Author Archives: trainmidwivessavelives

African Birth and Computers

What an opportunity to Train Midwives Save Lives!  African Birth and Computers

 

Birth kit instructions on the way to Guatemala

We are excited to hear of an obstetrician who is headed to Guatemala next week and will be taking clean birth kits with Train Midwives Save Lives instructions included.  These clean birth kits will go to traditional midwives and community health workers who will be participating in an approved health training session.

Have a great trip!

Birth Kits on their way to Ethiopia

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Train Midwives Save Lives clean birth kits are on their way to Ethiopia. A great new organization, Delivering Hope International, is kicking off a doula program in Ethiopia and TMSL was able to send along a birth kits to be distributed to expecting moms. Congrats to Delivering Hope International for getting off the ground. We look forward to following the work you’ll be doing to  positively affect maternal and child health in Ethiopia!

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Step 6: Avoid potentially harmful procedures and practices

Have you heard of the International MotherBaby Childbirth Initiative? (IMBCI)  If you haven’t, you should.  It’s an important movement, summarized in the 10 Steps to Optimal MotherBaby Maternity Services (see end of post for all 10 steps),  that has the revolutionary potential to shape maternity care as we continue to strive to meet the Millennium Development Goals.

Today, Step 6 is on my mind.

 Step 6: Avoid potentially harmful procedures and practices.

Please note that the recommendation to avoid the following procedures and practices applies to avoiding them in the course of a normal labor and birth.  Herein lies a particular challenge — how to teach what a normal labor and birth is.  But, it has been made more difficult than necessary because care providers routinely use the following procedures and practices in NORMAL labor and birth, thus complicating the process and often causing the normal labor and birth to move into the abnormal category.

Avoid potentially harmful procedures and practices that have no scientific support for
routine or frequent use in normal labor and birth.

Here is a list (from the IMBCI) of practices and procedures that SHOULD NOT BE PART OF NORMAL LABOR, BIRTH, and IMMEDIATE POSTPARTUM care:

  • Shaving, enema
  • Sweeping of the membranes
  • Artificial rupture of the membranes (AROM)
  • Medical induction and/or augmentation of labor
  • Repetitive vaginal exams
  • Withholding food and water
  • Keeping mother in bed
  • Intravenous (IV) fluids
  • Continuous electronic fetal monitoring
  • Pharmacological pain control
  • Insertion of bladder catheter
  • Supine or lithotomy position
  • Caregiver directed pushing
  • Fundal pressure
  • Episiotomy
  • Vacuum or forceps delivery
  • Manual exploration of the uterus
  • Primary and repeat cesarean section
  • Suctioning of the newborn
  • Immediate cord clamping
  • Separation of the mother and baby

Are you a midwife? Do you routinely “do” any of these practices and procedures? Be honest. Change starts with each individual care provider who is already in the field.  Change continues as we pass down our wisdom, knowledge, experience, and teach EVIDENCE BASED BEST PRACTICES to our students.

PLEASE! If you work in the MotherBaby continuum and find yourself doing any of the above (whether because you were trained to, it has just become habit, or because it seems like the best thing to do in your particular environment), then STOP these practices and procedures that are not evidence based in NORMAL BIRTH (and, by the way, birth IS NORMAL).

PLEASE! If you are a student midwife, teach yourself not to begin using these practices and procedures in the course of normal birth.

PLEASE! If you are a teacher of midwives — teach EVIDENCE BASED practices (and, coincidentally, you can conveniently use the above list as a guideline regarding some typical practices and procedures that you should NOT be teaching students to use in the course of normal labor, birth, and postpartum).

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Causes of Maternal Death in Africa … beginning to explore Niger statistics

Causes of maternal death (1997-2002) in Africa
Source: Progress for children 7 (UNICEF, September 2008)

… and sadly, a girl who gives birth between the ages of 15 and 20 is FIVE TIMES more likely to die than a woman in her 20s…   In Niger, over 75% of girls/women are married before the age of 18 … 

… with a fertility rate of over 7 per woman, Niger is the riskiest place to give birth in the world.

….Niger’s lifetime risk for women of dying as a result of pregnancy or childbirth complications – ONE IN SEVEN – is the highest in the world.

Training of these birth attendants on (a) distribution of misoprostol, (b) distribution of family-planning methods, (c) use of simple tools to measure blood loss, and (d) practice of postpartum visits has enormous potential to reduce maternal mortality and morbidity in the most underserved areas.

my my my, it’s been a long time since I’ve sat down to research and write!  Gearing up for some work in Niger, starting this fall.  Brainstorming and researching how to help decrease mortality there.  Here’s a good article:

Where There Are (Few) Skilled Birth Attendants

Haiti Day 5 (September 13, 2012)

The sunset last night was amazing. I sat watching the red blaze go down in the western sky and wondered how many sunsets like this one I would get to see from this country that is so beautiful and so fraught with turmoil. I didn’t have my camera with me and snapped an iPhone pic … and much to my amazement, the sun in the captured image was in the shape of a heart! 

After watching the sunset, I sat out front of our hotel and waited for the armed guard to do his rounds. I don’t know why, but this guy just makes me smile.  As far as I can tell, there’s only one armed guard at our hotel … and he shows up in the funniest of places. One night, Lisa and I were walking back to our room and he was standing in the shadows of the path … machine gun — or semi-automatic or whatever it is — at the ready. “Bonsoir,” we said. “Bonsoir,” he said in a friendly voice. Anyhow, as I waited for him, I was overwhelmed with the dichotomy of living conditions in this little corner of the world. Our hotel, with it’s security guard, restaurant, and air conditioned rooms … and, across the street, a few blocks of tent neighborhood. Sad, but true.  The more I’ve thought about this, the more it has struck me that this irony plays out no matter where you are in the world. The rich next to the poor. It doesn’t matter if you are in a developed country, a transitional country, or a developing country … It makes me cry, that I can’t make it better for everyone.  But, in one little way, perhaps Train Midwives Save Lives can make a difference for moms and babies and midwives. If even one life is saved because of this work, then it is all worth it.

Today is Thursday! I expected time to move very quickly while we are here. But, it’s not. I think it’s the heat!  Or, maybe it’s because my brain is in overdrive, trying to assimilate all that is and has happened. Liz and Dana fly back to the USA today. They have been a delight to travel with and have, I’m sure, taken amazing videos and notes of our activities over the past few days.  Their smiling faces will certainly be missed for the remainder of the trip.

John picks us up and we head out of the city toward Prospere.  I’m able to notice a lot more details of the trip this time, perhaps because I’ve been down this road before.  Jean and I note that there actually are power lines all the way out to the village. We had been discussing whether or not the village had power since we were here on Monday. I count the wells that we pass and see three for sure.  We pass a voodoo temple, which Lisa points out, and I wonder how she knows it’s a voodoo temple. The voodoo practices are something I would like to learn more about, as I’m sure the beliefs permeate birth practices, at least in some areas. Again I am awed by the beautiful crops that we pass as we near Prospere. It pleases my heart to know that these people are growing good food.

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After a little over an hour’s drive, we pull up to John’s clinic and the concrete gazebo next to it is once again filled with women! Beautiful pregnant women and their midwives! We bring out our trusty flash cards and spend some time talking with the group about different birth scenarios. Twins, breech, cephalic birth. What is hemorrhage? How is the cord cut? Because this group is a mix of pregnant women and midwives, the discussion is lively, but in a different way than it was with the group of only-midwives in Simone Pele. When we take out our models of babies at different weeks gestation, the reception is not as warm as it was when we were with the midwife-only group. At first, I am perplexed. But then an older lady who is standing off to my right tells me that some of the women are scared of the models because they are so life-like and are the same size as babies often are when they are stillborn. I really appreciated her insight. … and it raises the question: How often *do* these women miscarry or birth still babies before term?

After some time teaching, we give each pregnant mama her clean birth kit so that the midwife will have gloves and a new razor for their birth.  Then, we invite the midwives into the clinic.

Four lovely, hardworking ladies come with us. One of them was the midwife who had brought in a woman “in labor” on our previous day here. I am so happy to see her back!
ImageAs we talk with this little group of midwives, I snap a picture with my iPhone that is probably my FAVORITE picture from the whole trip … I call it “hard working feet” We spend most of our time with these ladies talking about what they want from training (recognition from the government that they are legitimate care providers). It is interesting that the midwives here are apparently women instead of men or a mix. This village is really too far away from the city to transport a woman who is in dire need of higher-level care. These midwives really need to be trained in how to stop hemorrhage and provided an avenue to have access to drugs like pitocin for stopping hemorrhage  I am very curious to find out how they deal with excess bleeding, but decide to leave these questions for another day. I wonder if there are local plants that can be used?

In the end, we share the last few birth kits that we have available. We give each midwife 15 kits and leave another 30 with John to hand out as they need them. A quick picture to lock this moment in time and we head back to the city. One burning question: HOW DO THESE LADIES KEEP THEIR WHITE CLOTHES WHITE?!?!?! Image

 

Haiti Day 4 — in the afternoon (September 12, 2012)

Our day today continues with a trip out to the village of Titanyen. This is the village where there is a sewing project and the wonderful women there made us bags to share with the midwives. The bags are well-made and, hopefully, will be useful to the midwives with whom we share them … at least they provide a good way of carrying clean birth kits!

The staff at Global Outreach in Titanyen has put word out to the two local midwives that we are coming today. When we arrive, we find out that two midwives had come early in the morning, hoping to meet with us then. Hopefully, they will come back at the appointed time. We relax and tour the grounds of Global Outreach, which are very well maintained and home to long- and short-term missionaries who have been working in this area for many years. I appreciate very much Sheryl Brumley’s willingness to open up her clinic to us and her getting the local midwives here.

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checking out the certificates of midwifery

Just as we are about to give up on the midwives returning (maybe they are at a birth, we figure!), up they arrive via motor-bike. A spry elderly man and a middle-aged man hop off the bike and come into the clinic, carrying aluminum cases. Introductions are made and we sit down to talk. The older man has been helping with births ever since he helped deliver one of his siblings as a teenager. Both have certificates from the government that they completed midwifery training in the late 1990s. The training certificate is signed by the Minister of Health and the aluminum cases they were given in return for finishing the training are stamped UNICEF. I will have to research what this program was and whether or not there is a possibility of resurrecting it.

Again, it is absolutely amazing to sit and talk with these midwives. We calculate that the older man has probably helped with around 15,000 births in his time. These midwives are very busy. I’m sorry to say that I don’t remember exactly how many births they are doing each month, but I think it was around 20, maybe more.

We talk about how they deal with the cord. They confirm for us what the midwives in Simone Pele said, that they soak gauze in alcohol and wrap that around the cord. We ask them to show us how they tie the cord and the younger man demonstrates on the older man’s finger. He only ties a single knot in each string and shows that they cut above the second string. Aha! I ask why he only tied one knot instead of a double or square knot. Many laughs ensue and he informs me that, quite simply, he didn’t want to hurt his friend’s finger! (and, by they way, he typically ties two knots.) Why they are cutting above the second string, I do not know. But, we gave them some clean birth kits with instructions that clearly show cutting between the strings. If I am able to talk with these midwives again in the future, I will follow up on this practice.

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checking out the clean birth kit instructions

We give them the clean birth kits that we’ve brought with us.  I only wish we had more for them because what we have will last only one or two months in their busy practice. If only I had known they were so busy, I would have brought more!

By the time we finish chatting with the midwives, we are hot and tired and hungry. Tomorrow, we will return to Prospere. Can’t wait to see what’s in store for us there!

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Haiti Day 4 (September 12, 2012)

Pulling a 50 pound suitcase through pea gravel in a tent city with curious eyes watching, asking “What’s in there?”

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TMSL Clean Birth Kit

Finally, we get to deliver Train Midwives Save Lives clean birth kits to midwives. The kits, as I’ve written before, are so simple. A black garbage bag, which provides a clean surface on which the laboring mama can birth. A little bar of soap, for hand washing. Three non-sterile gloves, two for the birth attendant to wear during birth and the immediate postpartum and one as a backup. Three clean strings, one to tie the umbilical cord a few inches up from the baby’s belly, one to tie the cord a few more inches up, and a spare. A clean razor blade to cut the cord. And, finally, pictorial instructions for use of the contents of the kit.

Because TMSL is a small little project at this point, the kits were assembled at my house, with my kids serving as workers in the process.  It was tedious work, cleaning each razor blade individually, fitting all of the contents into a 3 x 5 baggie, cutting strings to length, and folding those pesky garbage bags to size.  In the end, they turned out great!  16 clean birth kits fit into a 1 gallon Ziploc and weigh 2 pounds, which is great for packing purposes, since airlines are very strict regarding weight limitations these days. 

We are back in Simone Pele today.  The midwives have returned … and it is clear that they have been contemplating our talks since we left yesterday. Once everyone in assembled, the midwives have something to say to us … well, actually, they have a lot to say!

We want an association of midwives for knowledge sharing, peer review [my words, not theirs!], and to help each other.” I am not sure, in Haiti, if there is anything like this. We will find out. I am aware of the Caribbean alliance of midwives, which is a new organization that I suspect is targeted toward “Skilled” Birth Attendants, but perhaps we can build off of this organization to provide an avenue for the Haitian midwives to communicate with each other and learn from each other.

We want to learn more!”  The midwives are ready to talk about a training process! We talk with them about language issues, as in, French, Creole, or none? A good percentage of these midwives are illiterate, so we will stick with Train Midwives Save Lives initial plan to provide primarily pictorial training tools. The challenge is on! When there is material that needs to be presented “in language,” then we will provide it in Creole. This will be a challenge, for sure, because translating into Creole is no easy task. A loose plan is made regarding delivery of some materials in November, with a return trip to follow up in January.  

We want something other than razors to cut the cord!ImageOn the surface, this seems like a reasonable request. And, really, it is more appealing for midwives to be using scissors instead of razors. But, there are just a few issues with that … It is easy to deliver clean, single-packed razors, for single-use. Scissors, on the other hand, need to be sterilized between uses. It may be possible to do a small study on the use of scissors with chlorhexidine as a sterilizing agent with these midwives, but that will be in the future.  As we’ve talked with them these two days, we’ve learned that they cut the umbilical cord and then wrap it in gauze and drench the whole thing in alcohol. They are very open to using chlorhexidine on the cords instead of alcohol. Train Midwives Save Lives will get chlorhexidine into the hands of these midwives for this purpose. We will be looking at a way to include it in the birth kits, but in the liquid form that is tricky. 

We want to take the training out into the villages!” WOW! Such forward thinking from this group. One young man in particular, who is new to midwifery and who has impressed us with his technology acumen and self-study skills, is very vocal about wanting to learn and then go out into the villages to teach.

There are many other “wants” that come out in the lively discussion that ensues. Those above are what TMSL will concentrate on for the time-being.

— oh – and we MUST get some size Large gloves for this group! I never anticipated that there would be so many men midwives (or, well, any men!) who could benefit from larger gloves! –

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signing certificates

At the end of the day, we give each midwife a certificate stating that they have attended this two day training session. Lisa and I sign each one. As we are doing this, all I can think about is that I have learned so much from them! I feel like I should be receiving a certificate from these midwives because they have taught me so much about their culture, their needs, their wants, their work. Spur of the moment, I pull out two more certificates and write my name and Lisa’s name on them and then ask the midwives to sign our certificates. Great idea on the surface … except that not everyone knows how to write!  In the end, each and every midwife signs their name or has someone else sign for them, although I notice that even the oldest of the granny midwives insists on signing her own name and tediously prints out her first name. It is lovely and I am honored to receive this certificate from these midwives.

This group of midwives is so diverse and engaged and interested in learning – we have been blessed with a wonderful focus group!

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Haiti Day 3 (September 11, 2012)

Simone Pele! 

With the earthquake erupted tent cities in Port au Prince. These dwellings were meant to be a temporary solution to the problem of thousands and thousands and thousands of people not having a “roof” over their heads. Tarps and temporary structures have evolved into semi-permanent homes. Over the last few days, I’ve noticed that there are little tent cities all over the city. Some of them are only a block square, while others are probably a mile square. Some are made up primarily of plain blue tarps, while others are made of tarps bearing logos of nonprofits like WorldVision and USAID. The tents really are set up in a city-like format with front “doors” facing each other across walkways, much like a typical neighborhood. In most cities, there are big water containers that, I assume, hold potable water. There are outhouses, usually made of brightly colored plastic, that have morphed into permanent-looking little bathrooms, complete with drainage. People are living in these little microcosms and life goes on.  

ImageYou might wonder why people continue to live “like this” … simple answers are: 1. It is free and 2. It is what is normal for them now.

So … Simone Pele is a neighborhood of Port au Prince … it is a neighborhood that borders Cite Soliel, which is known as the roughest area of the city with a lot of gang activity.  This whole area is tent city.  We are going to Simone Pele because Lisa’s nonprofit, Aid in Action, does a lot of work there. As a result, we have been able to get the word out to the midwives that we are coming and we also have a place to meet (Pastor Exil’s church, which Aid in Action supports).  

We have planned to spend the morning with the midwives. We do not know how many will show up. We do not know what they are expecting of us. We do not know what kind of midwives will come. It’s like Christmas — full of surprises!

The goals of this trip are to begin to establish relationships with midwives in Haiti, get clean birth kits into their hands, and find out what their needs are. Train Midwives Save Lives aims to develop and provide training for Traditional Birth Attendants to help them provide better, more comprehensive care to the mothers who depend on them as caregivers during birth and postpartum. If you’ve been reading this blog for any amount of time, you know that there are a few very specific areas that must be addressed, regardless of location: Postpartum Hemorrhage  Neonatal Resuscitation  Prolonged Labor, Newborn Care, and Clean Birth Practices.  These topics are well-known to be *the* biggest influences on maternal and infant mortality.

In order to develop the training, we need to establish relationship with midwives in different locales so that they can be our focus groups and testers. It is a delicate balance — finding out their perceived needs and fulfilling known needs.  So, the time we are spending with midwives on this trip is critical. We are working to build relationships because that is the only way that this work can successfully move forward.

We arrive at Simone Pele. Today, we have brought only notebooks, flash cards with images related to birth, a model pelvis and model babies. When we get to the church, there are no midwives. Patience pays off and over the next 30 minutes, eleven midwives trickle in.  They are here! We are lucky enough to get to meet with them! TMSL does not want to be an organization that comes in and tells midwives how to do things. Because we are working with traditional midwives, it is very important that we take the time to find out how they do things and then work WITH them. They may not be formally educated. They may be illiterate. But, there is one thing THEY definitely KNOW, and that is BIRTH. Is there room for improvement? Yes. Any good midwife knows that she (or he [see below for details on that]) will always be learning and improving skills. Midwives love to learn. They do not love to be told they are wrong. It’s an interesting personality trait that is quite common in this line of work.

They come through the doors of the church, mostly one-by-one, but sometimes in pairs. It is fascinating — half of these midwives are men! Over time, I hope to learn more about this phenomenon — how did it come to be that men are midwives in Haiti?  I cannot think of another culture in the world (although I’m sure they exist) where it is as common for men to be midwives as it is for women to hold this position in the community. Some of the midwives are old, some are young. One young man in particular intrigues me, with his tidy dreadlocks and clean white clothes. We learn that he has been learning midwifery since he was 8 years old, at the side of his grandma. Another midwife is a stunning woman who we find out has hospital experience and has trained many midwives herself. Over the course of the day, an older man shines as someone who has many questions and is also a very experienced midwife, despite tome interesting beliefs that he holds. One older man steals my heart with his kind eyes and gentle hands … he exudes the heart of a midwife and I am privileged to be in his presence. A young girl and a young man who are just starting down the road to become midwives are also in attendance. I’m thrilled to have their input as to what they are most curious about.

The hours pass quickly as we use our birth-related flip cards to establish rapport and get an idea as to what they know and don’t know and how birth is practiced in this little corner of the world. Thank you to the Hesperian foundation for their open-copyright illustrations, which we used for this conversation! [side note: I had hoped to do some field testing of the Safe Pregnancy and Birth application, but did not have time to do it on this trip. We will do this next time around!] It is great fun to show the model pelvis and pass it around the room. Lisa and I both take great joy in watching the older midwives show the younger midwives the pelvis. For some, this is probably the first time they have seen a model like this … but it is clear that they understand that the tailbone is the tailbone and the pubis is the pubis. Image

All too soon, the time that we have allotted with the midwives is up and we have to say goodbye for the day. We invite them back for another visit tomorrow … and hope they will return!Image

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