Wednesday, May 5, 2010

Midwifery in Haiti

Angela Ferrari, a nurse midwife from Massachusetts General Hospital, recently completed a volunteer mission for Project HOPE at Hôpital Albert Schweitzer (HAS), helping to strengthen the hospital's midwife program. Enjoy her story on International Day of the Midwife.

Each morning, the entire provider staff at Hôpital Albert Schweitzer (HAS)meets to go over the cases of the last 24 hours. This multidisciplinary meeting is usually followed by a presentation from one of the providers on a topic of their specialty. The director of the hospital had asked me to talk about midwifery and how it might benefit the hospital. I was excited as I knew the hospital had sought out myself and other midwives from the U.S. to visit because of their firm belief that the hospital needs to employ a midwife. Further, I had been at the hospital for over a week and even had made a visit to the community and I had been coming to a wonderful conclusion: as limited in resources for maternal and infant care as the hospital and the community seemed to be, they already have everything they need to provide great and safe care. Certified Nurse-Midwives (CNM’s) with their unique training in all birth environments, were ideally suited to provide the care in the hospital’s tertiary maternity unit which has less technology than, say, a tertiary care center in the U.S. Midwives in the US are trained to work not only in hospital environments where large amounts of technology are available but also in birth centers and the home where less interventions are available and the care is more basic but equally safe. HAS is currently seeking to employ a Haitian nurse-midwife to attend the many normal births that occur in their facility and I knew I was speaking to a crowd that already knew the benefits of midwifery care.

My talk consisted of reviewing the history of nurse-midwifery in the U.S. and drawing parallels between the development of the profession in the U.S. over the last 100 years and what I had learned about the recent development of the profession in Haiti. In both countries, midwives had been used as part of large public health initiatives as it is often recognized that an easier way to access a population is through its pregnant women who are sometimes seeking prenatal care or labor care.

Preventative health initiatives, like vaccines, can then be administered to pregnant women and their infants through midwives. HAS in Haiti had used midwives in Haiti to wipe out the endemic of tetanus in the area of Deschapelles. The first Nurse-Midwives in the U.S. had administered vaccines in the mountains of Kentucky in the 1930’s. When looking to improve maternal and infant health outcomes, it was recognized in both countries that midwives attended most of the births and have the greatest access to women especially in areas of highest need. And so, here in Haiti as in the U.S., midwives were being trained to maximize their skills both in the mountainsides and rural areas as well as in urban areas of the country. I am certain that my audience’s favorite part of my talk was when I showed a photo of the Frontier Nursing Service (CNM’s) all saddled up on their horses and lined up for a photo. On horseback, the CNM’s appeared a formidable force to be used against poor high rates of maternal and neonatal morbidity and mortality.

While the Grand Rounds talk should be given in French (this is one of the languages that belongs to Haiti), I can only vaguely remember my high school French lessons and so the Canadian OB/gyn, Don, visiting for the week who speaks French and French Creole interpreted for my talk. But what I know for certain is that my American and Canadian colleagues walked away with a better understanding of midwifery. I had listed a series of skills that CNM’s are particularly good at and trained in and that would be particularly useful at HAS and in Haiti to improve outcomes: optimizing physiologic process of labor, intermittent auscultation, skin to skin care, breastfeeding, neonatal resuscitation in all environments.

The pediatricians who were visiting from Vermont were thrilled to learn about the breastfeeding skill as they were currently caring for a 2-week-old malnourished baby whose mother was telling them that her breast milk supply was diminishing (potentially the cause of the baby’s malnourished state.) My talk made them realize I might be a good resource for mom which would in turn help the baby and they asked me to consult with mom who was in the nursery.

With interpreter at my side, I visited mom in the nursery where she was with her small, slightly preterm baby (both set ups for low milk supply!) During our conversation, she mentioned that she had pain in her stomach and lack of appetite. She had had a c/section 2 weeks before for eclampsia as well as another indication and as we talked, it became clear that she had not once taken pain meds after the surgery. She had been prescribed a medication that the pharmacy did not carry by the covering doctor on the weekend she had her surgery. This M.D. was likely less familiar with the medications available at this particular hospital. Unable to get the prescription filled, the patient gave up trying to get medicine. I talked to mom about ways to help stimulate more milk production by her body but felt fairly certain that pain from her c/section might be a reason she was lacking in appetite which would in turn affect her milk supply. I prescribed her a pain medicine I knew the pharmacy had and hoped that with pain management she would eat more.

I visited her over the course of the day in order to observe her breastfeed and noted that despite her fears, her own milk supply was actually good. As a good multidisciplinary effort goes, the picture wasn’t complete until the next morning at breakfast when the pediatricians told me that they had talked to mom again and she had confessed that she did not have food to eat. I was embarrassed that I had not uncovered this fact but I also know that many times it takes many interviews with patients to uncover the entire story and that it often takes many providers to elicit the full story. At any rate, the pediatricians are able to “prescribe” food for the moms of malnourished babies under their care (there is no food available in the hospital available for inpatients—families must provide food for patients.) They prescribed mom food which I am certain would help mom make more milk for baby. I was confident that our care truly made a difference for the health of mom and her baby.

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