 I'd like to introduce Nadine Grunt, our presenter on Midwives from Haiti. Nadine tells me that she was raised on the dairy farm in Ohio, and she's the mother of three and the grandmother of five. Her first nursing degree was from Eastern Menomax College, and she has a master's degree in community health from the University of Virginia. She has a certificate in Midwifery from the Frontier School of Nursing and Midwifery. And after 15 years of full-stope nurse midwifery practice, she's the founder and the executive director of Midwives for Haiti, a six-year organization dedicated to increasing access to skilled care for pregnant women in Haiti. And I'm sure we'll all enjoy her presentation. Nadine, then Mike is going to you. Okay, good morning, good afternoon, good evening to all of you. It's really exciting to think about midwives talking to each other all over the world. I want to tell you a little bit about Midwives for Haiti and our efforts to increase access to skilled care for women in rural Haiti. I think we all notice that all the research has shown that what saves the lives of mothers and babies is access to skilled care. And what skilled care involves has been defined by the WHO and ICM. And so I want to tell you a little bit about our efforts to create skilled birth attendance and an increased access to that care here in Haiti. And for those of you who don't know, Haiti is a country that shares an island with the Dominican Republic and it's just its southeast of Cuba and it is which is south of Florida in the United States. So it's about a two-hour flight from Miami, Florida and it is a largely rural country. In Haiti, the bulk of people live in rural areas and have poor roads, little to no electricity running water, any of the amenities that more developed countries have. The area that we are in is largely rural and in the rural areas, although the statistics show that about 25% of Haitian women deliver in a hospital, in the rural areas, it's probably only 6% to 8% deliver at a hospital. So the reasons for that are the lack of roads, lack of money, cultural beliefs. Their mothers did not deliver in hospital so there are many barriers to care. In rural Haiti, the typical home is made of wood. Where in the cities you'll see more cement homes and a lot of women deliver on dirt floors. The problem all over the world is that women in rural developing countries live miles from hospitals, miles from clinics, and miles from midwives and doctors. So it's very, very difficult to figure out and this is what our task is all over the world. How do we figure out how to get to these women because these are the women that are in the statistics. This is a typical home in Haiti in the city. So even if you're in the city, you may not have the money to get the taxi. Most people do not have vehicles. Not only to get the tax to the taxi, but the bulk of the hospitals are private and require cash. For example, in Port-au-Prince, it'll cost you $600 to $700 to have a vaginal birth at the private hospitals and over a thousand US dollars to have a C-section and that is completely beyond the capability of the bulk of people in even Port-au-Prince. So in Haiti there have been in the past only two kinds of midwives. There are the matrons and the matrons are uneducated, untrained. Sometimes have received short little training programs by the government or other agencies. Most of them cannot read and write and they have an incredible amount of cultural beliefs about childbirth and pregnancy that make it very difficult to educate them. For example, they believe a woman's water breaks through her mouth. They believe the longer you leave the cord, the longer the penis will be. I think we seem to have lost Nadine, but I'm sure she will be back momentarily. And I see we have some new participants have joined us. Why don't you tell us where you're from while we're waiting for Nadine's connection to pop back up. Ah, some of them are still. Excellent. And Penny had asked a question earlier about isn't social distance a barrier as well, especially serving in a country like Haiti? I think that would be the case. She named me having difficulty with her internet connection. I know we had some issues when we were practicing with us, but hopefully she's able to loan out and log back in again. I'll keep an eye on her when she comes in. Oh, I thought she's left the meeting, so maybe that's what she's trying to do is log back in again. Do you want me to just advance the slide so that people can get an idea? There's a lot of it. It's very visual, and maybe she can capture stuff when she comes back in. Why don't we give her, yeah, there we go. And Sarah has shared the website for Midwesters for Haiti as well. So perhaps we can just wait another minute and see what happens. And here's Nadine. Okay, let me just promote her. Okay, Nadine, I advanced a couple of your slides. So we're at your discussion of maternal mortality here if you want to jump in at this point. Just one minute, I have to promote her. And there we go. As soon as you're ready, Nadine. Okay, can you hear me? Yes, we can. Yes, we can. All right, it's good. It's exciting. I advanced two of your slides. So if you want to jump in with your discussion of maternal mortality, that would be great. Okay, so I wanted to explain the two kinds of midwives that are in Haiti. The matrons that are uneducated, and most of them cannot read and write. And then there's the university-trained midwives who are required to have four years of nursing, three years of midwifery. And so there's only about 180 of those in the country. The bulk of babies born in Haiti are born with these untrained matrons. Therefore, the deaths per 100,000 births are really high in the highest in the western hemisphere. There are some statistics that show this more like three to 400 per 100,000 births. But many people in Haiti believe the 610 is more accurate. We know for certain that much of the maternal deaths that happen here in rural Haiti never get reported to any agency. So we believe the 610 is much more accurate than the latest statistics that were published. In Haiti, the causes of maternal deaths are most likely to be from hypertension. There's a high degree of chronic hypertension at a very low, very young age. And we're not sure why exactly if it has to do with genetic, long-term malnutrition, but pre-eclampsia and eclampsia are rampant in Haiti. Temerase is the second reason. And like all over the world, infection, obstructed labor and incomplete abortions are the next. So all of you know this that worldwide there are at least 254,000 maternal deaths each year. And I know for certain that probably is much higher because here in Haiti so many of them do not get reported. So one woman dies in birth every one to two minutes, which is the equivalent of two jumbo deaths crashing each day. In Haiti, we've been trying to figure out what we can do to change that statistic. And so we started by trying to train skilled birth attendants. We've had no curriculum when we began six years ago, no materials in Creel, which is the most common language. We started teaching under trees, hospitals, laundry rooms once we were in a hotel courtyard. But as of last year, we finally have an indoor classroom with electricity and ability to get internet and show PowerPoints and videos. This didn't do very, very well with visual learning. We found that the World Health Organization had midwifery education models, but they were in English. The American College of Nurse Midwives had life-saving skills manuals. They were in English. Other organizations such as UNICEF and JPEGO had some materials that they were in English. We have translated the main text, a book for midwives, into Creel. And so that is our main text used for students. We also use where women have no doctor, which is in Creel. And we have since picked up some textbooks in French for our instructors. And we're getting more and more materials translated into French. Some universities are helping us to do that. We decided to build our curriculum around the core abilities of a skilled birth attendant as defined by WHO and ICM. And there's 30-some abilities. I'm not going to read them all to you, but they include everything from assessing individual health status, performing screening tests, identifying abnormal lab tests, educating women in self-care during pregnancy, childbirth and postpartum, identifying illnesses and conditions that put a woman's health and her babies at risk during pregnancy, monitoring maternal and fetal well-being during labor, use of the partogram, managing third stage of labor actively, knowing how to do newborn representation, identifying hemorrhage, postpartum hemorrhage, preeclampsia and eclampsia, and doing first-line management of these emergencies. We also are trained to identify illnesses and conditions that are detrimental to women in the postnatal period and provide advice on family planning. And then the component also is there of us having shared responsibility with the woman and her community in having optimum health. One of the barriers to skilled care in the Central Plateau where we are, and I was going to show you on a map, I'm in Intady, which is YLOP Internet, in a very rural area. And the hospital that we are in serves an area of about 600,000 people. It is very poorly resourced. It's owned by the government. And so therefore it has added to the version of teaching students well. It's very difficult if you have the constraints of food supplies, of poor equipment, lack of trained staff to model care. And so one of our barriers to training skilled birth attendants has been what we have to work with. And as you can see, the delivery beds are one of those problems. We start with women or men who are either an auxiliar or an infaniate diploma. Auxiliers have about 18 months of some basic nursing. Jerry hands on, it's sort of equivalent in the United States of a nurse's age. They can take some vital signs. They can start at ease. Infaniates are different. They have a four-year nursing degree. And depending on the quality of that education, they have a pretty good understanding of some pathophysiology. But what we found is that putting them both in the same class has not been a problem, because both of them lack obstetric knowledge, obstetric background, and the skills needed to be a skilled birth attendant. We use infaniate systems who are the midwives from the university program in Port of Pints. And they're very difficult to find and very difficult to keep. We've lost two teachers to Canada. And that's been the biggest problem with this university program is because they have a nursing background and because they can speak French, one-third of the university-trained midwives have left the country. Most of them are in Canada working as nurses. So it's been difficult for us to find these teachers, but teaching in any language except what the students can understand is way too difficult and takes way too long. We have a ten-month program and most of it is done in this hospital where the people who come are really quite sick because if a pregnancy is deemed normal by the family and her friends, most women are still delivering at home. What we see come into the hospital are very sick women. This is a 17-year-old pregnant woman who arrives in seizures and the instructor and students quickly starting an ID and starting magnesium sulfate and then monitoring her urine output. And this baby did not make it. This baby was dead on arrival, but we did save the mother. So the students are working in very high-risk areas. The next slide shows that one of the issues we're dealing with and struggling with at all times is that people say to us, you're not training midwives, you're training skill birth attendance. And the reason they say that is that per the International Confederation of Midwives, a midwife is educated in a program that's recognized by the country it's in and it fits the framework of the ICM Global Standards for Midwifery Education. We think that we're able to meet the next three. Our students can meet essential competencies for basic midwifery practice and they're learning the scope covering pregnancy, labor birth, postpartum, prevention and detection of complications. And they're doing a lot of counseling and teaching to women in health and communities. But our program is not recognized by him. We do have a contract with the Ministry of Health and the Central Plateau and the Ministry of Health signs are diplomas. But that's for the Central Plateau. Our students work in about 14 different areas of Haiti. Haiti has 10 districts. And what we're making an effort to try to get Central MSCT, which is the health department of the government, to recognize our diploma in every district. But it's really difficult because they are changing their program from the four-year nursing as an entry requirement to a four-year direct entry program. So they currently are still developing a midwifery program and have not completely got that curriculum completed. So at many meetings we're told, well, we'll accept your program if it bridges well with our program, but their program is not developed. So we're still waiting on number one. Therefore, many people say you can't call what you're doing and that you can't call your graduates midwifery. The problem in Haiti, if there's only one accepted midwifery training and it's still in development and that the old four-year nursing program graduates, a third of them have left the country, we have to find a new way to educate midwives because Haitian women can't wait until it'll be four years before we even get graduates from this program in Port-au-Prince. What do Haitian women do in the meantime? What do we call our graduates? Right now our graduates are called either Azuliers or Insaniers with a specialized obstetric training. Now, the people they care for call them midwives and everyone here in inch calls them midwives. We're not sure what they're going to call the graduates of the four-year direct entry program even because they're not going to be Insaniers or Thames, they're not going to have started with the four-year Insaniers degree. When they decide what they're going to call the graduates of the four-year direct entry program, it'll give us some guidance of what we can call ours eventually. So, educating is not enough. We had to get out to where the women are, we started a rural prenatal clinic by going out to 16 villages a month where women come for miles around to get prenatal care. This is done with our deep, which is able to go places there are no roads and through rivers. And we see an estimated 20 to 60 women a day. We've had as high as 90 to 100 turn up in a village for care. So there are four to five midwives to go out because of the intensive work that's involved in seeing this many patients in one day. Every patient has a record and to get blood pressure, weight, a fundal assessment, fetal assessment. Basically, we try to give everything that she would get if she had gotten to the hospital, including HIV and syphilis tests, gonorrhea and chlamydia. HIV is about 2% in rural areas. Syphilis is about 11%. And we're finding gonorrhea is rampant here in the central plateau. We have to use rapid tests. We don't have a lab to take things, take any specimens to. HIV and syphilis, we cannot afford to treat. So we send them to the local hospital and there they get serum testing. And if they are positive, they can get free treatment through partners and health programs in inch or con armor abaly. We do treat the gonorrhea and chlamydia. We treat malaria. Every woman gets worm treatment in the second and third trimester because anemia is a real huge problem. And some of it is caused by poor malnutrition. Some of it by worms. And those who have malaria are severely immune. They all get prenatal vitamins, folic acid, iron. We give calcium when we have it. We get our vitamins from an organization called Vitamin Angels. We purchase a couple thousand dollars worth of medications each month for this mobile clinic program. The midwife does a lot of teaching about how to take medications because patients typically will hoard medications until they feel bad. There's an incredible amount of education needed as to why you need to take your pills on a daily basis. These are three of our five mobile clinic midwives who are really well loved throughout the community. And in our three years of doing mobile clinics have developed a reputation so that people seek them out for advice to their communities, the women in their communities of all ages, even those who are not pregnant, seek out these women for multiple health problems. What we'd like to see all over Haiti, and we think should be the model for all over the world, are rural birth centers where midwives do this kind of care and screen and then have transport to hospitals within 30 minutes to an hour for taking care of emergencies that turn up in obstetrics. We're trying to get a birth center started and hopefully in the next couple years we'll have several sites where we open those. Right now we're the women, most of the women that we take care of in these mobile prenatal clinics they're still going to deliver at home because they don't have access to transportation and the funds to buy transportation. They're fortunate that if they do get to St. Jerry's Hospital because it's a government-owned hospital the care is free. Then we started, because most of the births in rural Haiti are still done by May Crohn we decided we needed to reach out to these caregivers and make them a part of our system. So a year ago we started training May Crohn and May Crohn's been very excited about receiving training. We do a 20-week program that was developed by Management Sciences for Health. It's approved by MSCT, the government and the graduates of this 20-week program get little certificates signed by the Ministry of Health and by Midwives for Haiti. They get badges to wear and they're encouraged to bring their patients to the mobile prenatal clinics and to the hospitals when they notice risk problems. We were totally blown away by the results of doing this in just one rural community. What happened is that we saw an immediate increase in the number of women who came for prenatal care and we saw an increase in the number of women who came to the hospital with their May Crohn for care. The May Crohn are being encouraged to stay with their patients being welcomed so that they feel a part of the system and they feel like they're still taking care of their patients even when they come to the hospital. The patients trust these women because these are women and men because these are who have delivered the babies in their communities for years and years and years. But when these May Crohn say, I learned that when you have a headache and your ankles are swollen that we need to go get your blood pressure taken. They are much more likely to seek help than if they were not referred. This has been a very exciting part of our program and there's now some new research, although at one point funding for training these May Crohn disappeared because WHO felt the research showed that it didn't help at all. There's now some new research that if they're integrated into a system where of midwives and doctors and hospitals, it can make a big difference. We found it really exciting to reach out to these women and men because until Haiti's statistics change, this is still who's going to be doing most of the delivery. So we have to give them tools and knowledge. We not only supply them with a 20-week program, we are keeping each one that we train supplied with clean birth kits. And that has been very exciting for them to have clean razor blades, gloves, a receiving blanket, and a large, clean piece of paper to have the women deliver on these dirt floors in these dirt floor huts. In the meantime, we are working very hard at reaching as many women as we can with the message that they need skilled care. So we do classes both at the hospital and at these rural clinics. We do postpartum care. So what you see in that slide is a young woman who is having her second baby and went home about four hours later. So the midwife did a home visit. This is the father, his first wife died a couple weeks after childbirth. We're not sure of what. And so he is very happy each time this second wife comes home from childbirth and very proud of their baby. They always dress their children with the best things they have when they know someone is coming, but what they may have the next day is nothing. This is a woman who had a severe postpartum hemorrhage treated. She was delivered at a birth center that's run by Heartline in Port-au-Prince. And because of the severity of her postpartum hemorrhage, ended up getting transferred to a local hospital and having a hysterectomy. But the happy news is that because she's got care with skilled people, she was able to go home to this family. The result, as you know, when mothers are not able to go home and when women and mothers die, it means a significant loss for both the family and the community and the chances of children under 5 that that woman has with surviving past the age of 5 is more than 50% reduced. So it's really a tragedy for everyone if these women don't survive. And this is one woman who would not have survived. So birth centers in Haiti, we know there are several. There's one in Cai, which has excellent statistics. It's run by midwives. Four of our graduates are working there. There's one in Port-au-Prince, run by Heartline. There's one in K-Pace, run by Mama Baby. There's one in Fontaracine. There's one in Thomasique. All of these except the ones at Heartline have our graduates working at them. They are within 30 to 60 minutes of referring to a hospital. And we think this is the model that needs to happen in Haiti all over the country and that even more developed countries like the U.S. to develop this model would save lives and save hundreds of dollars. In the meantime, we're graduating about 15 to 20 graduates per year. We have currently 56 graduates working in 14 areas of Haiti. This was class four. Each year, the line of applicants gets very long. Two years ago, we had 67 applicants. Last year, we had 81 applicants. We screened them by looking at their diplomas. They are really a family of diplomas by looking at their past work experience and by giving them a basic competency test, finding out whether they test their reading skills, their math skills, and a little bit of nursing background. Here, back in the United States and in many of your countries, we are well equipped to take care of every obstetric emergency that comes through the door and we have everything ready to take care of a pro-left cord in 15 minutes to stop to... And we rarely see seizures in women because we touch preclampsia so soon. And the question has been asked, is this what we need in every country and is this realistic in every country? What we think and what World Health Organization has proven is that you need these three legs. You need skill birth attendance, which is what we're trying to do. You need transportation so that they can get their patients who are having complications to a well-staffed and equipped medical center. The birth center model is a wonderful model for Haiti and we're hoping to expand on that in the next couple years. Our mobile prenatal clinic midwives are begging us to get out to the villages where the women are delivering because they are very upset when they go out and find out that a perfectly healthy woman that they took care of during her pregnancy died from a postpartum hemorrhage and it's just a statistic that needs to have a solution. So transportation, skilled care, and a place to go, Haiti needs at least 1,200 skilled birth attendants immediately. It currently has less than 200 university chains midwives at the end of this year. We will have 79 graduates who are working and we are hoping to open up a second school in 2014. We hope to find a facility where we can have a better model of care but in the meantime, we know that there are just some basics that are needed to save lives and we can make a difference by what we're doing. I'll take questions now. Raise your hand if you want a mic or just type your question in the chat box, please. Do women, if someone put, do women there always birth in stirrups? At the hospital, yes, quite frequently, which is one of the reasons they don't come in because they're used to breathing, standing or sitting up at home. We have struggled with the lack of beds in this delivery area so that women can change positions and we've been accused of, we've been criticized because some of our patients who we walk as long as possible rather than put them in these positions have delivered on the sidewalk and on the floor and we are in the process of showing the staff that this is very acceptable if you can put down clean paper, clean cloth. I could talk for a day about all the obstacles that we have had at this government-owned hospital to doing care the way that is evidence-based and we're actually kind of tickled when a woman delivers in the antipartum room where there are just beds and we can deliver there but when they're deemed to be in really active labor and close to delivery, they walk down the sidewalk to this room that has these exam tables with spirits in them and so most women are delivering there although our midwives have seen many videos and examples of other ways to do it. One of the things that we have not done before but we're starting this year is we want to get the birth centers that do exist in Haiti which there are about five or six of them involved in our education of our students. For example, we have two students right now in our class that are from Lagunaib, that's the island that's just off of Haiti. They're not going to be delivering at a hospital, they're going to be delivering at a birth center so they need birth center experience so we are working on developing the problem right now is money. How do we house and pay for the room and board of our students at these birth centers while they get birth center experience but we are going to be putting Delana and Fluxelia at a birth center for six weeks in one, hopefully six weeks in three different because we know that what they need is birth center experience not hospital experience and that most of our students are going to be working eventually in birth center setting so we've got to get that, we've got to get out of this hospital with models such poor care in so many ways. Okay, Nadine, there's a question from Carrie Smith about if I interpret it correctly about having students from other countries come to work with you as part of their clinical experience. Have you explored that option with any of the midwifery programs outside of Haiti? We discourage midwifery students because they come with the goal of wanting to catch babies which can take away from the opportunities for our own students. Unless they plan, first of all they have to come with their own preceptor and they have to schedule their time at this local hospital at a time when our students are not there. So we have an agreement with the hospital that we will not have midwifery students teaching midwifery students. We have used them in the classroom. They, students from Philadelphia University, University of Pennsylvania have helped with classroom teaching but they can't be part of the clinical training of our students and they have to be precepted by a... they have to bring their own preceptor. So it's not impossible. We have on two occasions had midwifery students here with their preceptor working at the hospital but it had to be, they worked mainly nice when our students were not in the clinical area. Thank you very much for addressing that. Okay, there's something here from Ella. Go ahead. Okay, a question about Ella, from what kind of practices take place in birth settings that are more in turn with physiologic birth? Do you want to address that for a little bit? Yes, it depends on the birth center. In, for example, at Heartline Birth Center we find that no one delivers in syrup that they deliver, they frequently labor with a sling, labor walking, standing, and deliver on a regular bed. In general, all the birth centers have a lot more freedom to provide physiological birth practices than what we have here at the hospital although we entrain our students that they're, and model to them with the patient other ways of delivering besides flat on your back. So I know that students would love to, students who would like to get experience here and we would like for them to come with the goal of helping us increase our curriculum. We can always put them to work, but they would not be able to be in the hospital setting without a preceptor. So they can come and get an experience of the cultural experience of being in Haiti and being with women in Haiti. They can go on the mobile clinic, they can visit birth centers, but they would not be able to actually catch babies without a preceptor. Someone asked how the three mobile midwives establish such good rapport with the community women, and that's because they're out there every month. And while one of them is taking blood pressures and weighing women and doing fundamental height, the other is talking to the rest of the women. We have some kind of sort of an informal centering pregnancy happening in every village where some subject is discussed, whether it's breastfeeding, signs of preeclampsia, family planning that's available, the signs and symptoms of danger to be watched for. And so over time, these midwives are very loved because they demonstrate that they care very deeply about that these women have safe birth and are really concerned. And frequently say to a woman, you really have too many risks. When you go into labor, you need to have transportation to the hospital as soon as possible. Make sure you save up enough money and figure out who you're going to call to transport you, come up with a plan. And they preach this in every village that you need a plan in case there's an emergency. You need money set aside to pay someone. You need to know who you're going to call and you need to have gas fuel to put into that vehicle. Because the delays, we know that one of the problems in rural areas is the delay in seeking care and the time that it takes to get. There's a delay in the decision making. There's a delay in the transportation. And it's the reason that deaths happen in rural areas. Partners in Health, someone asked a question about that. There's a main organization that we have a partnership with because they actually support this hospital with all the medication that is available. And they have the clinics, the HIV, syphilis, STD clinics where people can get free care. Partners in Health also recently built a new hospital in Mirabilis. But the sad thing is that there are no birth centers around it and very few prenatal clinics I think only two in the surrounding one-hour area. So what they're going to be getting is simply self-referral. And we want to partner with them to create more antipartic care and more prenatal care out in the communities around their hospital because they will be much more effective if women are being screened for birth. Okay. Someone said, our birth attendants have little or no access to obstetric drugs. That's true about the MACE home. But not our graduates, our students do have access to obstetrician entomizer possible and know how to use it. And they use active management of Thursdays. Okay, Nadine, this has been fascinating. I'm sure people would love to hear you share more about your experiences. Can we refer them to your website midwivesforhady.org for if they have further questions or want to learn more about your work down there? Yes, and I did not. You can see that we're on Facebook. You can message us through that. www.midwivesforhady.org, the website there, also has some emails of board members and administrative assistants, people that can help answer questions about volunteering, about teaching. We really love to have people who can speak Creole and Sprint, and we know there's many people in the world that can speak Sprint to our midwives. So please access that site to find out more information. Okay, thank you so much. I'm going to wrap up the meeting now. Thank you, everybody.