My Spanish skills are improving slowly every day, but the gap between myself and the women I am serving in Honduras remains wide. Working cross-culturally isn’t just about being able to use the same language, it is about having an understanding of the different meanings of normal every day existence. It is about coping with different resources. It is about understanding the principle and not the rule.
As an example, one of my duties is to teach a childbirth class to a group of women who are staying in a maternity home. They come to the hospital two or three weeks before their due date to wait, leaving family, friends and everything they own behind. They are dressed in hospital gowns and given jobs to do to keep the place clean and everyone fed, but the majority of their day is spent waiting.
The fact that they are in this home tells me a few things about these women. First, they live very far away. It is not unusual to meet women in the hospital who have traveled two hours to give birth. Living far away means where they live is very remote. Their education, nutrition and health care opportunities are different than those of the women who live in the major towns. They tend to be young – which is not unusual where there are few opportunities for women.
In the hospital these women will encounter medical students who run the maternity unit. They are in their seventh year of university education in a school that is centered in the capital – a large and thriving metropolis. Some of them have been educated in bilingual schools and most hope to study abroad before entering private practice. They all have cell phones. They watch American television with Spanish subtitles on their laptop while they wait for the next round of labor checks. They own cars, have designer haircuts and live in a world where patients are expected to do what they say. In the midst of all this is their nervousness about being able to perform their duties well, a desire to learn and a desire to please their instructors (a difficult feat since each day a different doctor is on duty with a different approach to laboring women).
At five centimeters dilation the women will meet the student doctors. While I know some of the things the women will experience are unnecessary and potentially harmful, I also know the women (who enter the maternity alone and in a hospital gown) are powerless to change them. I know that if a woman challenges the orders she is given there is a chance she will be yelled at, slapped or otherwise mistreated. I know that if by chance she goes into labor on the wrong day she will receive an episiotomy before the head is on the perineum and the baby will be forced out with fundal pressure during the next contraction. But she also has a chance of being encouraged to walk around, push in different positions and having a student who attempts to protect the perineum.
As I prepared for today’s class about second stage, I found an odd conflict happening inside me. Do I help the women understand the worst possible scenario to help prevent fear as it is happening – help them work with the doctors to prevent the mistreatment that happens when a woman doesn’t follow orders on the wrong day? Or do I help the women understand what is most helpful in labor and how to push in a way to protect the perineum?
For the first time I begin to understand the dilemma of America’s childbirth education pioneers. One woman opposing the doctors doesn’t make change. Instead she makes herself the target of abuse. Yesterday I walked into the maternity to screams from the doctor for a mother to push. I could tell the student and the attending were angry and frustrated. I decided not to walk in, it would be over soon and I knew my presence would add another distractor for the woman – another source of frustration for the doctors. As I helped a 15 year old cope with the reality of being alone, two hours from home with contractions, the screaming went on. When I saw the fundal pressure doctor walk in, I knew what was coming and I braced myself for the mental images I was about to have. I hear the mother scream in pain; fundal pressure doctor barked orders; the mother screamed again; attending doctor demands the mother push; it is finally quiet.
How can I prepare these women in a way that is likely to make them the target of such abuse? These are twenty women with no economic or political power. Poorly educated country women who are looked down upon by the urban elite running the maternity. What is happening here is not a movement of the women to demand better treatment, it is one stranger coming in to educate 20-30 women. In a week I will be gone, the classes will be gone, the women will give birth and new women, women who did not participate in my lessons, will take their place.
I’m not really sure what the answer is, but I know what the answer is not. The answer is not to leave the status quo, for the women to continue to be mistreated. But the answer is not to force the women to demand an experience that is considered the best in the United States. Maybe the answer is simply to encourage conversation among the women, in the hope it will create a movement. And in the end, I opt to explain to the women that there are many doctors in the hospital, and that means their experiences may be very different from each other. But, I add, if there is something you want to try or do not understand it is always appropriate to ask questions and make adjustments to help you work better with the doctor, and to help the doctor work better with you.
I hope that is enough.