I don’t normally have my computer with me during the day and can only access the internet at the few cafes that provide free WiFi for my phone to tap into. But today I decided to work on my thesis and so here I am able to provide you with an update of the trip.
The first two weeks were in La Ceiba, a busy Caribbean city with a diverse population. My days were spent at a public hosptial providing doula care. I also spent a day providing neonatal resuscitation training to a group of rural midwives and trained two trainers of neonatal resuscitation.
It was in La Ceiba were I learned of an ongoing nursing strike in Honduras. The government health system is, of course, government funded. Unfortunately the money has run out for this year. Nurses and teachers – and possibly other federal employees – have not been paid for weeks to months. This sounded suspiciously similar to what I was told in Nairobi. However in Nairobi, the lack of funds is so chronic that nurses leave the country. In Honduras the locals explain to me this is an artifact of a system of supposed government corruption and an upcoming election (which I was told occur every four years). With the start of the new administration there will exist a new budget and new money available for the next four years. Opinions of whether the next administration will budget correctly and have money to pay employees at the end of their term vary. Please don’t take this as a thorough discussion of the matter, politics and public health are always much more complex than can be explained to an outsider who doesn’t have a full grasp of the language.
It was also in La Ceiba were I learned that the rural midwives in this area have little to no training. This was a shock to me – which says more about my continuing naivety than the state of midwifery in the world. I still believe in the midwife called to serve her community and trained by an older midwife – even though I have not seen evidence of the existence of this in any of my travels. The rural midwives in this area are not trained by other midwives. They just happen to be women who start attending births because someone has to do it. While this may be appropriate in some areas, these women have little to no access to training, books or tools to make their work any more safe than having an unattended birth.
Honestly, my interaction with them was a blow to my confidence in the lay midwife. Yet at the same time, what can I expect? Although Honduras does not stop lay midwives from practicing, there is no government support or training for women who choose to perform this necessary community function. This is in a country where the government provides education for nurses and doctors and provides the funding for most of the health systems (there are private facilities and private physicians). Allowed does not mean supported.
After my two weeks in La Ceiba I entered Santa Rosa de Copan, a colonial community in the mountains of western Honduras. I have completed two weeks in Santa Rosa and will remain for two weeks more. While here I am providing a childbirth education class for women in a maternity home (a place for rural women to stay closer to the hospital as they wait for labor to start), some childbirth education in the waiting area of a public health clinic where expectant women get check-ups and ultrasounds. I also spend time in the hospital providing doula care.
Santa Rosa has taught me many things, and has confirmed many of my concerns about international public health. One concern is the importance of the local health worker. I am providing education, but in reality what I can do is mediocre at best. My Spanish skills, while workable, are laughable – and some of the women do laugh at me (and with me) as I try to explain things to them in a language that is still very foreign to me. I am willing to be laughed at, and so I continue. Still I can’t help but feel the money I spent on my plane ticket would have improved education more if I had used it to hire a Honduran nurse or two to provide the services instead of me.
My work in the hospital takes a new level of cultural acceptance every day. The maternity is run by the medical students, with a different doctor in charge of them every day. Some of the doctors and students and most of the nurses I absolutely adore. They are patient and kind and provide care in a way that is very similar to what I am used to. Other doctors and students leave me cringing as they yell at patients, perform their assessments without talking to or looking at the women and provide care in a way that is completely unacceptable to American birth culture — I had to leave early the day I saw a doctor use fundal pressure for two births.
Yet in the midst of the strange contradictions I am watching, I am learning to see birth uninterrupted in a way I cannot see in the USA. The women are basically ignored until a doctor or nurse realizes the baby is on or near the perineum. Vaginal exams happen at four hour intervals according to WHO partogram standards. So I witness women who I know are in transition, who I know are pushing on their own, without the American practice of forcing a woman to push as soon as she is 10 centimeters.
I am also learning to question what I consider to be the appropriate standards of care. I cannot sit by and ask why they do the things they do here without also asking why we do the things we do in the USA. For example, there is a belief among some of the staff that women need to labor lying down, so despite the national standard requiring women be allowed to have freedom of movement the women are encouraged to be in bed and must be in bed if their water is broken. I’m not really sure why this is, but the exact same phenomenon happens in the USA – women labor in beds instead of moving around.
Then there are the contradictions the staff don’t seem to notice. Things like a woman is ignored to push slowly until someone notices, then she must push strong and hard through the entire contraction. Or that women are encouraged to stay in bed until the head is on the perineum, at which time they must transfer to the birth room by walking or moving to a wheelchair and then getting on the birth table/chair.
I cannot forget the things I absolutely love about Honduran maternity care. For example, student nurses are required to attend two women in labor and actually catch their baby as part of their training. Space is so limited that women are not admitted to the hospital until they are at least 5 centimeters which significantly decreases the amount of time a woman has to remain in the labor ward. Also, although the hospital has an electronic fetal monitor it is only used when absolutely necessary. So every woman is actually looked at and touched by a student every 30 minutes to an hour to listen to the baby’s heart rate with a stethoscope and to assess the frequency of contractions by placing a hand on the belly for a full 10 minutes. True, not all students take advantage of the time to talk to the patient, and some of them are downright rude with their back to the patient and talking to other students in the room, but the woman is not assessed from a desk in the hall never actually being touched (and sometimes seen) by staff for hours.
I have two more weeks to live and learn in Honduras. This is my first trip where I have traveled alone for so long. I will tell you it is isolating to not be fluent in the language. I can tell you that even though I have made a couple friends, it is lonely to be here. And I can tell you adjusting to a different culture is, as always, a difficult burden I have to struggle through every day. But to me, it is worth it.