Sunday, October 10, 2010

Birth by headlamp in Hinche, Haiti

We're back from a week in Hinche, Haiti, a mid-sized city about 80 miles northeast of Port-au-Prince. I was a trailing spouse, along for the ride while my wife Cindy took a turn with a midwifery training program run by Midwives for Haiti at the local hospital. We stayed at Maison Fortune, an orphanage and school for about 210 children, most of whom still have parents who can't take care of them, and about a quarter of whom are Port-au-Prince refugees from the earthquake.  My impression is that the school is a relative paradise for the children, in that they eat well, go to school full-time (a remarkable number of Haitians seem to be still slogging away at a high school degree in their mid-to-late twenties), and have plenty of play time, mostly basketball and soccer, under light supervision (in fact, from my vantage point all but invisible supervision). The children get along well, and the older take care of the younger to a degree.

No one needs me to describe the superficial signs of the terrible poverty of Haiti -- the unpaved, rocky, deeply rutted and mounded roads lined with one-room shacks and tiny, windowless storefronts, the children and old people patting their bellies at the sight of a foreigner, the malnourished babies lying in bare cribs at the Azil, an outpost of Mother Teresa's Missionaries of Charity. Nor to fill in the country's sad statistical profile: 30% of students reaching the sixth grade, less than 40% of the population with access to basic health care, 60% malnourished, about half of deaths from curable, manageable and preventable diseases.  Worth recording, though, are Cindy's experiences in the hospital with women in labor. 

Cindy participated in a program training some dozen Haitian midwives at a time, each of whom is a high school graduate who has already passed a course of training equivalent to that of a nurse's aide.  The current student cohort graduates the yearlong program in November, so they have particpated in quite a few births by this point. An edited interview follows.

What was the most striking thing about your work with the Hinche students?

How much they are able to do with limited resources they have. These are women who have not gone to nursing school as we know it, women with limited education and dealing with some very complex situations.

What was most disturbing?

Women aren't getting the care that we would consider standard here in US and because of that they're definitely suffering. 

What for example is lacking?

The women receive limited prenatal care, and they often don't to the hospital, whether because they have transportation problems or because they think [wrongly] that they will have to pay. The women are malnourished, often anemic, and prone to preeclampsia, a dangerous condition involving elevated blood pressure that can lead to seizures and is a leading cause of death in childbirth.

In the hospital, the women have limited access to basic medications  such as antibiotics -- if the pharmacy says they don't have it, the family has to go and buy it, and many have no money.  There is no pain medication. No oxygen -- if  you need to resuscitate, all you have is an ambu bag.

What's an ambu bag?

A mask that goes over nose and mouth, connected to a ball-like primer that you squeeze to produce an air flow. In the U.S., it  would  be hooked up to an oxygen source. 

Also, the woman and her family have to bring everything she needs or go without -- bring your own food, bring your own sheets, towels, rags used as sanitary pads, clothes for baby, blankets -- otherwise there's  nothing to wrap the baby up. There's no running water, no toilet, so you have to bring your own bucket.


Right.  Which the families dump in the little garden in the center of the courtyard.

What were some of the most striking cases of need?

Everybody's needy. Every woman in that room needs everything. They have nothing. No money, no food. It's not unusual for someone to stay there for a few days and not eat.

What was the most impressive thing you witnessed?

Haitian women are very stoic, and yet at same time there's kind of a resignation with maybe a little bit of a hopelessness -- I'm not going to ask for anything because I know it's not going to be forthcoming.   

Also, the students are very motivated -- they want to do good by these women, want to give good care, want to know what does it mean to give good care.

What is the answer to that?

I tried to model how to give a woman labor support.  How to rub someone's back, fan someone, tell someone they're doing a good job...they know how to do all that, of course, but it's not always second nature to do it.

We also try to teach anticipation: what are the danger signs when things are going bad? What steps can you take? For example, during a twin delivery: what should we prepare for? Bleeding. What do you need to have at the bedside?  They knew the answers. On their own, they may well have anticipated. You just want to help develop that habit.

What was the worst moment in your time at the hospital?

Thinking, "this baby is going to die at my hands," but luckily it didn't. 

Well then -- the best moment?

When that baby started breathing. 

What's the full story there?

It was on the night shift. A couple of hours after we had finished making the patient rounds, a woman whom we knew was carrying twins came to the active labor room saying she had broken her water and was feeling a lot of pain. She went out walking -- I walked with her --  and shortly after she said she felt like she had to push, so we brought her back to the delivery room. Just then -- at about 11:30 -- the lights went off, and they  never came on again that night. The three of us, two midwives and one student, worked by our headlamps. At about midnight, the  first baby came out -- a girl, nice and pink and crying. Twelve minutes later, the second baby, a boy, came out --  not breathing.  We dried him off and stimulated him and he still wouldn't take a breath. So we started bagging the baby [hand-pumping air through the mask, as described above ] but his heart rate dropped to below 60. We did chest compressions for  two minutes, and the heart rate shot up to 120 and stayed there, but still no breathing. We continued bagging for 30 minutes until the baby started spontaneously breathing. He turned pink, got good tone, started nursing -- and kept breathing.

I see that baby, lying in darkness with three beams of light trained on him, the three of us talking to him, two in English, one in Creole, telling him to breathe. 

What is your realistic short-term hope for what programs like the one in Hinche might accomplish?

The program is very much needed. 75 percent of births in Haiti are attended by someone who's had no kind of training. These women are learning how to handle normal plus high risk labor and delivery. It's a tall order. But you've got to start somewhere. In the end, Haitian women will be better served being cared for by women who've had some training.
For those interested in reading more about labor and delivery in Hinche, see the blog of Reina Galjour, a remarkable young woman co-running the training program.

A video of Midwives for Haiti and their students in action is here.

A short video of trucking through Hinche - and flying out -- is here.


  1. Wonderful post! I agree wholeheartedly with the assessment of the students - they are very caring and well trained for their limited educations.

    I had an almost identical experience in early September (we had 5 births that night!) Plus another 34-week baby from a Cesarean (under local anesthesia!) with respiratory distress and extreme hypothermia - I felt so helpless being unable to provide the simplest of solutions. The ER doc who helped me out was great, and managed to find oxygen after a good while, plus heat a blanket out on the street in a pan on an open fire!

    The baby was held by her grandmother in the "ICU" (the nurse went home - no replacement for the night) for hours while we attended to labors and births, and in the morning the little one was warm and breathing easier. A lot of very earnest and quick prayers went out that night.
    Bobbi Kimsey, CNM
    -definite repeat Midwives for Haiti volunteer

  2. Great to read this - I was there in April. The resuscitations were definitely the most amazing and rewarding - agree with the earnest and quickly spoken prayers. Good to hear of the students' progress - we were working on the same things when we were there, but earlier in the process.

  3. Thanks Andy and Cindy for a remarkable post!