Day 18

The ride to Jacmel was incredible. After about 2 hours on the “highway” back towards Port Au Prince, I was dropped off by our driver Zo and met by another, Komandan. I’d been texting with him in Creole (thanks to google translate) to coordinate this meet up, which often makes for a confusing moment when I have to communicate that I do not, in fact, speak Creole at all. I climbed into Komamdan’s truck for the last 40km to Jacmel, on twisting roads through the mountains with grand vistas of ocean, sky, and clouds. The sunset created ribbons of pink, purple, and orange, reflected over the vast ocean. Unforgettable. But not actually documented because I’m terrible at taking photos when other people can actually see me taking photos, and since I was sitting snugly in the cab of a truck between two Haitian men I’d only just met, there is no evidence of this amazing sunset. 

Technically I made the drive to Jacmel on day 17 of this trip, but it’s just easier to include here. 

Upon arriving to Jacmel and eating dinner with Sarah (midwife and founder of OTP) and her family, I settled in to spend my first night at the birth center since the house I’ll be staying in for the rest of the week had a minor plumbing problem. Sleeping in a patient bed is always a strange thing for me, but this was obviously nothing like an American hospital. No blinking lights from machines, no doors opening and closing incessantly, no beeps or alarms. Just a fan- that turned off at 4am when the power went out- and mosquitoes. 

The clinic day started with introductions to staff. There are two Haitian midwives at OTP. They completed their midwifery raining in Senegal, which was made possible by post-earthquake education grants (a great way to sustainably contribute to any relief efforts). There are also a few nurses and auxiliaires, cleaning and cooking staff, an administrator, and of course the two lead midwives, including Sarah. There were a few prenatal appointments first thing, which I observed, and then a prenatal class. Eight women attended to learn all about the basics of birth, including the physiology, the hormones, the stages, and of course when to call. After the hour-long class, a few women stuck around for their appointments. 

OTP has a really wonderful philosophy of care. Sarah sort of stumbled into midwifery and has created a center to compassionately care for women and their families while aiming to reduce the infant and maternal mortality rate. Women are expected to attend all of their appointments and classes, and can even sign up for a Centering Pregnancy option. They must keep their appointments to birth at the center. Midwives are on call 24/7 and will transport any woman in labor to the birth center when it is time. The postpartum care schedule is thorough, because for many women those first two weeks are the hardest and when most problems arise. Women who can’t pay the 4000 gouds for all of this care (less than $70) can set up informal payment plans. Women who must be transported to the hospital but cannot afford it will somehow be covered, even if it means OTP pays for it themselves and forfeits their own fees. If a woman cannot afford to feed herself and her family, they will try to help in any way they can. Sarah tries to limit the number of patients to about 15 per month to ensure this attentive, high quality care is provided to each client. 

After just one day at OTP, it is obvious that this model of care is a major boon for the Jacmel community. OTP essentially limits its own profits by capping the number of patients, but the care offered is extraordinary given the low-resource setting. Sarah’s intentions in setting up OTP was to empower women and families to thrive together, starting with pregnancy and continuing through parenting. It is a holistic, multi-dimensional approach to reducing infant and maternal mortality in Haiti, one that I hope can be simulated elsewhere. 

Days 15-17

With the arrival of Jim (the foundation’s executive director) last week, bringing with him a stash of cash dedicated for food supplies, and a shopping list from Rosena (the MN directrice), Monday morning was spent in the truck, hopping from one market stall to another trying to find all of the items. This is going to be the largest food distribution project yet, with the aim to supply 150 households with rice, beans, corn meal, sugar, pasta, canned milk, canned tomatoes, margarine, oil, body soap, laundry soap, toothpaste, toothbrushes, toilet paper, and candles. This isn’t a country where you can do one-stop shopping, there is no Costco for bulk purchases, so the morning was spent searching and negotiating. Eventually we loaded up the truck with the first haul back to MN and waited for the truck to return with more. After three more trips, all the supplies filled one of the storage rooms and we go to work divvying it all up into into household sized portions. Almost 1000kg of foodstuff separated into smaller bags took several hours of several people working relentlessly, but we got it done by the end of the day on Tuesday, when I got to take my second moto ride back to Les Cayes at sunset. Lots of kids yelling “blanc!” and waving adorably. 

Then it was election night and everything was the worst until I got back to work on Wednesday setting up an assembly line to fill packages for each household. In the end there were more than 150 kits because we were a bit conservative in measuring some of the bulk goods. Each staff member at MN was given a package as well as some other people closely associated with the clinic. Then the health promotion team would load up the trick to distribute the rest to the families who need it most. 

Other recent developments:

MN was able to get 6 new graduates of the Midwives for Haiti skilled birthing assistant program to spend a month relieving the MN staff. They arrived on Monday to train for a week before the MN staff could take some much needed paid time off to focus on rebuilding their own homes. 

Partners in Health sent a team to meet with Rosena and Jim to talk about possible partnerships. PIH is a major supporter of the hospital in Les Cayes and from now on will pay for the services of any woman who is transferred to the hospital in labor. Previously, MN covered those costs. PIH is also facilitating grants to be given to MN staff whose homes were destroyed by the hurricane. 

MN now has running water again and a brand new generator, thanks to the hard work of Jim. 

I moved from MN to The Olive Tree Project in Jacmel! More to come from OTP soon. 

Days 11-14

On Thursday, Dee and I made the bold decision to try to make a thorough inventory. We started in the pharmacy and the birthing room, both of which were pretty straightforward. Per the woman who works in the pharmacy, the items used most are: folic acid, prenatal vitamins, iron, vitamin C, ampicillin, penicillin, amoxicillin, metronidazole, ciprofloxacin, doxycycline, and acetaminophen. No real surprises there. The items she reported using often and in low supply are vitamin C, betadine, and sterile and exam gloves. She also included IV solution in this list, but I’ll talk about that later…

There were quite a few items still on the shelves that have expired and are collecting dust. Some others that aren’t used at all (Naproxen). In the birthing room just about everything stocked is necessary, except maybe tongue depressors. Two notable absences: peri bottles and saline flushes.

Next we tackled the 40 foot shipping container that houses many of the donations sent in the past. While there were some items in there that could be taken out and made more accessible for regular use (IV kits, patient gowns, chux pads, baby blankets, cloth diapers, gauze, sterile laceration kits, birthing kits, sterile surgical gowns, cloth drapes, umbilical cord clamps, sheets), there were many boxes of things that either aren’t needing frequent replacement (six IV poles, seven autoclaves, hundreds and hundreds of plastic speculums, scrubs, electronic continuous fetal heart monitors, ambubags, oxygen regulators, cold packs, dozens of blank patient registers, bulb syringes, and vaccine transport coolers) as well as items that the clinic just won’t ever use like books in English (our favorite was a travel guide to India),¬†adult clothing, and winter clothing of any size.

Dee and I enthusiastically climbed into that storage container. Without any air flow. In Haiti. Within minutes we were drenched in our own sweat, but we persisted. After about an hour I sat down to record our findings while she diligently carried on, box by box. Soon we found a thermometer. It was 114*F. We stayed in there for nearly 2 hours. Deliriously.

Over the next few days we also surveyed three additional storage rooms and the lab. We found hundreds and hundreds of bottles of prenatal and children’s multivitamins, many which will expire within the next 6 months. There are enough birthing kits for the next year, maybe three years depending on the volume (these are sent from Hope for Haiti and have many of the supplies needed for each birth including chux, drapes, baby blankets). We found adequate supplies of antibiotics, pain medication, and family planning options. And IV fluids. In the last room we got into there was a wall of normal saline. Coming from the US healthcare system, in which efficiency is highly valued, Dee and I just really wanted to organize all these supplies to make it easier for staff to grab what they need when they need it. There are too many different locations for specific things and only certain people seem to know where certain things are stored. A master inventory would reduce duplicate orders and donations, allowing MN to send out requests for what is truly needed rather than items that might just be in storage, collecting dust with the best of intentions from donor and recipient. Unfortunately we really only had time to organize one of the rooms, but hopefully it helps them out a little. We never did find any more betadine.

In one of the last rooms we got into, there was also a cache of foodstuff! We quickly got to work divvying and distributing it to one of the local communities. This round included a rice and soy packet, oil, biscuits, canned tomatoes, condensed milk, toothbrushes and toothpaste, aquatabs, and oral rehydration packs. We got to about 50 households and dropped off a good sized load at the orphanage, too.

Day 10

Today I went out for more home visits with the health promotion team. Heard a lot of the same things as yesterday, with this particular village in great need of a reliable source of potable water. They do not have a working well within a convenient walking distance, so even the water purification options are nearly moot for them. One of the people I was working with expressed some frustration with everyone complaining about needing roofs, because from his perspective, everyone needs a roof right now. And the health promoters are out to discuss health, not shelter. But. These are not unrelated. If people can’t sleep because they’re getting rained on, if they’re crowding together, health is at risk. These crowded shelters become breeding grounds for bacteria, and disease. Immune systems are compromised without adequate sleep. Shelter must be a top priority for health. 

Of the 25 or so households I visited, I met just one pregnant woman. She was about 7 months along and had not received any prenatal care. She plans to deliver in her home. After asking a few standard questions about her health, I inquired as to why she had not gone to MN to get checked out. She said it was too much money to get care. Now, I don’t know if she was aware the MN does not require payment if the patient cannot afford it (which I confirmed later so wasn’t able to share with her in the moment) or if she, like many, simply wouldn’t accept services without paying as a source of pride. I do know, however, that her intention to deliver her baby at home is risky. She told me she was scared of the hospital. Not uncommon, anywhere, but especially in rural communities within countries such as Haiti. Attempting to explain the differences between the city hospital and the birthing center did not seem to sway her at the time, but I hope she understood that there is another option for her. I hope the birth of her baby happens without complication, as it very often does. I hope she has enough food and clean water and is able to stay dry at night. 

At the end of the day, I stopped at one of the translator’s homes. Rosenbert is a sweet, inquisitive Haitian man. After his wife died a few years ago, and he noticed the same few children on the streets he walked everyday, he decided to open up his home to these orphaned children. He has since had up to 40 children in his home, in addition to his 2 biological children. He has managed to build two additional structures next to his own home to house them. He pays their school expenses and feeds them. He keeps them safe, healthy, and off the streets. He has no affiliation or sponsorship. He simply requests assistance from his community when they can, and otherwise works very hard to be able to continue supporting them. In the wake of Hurricane Matthew, he had to make the difficult decision to send about half of them to other orphanages, where he is certain they are not getting the kind of family care that he gives them. He simply could not afford to keep feeding them all. While the silo-like structures for the kids stayed intact during the storm, his own home was destroyed. Roof blew off, walls fell down. He spent the long night waist deep in water, holding his kids up on the rafters to keep them dry. Now, with half the kids in his care (about 15),he says about $500 feeds them for all for 3 weeks. Less than $1000 will fix his roof. He needs all the help he can get. 

Day 9

It’s a national holiday (All Soul’s Day), so the clinic doesn’t have any appointments scheduled. We’ve arranged to go out on some home visits instead. 

On the way into MN, our driver brings us to a local market where we look up the words for rice and beans, figure out the conversion rates for American and Haitian dollars, and drive away with two large bags of rice, cooking oil, bouillon cubes, and bags to distribute it all to individual households. Yesterday Deanna visited a small village just down the road from MN. When she asked a woman why her baby was crying, she stoically replied “he’s starving”. So, today we bring a meager amount of food. We couldn’t get our hands on any protein sources at this market, but we will try to figure out a way to get some later this week. Once at MN, we ration out about 25 bags, expecting to visit 15 households and reserve a few for the families of the children that Deanna met yesterday. And off we go!

We drive about 20 minutes to a stretch of road with houses, or really the remains of houses, on either side. We meet a man there who also works with MN as what I would call a health promoter. We split into two groups, each with an MN staff member, a US midwife, and a translator and we divide the road up. I join the health promoter. At each house, we go through some health education about the prevention and treatment of malaria and cholera, distribute a 30-day supply of vitamins per child, a deworming pill for each household member, 2 oral rehydration packets, and 12 condoms. We also record data about the members of the family, including if anyone is pregnant (no one is and several joke that it is a terrible time to be pregnant since everyday is hard enough) and if anyone uses any form of family planning (two women using the pill, and another couple of households declining the condoms, saying they didn’t need them). There are plenty of children around because their school building was destroyed and nothing has been erected to replace it. 

I offered myself to each household as a nurse and midwife, willing to address any health related questions and otherwise hoping to hear about the most pressing problems they deal with everyday. Questions were few: I tried to dispel some rumors about both hot sauce and alcohol as means of preventing cholera. I heard a lot of frustration about the lack of aid in their village, that they see trucks of supplies and aid workers driving by and flying over but no one stopping to help them. There were requests for assistance in finding tarps for make-shift roofs and mosquito nets. More aquatabs and water filtration systems are needed. One kind, older gentleman expressed his awe that Mother Nature could bring so much water to them, but as soon as it hits the ground they cannot drink it. Another described to me symptoms of what could have been an inflamed gallbladder that he’s been suffering for years. He was extremely appreciative that we were there asking about the health and wellbeing of him and his family, because no one else has. 

At the end of the visits, as we walked back to the truck to begin the careful distribution of the food supplies, a woman approached me asking that I take photos of her home. Her husband is a groundskeeper at MN. She and her family are now sleeping at a neighbor’s house, like so many other people, crammed into a small, warm space with a leaky roof, but a roof nonetheless. Two sheep were tethered out front and her toddler son followed as she gave me the tour. This woman’s house was not unique. Like ancient ruins, an obvious floor plan with some walls still climbing out of the pile of concrete, but entirely uninhabitable. (*photos to follow, when I have a better connection)

Lessons of the day: more food is needed. Cash is needed. Materials for construction. Clean water, aquatabs, filtration systems. There is still so much work to be done. 

Day 8

Monday, after two days off because we couldn’t quite coordinate the ride to a night shift on Saturday, made up for those hours spent lounging about in cool, quiet rooms. To start, the normal route we take to MN- which includes a right turn onto a dirt road from a paved main road and then a left turn onto another dirt road, where MN is situated about a mile or two down- was blocked. There were small fires and big logs dragged to prevent traffic from passing. Discontent and frustration with the lack of provisions, aid, etc. manifesting in impossible-to-ignore demonstrations. We took a long, circuitous way around, and saw communities in even more disarray. Worse roads, deeper standing water, denser sections of downed trees barely cleared from roads and often not from the houses at all, even more crowded villages. After about an hour, we arrived to MN with a crowd of women waiting for us. 
The clinic clearly has a heavy patient load for the day, plus two women in labor and one more on the way. Deanna and I quickly get to work, examining the two laboring women right away. One is just 2cm dilated and still easily smiling and walking. She doesn’t need much from us now. The other is 8cm and working hard through each contraction. It’s her second baby so this could go quickly. We encourage her to keep changing position: she alternates between walking, squatting, hands and knees, and the birth stool. Within a couple of hours she is complete. We see baby squirming in there, working into a position to get through the birth canal and out to meet us, but baby hasn’t descended any further yet. 

The MN nurse decides to release the bag of waters, and the amniotic fluid is lightly stained with meconium. Gestational age is 41 weeks so this could just be a sign of fetal maturation. The fetal heart rate has been reassuring throughout labor so far. We encourage the patient to stay upright, to let gravity do some of the work, despite her exhaustion. She’s been up all night. We get her some juice, or rather her mother runs out to a vendor on the street (“not good”, she says in English about the odd, watered-down-pepto bismol-looking, Tampico flavored juice). We hang an IV, let her rest a bit in bed. Baby’s head feels like it’s behind the pubic bone and needs just to make it ’round that curve to be born. 

Almost two hours with leaking amniotic fluid and the FHR has dropped into the 90s and pushing is still not effective. The meconium has changed character, it’s now thick and dark. She gets a dose of antibiotics. We encourage her to take deep breaths, and help move her to hands and knees but the heart rate continues to deteriorate. The decision is quickly made to transport her to the hospital. About 15 minutes elapses from decision point (which was probably less than 30 minutes from the first recognition of the nonreassuring FHR) to wheels moving, with the appropriate referral paperwork filled out, a set of vitals taken, and supplies gathered in case of delivery en route. 

I help her into the back of the truck, where one bench has been removed to make room for her to lie atop some padding and a sheet. By the time we have left the driveway I realize this is not going to work, it’s way too bumpy for her to be lying down. I help reposition her so that she is sitting up, leaning back into me with her legs draped across my legs while I support her, trying to cushion some of the harsher, bumpier moments on the ride. The most direct route is still blocked so it takes almost an hour to get to the city hospital in Les Cayes. The truck navigates the grounds of the hospital until we are just in front of the maternity ward, and she is escorted inside. I’m told to stay in the truck. The MN nurse and my translator return, climb in, and we drive away. I do not yet know the outcome. 

Back at MN, I jump back into the momentum of the day, finishing the last of the OB appointments by measuring bellies and performing ultrasounds as the nurses write prescriptions and arrange follow up appointments. No progress for the other laboring mamas. The clinic day ends like any other. 

On the way back to Les Cayes, I notice new growth on the trees. It’s raining and there’s a splash of rainbow in the distant sky. Piglets chase pedestrians. Families of four on motorbikes. Kids smile and wave as we drive by. Life continues, it vibrates here with a tropical fullness unlike any other. 

Days 4 & 5

Everyday I sit in the truck for about 25 minutes to and from MN. I’m not shocked by what I see: I’m surprised by my comfort in these surroundings. Bent and broken trees, piles of concrete, small fires burning roadside, collapsed houses, animals roaming, motorbikes everywhere, horns honking, throngs of people both busy and idle along the paved and dirt roads. Since this is my first time visiting Haiti, I have no baseline for what it looked like before Hurricane Matthew struck earlier this month. I imagine a vibrant tropical wonderland with the coconut and banana trees filling all the gaps between houses. Poverty, yes, everyone loves to say what a poor country this is (rather than lead with the astounding fact that it is the first independent black nation in the Western Hemisphere, born of a powerful slavery rebellion). But still, I imagine these streets always have that sense of being full of life. Now so much of the landscape is defined by destruction, a perpetual construction project, war-torn after losing yet another battle with nature. How long will it take to put back together?

At the birth center, they were fortunate to escape significant damage that would impede the work they do. Part of the roof of the administration building sustained some damage, but it is mostly intact. They just use generators for power because the lines are still down. There is no internet so they have to go back to paper charting instead of the EHR system. Patients have been affected in untold ways. Many show up with the records they keep with them tattered or torn, or lost in the chaos of these past few weeks. Many don’t show up at all, judging from the number of visits MN had in previous months compared to the volume I saw this week. 

The other US midwife volunteer arrived late last night and had her first day at MN today. She brought with her the birth mojo I’d been missing all week and 2 mamas delivered baby boys during clinic hours today. The first was a beautiful multip birth that  went just about as smoothly as possible. The second was a primip who labored…like a primip! When baby was finally ready to meet us all, he punched his way out with a compound hand presentation and a loose nuchal cord. He perked up quickly and was handed to mama while I attended to her 2nd degree laceration. Both mamas moved to the postpartum room to rest for 6 hours before returning to their homes. 

A couple of notes about the birthing room: sterile gowns (typically worn during a delivery by the provider) are being used for everything from a cover for the birthing stool to an under buttocks drape to perineal wipes and support. Versatile, yes they are, but having some more specialized supplies would be great (disposable and non disposable chux, peri wipes, more gauze and 4x4s). Women must bring their own blankets for baby for immediately following birth, and no matter how dirty they become they are likely to ball them up and take them with them when they leave. 

Week 1. I’m facing two distinct challenges, both with their own nuanced yet overlapping layers: Midwifery in a low resource setting and healthcare in a foreign language. While I feel that prioritizing navigation of the first will likely ensure better patient safety, the latter is also vital. I am working within a team and need to be able to communicate with them and the patient. In prenatal and postpartum visits, there is less urgency to communication than in the birthing room, where clear communication must happen throughout labor and delivery. More to come on this, I’m sure.