I wanted to share a photo of the maternity in one of the public hospitals in Honduras. As you can see, the layout is a bit different from any hospital in the United States.

In this hospital, the women labor together in one room. When the head is on the perineum they are moved to the expulsivo (through the door) where the baby will be born. There are some curtains for privacy, but they are not used in this hospital.

Your first thought may be that this is terrible.  That poor quality care is the result to expect in a less wealthy country.  I want to challenge you to look beyond the cultural difference in expectation of privacy in labor, and see some of the wonderful examples of high quality care that were normal.

• In this hospital, laboring women are not allowed to be admitted into the maternity until they are five centimeters.
• In this hospital, cervical exams are only performed every four hours to ensure a woman is within the normal bounds on the partogram.
• In this hospital, if a woman doesn’t respond to an attempted pitocin induction within a pre-specified time frame, she is asked to go home and return tomorrow.
• In this hospital, contraction pattern is checked by placing a hand on the mother’s belly for 10 full minutes every hour.
• In this hospital, baby’s heart rate during albor is monitored with a stethoscope to mom’s belly.
• In this hospital, women are not catheterized to make sure the bladder is empty before pushing.

Yes, some things happen here which are unacceptable in my birth culture.  But there are many things that happen here that are really great examples of a high level of quality care–things I wish would be normal in the United States.

I know planning for the next trip has started, but I wanted to share a few things from the Honduras trip.

One of my jobs in Honduras was the training of traditional birth attendants in neonatal resuscitation.  An interesting and useful fact about fresh babies is that 9 out of 10 times when a baby doesn’t initiate breathing on its own, breathing can be stimulated with positive pressure ventilation.  What is that?  Forcing a little air in the babies lungs.

In the hospital this is done with ambu-bags – those masks with the big bulb someone squeezes. I took some special ambu-bags with me on this trip to be distributed to traditional birth attendants.  Why special?  They were sized perfectly for newborns and were able to be sterilized in boiling water.  This makes them a practical tool for birth attendants who live in remote areas.

Unfortunately, the materials were held up in customs and were not released before I was scheduled to teach the birth attendants.  No problem, I taught them another completely reusable way – use your own mouth and the air in your cheeks.

The program I am working through in Honduras puts volunteer doulas in public hospitals.  The idea is that the presence of a doula will begin the process of making changes in the way women are treated.  It is a nice concept, and only time will tell if it will really work.  In the mean time, it does provide some comfort for women who would otherwise be left to manage labor alone.

The problem for me is that I now have skills beyond childbirth educator and doula, and the staff of the hospital knows this.  This gives me a bit more freedom with what I can do. For example, I make suggestions to the students when they are working with patients and have even given a shot when I was left alone in a room with the patient and one physician student. I don’t really like this part of it.  Not that it is difficult or that I cannot do this work, but that my presence is not intended to cover the problems of inadequate staffing.  I am here for the women, not the staff.

Yesterday one of the attending physicians asked why I wasn’t attending the births (meaning why was I not catching), and she reassured me I could do that if I wanted to.  Sounds like a great opportunity, doesn’t it?  It is not, and I have no intention of purposefully catching.

You see, her comment was not based on her seeing my skills and feeling I am competent to provide care. In fact, the attending is almost never in the room.  Her comment was made only because she knows I attend labors in the US – which she assumes means I am competent.  I don’t think she understands I am still a student.

Beyond her misunderstanding is the fact that my Spanish is poor.  If I had a problem alone with the patient (and the students are almost always left alone with the patients), I might not be able to get the help I needed because it would be too much work to figure out how to communicate what was happening.  It took me three tries yesterday to get one of the doctors to give an oxytocin shot (which I felt uncomfortable doing because I was with a student who didn’t speak English and I didn’t know how he would react to my doing it). Once the birth was completed, how would I ensure the student who would be responsible for charting the birth got the correct information?  I know it seems like a small thing – but for the postpartum nurses to know who is at risk for problems they need to understand what happened during the labor.  I don’t go into the postpartum unit, and have never met the nurses.

There is another layer of problem, that of authority.  This doctor is one of the attending physicians in the maternity, but there are others.  What if they do not all share her openness?  I have permission from hospital administration to be in this closed unit (not even family is allowed to peek in) as a volunteer.  If I broke that trust I could risk the possibility of other volunteers being allowed in.  This doctor also does not have the authority to permit me to provide nursing or medical care in Honduras – I am not here on a work visa and I am not licensed to provide services in this country. I know many Americans have an idea that you can just go into a country and start catching babies, but it really isn’t true.  Although the chances of being caught are small, I could be jeopardizing my ability to come back to Honduras with legitimate work papers.

Finally, and the biggest problem of all for me, is that in permitting me to do births this doctor is showing that she doesn’t really value the work I am doing.  I expected this, doula is a new concept in Honduras.  She doesn’t understand the importance of keeping the space or providing a presence and positive experience for the laboring women. She thinks I will be happier if I can catch babies, and she will then see the value of my being a volunteer in the hospital.  If I accept her offer, I will be demonstrating my agreement that catching the baby is the important part, not being with the women.  This sends the wrong message, and will hinder future volunteers who may not be trained as midwives.

I’m not willing to say it will not happen, I’ve had too many close calls alone with a crowning baby to be comfortable thinking I’ll never have to catch.  But to willingly change my role from doula to midwife would undo all the work I’ve accomplished in the past month. Just another reason why it is important to really think through things before jumping in and “helping” when working in a different culture.

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.

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.

While I am in Honduras I will have the opportunity to work as a doula in some hospitals.  This will force me to improve my Spanish (which slowly forms in my head but rarely makes it out my mouth).

I was searching for important terms to study when I came across this blog that gives you a month of midwife Spanish terms to learn.  How fun.  Enjoy!

For those of you who think you might want to get into international work, remember to be flexible.  Case in point, I had a conference call with the leader of the organization I am volunteering with in Honduras today.  There is a slight change of plans in the work she wants me to do – nothing drastic but a change.  Seems she has forgotten about the bonding part and is hoping I can teach neonatal resuscitation in the hospitals and to all the midwife groups in every area.  Hmmm…I don’t think I communicated right about what the program was.

But I am flexible and the equipment with the program is not necessary for neonatal resuscitation.  I can teach the assessment skills and positive pressure ventilation that is basically mouth to mouth resuscitation.  Hosptials will already have the equipment, so it will just be a matter of teaching the assessment and proper use of the equipment.

Did I mention that I’m struggling with my Spanish?  I am practicing every day, but don’t have time for the amount of work I want to put into it.  So I have this terrible fear that I’ll be useless because no one will understand me.

Then there is the small problem that we still don’t know where I will be staying or what the costs associated with that will be.

Crazy, right?  This is all pretty normal.  I’m somewhat used to it by now.  If it makes you at all uneasy, you might want to rethink working in developing countries.

The Honduras trip is coming up soon.  I’ve been quietly preparing for it as I finished the semester, completed my clinical hours and returned to Michigan for a much needed rest with family.  In fact, as I write this I have been in the midst of studying Spanish phrases relevant to maternal health.

When people find out what I do, they often comment about how they want to work in international midwifery.  I wonder if they are thinking they would like to tour the world with a focus on maternity systems, or if they truly understand what international/global midwifery is all about.

For example, I am not going to Honduras to assist at births or to do prenatal visits.  I may participate in this if given the opportunity to observe local practice, but will not be seeking this as an opportunity. Why? Because I am only in Honduras for six weeks which means that any gap in care I fill will return the moment I leave.  International midwifery is not about temporary gap filling.  Instead, I am about resource strengthening.

You may be wondering what resource strengthening actually looks like.  It has many faces.

• I will be training 2 or 3 health care workers to teach a neonatal resuscitation program called Helping Babies Breathe.  I will provide the organization with two training kits and 20 sets of materials so they can train 20 TBAs in this important skill before I leave.  They can then order the materials themselves to continue training.  If I did the training of the 20 TBAs, that would be all that could be trained until another trainer came.
• I will be speaking to nurses at a few hospitals about interventions that promote maternal-infant bonding so they will be equipped to make policy changes at their hospitals.  If I attempted to promote bonding by acting as a doula at a few labors the result would be a handful of labors rather than policy change at the hospital.
• I will be working to create a culturally appropriate childbirth education curriculum and training local volunteers to teach the curriculum.  As with the other tasks, the effect then reaches far beyond my six weeks in the country.

Actually, as much of my work is done before the trip as during.  I have to spend lots of time making sure I am ready to adapt to speaking Spanish 24 hours a day (I’m not doing very well with this one).  I have to order materials and ensure they reach the right places at the right time.  I have to collect as many resources as possible to alter and adjust when in Honduras so as I talk to women and learn about the culture I can quickly adapt what already exists and identify gaps in available resources.  I need to be able to assess what already exists within each community and identify ways to strengthen the resources – which means I have spent many hours reviewing available literature and health statistics. I need to be familiar with many programs, theories, ideas and methods – I need to be able to use them in an instant.   I also need to be able to communicate effectively to allow the local women to make the decisions about what is and is not going to become part of these new programs.  All of this has taken years of learning and months of preparation.

It’s nearly the end of the semester, and I am just about finished with the work I need to complete.  Well, complete for school this semester any way.

I am just starting work on my practicum, and now that I have the tickets booked I can announce that this summer I will be working with Dar a Luz in Honduras.

Off to do some more studying, but wanted to give you the link to Dar a Luz so you can start checking them out.