningstar's retreat center in the Ozarks. I enjoyed silence, worked in her gardens, read, feasted on vegetarian meals, and rested my soul for the work ahead.

Pictures: Morningstar's tipi where she holds many of her ceremonies, the Gaia Garden, Casita: my cabin in the woods, Morningstar's home: Rose Cottage, a view of the meadow that includes a vegetable garden that helps to feed us.

My times of silence and solitude become more important to me as the work load grows heavier. I am grateful for times of refreshment.

Haiti Here We Come- Again

2010-05-14T06:26:00.000-07:00

Just recieved permission from the powers that be, that taking nursing students to Haiti has been approved! This will be such a great experience for them. Now the fundraising can begin. It's a little too soon to recruit students, that will begin next month. For now, I'm seeking foundations who would be willing to let me apply for grant monies to cover student expenses, and any other simple, yet effective fundraising ideas. The trip is set for the end of September. Now to make it happen...

Some Things Never Change

2010-05-12T05:02:00.000-07:00

As I gave my Haiti presentation to the local doula group on Monday, I tried to explain the beauty of birth as I saw it manifested in the Haitian women as they birthed their babies. What struck me was a story I have not yet shared about my experience in Haiti on this blog. The story of how 'some things never change.' I was at the hospital on day 4 with one of the American midwives. She was quite a lively animated person, and I enjoyed both talking with her and watching her work. I could tell she loved being a midwife- she was really into birth. She really showed me what was possible and under her tutelage I saw the most remarkable things. Well we were in the thick of laboring a woman. She was dilated to 9, and we had her in the small delivery room along with her aunt and cousin to help her (her cousin spoke English so we used her as our interpreter). She was all over the floor laboring in the most amazing positions, really working hard and effectively bringing her baby down. I was utterly amazed by this labor and how well this woman was working. Then he came. The Haitian obstetrician chose this time to make his rounds. He spoke English and was young and handsome (looked a hellava lot like Taye Diggs). He swooped down on the unit we had been running all day and started to take over. The midwife was miffed to say the least. Prior to his arrival she had given me this sweet little speech about how we were guests here in Haiti and should not behave like colonialists and take over everything. However when that Haitian OB came in and told the family members to leave and our patient to get off the floor and up on the delivery table, I could see the mama bear come out of this tiny little woman. She got right up in the doctors face and said, "Is this my patient or your patient?" She wanted to know who was going to do the delivery. They toussled for a while, there was some give and take. My midwife shook her finger in his face, 'don't you cut her' (referring to the routine episiotomy she thought her patient might get from him.) We slowly allowed the aunt and cousin back in. However we also got the patient on the table and put in an IV at the doctor's request. The doctor had brought along a little patient he intended to do a cesarean on, and I prepped her for surgery as well. While he was over in the main hospital building preparing his OR, our patient delivered, with her female relatives at her bedside coaxing her on. It was a fantastic birth, that almost didn't happen that way. It was because the midwife did the very thing she said she would not (get all colonialist on his ass) in an effort to protect her patient. How many times do we as midwives, doulas, nurses have to put our bodies between the patient and the physician to protect birth and keep it sacrosanct? I could feel the burden of this midwife. I too wanted him to get the hell out of our little delivery cocoon and leave us be. Technically these were his patients. Technically his western-infused ideas about how to conduct safe childbirth came from his American-influenced education. He was puzzled by why and how we were allowing sacred space for this woman to birth in her own body in her own way. He only knew his way, the way he had been taught, the way that didn't allow for individualities of person or cultures. (By the way, this application of western medical values into third world realities leads to some pretty brutal births- think pit induction without epidurals, or cesarean births without post op pain meds.) I understand that a lot of physicians Haitian, American, and otherwise think this mechanization of birth is the key to good outcomes. I understand it, I just don't happen to agree. Watching my little midwife go toe to toe with that physician reminded me that some things just never change- without a revolution. And in the midst of revolution you may find yourself saying and doing things you thought you never would.

Photos from the Mother's Day Luncheon

2010-05-05T14:37:00.000-07:00

Here are photos from the luncheon yesterday. Midwife Cathy (white hair, pink shirt) was honored as one of the 25 Shining Stars (always been a star in my book!) next to Rachel (another midwife) determined to open the next birth center here in town. There's a shot of my table and all my guests. Dr. Palmer a dentist who has done some kick ass research on the relationship between breastfeeding and good dental health (brianpalmerdds.com), Pat, my partner in crime who teaches pediatric nursing, Airick West, president of the KCMO school board, Pakou, local birth activist writing a book of birth stories of women of color, Liz, mom extraordinaire and fellow nursing educator, Mariah (my mini-me) all around birth and breastfeeding advocate and professional volunteer. The final photo is of Liz and I. Another nicely done luncheon, honoring folks who deserve the recognition.

Travelogue Announcement

2010-05-05T05:23:00.001-07:00

I will be giving another travelogue on my trip to Haiti next Monday, May 10th at the Doulas of Kansas City meeting, at 1pm. They meet at Cornerstone Community Church at 74th and Metcalf. Everyone is welcome. I'm actually more busy planning the next trip. I'm taking a couple of collegues and some nursing students to Haiti in September. The honor society would like to collect items for me to take based on the presentation I gave at school. They want to have a 'pad drive'. Now I am thrilled that they want to collect sanitary napkins, however my problem is that ecologically, it may not be a good idea. I'm going to research companies that sale cloth pads and see if we can do some fundraisers to purchase cloth ones instead. I may also steer them toward the purchase of cloth diapers. I'm busy trying to set up birth centers, hospitals and clinics for us to visit. Its fun to watch a new trip take shape. And... I'm also open to doing more travelogues!

Late Preterm

2010-05-02T07:08:00.000-07:00

I used to hear the term 'late preterm' and wonder, what are they talking about? Now I know all too well. Now that I've had a week to ruminate about the speaker last Saturday at the birth conference (not Ina Mae, the neonatologist, or was she a perinatologist, I can't recall). Anyway, she gave the most compelling presentation on late pretermers, that is babies born between 34 and 37 weeks pregnancy. Almost all the students that come into my classroom thinks that 37 weeks is full term. Some think 36 weeks is. How can this be? Easy, when our casual practice of inducing every woman anytime after her 36th week of pregnancy for every reason imaginable has made preterm birth commonplace. Even the March of Dimes is finally going after physicians for it's massive social induction rates. It's absolutely startling that folks are beginning to forget that babies need 38-42 weeks to gestate. I quiz every class of students about how long a normal pregnancy should be- and I always hear 36 or 37 weeks. These babies are actually premature, and belong in a class known as 'late preterm.' The speaker spoke compellingly about how these babies may be endangered by the fact that they appear physically mature, and as a result monitoring things like respiratory status, thermoregulation, serum glucose and other measures of neonatal wellbeing may not be as diligent. There is no doubt as to the cause of the spike in preterm deliveries. The culprit is inductions. Women have become intolerant of their pregnancies. Physicians can't resist the ability to jumpstart labors for the least provocation, sometimes for no provocation at all! All this belies the fact that babies still need the same amout of gestation time that they always have. Having babies be born prematurely for any reason other than medical imperative should be considered unethical. Yet it is so common, the practice of induction has slowly but surely redefined the public perception of what constitutes, 'full term pregnancy.' Many women now consider the presence of a NICU an important consideration in selecting a birthing facility. Well if they submit to induction technologies used prior to the start of true labor, they are probably going to need one.

Old Hippie, Talking Smack

2010-04-24T05:02:00.000-07:00

Ina Mae is here in town! She is speaking at a conference here in town. Here is a snapshot of her I took in California last Fall. For those who don't know, Ina Mae Gaskin is a pioneer in birth here in the US. She and her band of hippie followers started a commune in the 1970s in Tennessee devoted to (well lots of things, but one was natural birth) that triggered the homebirth movement here in the US. When I read her book, Spiritual Midwifery in 1978 as a 15 year old pregnant teen, it transformed my thinking on childbirth and truly set me on the course I am today. Her recent work on maternal mortality is, like her work on homebirth, ahead of it's time. She is a true hero to me. I've seen Ina Mae speak lots of times, but never here in my city. She rambled on the way she does in her stream of consciousness style of speaking. Her photos and stories of the commune days are always enjoyable. Her rantings about the benefits of 'socialized medicine' don't play as well here in the conservative midwest. A natural born storyteller, she was at her best, telling birth stories and spouting 'old folk' wisdom. What was best about the presentation was actually her audience- the people she drew to her. The audience was chock full of nursing babies and moms, as well as every type of midwife imagineable. That in itself is a feat. Ina Mae is one of a few people who can draw CNMs, CPMs, and DEMs, all to the same table together. I loved that audience. It was full of MY people. I wanted to rush around and hug everyone. I know all those women (and some men) are out in the world doing their thing to make birth better. I'm looking forward to the second day of the conference today and the learning and networking that will take place.

Travelogue Today

2010-04-13T04:44:00.000-07:00

Today I will be holding the second of my three travelogues about my trip to Haiti at Brown Mackie College in Lenexa at 12-1. Anyone is welcome to attend.

Infrastructure

2010-04-11T05:48:00.000-07:00

Since I have returned from Haiti, folks often asked me, what is the single greatest need. My answer is always, unequivically, infrastructure. Like the bones of a body or the steel beam skeleton of a building, infrastructure is what you hang everything else on. Haiti lacks a public healthcare infrastructure from what I observed. This is why I fear there will be many more deaths to come. With the advent of the rainy season, standing water means disease, and in the tent cities, disease will spread like wild fire. Public health requires a preemptive strike such as immunizing against possible communicable diseases. Secondarily, you enact measures to control the spread of diseases that are not preventable, such as treating disease as it occurs. Third, you can teach prevention, such as teaching the public to cover their coughs, not share cups and glasses, wearing masks, etc. I see these kinds of public health teaching and public awareness campaigns as very difficult for a country that can't even keep electricity going throughout the day. Public health is built on a healthy infrastructure of rapid public communication with common goals and mission. Just the fact that so many countries have swooped in to help without a Haitian bureacracy to oversee it, betrays a lack of organization. I saw very little structure to the relief effort. My experience at Diquini Hospital was a prime example. On my last day, with the two American OBs, they sought to impose structure. I numbered all the beds and all the charts at their request. But the Haitian nurse saw it all as a nuisance. She had her own order, and it had nothing to do with ours. There is no consistancy in place to ensure that the 'order' we imposed on the unit will remain. When we left, it most likely went away as well. That is what Haiti needs, an imposed authoritative systemic order for delivering healthcare to a population that continues to have chronic healthcare needs apart from the acute ones imposed by the earthquake. A woman should not have to have her yeast infection treated at a temporary tent clinic. There should be a healthcare structure for that. How does Haiti acquire this public health infrastructure? Well that's another post entirely.

Travelogues

2010-04-09T04:52:00.000-07:00

The dates are set. Here are my 3 upcoming travelogues about my trip to Haiti:

This Sunday: April 11, 2010

Cornerstone Community Church

74th and Metcalf

Overland Park KS

12:45-1:30 pm

Next Tuesday: April 13, 2010

Brown Mackie College

9705 Lenexa Drive

Lenexa KS 12-1pm

Next Sunday: April 18, 2010

New Life Community Church

16111 Vicie

Belton MO

1:00- 1:30

I'll also update everyone on my plans to return, and hopefully take a team of folks (including you) with me.

Church Clinic

2010-04-08T17:32:00.000-07:00

All these images were taken at our clinic held in a church. We didn't know at the time how luxurious our accommodations were. We were sheltered in a building out of the heat with private areas to talk to patients and give exams. Our entire team is pictured along with our interpreters. YaVonne in pink is a cardiac nurse, Emma ran our pharmacy, the other woman in green is a neurologist from New York, and my interpreter Kicki. We all worked well together and saw about 100 patients that day.

Quisqueya Calling

2010-04-08T06:29:00.000-07:00

What a week. My students have been wonderful and clammering for a trip to Haiti! I even got the idea into my head to ask some local philantropists for the money to take them. I may be getting a little ahead of myself. My proposal for MANA was turned down. It wasn't very good anyway, and my book won't be ready by this Fall, so it's just as well. I am submitting a proposal for City Match though about Lessons from Haiti. All my speaking proposals for the next year will be about lessons from Haiti frankly (fined tuned to each conferences theme of course). Right now I'm busy planning at least 3 travelouges. Look for them on Facebook events. I really want to go back to Haiti as soon as possible. I recieved an email message from Quisqueya asking for medical teams to come. How can I make this happen?

Haitian MD

2010-04-04T06:39:00.000-07:00

I learned about a phenomenon that is probably ubiquitous in international medicine, and relief circles. It was however, new to me. On this particular trip, it was referred to as 'getting your Haitian MD.' I'll tell you a story that illustrates this phenomenon.
While at the Haitian Family Mission on the fourth day, we were in the midst of our outdoor clinic, under the almond tree. A man arrives carrying his crying little boy. Being in acute distress, they are ushered to the front of the line. The little boy has lacerated his finger while playing atop a building debris pile. (Remember, the piles of rubble are everywhere. Most of the buildings appear to be built of concrete, and it is piled mountain high with wires and metal pipes shooting out all over. They must be very tempting for a little boy.) It is a very severe cut requiring three or four stitches. There is no doctor with us on this particular day. I am on a team with a pharmacy tech, a couple of medics, an EMT, and a non-medical. The doctor working with the mission is on vacation. I am selected to do the stitches. Now I have only done stitches on uncooked chicken breasts. But thats more experience than anyone else on the team. We could send him to a hospital, but he might wait hours (even days). He's at the top of our clinic list, but he would be at the bottom at a hospital. So I resign myself to doing my first stitches on a real person. I draw up the lidocaine after locating a suitable needle and syringe and am about to administer it when I hear, "Here comes so and so, she can do stitches. She does them all the time." Talk about saved by the bell. I happily hand my syringe off to so and so and proceed to assist her as she administers four neat and tidy little stitches into the tiny finger. After she's done I wrap the finger in guaze and with the help of an interpreter, give Dad instructions on care and returning to have them removed. This shouldn't be a problem since the stitcher lives at the mission. Later in the day, when I ask the stitcher what specialty of nursing she practices, she stated matter of factly that she wasn't a nurse at all. Taken somewhat aback, I asked her what her training was in. She told me her formal training was something akin to a medic (I'm not sure what that training is.) I ask her where she learned to do stitches. She told me that even though she has very little formal training, she learned her skills from various doctors and nurses that pass through the mission. They let her observe and try skills out as they guide her. She got her training informally, hence, the "Haitian MD." She wore a white lab coat and had a stethoscope around her neck. It's true that even I was diagnosing and treating in the tent cities. I was treating diseases I had never even seen or heard of before. Does this sort of thing result in subpar care? I'm sure it must. Twice, my interpreter KiKi diagnosed my patients when I had no idea what I was looking at. A child came with a hard white plaque on her tongue and upper palate. I thought it was yeast until I palpated it and found it hard and unmoveable. I had never seen anything like it. I asked the other healthcare providers. They didn't know either. Then KiKi spoke up. "I don't know what the name is in English, but in Kreyol, we call it 'shunk' and they treat it by rubbing it with lemon and salt until it is rubbed off. It comes from kids putting all kinds of dirty things they find into their mouths." Well that was good enough for me. "Kiki, tell the Dad what you just told me, and tell him the treatment." I was horrified to think what that pretty little girl had put in her mouth to cause that awful looking fungal growth. She could no longer eat, and could barely talk. I shuddered even more to think of her Dad scrubbing her tongue with lemon and salt until it bled. But hey, I couldn't come up with anything better. The home grown cure seemed reasonable to me. We didn't have any antifungals except those to treat a yeast infection, and this was no yeast infection. In that moment I didn't think of KiKi as overstepping his bounds as an interpreter. I was very grateful to him for giving guidance on something I had never seen the likes of. My trip had been filled with many moments when I was looking around thinking, 'should I be doing this?' (things I would never be allowed to do 'back home.' But I wasn't at home. There was no one else to do it and I was knowledgeable (sometimes) and willing (everytime). In those moments, I know I too was getting my "Haitian MD."

Art and Miquette

2010-04-03T06:40:00.000-07:00

This lovely couple were our hosts at Quisqueya. Art ran the day to day operations, and Miquette gave us our daily assignments. They kept everything running smoothly for all the relief workers. Thanks Art and Miquette for all your hard work.

Kickolito- The Hope of Haiti

2010-04-02T04:30:00.000-07:00

My interpreter, KiKi, is a 21 year old young man, with an earnest face and wise, old eyes. He is seated next to me in this photo with the baseball cap. I fell in love with KiKi. Unlike many of the interpreters (all bright young men from 19-25 years old) who joked and laughed, KiKi was always serious and focused. When we finally got a chance to chat, he told me his father was deceased, and he lived with his mother, and two younger brothers (18 and 14). He also has an older sister, but she lives on her own, so at 21 he is the man of the house. He spoke about the restoration of Haiti. How he wants to be a part of seeing her restored. I asked him what he wanted for himself. He said he is interested in designing energy efficient automobiles. That he plans to attend college here in Haiti. He thanked me for coming to help the people of Haiti. On our last day together, I wanted to take him out to dinner, as a thank you. He refused, stating, "If I come home late, my mother will worry." I thought of him riding home, an hour away in those crowded city tap taps. I asked him if his home was damaged by the quake. He said no. I can't imagine what life is like for him, and yet I feel such an affinity to him. Kiki is Haiti to me. If and when I return to Haiti, it will be partly to know that he is well.

Images from Haiti

2010-04-01T08:01:00.000-07:00

These are my first few images to post, in no certain order. There is a picture of me and my interpreter, Ki Ki, in a tent city clinic. I am giving instructions to a Dad on how to administer a medication to his child.

There is also a photo of me standing in front of our tap-tap that took us out to clinic everyday. The cages were for our safety. Driving over those bumpy roads could cause someone to fall out.

Position, Position, Position

2010-04-01T06:04:00.000-07:00

I just have to say that those Haitian ladies really know how to move in labor. Without medications to keep them drugged and bedridden (they are no beds either after all!) they get up and move throughout their labors. In early labor we have them walk and drink water. During active labor I saw them sway their hips, kneel on the floor, get on all fours and sway back and forth, crawl around, stand and squat repeatedly, bend over holding on to beds and tables, lean against loved ones while squatting between their knees, tailor sit, and on and on and on. Because the women squat a lot while doing chores and cooking, they found it really easy to get into positions I can only dream of getting into. I was really impressed. The positions they were using as they labored, really allowed the pelvis to open and the babies to come down. More than once I suggested (to the OBs, not the midwives) to let the moms off the delivery table and let them move around. I did very little to direct their movement. I let them do what felt good to them and they sure showed me some new stuff. They were all over the floor. No birth ball needed! I never saw American women do the kinds of positioning I saw the Haitian women doing. Some were absolutely silent, but others were very vocal with their contractions. They chanted and even sang throughout their labors. I learned so much about the wisdom of the body in labor as I observed and worked with the Haitian mothers. My homebirth experience really prepared me to be useful in this kind of birthing environment.

Paradise for Babies

2010-04-01T05:23:00.000-07:00

I was en route to Diquini hospital on my fourth day in Haiti when I passed a huge billboard that read: " Paradis Du Petites." There was a picture of a lovely Haitian mother holding her beautiful baby. Paradise for Little Ones. I assumed it was advertising a school or daycare center. But in truth, Haiti is not paradise for babies. The infant mortality rates are among the highest in the Western Hemisphere. (Maternity mortality rates are high as well.) I still wonder if that baby I saw on the first day with typhoid fever and a temp of 104 ever made it to the hospital. I understand the obstacles that keep families from going to the hospitals. First they need a way to get there. The hospitals are few and far between. Then they may wait many hours to be seen. If their child is then admitted, the family has to stay as well. Hospitals may not provide linen for the beds, or meals for the patients. Some may not give medication unless is is paid for first. Speaking of pay, financial burden is a big barrier as well. The hospital will insist on being paid and the family may not have the resources available. Babies with fevers and diarrhea are in a race against time. They may succumb to the dehydration before the fever breaks. Most of the babies I saw were on the downside of the disease process and were already afebrile. I was told that often if a mother sees her baby is ailing, she will emotionally detach from it. I was also told that if a hospitalized child appeared to be failing, the parents would leave the hospital and not return. I cannot judge how people find a way to cope in the face of such overwhelming challenges. I noticed that it took some work on my part to get the new mothers to warm toward their babies. Fortunately the grandmothers or aunts or female cousins were there to model bonding behavior. We often broke with hospital protocol and allowed the families to be with the laboring mothers. The Haitian doctors would shoo them out of the room, but when they left, we would let them right back in. I loved it when one of the midwives greeted each new baby with, "Welcome to the world, you are the hope of Haiti" and indeed they are.

Vaginal Breech

2010-03-31T05:37:00.000-07:00

I arrived at Diquini Adventist Hospital for my last day in Haiti, this past Saturday. I knew the 3 midwives that I enjoyed working with would not be there, as it was their day off. Instead I found 2 young American OBs. Since it was their first day and they were getting acclimated to where things were, I was able to give them a quick orientation to where things were located. (I had helped one of the midwives organize the supplies a few days before- so glad we did that.) The maternity unit is located in a separate building from the main hospital. It is just adjacent to the hospital in a little one story building that houses pediatrics, maternity, and the GYN clinic. A cloth curtain separates the pediatric section from the maternity section. To reach the GYN clinic, we have to exit the building and walk around to the other side. There is much construction going on that separates the two ends of the building. The GYN clinic is basically done on the 'back porch' of the building. The maternity clinic has a 4 bed 'ward' with 4 more beds added in the hallway for a total of 8 beds. One of the OBs has a great idea to number the beds and locate all the charts for each patient. Simple as it sounds, this has not been done. I set to work making signs from masking tape and markers. I locate current patient charts stacked on the nurse's desk. We file away the patients that are no longer there, and place signs on the charts denoting which bed each patient is in. Now that we are organized (somewhat) we can better manage our care. Miraculously, the Haitian nurse assigned to this unit, seems to know all her patients, where to find their charts, and is very on top of the patients assessment and medication regimens. She carries on with her duties quite oblivious to us, and seems more annoyed than amused by our attempts at 'organization.' I decide not to give any medications because I'm afraid they'll be given twice, as she has not missed a dosage for any patient. Instead I assess new patients coming in who think they might be in labor. As usual it is a busy day. I set up for deliveries in the delivery room. Our delivery room, and the three surgical suites in the hospital are the only air conditioned rooms to be found in the hospital. As result, we get lots of staff wanting to 'visit' us. But its nice to meet and talk with folks when we have the time. Today the pediatric unit is staffed with ER nurses that came from Quisqueya with me this morning. We had a group of about 14 providers come to Diquini today- a huge group, including several physicians who will be kept busy all day in surgeries. There is never an inactive moment on the maternity unit. I do labor checks on the pregnant women, and postpartum checks on the recovering mothers. I make sure babies are getting on the breast, bleeding is under control, and that vital signs are normal. I chat with the two OBs who are adjusting themselves to the circumstances. One OB orders pain medication for a laboring patient. I assure her I have seen no such meds and that all labors are unmedicated. The other OB goes over to the hospital and brings back one small vial of nubain (1 vial!) It was all he could find. We treat it like gold. At one point, early in the day, the two OBs go over to the hospital to scout out the facilities, while I hold down the fort. While they are gone, one of the ER docs (whom I met at Quisqueya this morning on the truck) comes running in to tell me that a woman just arrived in the ER on the back of a truck in obvious labor. They didn't even get her out of the truck, they are just driving her right over. Do we have a stretcher to bring her in? Well, of course we don't, but no worry, a minute later she comes walking in between two of her relatives, and get on the delivery table (which is really just a rickety old GYN examining table without the stirrups attached.) I shoo everyone out so I can check her, one of the ER nurses from pediatrics stays to help me. I do a vaginal exam to check for dilation (she does appear in great discomfort) and the following thought pops into my head: "What the fuck is that?" I'm feeling something that I have never felt before after doing hundreds of these exams. It was bony and angular and I could not find cervix no matter where I "looked" (ie. touched). I'm not entirely sure what I'm feeling, but I know it is not a head. Besides that, mom was making pushing sounds. I check for cord, but do not feel that either (thank goodness). It occurs to me that I have never felt and actual breech presentation before, because in the US these patients are scheduled for cesareans before they start labor, typically. I withdraw my hand and attempt to find heart tones. Not sure of what exactly I felt, I placed the doppler at the base of her belly, and find heart tones of 110s. At this point the ER doc comes back in, and I relate to him my heart tone and exam findings. Did you check mom's heart rate, he asks. Great question. I get my stethoscope and get an apical pulse of 90s. What I heard on mom's lower belly could have been her. I had placed the fetoscope on her upper belly earlier and couldn't find heart tones. The ER Doc picks up the doppler and finds heart tones on her upper belly in the 130s on the first attempt (shoulda used my Leopold's!). We say simultaneously, 'breech'. Where are my OBs? The ER guy asks, Do you think they'll want to do a cesarean? I said, I'm sure they will. It just so happens I overheard a conversation they had with one another earlier about breeches. One asked the other if they had ever done vaginal breeches, and the other answers they had done 3 or 4 but that they would rather not. ER Guy leaves to scope out the possibility of a surgical suite for a cesarean. I get vitals on the woman and hope the OBs show up soon. I still don't know if she's complete or if I just can't feel the cervix, but I do know she is pushy. If there's going to be a cesarean I'll have to start an IV and foley. Just then, they return, I explain what's going on. (There's been a lot of commotion in the hallway with relatives, ER staff, interpreters, and pediatric staff). They both want to do a cesarean, but when the male OB checks her again, he says, it's too late. The pediatric nurses rush in and set up the warmer (newly arrived and circa 1980s) for infant resuscitation. They spend the entire delivery trying to figure out if and how the thing works, and getting the oxygen going (bless their hearts, they were working really hard with such limited supplies- they kept bringing in supplies from their area when they couldn't find them in ours). The male OB preps for delivery, sending me on a frantic search for a gown. (The midwives didn't bother, but both OBs insisted on being properly covered for deliveries.) I found one, helped him get it on and gloved and the patient is still pushing. We get her into pushing position (I hold one leg, the other OB holds the other) and on the first push like that, out pops a little leg. A couple pushes later, we get the other leg, and the OB delivers the baby to the armpits and wraps a blanket around the body (baby blankets are hard to come by around here, its really just a square piece a fabric we found). Next the OB doing the delivery (the male OB) reaches in to manipulate the arms out. With that done, the baby is out except for the head. We expect baby to be born any minute, but that is not what happens. It takes at least a full 10 minutes of manipulation, praying (The OB doing the delivery was praying audibly right next to me as he worked frantically to get the baby out. At one point the ER doc returned to report back about the availability of an OR. There are no phones, no intercom system, no pagers, nothing. The only way to communicate with another part of the hospital is to send out runners. That's why folks just walk back and forth when they want to find something out. So the ER doc comes back to say that there won't be an ER available for at least 30 more minutes. (Either its still in use or being cleaned.) The OB had just a few minutes before mentioned again the possibility of a cesarean and pushing the baby back up,but now without that as an option, he redoubled his efforts at manipulating the stuck head. I remember shouting to the ER nurses where things were located as they frantically tried to put their supplies together while I held on to mom's leg, tried to comfort and reassure her (in a foreign language!) and instructing our interpreter to glove up and hand the OB whatever he asked for. The other OB offered to do fundal pressure. Not sure about the merits of fundal pressure, I offered to apply suprapubic pressure. He said okay to both. We both applied pressure, the OB on the top of the fundus, and me with a fist right above the pubic bone, with mom's pushing. This made a little progress, then, with time quickly ticking by, the OB handed the wrapped baby to me (limp and blue in my hands) and cut an episiotomy and with a little more manipulation, baby's head finally came, followed immediately by the placenta. (more on that in a minute). We were all holding our breaths and praying. We all thought the same thing, this poor baby probably won't make it. He quickly clamped the cord and passed baby off the the waiting team of nurses at the warmer, two ER nurses and a family nurse practitioner leading the team. (Not a NICU nurse in the bunch!) I quickly turned my attention to mom as the OB and I worked to control her bleeding. I gave her pitocin IM and then set up supplies and lidocaine for a repair. I had the interpreter scrub into the sterile field and hand instruments to the doc because I ran between mom and the baby fetching supplies and equipment for both teams. Several minutes into the repair, we heard a baby start crying! Incredible. Surely this baby was snatched back from the jaws of death. I was amazed that our hodge podge team with our pieced together supplies and equipment had been effective. Even the OB was startled to hear the baby crying, and looked up from his repair with surprise and relief. Later as we all tried to piece together the delivery summary with the correct times (keeping track of the time everything occurred was actually MY job as the delivery nurse, but I had not looked at the clock even once during the entire ordeal) we mused about the placenta. It was worrisome, because we had no way of knowing how long that placenta was dislodged prior to the baby being born. It appeared to already be right there after the head was born. There was some risk of hypoxic injury to the baby, but we could ony speculate. The female OB thought there might have been an placental abruption, but I still wonder if fundal pressure might have had a role in dislodging the placenta prematurely. After mom and baby were stabilized, they were placed in a bed and left to breastfeed. We went on to another delivery.

Last Day

2010-03-28T05:17:00.000-07:00

Today is our final day at Quisqueya. Even though it has only been a week, I have made family. Grace the neurologist, Junith, the Hatian American OB, Matt and Emma, Ki Ki my interpreter, Kathleen, Lorraine and Dee the midwives at Diquini, Shawn the videographer, Wendy, our roommate, Art and Miquette, our hosts, Bly, Robert, Morio, Roodly, Alex and several other young Hatian interpreters, Dan our driver (and Miquette's brother). I have made friends and some family. It has been good. I am content to go home, but I am blessed to have come. I will miss Ki Ki, he is my Haitian son, and the hope of Haiti. I got word this morning that the 31 week baby survived the night. Yet another miracle in Haiti. It has indeed been a week of miracles. We fly to Ft. Lauderdale this morning and back to KC Monday morning. I'm hoping for a much needed massage and manicure once I hit the states. A walk on the beach might be in order as well. Yes there are beaches here in Haiti, but the once we had access to were polluted. I look forward to blogging more in depth over the next few days about my experiences. Stay tuned...

Diquini III

2010-03-27T17:59:00.000-07:00

Had an awesome day at Diquini (pronounced de ken ny). Arrived to find my 3 lovely American midwives away on a day at the beach, and the maternity unit staffed by 2 young American OBs (one African American, the other Haitian American). We had a very eventful day together that included a vaginal breech with infant resuscitation, a first time mom with a postpartum hemorrhage, and a preeclamptic mom with out of control blood pressures who needed an emergency cesarean (at 31 weeks!) None of the other hospitals or even the Red Cross tent hospital would take her because you really need a NICU for any hope for a 31 week baby. Diquini doesn't even have an incubator. But since skyrocketing blood pressure can lead to seizures and death for the mother they elected to go ahead. I helped take mom to the ER and then had to leave for the day. I'll never know how things turned out, but I can guess...
My time at Diquini was my absolute favorite. I loved going to that hospital. Because I had been there two other days, and had helped one of the midwives organize all the supplies, I could really help the OBs find what they needed. I knew immediately if they asked for something, if we had it or not (mostly not). They wanted to medicate the laboring mothers, but I told them there were none of those medications, everyone delivered naturally. They were astonished. They then let me take the lead in laboring the moms and managing the flow of patients. It was fantastic. We really worked as a team, and they were very humble in the face of such a drastically different work environment. I told them I had homebirths and was comfortable managing natural labors and they seemed to breathe a sigh of relief. I got to say goodbye to my beloved midwives, I ran into them returning from the beach. I so appreciated my experience with them and the OBs, and my time at Diquini. I hope to someday return to Diquini.

Haiti Family Mission

2010-03-27T17:25:00.000-07:00

I feel badly that I haven't got to post like I really want to. The internet connection has not been good, and my time to post has been very limited. My days have been long and eventful and I have so much to tell. Once I get back in the states tomorrow, I will go back and review everyday. Yesterday we were assigned to Haiti Family Mission, which was an outdoor clinic (not even a tarp this time, we were under an almond tree). It was another busy day of seeing women and babies (they were specifically assigned to me- no men). I treated lots of yeast infections, bacterial vaginosis, and bladder infections. Even though I was given a private space to do exams, I got very good at diagnosing by getting the patient to describe their symptoms, so I didn't have to examine them on the hard ground. White lumpy discharge? yeast infection, yellowish discharge with fishy odor? bacterial vaginosis, greenish frothy discharge? trichomonas. I knew my vast knowledge of vaginal discharges would come in handy some day! My saddest case was having to explain to a young lady that that 'bump' in her vagina was herpes. When I asked the interpreter to ask if she currently had any sexual partners, she said she " had a man back at the house". For the rest of the day we all joked, that we had a 'man back at the house'. After returning to Quisqueya (pronounced "kisskaya" by the way) I finally gave a call to my 'man back at the house." It was good to hear his voice.

Diquini II

2010-03-25T18:07:00.000-07:00

Well apparently, Quisqueya crisis center is in the 'good' part of town. Yesterday, when I was assigned to Diquini Hospital, we were driven for an hour and a half through some of the worst urban landscape imagineable. As we neared the 'downtown' area of the city, we saw the worst destruction, and people just lived on top of the rubble. Its difficult to put into words how I saw people living. Piles of rubble everywhere. Sewage filled canals. People living in shanties in the middle of the street. Tents pitched right on sidewalks and in every spare corner. There were thousands of people EVERYWHERE. So many people. The dust from the gravel roads, or burning garbage, or both forced us to wear masks during the long bumpy ride there and back. At Diquini I found 3 American midwives who welcomed me warmly. The rest of my team was assigned to the very busy ER and OR. The maternity unit was a separate small building adjacent to the hospital. The building held the 4 bed maternity unit, a gyn clinic, a pediatric unit, and a tiny room devoted to the NICU.

Diquini

2010-03-25T05:00:00.000-07:00

I have so so little time to write. Yesterday morning I couldn't get my computer to work, and last night we returned to the compound very late after dark- no internet connection. It has been very eventful, but no time to write. Yesterday and today I go to Diquini Hospital, the smallest of the three hospitals we are being sent to. I spent yesterday with an American midwife, running the maternity ward. Assisted with two births. Will return today. The need is so great. Saw the presidential palace, crumbled in on itself. Looked much worse than on tv. So crowded, so poluted, so many people, so few resources. Have to go, will try to write tonight if we don't get back too late...

Jungle Medicine

2010-03-23T14:04:00.000-07:00

Just returned from practicing true guerilla medicine/nursing. None of the luxuries of yesterday. Gone was the cool comfortable ( not air conditioned)church building with a separate building for waiting patients. Today we were sent to another tent city. Our 'clinic' was under a tarp and our pharmacy inside a parked tap-tap. We saw many more patients with totally different problems. Our open air tarp covered clinic was hot and dusty and crowded. Internet went out, will have to finish this post at a later time.

Morning in the Compound

2010-03-23T05:18:00.000-07:00

Another warm and beautiful morning in paradise. It truly is beautiful here. Port au Prince is ringed by mountains on three sides which you can see in a distance from any direction. The foliage is lush and abundant. The people are beautiful too. Handsome and strong, the Hatian people have the best posture! It comes from the large loads they carry one their heads. They are fine boned and short statured but lanky.
It is busy in the compound as everyone prepares for their day out in the city. A small army of interpreters sit under shade trees waiting to be assigned to various groups. Drives gas up their vans and tap-taps from the compound gas tank. Physicians and nurses visit the on-site pharmacy to stock up on needed medications for the day. I consulted with family doc this morning. That illness that was 'going around' that I saw in every baby yesterday was Typhoid Fever. The good doc gave me some great treatment ideas and I was glad we were on the right track yesterday, when we didn't even know what disease we were treating. Very high fevers and diarrhea are the hallmark signs. I did some reading up on the disease process. Most times it will run its course, but for children who are already compromised, the dehydration can send them on a downward spiral. The little girl I saw yesterday was very bad off. She needed IV hydration or she might succumb to the disease before it ran its course. I also saw a 14 year old who was the size of an 8 year old. Chronic malnutrition is to blame. With any hope if he gets better nutrition he can recoup some of that growth during puberty.
Today we are being sent to a different tent city. We will have a different driver, but hopefully the same interpreters. I am quite smitten with KiKi. the is a beautiful and bright young man with a quick sense of humor. He is also quiet and wise and reminds me of my 21 year old. William would have loved meeting KiKi, I'm sure of it. I can hardly wait for the adventures the day holds. I'm trying to post pictues of some of the sites. The city is in disarray, but the school compound is our little paradise. I'm meeting and working with wonderful individuals. A group of school girls cross the campus. I forget that the school is still in operation. All the classes take place in the chapel, in the far corner of the campus. The relief organization has taken over every other area of the campus. There is so much work to be done. Every evening, Mequette (the Haitian school nurse and assignment organizer) begs for volunteers to work the night shift at the locals hospitals. Mequette spends all day on the phones, communicating with hospitals and clinics all over the city and outlying areas. She is the one who assigns where everyone goes and with whom. Art (an American phys ed teacher who has taught at the school for two years) it the camp organizer. He and Mequette bring amazing organization to a place that has new people arriving daily. I have met people who will be here as little as a week, and who have been here for months. There are about 60-80 relief workers at any given time, not counting the military who reside on the other side of the soccer fields. Sadly, I am only one of two African-Americans I have seen here. But of course, I am grateful for whoever comes. Matt, my team leader, is meeting with our driver for today. It's time to grab my suitcase of supplies and hit the road. I do not know what to expect in the new location. It probably won't be as nice as the church yesterday. We also lost YeVonne, our most experience relief worker. She was assigned to another group, and we got a homecare nurse who just arrived yesterday. I guess that makes me the veteran. I'll be showing her the ropes. Thank you for your continued prayers. I'm having the time of my life.

Bonsoir

2010-03-22T14:35:00.000-07:00

We had a fantastic first day. Our team consisted of a physician, two nurses, a pharmacy tech, a team leader, 3 Haitian translators, 1 Hatian driver, and an American documentary maker. Our translators were adorable. They were all 21-24 years old and translater for us throughout the day. There was one translator for every healthcare provider. My translator was Ki-Ki. I could have pinched his cheeks he was so adorable and reminded me of my own 21 year old. We started the day with a death-defying 40 minute drive to the slums of Port au Prince. There is nothing quite clearly defined as a 'lane' on the Haitian rodeways. There was some paved road, but a lot of the side streets could only loosely be termed 'streets'. There are no such thing as 'speed limits', you go as fast as you possibly can given the circumstances. Not only do you have to avoid the other vehicles, there are all the people (no distinction between sidewalk and street), and livestock, such as hogs, chickens, goats, sows. Having arrived safely (barely) we set up our clinic in a church. The pastor greeted us warmly and had a small army of helpers to assist us in any way. We unpacked our two large suitcases of medicines and supplies. We set up a makeshift pharmacy on the alter, manned by the pharmacy tech and the team leader. The physician and us two nurses each had a small table with three chairs, one for us, one for the patient, and one for the interpreter. There was a draped pulled across one room with a bed behind it for examining patients in private. The three of us each saw patients simulataneously, stopping to ask the other questions if we needed a 'consult'. I asked the physician to give an opinion on an umbilical hernia, and was asked by the physician to do a pelvic exam on a young woman. The cardiac nurse asked me to assist her with a breast exam. Otherwise, we all assessed, diagnosed, and treated our own patients. Between the three of us we saw 106 patients. I saw many babies, almost all of whom were suffering from fevers and diarrhea (a deadly combination in such a hot climate). We treated them with antibiotics, except one that had a temp so high (104) and was so lethargic she couldn't keep anything down. We told her family to take her to the hospital immediately. In the adults we saw, fungal infections, headaches, body aches, back pain, various infections. I also saw what I thought was a possible abdominal aortic aneurism, a potentially life threatening disorder. She came in insisting she was pregnant (at age 52) because her belly was getting bigger. Sure enough, a pulsing mass could be felt in her abdomen proximal to her umbilicus. We insisted she go to the hospital immediately, but she probably won't. After we saw every patient, we held hands with the pastor and his team, sang songs, and prayed and then packed up the pick up truck and made another death defying ride 'home'. I'm looking forward to my dinner of beans and rice, and a walk through the neighborhood to the local patisserrie for a croissant and ice cream! Today has been wonderful. I can't wait to do it again.

Bonjour

2010-03-22T05:26:00.000-07:00

I woke this morning to a beautiful Haiti morning, with soft cool breezes. The sun will rise and bring intense heat, but the compound was quiet and lovely before the missionaries/relief workers were up. There was the sound of my next door neighbors, two roosters, living in the compound across the street, taking turns crowing every few seconds from about 4am.
Last night's entertainment consisted of watching the Haitian men who live on the school compound play a rousing game of soccer against the relief workers and soldiers (who reside on the other side of the campus). There is no TV. About half the relief workers choose to reside in a small 'tent city' on the school grounds. The other half of us sleep in classrooms on airmattresses and cots we have dubbed, the "Hatian Hilton". We have electricity and running water, but no air conditioning. The Haitian women that live on the school compound provide laundry service and cook our meals. The school set communal showers, quite a luxury to have water for showers. They have the water trucked in and the tank refilled daily so we have enough for showers. Most workers shower at night after a long hot day. There is no hot water of course, but the cool showers feel exquisite after a long day in the tropical heat.
Last night I was assigned to a team going to a tent city. I thought I might get to go to a prenatal clinic, but I will see what this opportunity holds. Whatever comes to me, I will be grateful.
For breakfast we were served coffee, hot chocolate, croissants, beignets, assorted rolls and fresh fruit including oranges, pineapple, and mango. A wonderful way to start the day. My team is now packing up and we will be heading out shortly. I'm a little bit apprehensive. In the tent cities we have only what we carry in and our wits to guide us. It seems so little to offer, when we don't know what kind of cases we will see today. Our physician is a neurologist, plus one cardiac nurse, plus me, a maternal infant health nurse- kind of a hodge podge team. We do have the ability to make transfers into one of the local hospitals if we deem it necessary, but the hospitals don't always accept the transfers. Yesterday we heard the story from the OB doctor, that a young woman (age 20) came into the small hospital she was assigned to after being hit by a car. (The traffic here is crazy- someone probably gets hit everyday) The OB wanted to transfer her to one of the larger, better resourced hospitals, but it would not accept her, even though she had severe head injuries. She died about 20 minutes later. I felt badly for the OB, who also delivered a baby of a 17 year old with severe pre-eclampsia. They tell us we will see bad things, that we will feel overwhelmed, and that we may return home and need time to heal and adjust. All these things sober me, and yet and will do what I can and what I must to serve who I can. Whatever comes, I recieve with gratitude. My tap-tap awaits.

Night Falls Over Port au Prince

2010-03-21T16:46:00.000-07:00

Night has settled upon Port au Prince. The air is still and warm. Our compound in Quisqueya is filled with American relief workers returned from a day of service in various corners of the city. Tonight in about an hour, tomorrow's assignments will be given out. I am tentatively scheduled to go out tomorrow with a Haitian American OB/GYN. I haven't met her yet, but I am eagerly looking forward to it. I'm glad to be partnered with someone who is fluent in the local language of Kreyol (Creole). Those returning from a day of work look exhausted, but are full of stories they eagerly share over our communal dinner of beans and rice and chicken in the open courtyard "dining room". I look forward to collecting stories of my own. I take deep breaths and try to be present for every moment. I am in Haiti. I want to soak in every detail. I want my entire focus on the here and now. That is how it must be, or one misses the experience even while in the midst of it.

I'm Here!

2010-03-21T12:02:00.000-07:00

We have finally arrived in Port au Prince after two days of uneventful travel. The plane rides were comfortable and accommodating. On the flight into Haiti this morning, I sat next to an American relief worker, and struck up a great conversation. He at first thought I was Haitian (as most of the people on board were), but when I greeted him, he knew otherwise. I told him we were neighbors. His shirt had a reference to Omaha on it. (Omaha Nebraska is 3 hours from Kansas City) We ended up talking the entire flight. It turns out Brian had spent 10 years coming to Haiti for relief work, as well as lots of other interesting places in the world. We discussed the politics of international relief work, the history of Haiti and the impact of colonialism, and worked our way up to racism in America, and the impact of (American-style) christianity on other cultures. I don't often get to chew on such weighty topics. Drop in a comment Brian if you are reading this. Once we landed, Brian was headed to a destination about 100 miles away from Port au Prince. After reconvening with my travel companions, Matt and Emma, we got through customs and waited for the crisis center to send over a Tap-tap for us. A tap-tap is a makeshift taxi that consists of a truck, with benches on the truck bed to accommodate passengers. As we drove through PAP, we witnessed several rubble strewn streets and collapsed buildings. Otherwise life seemed to be going on as usual with people roaming the streets attending to the business of living. We passed many tent cities, and saw UN peacekeepers and military personel from several countries such as Egypt and Brazil. The compound where we are staying is Quisqueya School, a private school for American missionary children. They still hold classes for about a fourth of their students still in Haiti, but otherwise the entire campus has been re-made into a crisis relief command center. Relief workers from all over the US are camping on the spacious grounds or sleeping in former classrooms. The school organizes relief efforts in the city, and sends the relief workers out during the day to work at various Haitian hospitals. Today we rest, but tomorrow we will be sent out into the community to hospitals, orphanages, tent city clinics, etc. There is a cummunal kitchen house where Haitian women prepare our daily meal of rice and beans and chicken. It felt good to sit down to a hot meal and the food was delicious. The US military is here, they are in a separate school building on the compound and have been assisting with relief efforts. I'm meeting lots of nice folks, and the weather is quite pleasant. Much hotter than Florida, in the upper 80s but not uncomfortable at all. There is a constant breeze that makes it quite pleasant. Matt, Emma and I share a 3rd grade classroom with 3 others women from another agency. The school supplied airmattresses to sleep on and mosquito netting. We are provided breakfast and dinner. Haitian drivers take us to our sites at 8am and pick us up at 5pm. We have to get lunch on our own, but most folks have brought their own prepackaged food for that. I have a huge supply of protein bars that I plan to supplement with fresh fruit. We were told we can eat anything with a skin that can be peeled. We are encouraged to take our own bottled water which the school has in great supply. All our creature comforts are met so that we can focus on giving care to the Haitian people. Even this laptop I'm typing on and the wifi to transmit it to you are generously supplied by Quisqueya Crisis Relief Center. My companions have gone on a walk around the neighborhood to explore, but I intend to write, first to you Dear Readers of this blog, and them in my notebook journal. After that, a much anticipated nap! Thank you for your continued prayers, which have seen me safely here.

Three Planes Later...

2010-03-21T04:49:00.000-07:00

I woke up this morning in balmy Ft. Lauderdale Florida. We have an early morning flight into Haiti. So far the most noteworthy event of the trip has been that I forgot my cell phone cord, so in a couple of days it will be useless. The temperatures in the 70s that I'm experiencing now, I'm told will seem cold compaired to the weather in Haiti. The sweet young couple I'm traveling with are veterans in foreign relief work, so I listen carefully and do all that I am told. When we arrived at our hotel last night, I saw a black postpartum cat. I could tell she was feeding kittens, and she was scavenging for food. Is this a foreshadowing? My heart remains open, to what the experience holds.

From Snow to Sun

2010-03-20T04:56:00.000-07:00

The day of departure has finally arrived. I woke up this morning to find snow on the ground, after several weeks of spring like weather. Now I'm not quite sure how to dress. I am sobered by this journey, this opportunity. I know what I see will break my heart. The donations keep coming, even though my suitcase is past full. I hope to pack the remaining items with my traveling companions. There is still so much to do today. I try not to think about the immenseness of the task, I just focus on one thing at a time. I try to remain open, to whatever the experience holds.

A Force of Nature

2010-03-19T05:26:00.000-07:00

I went to the thrift store yesterday and purchased a used suitcase. Found the perfect one. My kids and I sorted through everything and re-packed it all in plastic bags. I learned the proper way to pack a suitcase for overseas medical missions from Miss Mattie. I went to her house yesterday to pick up medical supplies. We ended up visiting for an hour as she showed me the little warehouse of medical supplies and medications she keeps in her basement. She was a wealth of knowledge and gave me many wonderful tips about traveling to Haiti. She is an experienced traveler to third world countries. She is just what I want to be when I grow up. I long to spend my "retirement" years traveling the world doing medical missions. Miss Mattie is a force of nature. She even has a scholarship named after her, sponsored by the Greater Kansas City Black Nurses Association. It was an honor to get to meet her, and carry away two boxes of medical supplies. Now the challenge is to fit it all into the suitcase, and not max out my 50 pound limit. Thanks again to everyone who has generously donated. I carry your spirit of love and healing with me.

Home Stretch to Haiti

2010-03-18T02:51:00.000-07:00

The hunt is truly on for a bigger suitcase. The response on such short notice has been truly overwhelming. I think everything really can fit into one suitcase, but it must be a very large one. I will pack all donations into the one suitcase, and put my things into one small carry-on. I really am good at packing light, and besides I hate hauling a bunch of stuff around airports. Haiti will be an adventure. I've decided to wait until I'm there to decide if I will visit the midwifery school or birth center I've been invited to (they are on opposite sides of Port au Prince and both require an expensive chartered plane ride). When I went to get my malaria pill prescription yesterday, the nurse practitioner I saw, told me about her many trips to Haiti, and gave me more good advice. I have discovered so many connections between Haiti and Kansas City over the past two weeks. At a meeting yesterday, I was asked if I would be visiting Frank Vaughters facility (he was a much beloved Kansas City pediatrician that died in Haiti during the earthquake), but I have no news or contacts to his facility in Haiti.

I feel humbled and greatly sobered by this experience. I don't know if I'll be up to the task, or if an L&D nurse will be useful. (They really need surgical nurses, orthopedic nurses, wound care nurses). All I know is I will go with an open heart and do my best.

Calling All Condoms

2010-03-17T05:08:00.000-07:00

Donations continue to arrive daily. I'm so pleased by everyone's generous donations. All the donations are laid out in separated piles on my dining room table, in preparation for packing. When I walked in the door last night, my kids came running up to me, "Daddy stole from the Haitians!" "What are you kids talking about?!" I was thinking, what could he possibly want from the dining room table? It was full of prenatal vitamins and hairbows, and .... Condoms!!! I tracked him down. "Honey, did you take something off the dining room table?" He smiled shyly. "I only took one." "Did you really think you were going to get lucky with a stolen prophylactic?" I asked.

On a serious note though, more condoms would be greatly appreciated (I promise to protect them from both husband and teenagers). The blog from the crisis center mentions unplanned pregnancy and complications from abortions were a growing problem. As is typical after a disaster, so is sexual abuse and assault and physical abuse of women. Women and children are just more vulnerable after a disaster, as social constructs (and the men) that protect them fall away. Condoms are just one small tool in an arsenal of protection for women. I hope to give them that tool. Condoms protect against both sexually transmitted disease, and unwanted pregnancy. No other contraceptive device offers both.

Quisqueya Crisis Relief Center

2010-03-16T16:02:00.000-07:00

I have discovered a blog about the place I'm headed to in Haiti:
(warning, some of the photos are graphic)

http://quisqueya.org/qcsrelief/category/relief/

Donations for Haiti

2010-03-16T05:46:00.000-07:00

I have been delighted with the donations rolling in from everywhere. I'm definately going to need a bigger suitcase! I've already been thinking about planning a couple of travelogues when I return, perhaps one at my church and one at my school. I'll do them sometime in April. I'll set up another event page on facebook and post them here in the blog. Everyone has shown such an interest, I'd like to offer them something for their good will and donations. The only preparations left are to 'acquire' a camera and pack all my donations. My spirit is at peace for whatever the experience holds.

Haitian Dreams

2010-03-15T05:32:00.000-07:00

I had dinner with someone who was in Hinche last month. It was very informative. It has been incredibly helpful to talk to people who have been there. The pastors prayed for my trip in church yesterday. I had many well-wishers and prayer partners. This is such a comfort. I do not wish to undertake a journey like this without the prayers of many. Everyone has been kind, encouraging, and generous in supporting my efforts. I got lots of shopping done over the weekend, and have packed my bags. Now I just wait for more donations to arrive. I read books about the bloody history of this country, and try to recall my high school French. My dreams are of Haiti.

Getting to Hinche in a Cinch

2010-03-14T06:29:00.000-07:00

Now the ball is starting to roll. I just received an invitation to teach lactation support to Haitian midwifery students at a hospital in Hinche Haiti. I don't know how far Hinche is from Port au Prince, but it does involve a plane ride. Now it's time to get the universe moving. I need this to happen. I already have a text book to use for the teaching, it's a simple text written for developing world maternity care workers. However it is in Spanish, I need it in French or Creole. I'm trying to contact the publisher and the writer, Dian Doody MD, who happens to be a pediatrician from right here in Missouri. Any assistance you can give Dear Readers would be greatly appreciated. In less than a week, I must get the book translated, printed, and funded, or find another one just as suitable, already written in French, and make plans to travel (probably alone) to a distant city. The universe can pull that off, right?

Mission to Haiti

2010-03-13T05:33:00.000-08:00

The facebook event page is up! The "event" is called Mission to Haiti and you can link to it here. Now that I've taken care of getting the work out, I can focus on getting myself ready. I've made an appointment to get my immunizations and a prescription for malaria pills. Today I'll find a French phrase book and a pancho. Someone gave me a wondeful website, Midwifes for Haiti, that was full of practical advice. I still need to contact the list of drug reps I have, to hit them up for medication donations. I will also try to make contacts so that I can visit some of the midwife run birth centers in the outlying areas. I want my soul to be open to whatever the experience brings.

Haiti Countdown

2010-03-12T04:52:00.000-08:00

I met with Captain Belardo yesterday of the US Public Health Corps. He was just 10 days returned from a 2 month assignment in Haiti aboard an aircraft carrier converted for hospital use. Though he and his team were charged with water sanitation, and human and livestock immunization, the most difficult cases were helicoptered back to the ship for surgical procedures. He showed me hundreds of photos he had taken of crushing injuries, broken bones, amputations, burns, and severe bed sores (stage IV!). It seems the injured would lie for days unable to move themselves and without anyone to move them they would develop bed sores. He stated how sometimes the press overhypes things and blows them out of proportion, and how he was surprised to arrive in Haiti to find things much worse than anything he saw captured on CNN. The only redemptive element he found was 'the spirit of the people.'

I asked him specifically about maternal-infant health and was surprised to hear him mention the importance of breastfeeding. When I pointed out that most disaster relief folks want to rush in the formula after an event, he chuckled and confessed to being an old MCHBer (Maternal Child Health Bureau of Health and Human Services). Then he look very serious and said formula would be disasterous to send formula to Haiti- they barely had clean water before, they definately don't now. I was so relieved to hear someone in a government uniform was getting it. Don't send formula, send lactation support workers!

However, I digress. When I asked Captain Belardo what I should take with me, he informed me that I would be arriving during MANSOON SEASON! Yikes! Not just little periodic rain storms, he tells me, but hard driving rain and wind for days on end- but still in the 90s everyday. Sounds like hell with a beach. I asked about immunizations and was told: malaria, hepatitis A, and tetnus. When I told him I was thinking about skipping the hep A, he leaned across his desk, peered over his glasses and said, "Don't." Okay, then, Hep A it is. When I asked for what I should ask for he helped me to ammend my list to the following:

baby slings
folic acid and prenatal vitamins
antifungal cream
hair accessories
condoms

Ok, the last item might throw you off a bit, but Cap. B assured me that sexually transmitted disease was EVERYWHERE, including AIDS (that shouldn't come as a surprise in a third world country without a public health infrastructure). I did remember from my previous research that STIs and uplanned pregnancy rose precipitously after a disaster (so do sexual assaults, but that's another story). He said he made fast friends when it became known he had condoms to give out. I was just lecturing my students earlier this week about the long term effects on female fertility from recurring bouts of genital infections- it ain't good news. So to promote maternal health, I'm going to pass out condoms to every nonpreg woman I see.

All in all, a very helpful visit. Working with pregnant women seems a little anticlimactic in the face of such devestation, but I know every little bit helps.

Haiti to do list

2010-03-11T05:08:00.000-08:00

To prepare for my trip to Haiti, I need to do the following things:

get immunized (malaria, tetnus, etc.)
create an event page for facebook for donations
have two coffee dates with the two folks I know who just returned from Haiti (a captain in the US Public Health Corp who spent two months immunizing people and livestock, and a midwife who recently returned from 2 weeks there) in order to pick their brains
learn a few Haitian terms
review the history of Haiti to gain some understanding of the culture
acquire a digital camera and an extra memory card
make my packing list- it will be short, I plan to forgo make-up, and live in scrubs
continue to cultivate an open and accepting attitude (I've been re-reading The Four Agreements)
organize things at home so as not to unduly burden my husband
organize things at work so as not to unduly burden my teaching partner
ask for prayer from my church
I'll think of other stuff, or you can offer some suggestions

Preparing for Haiti

2010-03-10T10:13:00.000-08:00

It is now official, so I can blog about it. I'm going to Haiti in less than two weeks! From March 20-28, I will be in Haiti working in a crisis relief center with pregnant women. I can hardly wait to go. I will be going with Mercy and Truth Medical Missions and will meet up with other healthcare providers from other organizations working at the relief center. All I know so far is the relief center is housed in a school, and we will have accommodations there as well. Meals will be provided by the military. Here is where you come in. I would love to give folks the opportunity to give to this effort. I am accepting the following items to take with me:
1. fabric slings to give to women with small babies
2. unopened bottles of prenatal vitamins and folic acid
3. small vanity items for women and girls such as combs, hair accessories, hair bands, ponytail holders, hair clamps, barrettes, etc. (Nothing bigger than a banana please)
If you feel compelled to give money, please give to one of the fine organizations already set up to take donations such as the Red Cross. My trip will be completely self-financed (I plan to take it off my taxes next year.) I will post more information as it becomes available. My goals for the trip are the following:
1. Serve in whatever ways I can
2. Observe and learn more about the gaps in disaster relief services for maternal-infant populations
3. Document everything (in both words and pictures)
4. Practice maternal health nursing skills
5. Participate in some births
6. Experience and appreciate an entirely new culture
7. Become better and stronger as a nurse and person

Breast Lecture Ever

2010-03-09T05:36:00.000-08:00

Today is my lecture on lactation. I have two giant breast pillows to discuss anatomy. I have a breastfeeding bingo game I made to discuss benefits. I have a brand new $260 video from INjoy to highlight correct technique. I have posters, infant models, anatomical drawings of breasts in full color to introduce all my content. I think I'm ready. This lecture delights my soul because I usually make at least a few converts, but there are always the resisters. The trick is to deliver a message that touts the virtues of lactation without making those who did not choose it feel guilty. Why does this induce guilt and defensiveness??? I can't think of another topic that impacts folks with quite this intensity (on a day when we also discuss human sexuality, abortion, contraception, teen pregnancy...). My goal is to enthrall students with the wonders of mother's milk, and equip them with basic skills to support the newly breastfeeding mother. I'll let you know how it goes...

Stand and Deliver

2010-03-07T05:56:00.000-08:00

We were having dinner with three other couples from my church the other day. The hosts were a sweet young couple having their first baby. After dinner we played a pictionary type 'parlor game' that involved drawing a picture of a woman having a baby. I was very proud that my husbnd drew a picture of a woman giving birth standing upright! When I pointed out his drawing in contrast to everyone elses of a prone woman with legs elevated, the hostess asked, if that's the best way to give birth, why is it done lying down? When I said for careprovider convenience, I got dead silence. I dread conversations about birth anymore. I never say what people want to hear. It's all bad news. A couple of weeks ago when I asked a co-worker how his baby's birth went (I need to stop asking that question), he gleefully told me all about his wife's induction and how wonderful the whole thing was. I smiled politely and nodded. I can't speak nicely about birth, and I can't write nicely about it either.

Making Headway

2010-01-20T04:36:00.000-08:00

I took my students to my blog, homebirth diaries. I wanted to give them a glimpse of what's inside my head. Still, it seems so intimate, as though I've told a secret. Today I lecture on lactation. I'll show the video of the circumcision again. We'll discuss both topics, again. I'll try to make headway, again. It's all become a lovely rhythm. My students inspire me. I hope I inspire them, too.

Writer's Poem for a New Year

2010-01-03T06:49:00.000-08:00

I am here in my solitary little world, snow bound as it were, to my computer. The husband and children are asleep, as they always are when I write. I remind myself to enjoy the journey and each word placed on paper is part of the journey. Never mind the destination, it's the journey that counts. I want to write about birth in such a way as to seem wise and to cause a stir. That seems such a burden, so instead I tell myself to simply tell my stories. Write them down, one by one. String them together into a comprehensive whole. So that is what I do. Each day, I rise before the sun and tell my stories into my computer. Like a whispered prayer, my confidences are kept. My computer has become my god. My stories, my salvation.

Book Update

2009-12-17T06:13:00.000-08:00

Just an update for longsuffering readers. I have taken this hiatus to complete my book proposal slated to go out in early January. As my book nears completion, I am busy securing an agent and publishing house. Thanks for your support.

MANA Musings

2009-11-08T07:45:00.000-08:00

I am so glad I was able to attend MANA this year. It's always a privilege and I learn so much and meet old and new friends. Highlights include:

Meeting Jenny Joseph and getting an introduction to her model for prenatal care. I would love to bring this model to KC- have some ideas in the works for my FIMR board. I've got to get her here.
Participating in a white privilege game. Its where everyone stands in a line and takes steps forward or backward depending on their socio-economic and racial factors. I was at the tail end, by a mile. I can't wait to do this exercise with my nursing students. I found it quite powerful.
Being near sea and mountains- as a child of the midwest I hardly ever get to do both at once. Taking my little rental car on a coastal tour was a wonderful experience.
Vegetarian meals served at the Asilomar Resort were fabulous.
Getting to room with Morningstar and Alison, a midwife from San Miguel de Allende, Mexico.
Seeing Diane Paul of Sage Femme and witnessing more of her birth videos.
Bird watching- saw some new ones I haven't seen before.
Seeing so many midwives of color- there are more and more every year- good to see the next generation answering the call.
Conference bookstore: purchased two new books, a purse, a pair of earrings, gestational wheels for my students and a host of souvenirs for my kids
Favorite session: At your cervix: the ethics of how we teach pelvic exams
Most transcendent session: Morningstars session on using storytelling to teach instinctual birth
Most practical session: Using social media to promote better birth care
Goal for next year's MANA: do a presentation from my newly published book

MANA Faces

2009-11-08T07:37:00.000-08:00

Photos from Monterey Bay

2009-11-02T06:28:00.000-08:00

MANA Update

2009-10-25T08:01:00.000-07:00

MANA has been wonderful, as usual, and has gone quickly, as usual. I've attended sessions on, teaching cervical exams in a humane way, using social media (like this one) to expand business or advocate for a cause (like I'm doing now), cultivating cultural sensitivity, and using storytelling to teach instinctual birth. I will use all of this new knowledge in teaching my nursing students, and in furthering my work at home with lactation, infant mortality, and humane maternity care. I'm off to have breakfast, stroll the beach (dip my toes in the ocean/bay one more time) and visit the Red Tent which is always a treat. I will also listen to Ina Mae give her keynote address this morning- which starts right about now...

Rebel with a Cause

2009-10-24T10:34:00.000-07:00

I'm here in Monterey California at MANA 2009 sitting on white sand beaches, in temporate weather, contemplating my role in materal infant health in the United States. What mark will I leave on future generations of mothers and babies? I came here to see and hear my heroes in the cause, only to hear how overwhelmed they sound and defeated they sometimes feel. Still I must take up the charge. Morningstar's book, "The Power of Women" is making it's debut here at the conference. I make a solemn vow to myself, that next year, I'll be sitting at the author's table. People have begun to approach me about 'my work'. So far my work has been verbal and written, now I feel the universe telling me its time to get some skin in the game. I have an idea for a pilot program, to increase utilization of prenatal care for high risk women. I have to secure funding from somewhere, and I have to coax the powers that be to partner with me. Now that I sit on the FIMR board, I can use it as a jumping off place. I've been offered a leadership role on the Health Commission. There are lighthouses here- beacons of light and hope to ships lost in dark and dangerous waters. How do I shine a light on the darkness of infant mortality?

Doctor Dick

2009-10-19T09:41:00.000-07:00

Okay, Even though I would run screaming from the facility if a physician handed me the following document, I still find something refreshing about his or her honesty. Most docs just say, "sure okay, we can try that" and then when labor hits they do whatever the hell they want.

A healthcare consumer posted this on another blog. She stated her plan to find another physician. Good for her.

DR. ________ "BIRTH PLAN"

Dear Patient:
As your obstetrician, it is my goal and responsibility to ensure your safety and your baby's safety during your pregnancy, delivery, and the postpartum period. My practice approach is to use the latest advances in modern obstetrics. There is no doubt that modern obstetrical advances have significantly decreased the incidence of maternal and fetal complications. The following information should clarify my position and is meant to address some commonly asked questions. Please review this information carefully and let me know if you feel uncomfortable in any way with my approach as outlined below.* Home delivery, underwater delivery, and delivery in a dark room is not allowed.* I do not accept birth plans. Many birth plans conflict with approved modern obstetrical techniques and guidelines. I follow the I follow the guidelines of the American College of Obstetrics and Gynecology which is the organization responsible for setting the standard of care in the United States. Certain organizations, under the guise of "Natural Birth" promote practices that are outdated and unsafe. You should notify me immediately, if you are enrolled in courses that encourage a specific birth plan. Conflicts should be resolved long before we approach your due date. Please note that I do not accept the Bradley Birth Plan. You may ask my office staff for our list of recommended childbirth classes.* Doulas and labor coaches are allowed and will be treated like other visitors. However, like other visitors, they may be asked to leave if their presence or recommendations hinder my ability to monitor your labor or your baby's well-being.* IV access during labor is mandatory. Even though labor usually progresses well, not too infrequently, emergencies arise suddenly, necessitating an emergency c-section. The precious few minutes wasted trying to start an IV in an emergency may be crucial to your and your baby's well being.* Continuous monitoring of your baby's heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby's heart rate are not allowed.* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.* Epidural anesthesia is optional and available at all times. The most recent scientific data suggest that epidurals are safe and do not interfere with labor in anyway even if administered very early in labor.* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.* Episiotomy is a surgical incision made at the vaginal opening just before the baby's head is delivered. I routinely perform other standard techniques such as massage and stretching to decrease the need for episiotomies. However, depending on the size of the baby's head and the degree of flexibility of the vaginal tissue, an episiotomy may become necessary at my discretion to minimize the risk of trauma to you and your baby.* I will clamp the umbilical cord shortly after I deliver your baby. Delaying this procedure is not beneficial and can potentially be harmful to your baby. * If your pregnancy is normal, it should not extend much beyond your due date. The rate of maternal and fetal complications increases rapidly after 39 weeks. For this reason, I recommend delivering your baby at around 39-40 weeks of pregnancy. This may happen through spontaneous onset of labor or by inducing labor. Contrary to many outdated beliefs, inducing labor, when done appropriately and at the right time, is safe, and does not increase the amount of pain or the risk of complications or the need for a c-section. * Compared to the national average, I have a very low c-section rate. However, a c-section may become necessary at any time during labor due to maternal or fetal concerns. The decision as to whether and when to perform this procedure is made at my discretion and it is not negotiable, especially when done for fetal concerns.

Spawn of the Devil or Angel of Destruction?

2009-10-18T08:56:00.000-07:00

Josiah turned 3 last week. While he is cute and adorable, inquisitive and intelligent, we seem to be experiencing a greater volume than normal of broken electronic major appliances in our home, lately. It seems in the last couple of months he has broken our TV (poured water over it to 'wash' it), our computer (kicked it over in a fit a rage, hasn't worked since), lost an IPOD (last seen in his pudgy little hands), broke the IPOD port on our CD player, and has been implicated in the malfunction of several cell phones. We went to look at computers yesterday, and will budget for a replacement TV next month. Has he been sent to us as a plot by Satan to break all our stuff? Well even if that turns out to be the case, he's still a lot of fun to have around. His vocabulary increases every day, he's spoiled rotten, and still insists on sleeping in bed with us or one of his siblings. Potty training is optional, right? He's still in the throes of a Batman fetish, and insists on being Batman for Halloween. Later today we head to a local pumpkin patch so he can pick out some pumpkins. Despite how expensive having him around is turning out to be- we couldn't be more thrilled. Thankfully, he hasn't broken anything today.... wait... what was that crash???

Obituary

2009-10-10T08:43:00.000-07:00

Our 17 year old cat, Indigo passed away quietly at home yesterday. We found her late in the afternoon on our bed where she had snuggled up to nap. She never woke up. When our son Greg was 14 (now 31), his friend found Indigo as a kitten abandoned in a box in an alley en route to our house. He heard her meowing and picked her up and brought her to us. She's been ours ever since.
She was a very wild kitten, earning herself the nickname "Crazyhead" She had 2 litters of kittens early in life, and then settled down to become the mellow stranger-shy cat we grew to love. Her secret to longevity? She was an indoor cat, who didn't like to over exert herself. Many years ago, she had to have surgery that cost us $1,000 and I told her she had to live at least until we paid off the bill. She happily complied. She was always good for a snuggle, loved a good head scratch and enjoyed a high quality of life up until the end. The day she died, I saw her last in the kitchen eating her morning meal of catfood and water, while the dog and our other cat, Carl, patiently waited their turns until she was finished. She was very arthritic and slow moving, but the other animals aways gave way for her. She was always the matriarch of our animal family and beloved by our human family. She will be missed.

Indigo "Crazyhead" Payne
date of birth: unknown
deceased: October 9, 2009

PS: People have asked where we got the name Indigo. At the time she came to us, I was reading Ntzoke Shange's novel, "Sassafras, Cypress, and Indigo" a story of 3 sisters. Indigo was a midwife. It seemed to fit. I think the name Crazyhead came from the baby of the family at that time, Evan.

The Spirit Catches You and You Fall Down

2009-10-04T07:18:00.000-07:00

I've started reading one of the two books I purchased at the conference on cultural competency called, "The Spirit Catches You and You Fall Down: A Hmong child , her American doctors and the collision of two cultures." The other book was about medical missions. Spirit catches you is the well written assessment of what happens when a non-English speaking refugee family intercepts with the American healthcare system. It is a riveting story, though the author at times becomes bogged down in clinical analysis. I remember the Hmong refugees. I was a young teen in the 1980s when they seemingly 'invaded' the housing project where one of my aunts lived. They were quiet solitary people who kept to themselves. I could only imagine how foreign our world must have seemed to them. Could anyone have possibly chosen two more unalike populations to put together- Hmong refugees fresh from the mountains placed in the urban core housing projects with low income Americans, mostly African-American? Each group kept to themselves and there were few clashes, but only because there was no interaction. Each eyed the other suspiciously as I recall. In the book, the Hmong parents of the story present to the emergency room with a child afflicted by seizures. Since they don't speak English and this is prior to the time of having interpreters on staff- the doctors don't know what the problem is. It takes several visits, until the child is brought in still in the throes of a seizure, for them to figure it out. The book goes on to catalog the highs and lows of treatment for this child with all miscommunication and misunderstanding that accompanies their interactions. It is a fascinating read- amusing in some places, heartbreaking in others. It makes me want to work harder to impress upon my students the importance of taking the time to understand the health beliefs of the person for whom you are caring. It's also changed my mind about another thing. It is not enough to seek patient compliance as the highest goal for the nurse's efforts, but rather client collaboration. The healthcare consumer has to have buy-in. Clinicians and consumers must work together to create and individualized plan of care- this is the only way, in fact, that it can be individualized- the individual has to help create it. We in our authoritative cloak cannot arbitrarily decide what is best for someone else. For true healing, rather than merely curing, to take place, we need to involve the body, mind, and spirit of the client. All of these aspects of the person are embraced by culture. In the book, progress begins to be made, when a few astute clinicians, inadverdantly begin to ask some of Kleinman's Questions, such as what the child's illness means to the parents. I can't wait to finish this book.

What is Cultural Competency?

2009-10-03T08:30:00.000-07:00

I attended a conference yesterday (what a shock right! Everyone must think I have a hidden trust fund to attend all these conferences, when really I'm just resourceful and I live in a metropolitan area that has lots of conferences to choose from). The topic was cultural competency. I attended because, 1. I think cultural incompetence feeds greatly into health disparities which greatly impacts the health of African-Americans and Latinos, and 2. I guest lecture on the topic and felt the need for more info, and 3. it was free to nursing students of the school I attend where I'm working on my masters.

What a lovely conference! It was hosted by INMED whose focus is international medical missions, so the focus was more on healthcare professionals dealing with clientele from other countries of origin, but as we all know there are plenty of American subcultures that are misunderstood by the majority of healthcare providers, whether those subcultures are characterized by race, class, religion, region, language linguistics, language dialect, health literacy levels or any other number of factors. The conference did an fairly nice job of pointing to the fact that healthcare is a 'foreign culture' unto itself.
(I have long been an ardent supporter of this philosophy. Healthcare has its own language, its own mode of dress, its own customs, power systems, etc. Since it is populated mostly by educated caucasians, their norms have become the norms of the this 'foreign culture' we call healthcare. So even caucasians entering the healthcare system to some extent have to step into this culture in the 'patient' role. Everyone else has that to contend with putting on the patient role plus whatever cultural divides exist, known and unknown.)

The sessions were on such topics as, 'Health thru the lens of culture,' Health beliefs and traditional health practices,' 'Health disparities in relation to cultural identity,' Defining culture and cultural competency,' and much more. Fabulous topics all. The most practical information was Kleinman's Questions which are 8 questions this researcher came up with for pulling out the health beliefs (or illness narrative as one speaker so eloquently put it) of the healthcare consumer- so if you learn to incorporate these questions into your history taking, it doesn't matter if the patient is from the same or a different culture than your own. Almost every speaker quoted Kleinman's Questions so google it for yourself to find out what they are. I'm incorporating them into my history taking lab for my students.

At lunch I approached a table of older caucasian gentlemen. (This is how I challenge myself now, to sit at a table of folks I don't know and suspect that I don't have much in common with.) After polite introductions we launched into an animated discussion on what cultural competency looks like in our individual practices. There was a surgeon (I think he was a cardiologist, but he never said), a homehealth case manager/manager who was a nurse, a home health physical therapist, and me, a nurse educator. The surgeon made the (for me) shocking but typical statement that it was enough that he was kind and polite to everyone he saw, that was his idea of cultural competence. I reminded him that he could very politely offend the hell out of someone by not understanding the customs or health beliefs of their given culture. As we talked more the nurse manager gave many excellent examples of how he ammended his care to the cultural needs of the client, but the surgeon really didn't get it. I told him I could 'blow his mind' with some examples of things he didn't know about his African-American client's health beliefs that he probably wasn't taking into account when he treated them. "Name me three," he challenged me. Only three? Sure.

Your African-American clients don't trust the healthcare system, and by extension don't fully trust you.
You are not the final authority for your African-American clients, you are at best a second tier authority on health and wellbeing.
Most if not all your African-American clients indulge in folk medicine practices that you are unaware of.

I don't know if nurse manager and I convinced surgeon of anything, but we gave him some food for thought. This is why I always try to sit with strangers over a meal. Good rousing conversation always is a possibility. There's nothing I love more than thrashing around ideas with good conversationalists. I also remind myself that as an African-American woman, my voice and my story is seldom heard, and others need the benefit of my healthcare narrative and perspective.

All in all a fabulous conference and time well spent.

Have you looked up Kleinman's Questions yet?