Running head: SERVICE LEARNING PORJECT WITH MIDWIVES FOR HAITI

Service Learning Project with Midwives for Haiti Denise S. VanderWeele Ferris State University

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI Abstract Participating in a service learning project is a requirement for graduating with a Bachelor of Science in Nursing degree from Ferris State University (FSU, 2013). Service learning is, by definition, a process of giving service to a community while learning through participation and reflection on the experience (Service Learning Clearinghouse, 2013). The purpose of this paper is to relate my experiences with the Midwives for Haiti, a non-profit organization that trains Haitian men and women to become skilled birth attendants in their own country. The organization also has outreach programs in the community for prenatal clinics and education for matrons, the traditional birth attendants in Haiti.. After brief background information, a

critical reflection on the experience and syntheses of understanding will be given. Consideration will be given to the program outcomes for Bachelor of Science in Nursing students at Ferris State University.

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Service Learning Project with Midwives for Haiti Service-Learning is a teaching and learning strategy that integrates meaningful community service with instruction and reflection to enrich the learning experience, teach civic responsibility, and strengthen communities (Service Learning Clearinghouse, 2013). It is the expectation that students in the Bachelor of Science in Nursing (BSN) program at Ferris State University (FSU) will choose an agency that will allow them to give service as a nurse that will enhance their professional development while meeting program outcomes of the school of nursing (FSU, 2013). In choosing to work with the agency called Midwives for Haiti (MFH), I was seeking a learning experience in which I could indulge my passion for maternal/infant nursing, learn about a different culture and deliver care in a high-need area that had few or limited resources. When I found the MFH organization on the Service Learning Clearinghouse website in early 2012, I knew that this was the type of experience I was seeking. In the past I yearned to use my nursing skill in my area of expertise (maternal/infant nursing) while participating in faith-based mission trips, but nursing care was not the focus of those trips. With MFH, I knew I would be working with other nurses and midwives in providing care for pregnant women and newborns. The idea of being able to physically touch patients and by extension touch their lives was appealing to me. The organization didnt oversell the experience, however. Volunteers were cautioned to be willing to live somewhat like a Haitian woman for one week. No AC, a toilet that may or may not flush, short and cold showers, and beans and rice for meals are a given (MFH, 2013).

Background on Haiti

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI Haiti is located southeast of Florida on the western 1/3 of the island of Hispaniola. Its boarders touch the Dominican Republic (see map below), which occupies the other 2/3 of the island. The Atlantic Ocean is north of Haiti, and the Caribbean Sea is to its east and south. Many Haitians speak fluent French, but Creole is the official language of Haiti. The site of the school of midwifery operated by Midwives for Haiti is in Hinche, located on a central plateau in the mountains of Haiti. The capital city of Port-au-Prince is about 60 miles south and west of Hinche. The journey from Port-au-Prince to Hinche takes over 4 hours by rugged jeep over poorly maintained roads.

Port-au-Prince

(map from www.geology.com)

Hinche

The infrastructure of Haiti is not well established. Even prior to the earthquake that occurred in January of 2010, there were few government projects that maintained roads, treated

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI sewage, disposed of trash or provided clean drinking water. In his book Haiti after the Earthquake, Dr. Paul Farmer the United Nations Deputy Special Envoy for Haiti, details the history of a country that has struggled with poverty and unstable governments since the early 1800s when it became the first nation of freed slaves. As Dr. Farmer noted, The earthquake was another reminder of the weakness of Haitis public institutions and the vulnerability of its population without any kind of social safety net (Farmer, 2012). The living conditions of most Haitians include a small house of wood or cement block

without running water or a bathroom. Cooking meals is usually accomplished in the front or side yard of the house. Most transportation is accomplished on foot, with the women carrying large baskets or buckets balanced on their heads. Some Haitians own motorcycles, and entire families both parents and 2-3 children, including babies - were seen riding on one motorcycle in order to attend church on Sunday. There are few cars or trucks. The area around Hinche is mostly rural, with dirt roads and few bridges. Laundry is done in the river in the center of town. Water for cooking and bathing is obtained from three city pumps (non-potable water) or purchased from a water supplier. The ground water is extremely contaminated with human waste and parasites. Midwives for Haiti Midwives for Haiti (MFH) is a non-profit organization that works in collaboration with the Ministry of Health in Haiti and various faith-based organizations that are working in Haiti to improve the health of the Haitian people (MFH, 2013). The World Health Organization estimated that 1 in 28 women died from childbirth in Haiti during 2010 (WHO, 2012). This was due mostly to pregnancy-induced hypertension, eclampsia, sepsis and postpartum hemorrhage (MFH, 2013). At present, 76% of women who deliver babies in Haiti are not assisted by a

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI skilled birth attendant (MFH, 2013). The presence of skilled birth attendants has been proven to

decrease maternal mortality according to the World Health Organization (WHO, 2013). It is the mission of Midwives for Haiti is to train Haitian men and women to become skilled birth attendants to reduce maternal/infant mortality in their country (MFH, 2013). Haiti has the highest maternal/infant mortality rate for any country in the western hemisphere (WHO, 2013). MFH gives care to 4.600 women annually through mobile clinics and graduate midwives working within remote communities (MFH, 2013). Most of the midwife trainees at the MFH school are Auxilliares, who have the equivalent training as that of License Practical Nurses in the United States. After receiving their midwife training most graduates relocate to rural areas where there is little to no medical care for pregnant women. One there they establish prenatal clinics, deliver babies, and refer high risk patients to the nearest hospital. MFH and other organizations pay the salaries of some of the midwives to keep their practices solvent. Other midwife graduates staff their mobile prenatal clinics and teach the next class of students in a clinical setting. These clinics supply vitamins, screen for complications of pregnancy such as hypertension, preeclampsia and sepsis, and offer advice to expectant women. These midwives also provide childbirth services, postpartum follow-up and breastfeeding support at Sainte Therese Hospital in Hinche. Funding is largely by donation, and the incomes for midwives is not dependable. Usually, the patients pay what they are able with a few Haitian dollars, which are each worth about 40 cents in U.S. currency. Volunteer Preparation In preparation for volunteering, qualified nurse midwives and labor & delivery nurses from the United States, Canada and Europe are interviewed and sent links to the volunteer website. Volunteers are expected to complete a packet of information on Haitian culture and six

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI foundational modules for midwives published by the WHO. These modules are written to guide midwifery practice for areas around the world that have few resources. The topics include

prolonged and obstructed labor, puerperal sepsis, managing the incomplete abortion, postpartum hemorrhage, managing eclampsia, and the role of the midwife in the community (WHO, 2006). These documents are some of the foundational texts that arevused to teach the Haitian midwives. Volunteers are also encouraged to read Mountains Beyond Mountains (Kidder, 2004). This is the story of Dr. Paul Farmer and his work at Zamni Lasante (Partners in Health) in Cange, Haiti, which is located about 20 miles from Hinche. Also recommended for reading was Haiti after the Earthquake which is Dr. Farmers account of the aftermath of the 2010 earthquake in Haiti (Farmer, 2012). These books provided a context to operate from prior to actually being in Haiti and prepared me for the poverty and apparent lack of interest in the health and welfare of the Haitian people by their own government. The role of the volunteer for MFH is to work alongside the Haitian students and be preceptors for them in clinical settings. For certified nurse midwives (CNMs), this can include assisting in classroom instruction and supervising the midwives during hospital births. For RNs like myself who have labor & delivery experience, their role is to assist in the mobile clinics and provide a supportive nursing care in the hospital with labor management, postpartum care and breastfeeding assistance. During the week that I was in Hinche, I attended three mobile clinics, one day in Ste. Therese Hospital and a day with the matron outreach program.

Mobile Clinics Assisting with the mobile clinics was everything I imagined it to be! Our transportation was a modified pink jeep that is easily recognized throughout the area. On our way to clinics we

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traveled dirt roads, crossed flowing rivers without bridges, and covered a lot of rugged terrain. It reminded me of scenes from movies that I had seen as a child about medical missionaries in Africa.. The most striking thing about the mobile clinics was how much the women looked forward to being there. Many times, we were told that they had walked several hours to be there for their check-up. Each clinic is at a specific site only once a month. The range of women attending the clinics was from the newly pregnant to those who had recently having given birth. The clinics were set up at a pre-arranged location which didnt always work out. For example, the first day, the local priest did not unlock the church that we were to use for the clinic, so the midwives rigged blankets in the windows of the jeep for privacy and were able to examine women in very close quarters. The midwives were inventive, flexible and upbeat. The shortage of equipment or lack of space for the clinic did not discourage them, but they found creative solutions for the problems that arose. The patients were unfazed by the change in plans. They waited patiently for their turn and seemed truly grateful for the care they received. Prior to the clinic starting, there was a presentation by one of the midwives alerting the women to signs of complications in their pregnancy and advice on seeking medical attention. The midwife also talked about nutrition during pregnancy and ways to get more protein into their diet. She cautioned the women to have a plan and a small amount of money available so that they could pay someone to take them to a hospital if there were complications with the pregnancy or during birth. My interpreter explained to me that in Haitian culture, if the husband refuses to pay for the woman to be transported to the hospital and she has no money to pay for it, then she does not go to the hospital. Each clinic had 30-40 women attending them. It was assumed that most of the pregnant women would be delivered by the traditional birth attendant (a

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI matron pronounced may-TRONE) in their village because there are not enough midwives to fill the need. After this, I noticed that the procedures in the prenatal clinics were similar to what I did as an office nurse in an Obstetrics/Gynecology office several years ago. The women were weighed, their blood pressure taken, their fundal heights measured, questioned about fetal movement, then the fetal heart rate was heard using a hand-held Doppler. I had actually expected to use an old fashioned fetoscope. These Dopplers were battery-powered and sensitive

enough to pick up heart rates early in the pregnancy. Anything out of the ordinary was referred to the hospital in Hinche or the nearest clinic that had a doctor or nurse practitioner associated with it. One work-around that the American midwives addressed with the clinic midwives was that they were not checking everyones urine for protein or sugar as a screening tool. The equipment was available, but not being used. They were told that there were a limited number of testing sticks and the midwives trying to conserve them. They explained through our interpreters that pregnancy-induced hypertension and gestational diabetes can sometimes be detected by protein or sugar in the urine sooner than other symptoms may occur such as excessive weight gain and elevated blood pressure. They also reminded them that the women can be referred to the hospital for further diagnosis and management to prevent adverse outcomes in the pregnancy, especially life-threatening eclampsia. We later found an abundant supply of test sticks in the storage closest at the midwifery school and helped the midwives to find a way to keep the supply plentiful for the mobile clinics so that their assessment of the patient was more complete. Days two and three in the clinic were similar but at different locations. On day three, we had to cross a wide river that was about three feet deep most of the way across. The current was

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI 10 pretty fast, and the jeep responded as was expected with the pressure of the water on it by tilting to one side. We later found out that after a sudden and plentiful rainfall the previous day, two men were swept away by the current while crossing at the same spot on the river. It was sobering to know that their bodies had not been found downriver due to the swiftness of the current. This opened my eyes to one of the real dangers that the women who walked to the clinics had to face in order to be there. Hospital Midwifery The hospital was possibly the biggest culture shock that I had that week. The walls and floors were cement, the wards were occupied by 20-40 patients, and the open windows had no screens. The temperature outside was typical for Haiti in June, which was in the 90s and very humid. Any slight breeze was completely welcomed by the patients and staff. The only restroom for the entire hospital was located behind the hospital in a separate building. This required the patients to walk out of the ward and around to the back of the building if they were able to use the latrine. Any bed pans or commodes that were emptied had to be carried back to this building also. Supplies from donations to MFH were under lock and key because they would be borrowed by other areas of the hospital and not returned. In the labor and delivery ward, there was one large room that was divided by shower curtains to create three smaller labor areas. On the day I was at the hospital, all labor three labor areas had two women in each of them. The rooms contained two narrow examination tables, similar to those found in doctors offices. The room that my patients were in also had the only sink in the labor area, a small autoclave, and an open window (no screen) with a baby scale located just below the window. People came into our room freely to wash their hands and weigh babies. The women in labor were not given hospital attire, and had to labor in the clothing they

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI 11 wore to the hospital. There were no wash cloths or towels available to apply cool cloths or heat therapy to the women. No pain medications were offered, because there were none to be given. These women instinctively moved in ways to help their labor progress. They did a beautiful dance of what we would call natural childbirth, although I dont know if going medication free was their choice or merely the accepted expectation. I assisted a midwife student who was in charge of two laboring patients who were induced because their membranes had ruptured and the amniotic fluid had thick meconium in it. The Pitocin was given via IV line that hung from a nail in the wall. The rate was anyones guess, but it looked to be infusing at a rate of 8 mu/ hr. Thankfully, I am old enough to remember doing drip counts on IVs prior to the use of infusion pumps. Charting was done on scraps of paper, and there was no official record of the labor. A summary would later be written on their official chart. Mostly, the women were left to their own devices during labor. The midwives were aware of their progress in labor but did not have the time to offer comfort measures such as back rubs or sacral pressure like we would in the U.S. I was able to do this for two of the women because I was extra staff, and the women were very grateful. One husband brought his wife food to eat because she had been in labor a long time. He was quickly removed from the area and waited outside in the hospital courtyard. Later I learned that his wife was giving birth to their eighth child. She had three live children, one fetal death and three children who did not survive their first year of life. This baby was hung up in the birth canal because its head entered the pelvis at an angle. Through changing positions and allowing her to be on her hands and knees to push, she was able to deliver an 8.5 lb. baby girl. In the U.S., she would have had a c/section for three reasons: she was 50 tall, the labor had stalled for over

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI 12 2 hours even after the administration of Pitocin, and it was a large baby for her to deliver. C/sections are rarely an option due to the lack of physicians, lack of supplies, and lack of operating rooms. There was one OR for the entire hospital and it was booked solid. . While caring for the women in labor, my interpreter (a young male) was not allowed in the labor area. This left me on my own to communicate and assist the women. I took comfort in knowing that if I showed that I cared about them and helped in any way that I could that I would be doing the most good. The situation reminded me of the assumption in Leiningers theory of transcultural nursing that states culturally based caring is essential to curing and healing, for there can be no curing without caring, but caring can exist without healing (Alligood, 2009). This gave me the freedom to approach their nursing care by communicating with them through my actions and anticipating their needs during the process of labor without needing to understand every word spoken. One time, I tried to leave the room to relieve myself and the woman grabbed my scrubs, looked me in the eye and said Non! I knew she didnt want me to leave, so rather than risk embarrassing myself with a lack of bladder control, I found (female) interpreter to tell the woman I would return in five minutes. She relaxed her hold on my scrubs and smiled at me. That was the only time I felt the frustration of not being able to speak Creole while caring for her. Another shock for me at the hospital was the lack of supportive departments such as the laboratory. There was a room called Lab but no one was there to run tests and there were few supplies that could be used to do so. The act of diagnosing anemia from blood loss after delivery is a long drawn-out process there due to these constraints. It can take up to days to diagnose anemia from blood loss, match the patients blood type and actually acquire the blood to give the infusion.

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI 13 The Haitian nurses work very hard and do the best that they can with limited resources. Just seeing how little they had to work with made me extremely grateful for all that we have and can do because the systems are in place to provide quality care for everyone. Even though our health care system is has some huge flaws, at least we have support as hospital nurses from other departments such as laundry, dietary, and social work to treat the whole patient. We are also not burdened by a lack of clean water, adequate rest rooms, trash removal or tropical heat without even a fan present. Matron Outreach The last day, I attended an outreach class for matrons, the traditional birth attendants in Haiti. The class had 27 matrons in attendance. They were avid listeners. The signs of preeclampsia were reviewed with them through a lively song with hand and body motions that the midwife student taught the matrons. The song ended each verse with (loosely translated) if you see these things, then to the hospital you go! They really seemed eager to learn how to improve the outcomes for the women they serve, and are a vital link to getting medical help when needed. I found out later that the class of matrons that we attended was the very first one of its kind. What is especially exciting for me is that on the night before we attended the class, we created individual clean birthing kits to give to the matrons for use in their practice. These kits were included hand sanitizer, alcohol wipes, umbilical tape, scissors to cut the cord, clean gloves, two clean surgical towels to create a clean area for giving birth & drying the baby, clean gauze and a bulb syringe to clear the babys mouth and nose if needed. We had these supplies in abundance in the supply room due to generous donations made by previous volunteers, and the assurance that more supplies would be brought in by each new group of volunteers.

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI 14 The idea came from breakfast seminar that I attended at the national Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) convention the previous fall. The seminar was about the maternity care for women immediately after the earthquake in Haiti in January 2010. Clean birthing kits were given to women who were close to delivering their babies which contained items they may need such as umbilical string and hand sanitizer. I presented the idea to the two American midwives that were volunteering with me, and we cleared it through the Haitian midwife who ran the matron outreach program. There was enthusiastic support because while it gave the matrons tools that they would use in caring for women, it also showed that we respected what they did with their clients. This respect opened them up to learning better ways of delivering babies in a clean, safe environment. It should be noted that supporting the work of the matrons is not counter to the mission of MFH. Although the central goal of Midwives for Haiti remains focused on increasing the number of Skilled Birth Attendants in Haiti, we recognize the critical role that Traditional Birth Attendants play in Haiti's maternity care system. By improving the skill and knowledge of matrns, Midwives for Haiti plans for matrns to manage out-ofhospital births more competently and to become better integrated into the medical system. In effect, we hope to see the number of high-risk referrals to the hospital increase and the use of clean delivery practices promoted (MFH, 2013). Apparently, it is working! After graduating our first class of 29 matrns in September of 2012, we witnessed an immediate increase in attendance at our mobile prenatal clinics, as well as a rise in the number of referrals by matrns of high-risk maternity patients at the local

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI 15 hospital (MFH, 2013). They now supply clean birthing kits to matron outreach program on a continual basis (MFH, 2013)! This relationship that the MFH organization and the midwives themselves are forming with the matrons is collaborative leadership at its best (FSU, 2011). By integrating the matrons into the health care system instead of being territorial and excluding them, patient safety and the quality of care for pregnant women in Haiti will be improved on a broader scale. Changes in Paradigms I do not believe that I could remain unchanged after such an incredible experience. What has surprised me the most is the resourcefulness of the Haitian midwifes to make do with whatever they have. They accept that there will be unfulfilled needs in their practice and supplies that dont show up on time. Yet, they do not give up on the women they serve. This is the embodiment of professionalism (FSU, 2011). No matter what the difficulty, the nurses performed their duties within the constraints that they were given and kept the needs of their patients above their own needs. What made the most impression on me was the health care environment in which the midwives practiced. The smallest things that we do for our patients such as washing our hands or applying a cool cloth to the forehead is compounded in difficulty by the lack of clean water and the availability of basic supplies such as soap and towels. Emptying a bedpan is a major undertaking due to the lack of indoor plumbing. Clean hospital gowns are not supplied to all the patients due to the limited number of them and the primitive laundry facilities. And yet, the midwives and Auxilliers do the best that they can to deliver good nursing care to their patients. Nurses in Haiti are advocating for public programs that will improve sanitation, clean water and limit environmental toxins, but they have few role models and little experience with working

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI 16 within their political system. Dr. Farmers book gives a vivid account of attempting to change the health system with little government support (Kidder, 2004). I am amazed that the Haitian nurses are not completely overcome with hopelessness and despair. Concluding Thoughts on Service Learning This service learning project highlighted the differences between Haitian and American cultures and medical care systems. I was exposed to a completely different way of life and a different way of looking at situations and health care. . Cultural immersion is scary, disconcerting while at the same time exhilarating and very enlightening. It was so rewarding to be able to use my nursing expertise in an unfamiliar situation. I found out that the basis of nursing is the same no matter where in the world you are located. We still all need the same theoretical base for practice, the generalist nursing skills, scholarship to underpin our decisions, working together collaboratively, improving the health care environment and always being a professional (FSU, 2011). I would heartily encourage RN to BSN students to step way out of their comfort zones and attempt nursing in a different cultural setting. Being in such a setting opened my eyes to many of the things that are right with our own health care system, and exposed some of the universal truths of what it means to be a professional nurse. This was a highlight and a great asset to my studies while earning my Bachelor of Science in Nursing from Ferris State University. .

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References Alligood, M. (2009). Nursing theorists and their work (7th ed.). Maryland Heights, MO: Mosby Elsevier. Brunk, N. (2012). Reducing maternal mortality in Haiti. Retrieved from www.womentdeliver.org/updates/entry/reducing-maternal-mortality-in-haiti Farmer, P. (2012). Haiti after the earthquake. New York, NY: PublicAffairs. Ferris State University (2011). BSN program outcomes. Retrieved from http://www.ferris.edu/htmls/colleges/alliedhe/Nursing/BSN-program-outcomes.htm Ferris State University (2013). What does the service learning requirement entail? Retrieved from http://www.ferris.edu/HTMLS/colleges/alliedhe/Nursing/RN-to-BSN/FrequentlyAsked-Questions.htm Author: Kidder, T. (2004). Mountains beyond mountains. New York, NY: Random House.. Midwives for Haiti [MFH] (2013). Matron outreach program. Retrieved from http://www.midwivesforhaiti.org/index.php/our-work/matron-outreach-program Midwives for Haiti [MFH] (2012). Volunteer orientation module: Midwives for Haiti mobile clinic. Retrieved from http://learn.midwivesforhaiti.org/mod/resource/view.php?id=27 Midwives for Haiti [MFH]. (2013). What we do. Retrieved from http://www.midwivesforhaiti.org/index.php/our-work/what-we-do Author: Service Learning Clearinghouse. (2013). What is service learning? Retrieved from http://www.servicelearning.org/what-is-service-learning Author: Taskier, M. (2011). Celebrate solutions: Cultivating a new cohort of midwives in rural Haiti, midwives for Haiti. Retrieved from

SERVICE LEARNING PROJECT WITH MIDWIVES FOR HAITI 18 http://www.womendeliver.org/updates/entry/celebrate-solutions-cultivating-a-newcohort-of-midwives-in-rural-haiti-mid World Health Organization [WHO] (2012). Region of the Americas: Haiti statistics summary (2002 - present). Retrieved from http://apps.who.int/gho/data/view.country.10000 World Health Organization [WHO] (2013). Maternal, newborn, child and adolescent health: Skilled birth attendants. Retrieved from http://www.who.int/maternal_child_adolescent/topics/maternal/skilled_birth/en/index.ht ml World Health Organization [WHO] (2006). Maternal, newborn, child and adolescent health: Midwifery education modules (2nd ed.) Vol. 1-6 Retrieved from: http://www.who.int/maternal_child_adolescent/documents/9241546662/en/