the circumnavigation ends, but the journey continues . . .

Three weeks ago I returned from my trip to the startling heat of Arizona and the loving community of my family and friends. Over the past few weeks I have unpacked my suitcase and am learning to sleep in the same bed for more than a handful of nights, appreciating the familiarity of using the same shampoo in the same shower and knowing where to find my hairbrush. I missed routine this summer. And I grew addicted to the wild adventure of arriving at new places and exploring new spaces and connecting with people — only to leave again in a few days.

The whirlwind life thrills, but the time has come to settle again.

This summer shaped me in so many ways. One major change has been the development of my calling for what comes next. I know that I am meant to work in maternal health. This field has given me more life and fervor to contribute than any other discipline I have pursued. I wrestled with what vocation would allow me to have a significant impact. I grappled with becoming an OB/GYN – medical school would be so interesting and as a doctor I would have the skills to save lives and the medical authority to make changes in the US. The more I worked with midwives the more I dreamed about becoming one, realizing that the posture and role of a midwife aligns better with how I want to engage with women. I was very caught up in this idea of what identity should I choose. The words of the first midwife I interviewed have resonated with me all summer: “I am a human first — and I work as a midwife.” It wasn’t until I returned to AZ and quoted this midwife to a friend that I realized my journey didn’t help me figure out what I want to be, it guided me to discover what I want to do.

Here is what I want to do: listen to and support the individuals who are serving women in their local context. This includes facilitating systems of maternal healthcare that provide women with access to quality care that respects their human dignity. I want to increase collaboration between medical professionals including doctors and midwives so that women receive the best care according to the scope of their needs. I want to establish birth clinics that serves women of ethnic minorities. I want to help change the culture surrounding birth in the USA so that more people understand the scope of various providers and feel empowered to make the best choices for them. After I graduate with my bachelors next spring, I plan get my masters in public health with an emphasis on sexual and reproductive healthcare. As I learned this summer, I will set my intentions, remain open, and follow what happens from there.

But my vocational path was only one aspect of how I was shaped this summer.  “My Circumnavigation” was not a product of what I made happen, but came together based on the generosity of countless individuals who said yes to a random Arizonian student looking for some answers. People around the world have shared their homes and food, busy schedules, professional connections, their research endeavors and frustrations and vision. Thank you for responding. Thank you for opening yourselves and your lives to me. Thank you for sometimes speaking about really difficult things in a language that wasn’t your first or even second language. Thank you for picking me up from metro stations and carrying my suitcase up four flights of stairs. Thank you for inviting me into the maternity ward to watch infants enter the world. Thank you for allow me to be present as you met your baby for the first time. Thank you for connecting with me in overwhelmingly meaningful ways.

IMG_9017 IMG_8630 IMG_8293 IMG_6850

IMG_7418 IMG_7244

IMG_8525 IMG_8589

my ladies <3

IMG_1087IMG_0653

I am so deeply grateful and humbled because I will never be able to repay these gifts in the same way to the same people. Yet I’ve also realized it’s not about me receiving and giving, but about the power of human connection and story-sharing. I feel so honored to have been entrusted with so many raw and honest stories. The gift of gathering these stories around the world compels me to share according to these individuals’ visions for change and for the future.

So, here’s what comes next:

The summer wanderer plants her feet for a spell and writes a book.

I have one more year left for my bachelors degree in Global Health at ASU, and due to frantically pursuing all of the classes over the last three years, I have the space to lower my course load and take a breath and sit with this project that seizes me with urgent excitement. Before my trip I planned to write up my results into my thesis by qualitatively analyzing the interviews according to my survey criteria. But travelling jolted me from the notion that my purpose is to evaluate and define what-is-going-on-in-global-midwifery. Rather, I am called to share the words of the experts, infused with perspectives I gained from what I experienced and saw.

When I’ve mentioned to professors that I want to write a book, they smile encouragingly and respond, “Good for you! But you should do your thesis first, so that you can actually graduate.”

Last week I sat across from my thesis advisor and said, “I can’t wait to write my paper!’ Then more quietly, “and I also want to write a book…” Instead of grimacing at my naïve optimism, he told me, “Why can’t you do both at once?” Then he quoted something he told me two years ago when I sat in his office as a sophomore, musing about my future thesis, and told him that I was interested in research but would prefer to focus on a creative project. He said, “I don’t understand why research isn’t considered creative. Isn’t the process of observing, questioning, investigating, and reflecting one of the most creative things you could do with your interests?”

This world is full of the most truly wonderful people.

My director and I decided that for my thesis I will analyze the interviews according to some of my most important questions: how do you define a midwife, why did you become a midwife, what are barriers to maternal healthcare, and how do we improve collaboration between maternal healthcare providers? I will write up a few chapters in the book with this qualitative research approach. Other chapters with focus on the different countries and related themes through the medium of personal narratives. Like the other professors, my director also wants me to graduate, so he recommended that over the next semesters I write the core chapters and design a plan to finish the book.

I left his office dancing. My director believes in my passion to bridge academia and public knowledge, and is supporting me to throw myself into everything I could have dreamed of for my thesis. I will do the work of connecting and comparing, and I will share the stories.

my work-space surrounded by my new friends around the globe

my work-space surrounded by my new friends around the globe

Usually I only blog during the summers, but this year I hope to continue to write periodically to provide updates about the work of re-engaging all of the conversations I had with the amazing people I met this summer. If you are interested in continuing to follow this journey, I welcome you along. Thank you so much for following and supporting me on this adventure by reading this blog and reaching out and connecting. The comments and conversations that have arisen from people encountering these stories has given me hope for the ways this summer research trip can expand into urgently needed cultural change surrounding maternal health – both in the US and for the world. This change begins with the public knowing what options are available when they bring a child into the world, understanding the actual role of various medical professionals like midwives, and contributing to the movement to make the journey to motherhood more safe, respectful, accessible, and reflective of each woman’s immeasurable value and beauty.

Let us work toward a world where women not only survive childbirth, but flourish into motherhood.

With deep gratitude,

Annie

comadrona means midwife

Guatemala has some of the most gorgeous views I’ve ever seen. IMG_0848

I have been spending the past two weeks in Tecpan, Chimaltenango with Elizabeth, previous Circumnavigator from Chicago who I skyped earlier this spring when she gave me awesome tips for travel. When I arrived in Guatemala we got in touch and she happened to be here too! She is volunteering with Wuqu’ Kawoq, a Mayan health organization that provides care to people in the surrounding towns and villages. This organization is amazing and has a really special and effective mission to serve people in their own contexts and languages. I have had the pleasure of getting to know a lot of the staff and volunteers and shadowing on some of the trips to the villages. I accompanied them on their diabetes project where they meet with patients and test blood sugar and provide education, as well as a women’s health teaching. All of their programs provide an educational component along with clinical care and medicinal support. This organization reminds me a lot of LAMB hospital in Bangladesh, but with an outward focus of bringing health support to the people.

women's health teaching

women’s health teaching

The women’s health teachings include 8 week courses where women in the community bring their children and learn about health and family planning. Last week the ratio of moms to children was 2:4. It was precious to watch the women listening intently while their babies nursed and toddlers played. Family planning is a pretty sensitive issue in the rural communities. Many family reject family planning for religious reasons, and others have misunderstandings about how different methods work. For example, there is a common believe that birth control pills build up in the uterus or that people can tell that a woman is taking them by marks on her back. After the lesson, the woman to the left said that she has learned so much during the teaching. She has 7 children (the youngest sleeping on her back). She has always believed that birth control is a sin, but now she things differently. She says she wishes she had the opportunity to go to school and read, and she hopes that her children will have that opportunity. She said it is difficult that she cannot even read the text of the manual. Even though she thinks differently about birth control, she says that her husband will not allow her to use it. Attending this teaching made me realize the importance these kind of information sharing services. When women are not able to learn through reading, they only have access to the beliefs of their community. Without an understanding of different family planning methods they don’t even have the option of choosing one that works best for them. The intersection of knowledge and resources is so critical, and I have such respect to Wuqu’ Kawoq’s commitment to provide both of these aspects in the local language.

***

Midwifery:

On Wednesday Wuqu’ Kawoq helped me organize an all-day trip to surrounding villages to speak with midwives. In Spanish, the midwives are called comadronas. In Kaqchikel, the Mayan language, midwife is k’ exelom.

We drove through breathtaking mountains between each interview. In total we spoke with 5 midwives, walking down tree-lined paths to their house, sitting on the porch while chickens ran about and babies gurgled in swings. The comadronas are amazing women in the community. A translator fluent in English, Spanish, and Kaqchikel came with me to facilitate the interviews so that I was able to keep up throughout the conversation and respond with more questions. We heard some truly wonderful and different stories that paint a much broader picture of midwifery than I had encountered this summer.

IMG_1087

  • Midwife Calling~ the comadronas all decided to become comadronas after having significant dreams and experiencing illness until they accepted the calling. One comadrona realized her calling when she delivered her own child at age 17. Another comadrona graduated from the mandatory 1 year license training in just a few months because although she is illiterate, all of the answers to the questions came to her in a dream. Another comadrona told me she didn’t want to become a midwife, but she continued to get viollently ill until one day she helped a woman deliver her baby and instinctivley knew what to do. These are spiritual, powerful women.
  • Temascal~ one very unique Mayan tradition is for the woman to spend a lot of time in the sauna durng her pregnancy and up to 8 days after birth. One of the midwives we met with arrived at her house sweating. She told us she had delivered 8 babies that month and had just been in the sauna with the mother. It was only August 5th.
  • Midwife training~ in different regions the Health Centers offer monthly trainings for midwives to receive their license. This license is necessary for the mom to register her baby in a hospital. Some of the midwives said they found the trainings very helpful, but others said that they were in Spanish an inaccessible. Due to splintered government infrastructure there isn’t a regulated and established pathway to midwifery. After visiting Rwanda – a few years out from developing a direct-entry program, and Bangladesh – on the cusp of graduating their first midwives, I can see Guatemala being in the prime conditions to introduce an official, regulated and recognized profession of midwifery. However, the progress in Rwanda and Bangladesh came from rigorous commitment from the government and ministry of health, which the Guatemalan government is not able to provide. It is so interesting to observe different stages of the professionalism of the practice around the world.
  • Rural-Urban divide~ Although midwives are not recognized as autonomous, trained medical professionals by the official medical systems of Guatemala, they are the trusted and primary caregivers for the rural communities. Every midwife told me that a critical part of their job is referring women to the hospital and health center when complications arise. The midwives all value the services these medical facilities are able to provide, and their goal is to help the patient receive appropriate care. Yet the women doen’t want to go to the hospital. The midwives said they the biggest barriers to care are convincing the women to go to the hospital, and having the hospital staff utterly reject and discredit the midwife if she arrives. The women don’t want to go to the hospital because the staff often don’t speak Kaqchikel, they don’t inform the family of the mother’s condition, and they often discriminate against indigenous women. One midwife told me that she took her patient to the hospital and told the doctor the patient had placenta previa. The doctor banned the midwife from the hospital and left the women without care until another doctor took shift the following morning. By the time they performed the C-section it was too late for the baby. The midwife shook her head. “It is so sad and angering. They do not value us. It is simply malpractice.”
  • Local birth~ The midwives said that the women need indigenous birth centers staffed by workers who treat the women with respect and speak their language. They need better trust among medical professionals. They desire more education and more training. This follows what I found in Australia and heard about the Inuit people: indigenous people need to have the facilities to give birth safely and respectfully in their communities. Cultural clashes in the medical system leads to the death of  mothers and babies and fearfulness to receive care.

This is the first country where I have seen such a distinctive divide between the high trust mothers place in the midwives and the dismissiveness the medical system displays towards midwives. Maybe indigenous birth centers would provide further solutions for women. Maybe an official pathway to midwifery would create better trust in the system. These are all steps the midwives suggested. Despite these significant barriers to care, the comadronas continue to serve women and welcome the new generations into the world.

I have been so humbled to research here in Guatemala, where I need significant translation help and won’t be easily able to give back (in terms of my results). I do hope to translate a short reflection to Kaqchikel for the midwives who are interested to hear about different iterations of comadronas around the world. Yet they sat patiently with me and told me their stories and kissed me on the cheek goodbye. That is a gift to carry with me forever.

***

On travelling in Guatemala:

Last weekend we went to an avocado farm near Antigua, high up in the mountains. It was absolutely glorious.

IMG_0814

I have really enjoyed eating at the comadoras ~ this was an especially beautiful meal

IMG_0952

I went to mass at a beautiful church in Antigua. When I was walking out, a professor from San Diego State started talking to me and told me he wanted to convince his students to come to Guatemala instead of Spain. So I filmed a promo video encouraging his students, “come to Guatemala! The midwives are amazing!”

IMG_0923

This past week I’ve been staying with a host family in Tecpan. They have 3 adorable kids and are so gracious even though I only speak a tiny bit of awkward Spanish. I try, and Chinese comes out, and we laugh a lot. It’s a good time. My friend Kate and I made some Swedish pancakes for the family one night, and they were quite a hit!

IMG_0964

Guatemala has been a whirlwind of site visits, days in town, picking up Spanish, gawking at the beautiful views, and soaking in the last few days of travels. I’m so grateful for this opportunity to spend time with Wuqu’ Kawoq and encounter so many passionate and patient individuals.

Cheers to finding Circumnavigators around the world!

Elizabeth Larsen & (Annie) Elizabeth Carson

Elizabeth Larsen & (Annie) Elizabeth Carson

midwifery down under

*Forward: I am currently in Tecpan, Guatemala settling in with a public health organization I will be working with for the remainder of my trip. It is crazy cool here and I’m so excited to work with everyone and resist speaking Chinese instead of Spanish. Yet I’m not done chewing over last week’s crash-course immersion in Australian Midwifery, so here follows my processing of the experience.

Latest in “Who is Annie Staying with Next” Chronicles: When I knew I was coming to Sydney, a former priest in my Diocese who now lives in Connecticut put me in touch with his goddaughter who is from Georgia but now lives in Australia. She was hosting an American high school student, so put me in touch with her lovely friends the Hamiltons who I stayed with for the week. This family is so beautiful and welcoming and willing to both listen to all of my passionate opinions and offer their own. They also taught me some important Australian terms, such as to use “lolly” instead of “candy” and that “fair dinkum” is an expression for being stumped. This is me with their gorgeous oldest daughter Abbey, who is an absolute doll. I tried to take her home to add to my collection of sisters, but she gave some excuse about finishing high school… 😉

sis

Way way back in September I was referred to the University of Sydney by someone in the US (it’s hard to remember the original connections) and I contacted the dean of nursing. She referred me to the director of the midwifery program who told me, “you are absolutely welcome to come if your grant works out!”

Almost a year later, Professor Sally Tracy, one of the first midwife to receive her PhD in the world, met me last Monday and took me to lunch at a lovely café. We chatted about midwifery and travels feminism and publications. This woman has done so much in the field of midwifery to contribute solid research regarding cope of practice and especially the best context for maternal health care. Professor Tracy was educated in New Zealand, which I keep hearing is the utopia of both midwifery care and respectful relationships with the indigenous people. I do hope to visit New Zealand sometime, but the more I learned about the Australian healthcare system the more relevant it seems to care in the US.

university of sydney

university of sydney

Over the course of the week I spent a couple days at the Royal Hospital for Women which has a midwifery research department attached. There is also a special program that links care for the Aboriginal people. I spent 2 days at the Royal, and within 3 days had interviewed 9 midwives and an OB. During the rest of the week I went to the University of Western Sydney, where I met with a midwife who is speaker for the midwifery council and has done amazing work in the field. I feel so privileged to have spent the week shadowing some of the forerunners in midwifery research and policy, to listen in on the political successes and dramas, and gain such respect for the tireless work to collaborate and support midwifery practice. Midwives are just some of the most connective, supportive people to spend a summer with.

Professors Sally Tracy and Donna Hartz!

Professors Sally Tracy and Donna Hartz!

During my time, these are some of the main themes I encountered:

  • Public vs. Private System

In Australia, every resident has access to the public health system for free. People can pay for private insurance if they would like to. When I talked to doctors and nurses both in and outside of the women’s health field, everybody agreed that the public system had the best doctors and resources. Why, then, do people choose the private system? I was told that a lot of it has to do with the culture of having money and expecting that paying for care means that people will surely receive better care. Yet in the private OB/GYN sphere, women are more often told that their babies are too big, their pelvises are too small, and that a C-section would be so much easier. When a birth gets too complicated, private doctors transfer their clients to the public hospital because they have better resources. Still the ideology remains that paying money for something will ensure better care. In the private system women do have individual rooms and more fancy service. One of my favorite quotes from stunning midwife speaker and activist Hannah Dahlen was “you get a mint on the pillow and a cut in the belly.” I heard of some Australian celebrities who wanted to have a more private birth in the context of the private system. They built a separate wing onto the hospital and donated it after the birth of their child. What a fantastic example of supporting the public system. I found it so fascinating that most people agree that the public system is so superior, yet the culture of private health care related to wealth remains pervasive.

  • Continuity of Care

Professor Tracy and many of her colleagues have conducted studies of the impact of continuity of care on birth outcomes. Continuity of care basically means that a woman sees the same individual or several practitioners during her prenatal, birth, and postpartum care. One of the most striking studies shows that women who receive continuity of care have lower rates of preterm birth. Women tend to have higher satisfaction with their prenatal care and birth experience. Midwives like to develop this relationship with their patients. Yet this system has been difficult to implement in the current context of shift-midwifery in hospitals, as I found in Sweden. The best ways for women to experience continuity of care are either through home birth (which is not too common in Australia) or through midwifery group practice

  • Midwifery Group Practice (MGP)

MGP refers to practices where about 4 midwives and a doctor work on a team to provide continuous care to women. Professor Tracy developed the first MGP program in Australia at the Royal Hospital, and the midwives I interviewed loved working there. Did I mention Dr. Tracy is the best? During their pregnancy, women have a primary midwife but will also rotate appointments with the others. When she goes into labor, the woman will deliver her baby with the MGP midwife on shift, whom she has already developed a relationship with. I interviewed a few midwives who work in this practice, and they said they appreciate the connection with the woman and also the ability to not be on call 24/7. Another big theme that arose in Australia is the importance of work-life balance, where the women who are clients have good care and the midwives caring for them have manageable and fulfilling lives. Another very extensive randomized control trial showed that MGP practice has significant economic savings over standard practice.

  • Midwifery in Indigenous Populations

During my time in Sydney I spoke with midwives who worked with a link program in the Malabar Aboriginal community, where local community workers are partnered with women for antenatal care and attend their births in the hospitals. One of the most severe barriers for women in aboriginal communities is the lack of opportunity to give birth on their own land. Aboriginal spirituality is integrally connected with the land of their birth, but many of the communities do not have birthing facilities within many hours of travel. I watched a documentary comparing Aboriginal birth with Inuit birth in Canada which portrayed the difficulty women face when they must leave their towns days or weeks before their due date to give birth in a medical facility. The midwives I shadowed have been working hard to set up birth centers in these areas that provide respectful, culturally appropriate care to women. In this way also, the situation in the US resembles the issues Australia faces and both countries can work to build the broken relationships with indigenous communities.

  • Research vs. Implementation

The research shows that continuity of care and midwifery group practice reduces preterm labor, reduces interventions, reduces costs, and results in happier moms and midwives. I sat in on a class of final-year midwifery students discussing models of care, and I learned so much by listening to their stories about placements in the field. One had worked in an MGP, one had worked in a jail, one had worked in an aboriginal clinic, and one worked in a private hospital. Actually, two worked in a private hospital but one only lasted 12 hours. During the time in the private hospital, midwives who questioned the doctor were told that “they were not here for their ideas,” they spent their time changing diapers instead of coaching the moms on caring for the baby, and even had to run a non-responsible newborn down the hall to the public hospital for treatment instead of resuscitating him locally. Each midwife expressed their desire to work in MGP, to develop relationships with women and work as autonomous practitioners in collaboration with physicians. Yet MGPs such as the Royal are frequently threatened by shut-down, often by management that doesn’t adequately support the structure. I spoke with an amazing OB at the Royal who affirmed that the most essential component of collaborative care is the ability for all individuals to focus on the goals and problems at hand instead of faulting one another. His emphasis on communication for an effective team was so powerful.

I heard that recently insurance companies have begun to investigate why some births and intervention cost so much, and they are asking midwives how these costs can be reduced. Despite the research and intentions and ethics – money will be the mover and shaker. Hopefully it can make the positive difference. The evidence seems clear for what structures of collaborative care best serve women. The big question the midwives are working on and that I was left asking: when is both the culture and healthcare system going to support what mothers and midwives want?

  • Movements in the US

In a recent New England Journal Publication, Dr. Shah raised questions about the United States’ high rates of C-sections and interventions, and referred to Britain’s integrated midwifery structure as a role model for keeping birth normal. The NPR article about his perspective can be found here: http://www.npr.org/sections/health-shots/2015/07/13/419254906/should-more-women-give-birth-outside-the-hospital  I found it so interesting that the tagline indicates the allopathic medical system is normalizing home birth. While Britain’s positive outcomes and my own research supports that for low-risk mothers with access to referral may have better outcomes with at home, homebirth is not the radical point addressed in this article. Rather, the article argues that collaborative care can reduce intervention by acknowledging that midwives and doctors have different scopes of practice. Midwives are the experts in normal birth – and they know the signs of when to refer to more complex treatment. Obstetricians are the experts in high risk birth – they have spent more years of surgical training to handle breech twins and hemorrhaging. In the climate of medical hierarchy in the US, an obstetrician’s credibility has huge impact on the legitimization of midwifery in the trusted childbirth arena. To me, NPR’s tagline sensationalizes the context and takes away from the actual eureka moment of the article by emphasizing ever-polarizing homebirth.

One of the midwives I interviewed brought up this article and told me it was good news for the US. After all of the research I had heard about in Australia, I felt a little embarrassed for the US. Aha! Now we are realizing the importance of midwifery! But each society requires its own time to development, so it’s good that we are facing a transition from villainizing and sensationalizing homebirth to evaluating how midwifery care may provide sustainable support for maternal health.

Additionally, last week the filmmaker Brigid Maher released the film “The Mama Sherpas” documenting women’s experiences of collaborative midwifery units in hospitals in the US. I downloaded it and watched it on my cross-Pacific flight, tearing up many times as each family meets their baby. “Would you like a tissue with that orange juice?” I expected the flight attendant to say. The film does a beautiful job of normalizing birth. Each birth occurred in a hospital with medical resources available, but focused on continuous midwifery care whose principals are that women’s bodies are so capable of giving birth – not just being rescued from birth. The film shows midwives as qualified medical professionals and not rogue vigilante hippies, as is sometimes assumed by the expression on people’s face when midwives are mentioned. I would highly recommend a watch with a side of tissues.

Cultural change of the magnitude surrounding childbirth requires trustworthy evidence, credible endorsement, and broadening the collective imagination. The public discourse surrounding Dr. Shah’s article and this new documentary both indicate the potential movement underway in the United States. One day we will arrive at a place where women who want continuity of care and midwives who want to deliver this care will be supported by the medical system that values outcomes of maternal/family satisfaction and low intervention rates rather than economic gain and maintaining the status quo. I am thrilled to be doing this research work during such a time as this.

***

Midwifery in Australia inspired and invigorated me. I am exceedingly thankful to the midwives spending so much time with me despite being busy saving the world ❤

ANZAC bridge, Sydney

ANZAC bridge, Sydney

sources:

1. Continuity of Care: http://www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-versus-other-models-of-care-for-childbearing-women

2.  MGP: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235961/

Aussie Aussie Aussie, joy joy joy!

G’day mates – check out this croc!FullSizeRender

Ah good, now that we have the obligatory Aussie comments out of the way, let me tell you about the past 3 weeks Down Under. This island continent is so spectacular and I feel very blessed to have had extra time to enjoy the people and scenery in New South Wales. Regarding midwifery and the medical system there is so much that mirrors the US in terms of hierarchical power structures and conflicting perspectives about structuring the best maternal health care. I can’t wait to blog about my midwifery encounters here where I shadowed a fabulous doctorate midwife who is pioneering maternal health in this hemisphere and met over a dozen midwives who are truly the movers and shakers of women’s care. Some really big things have been happening in the US as well in the past few weeks, so I will definitely be commenting on those developments and how they are being perceived by other countries. It’s such a privilege to be engaged in this work in such a dynamic time.

But for this blog I just want to share my experiences enjoying Australia and becoming acquainted with the country. Due to the availability of people in both Bangladesh and Sydney I had a little buffer time to put down my research participation forms and just travel — with some of my very favorite people.

When I told people about my Circumnavigation trip before I left the U.S., the most frequent comment was, “that’s amazing! How brave! How do your parents feel about you going all these places alone?” And I had to explain that my parents are quite to blame for my wanderlust, after they took us on our first international trip to Peru to adopt my youngest sister when I was 11. After living in China for the next 3 years and travelling to many countries together, no wonder I developed the hunger to explore. So when it came time to prepare for my trip, they expressed their confidence in me, my dad helped me design a spreadsheet organizing all my contacts, communications, and appointments, and my mom loaded my suitcase with enough vitamins, probiotics, and supplements to last three months. These people, I’m telling you – such amazing humans. I seriously wouldn’t be here without them 😉

IMG_0367

just precious ❤

Once I told them I had my tickets to Australia as part of my trip, and they told me that they were going to take my sisters and beat me there so that we could overlap for a few weeks. So the day that I travelled to LAMB hospital in Bangladesh via a wing-on-fire propeller plane (that’s a good story), the rest of my family headed to Australia to visit the Great Barrier Reef and Brisbane before I arrived 2 weeks later. When I landed in Sydney (no flame on the wing) I was allowed to pass through customs despite the very strict Ebola warnings for passengers who had been in Africa recently, and hence began some quality time exploring Down Under with my people.

IMG_9458

all the girlz!

Opera by day:

it's difficult to resist taking a million pics of the opera house

it’s difficult to resist taking less than one million pictures of the Sydney Opera house

Heading to the opera by night!

daily elevator selfies was my idea...

daily elevator selfies was my idea…

We took time to wander Sydney and encounter the disputes over original residents struggling to preserve their neighborhood and developments attempting to meet constant demands for city growth.

IMG_9779

One night we attended an art gallery exhibit and witnessed striking artwork portraying themes of Asian oppression and revolution.

IMG_9566

We had such a lovely time in Sydney, Port Macquarie, and Tamworth. I loved learning about the history of Australia and drawing close comparisons with the United States in terms of colonization, relationship with the indigenous peoples, and economic/political system. I really enjoyed the time and space to take in the scenery and expanse of Australian countryside through our roadtrips.

IMG_9653

IMG_0267

IMG_0380

After planning travel in 6 countries at once, I have so much respect for the planning my dad has done for our family trips. Also such respect for his flawless picturesque poses.

IMG_0268

I loved the opportunity to visit a koala rescue hospital and a zoo where we could get up close to the animals. I’m pretty crazy about koalas now. Also wallabies and kangas are so.cute.

IMG_0157

OLYMPUS DIGITAL CAMERA

note the joey

Wallaby breastfeeding was an enlightening perspective on a topic I discuss with midwives daily.

IMG_0026

Our journey as a family was so wonderful and I really appreciated transitioning into Australia alongside my lovelies. This was our 6th continent together since 2005! It only took 10 years…. Also, it snowed so we put on some Elvis Christmas and had Christmas in July for a few minutes!

I recognize that no matter how many hours of this #92days around the world I travel alone,

IMG_0515

I couldn’t do this without my family’s love and support.

IMG_0514

More on this week’s research next time,

Annie

zen & the art of rickshaw riding: Dhaka, Bangladesh

a country – a name
a handshake and nod
may I record?
questions and response
we will be in touch
another name in another city
leads to handshake,
questions.and.response
do you know so-and-so?
invitation for homestay
shared meals and family photos
then
onto another red-eye flight
onto another country

IMG_9367

I didn’t plan to stay in Dhaka. Then I went to Sweden and learned about the Bangladesh Midwifery Society. I met a midwife who worked in Bangladesh and told me I should email another American midwife who just relocated to Bangladesh – Rondi.

Then I arrived in Rwanda. I heard about an American midwife who had worked there for 2 years and had just left for Bangladesh – Rondi. We were introduced and she offered for me to stay at her place in Dhaka.

As I interviewed more midwives in Rwanda they always mentioned Rondi, and I got to nod knowingly and respond, “Yes, I am meeting her soon!” What a connected world.

I arrived in Dhaka after my week at LAMB hospital, and took a CNG (motor-taxi-deal) with Shathi to Rondi’s house. The traffic is dense with Dhaka’s commuters – a trip Google maps indicates as 15 minutes by car easily takes over an hour. Wednesday through Sunday I had many good and inspiring interviews, but I spent most of the time in transit.

While travelling I often look around me to experience the culture through language, food, religion, weddings, and hospitality. In Dhaka, I learned that the way humans move their bodies from one place to another is much more complex and interesting and involved than I realized. This is coming from a girl who lived in China for 3  years. I have experienced “crazy” traffic and driving, roads that end abruptly and taxis that clearly heed No Higher Power. Yet Dhaka was different.

Hence my musings on the act of actually travelling. This summer I have the opportunity and resources to get my person around a whole lot of places – and usually quite comfortably. On planes, trains, ferries, buses, cars, CNGs, rickshaws, and foot I have moved around a lot. The rickshaws were especially exciting – small and open and liable to bounce the passenger off at every pothole. Often I focus on what it means to be somewhere. Be present, be engaged, be focused. In Dhaka, I focused on getting somewhere. How do you learn presence in going? Allow the going to enrapture every sense.

a view of a CNG from a CNG

a view of a CNG from a CNG

I ride in the midst of the loudest din you have ever encountered, where the beeps and toots of horns swell up from the city’s packed roads like steam after the rain. The humidity closes in as I try to move every limb as far from the other as possible for the hope of dispersing the my own heat. Frying breads tempt me to stop-the-car and purchase some lunch, but the smell quickly transitions to thick pungent sewer wafts and I pray we carry on. I taste the bottled water, warm and refreshing, in quick sips because I know the driver is fasting for Ramadan. Discretion of consumption is key. Through the CGN grails I watch the city – sometimes fly by in dusty browns with colorful splashes of saris. Other times we are still and the horizon wavers to the rumble of the engine below my seat. In the stopped moments, when boy jump off the crowded bus to wait beside the road, I am seen as much as I see. Beggars walk up to the car, “Madame… madame…” and then I feel (the heart-feel: perhaps the 6th sense?). I wait, avert my gaze, the wire grails stark. I wonder who is really enclosed in this moment. Then the traffic moves and the boys jump back on the bus and the driver moves his feet from the dashboard to the gas pedal, and I brace myself to bounce away from the human outside my CNG, an imploring madame still on his lips–

IMG_9357

***

               In Dhaka I talked with people who are leading the midwifery movement in Bangladesh. The president and secretary of the Bangladesh Midwifery Society told me about the formation of the diploma midwife program, the work to recruit students from rural communities and send them back to serve those communities, and spoke so highly of the prime minister’s commitment to meeting Bangladesh’s needs for midwifery. I visited a hospital where the labor room bustled with women, grandmas, children, and husbands. My guide told me that men aren’t allowed, but they come in anyways. This situation was a lot more supportive for the women than in Rwanda, where visitors are not allowed and women only have each other for company. From my cultural perspective where fathers are generally involved in the birth process, it was heartening to see dads showing up for their wives.

IMG_9295

(L) president (R) midwifery-award winner

(L) president
(R) midwifery-award winner

I met with the interim director of the BRAC midwifery program, which is a global health organization that runs the midwifery programs across the country. A BRAC program partners with LAMB midwives also for training. The courses are all taught in English because of the English textbooks, but this often requires the midwives from the community to learn a lot of language as part of their program. I have heard this can hinder that midwives from fully engaging with the sometimes science-heavy curriculums, so I wonder how the English language medium may affect practice after the midwives graduate and return to Bangla-speaking communities. In Rwanda, the curriculums were often in English or French, but the instructors used local language to adapt the teaching when appropriate. As I travel, I recognize the power of international information-sharing, which often requires a shared language. However, I question the effectiveness of English teaching for midwives who are specifically chosen to practice in rural, Bangla-speaking areas. How do we make education and practice accessible with language on the international and local levels?

Each person I talked to basically told me, “We have many birth attendants and no midwives yet. So we will see how it all turns out.” I feel very honored to be visiting Bangladesh at such a transitional time in their maternal healthcare, and I really look forward to hearing about the impact of new midwives working in communities across the country. This December during holiday season, be thinking of Bangladesh’s gift of midwives to the country…

My time in Bangladesh was really special, and I am excited to continue to learn how their developments unfold.

IMG_9319

Writing from Sydney – Australia on the blog next

Annie

Bangladesh with subtitles

Bangla is a language that I would get a random tattoo in*, find out it actually says “toilet,” and still be happy about it being permanently inked on my body. The script is just that beautiful.

IMG_7289

*alas, no tattoo

But the language is hard, and on this leg of the journey I experienced what it means to research in a cross-lingual context. In the previous three countries, the people I talked to were either fluent in English or knew enough for us to communicate very well. In rural Bangladesh, I conducted two of my ten interviews in English – and the rest I merely nodded along to.

Fortunately I was welcomed to work with an amazing team at LAMB project in Saidpur. This compound is such a special place. There is a hospital, school, medical training center, research department, and staff housing available to the community in northwest Bangladesh. I loved staying in the guesthouse tucked away in jungly foliage, with the hospital and research center a few minutes walk away. During my time I met doctors from the UK, New Zealand, Germany, Netherlands, and other countries. They come to live at LAMB for a few months to a dozen years to work along local staff, training, caring, and sending into the community. I was so moved by the love and dedication of these people, and really appreciated the welcome and assistance I received even though my project doesn’t immediately impact the hundreds of people who show up at the compound every day. “When I have clinical skills I’ll come back!” I promised. But once again I hope that the shared stories and words of the local experts will make the biggest impact.

IMG_8757

I really enjoyed watching the synchronicity between the hospital and the research department. In my interviews, I have really been pressing into the question of how research impacts practice and profession in my interviews, and it’s a relationship I got to witness here at LAMB. I was told that for years the hospital was practicing and providing quality care without necessarily recording all the causes of deaths, procedures, etc. After developing the research department, they were able to count and analyze causes of death and provide that information back to the community in the form of teaching and prevention. As a public health person, that intersection of practice and education gives me chills (the good kind). At the hospital there is so much already going on and so much potential  – truly a thrilling environment.

MIS/R research cove

MIS/R research cove

For my research, on day 1 I sat down with Sweety and Shathi, local research and public health rockstars, and they helped me to translate my FORTY-TWO questions! When I have the interviews in English I hadn’t realize how much my questionnaire had subtly expanded with probing questions or new developments that arise as I learn more. For the sake of translation, we had to write out everything I possibly wanted to know. I didn’t ask each question to each person – there are about 10-15 standard one that everybody gets so I will have a baseline to compare with qualitative analysis. During the interviews as I would try to track along with body language or emotional response to the questions I would point out which one I wanted to hear more from. Sometimes that just caused more confusion, so I really let Sweety and Shathi take it away.

my ladies <3

my ladies ❤

It was such an interesting experience to stay present and engaged in conversations that I was indirectly guiding through my questions, but could not understand at all. I occasionally took notes like “raised hand dramatically” so that when I get the English transcription back I may be able to interpret the emotion. The ladies are going to transcribe and translate each of the interviews and send them back to me in a few months.  I absolutely cannot wait to get the results and hear the stories told!

A few aspects translated to me along the way really indicate the unique midwifery situation in Bangladesh. Here, there are about 4 types of “midwives”: the traditional birth attendant (TBA) called a dai who tends to be an older woman who has learned about delivering babies from local experience. The community skilled birth attendants (CSBA) have received some formal training from programs such as LAMB, and are equipped to work in rural birth centers. Nurse-midwives have been the most official midwives for several years, and usually have a 4 year degree with a 6 month midwifery focus. The newest version of midwives haven’t entered the field yet. In 2012 to respond to Bangladesh’s need for more birth support, the government founded a 3 year direct-entry program that aligns with international standards. The first class of about 600 midwives will graduate in December. I asked a lot of questions about people’s perspectives on the new program, but was often told that we will just have to see what happens.

From brief translations I received along the way, a major barrier to care in Bangladesh seems to be women’s limited role in decision making. In some cases the mother –in-law or husband will decide that the mother should stay in her home instead of going to a medical facility, they will refuse treatment, or even encourage her to have an elective C-section (some hospitals have C-section rates of over 70%). High C-section rates are often due to being able to control the unpredictable, avoid the pain, and earn the doctors more money. In 2013, only 41% of birth were attended by a professional with medical training. While the first step is to equip more people to work as midwives, another crucial step is successfully transitioning these midwives into fields where traditional birth attendants still garner the greatest trust. Organizations such as WHO have presented evidence that TBAs don’t reduce maternal mortality, and as a result TBAs are not currently funded for any involvement. Shockingly, community knowledge and belief doesn’t usually adapt as quickly as international sensibilities, so I have heard criticism that Bangladesh is missing the opportunity for TBAs to be included in the process of referring mothers to receive care. I actually hadn’t heard about the TBAs losing funding until we went to a community health center and we interviewed a TBA!

She was honestly exactly what I imagined: an older lady who spoke animatedly and probably quite candidly (so excited to get the transcripts). As you see in the picture, she was quite ecstatic to meet me too:

IMG_9389

She told me that she wanted us to bring them flashlights and umbrellas so that they could make their way to the community health center in the dark and rain. I thought that was such a sensibly request and I really wish I had known ahead of time.

IMG_8859

My time in Bangladesh has been quite culturally different, but not quite as emotionally wrecking as Rwanda. A large part of that is due to the language barrier and that I didn’t comprehend many of the conversations I was a part of. This delayed understanding phenomenon is going to be very interesting. Additionally, I focused a lot more on the interviews than the antenatal cases that I encountered at the Rwandan clinics.  I did have the opportunity to shadow at the delivery ward on two separate occasions, which was amazing.

On my last day at LAMB  I spent the morning in the delivery ward and watched 4 babies be born. I loved the building anticipation and the sudden frantic miracle of each human’s entrance. I wished so badly I could have spoken with the women, encouraged them or exclaimed how beautiful there baby was. Two of the babies were born quite prematurely, and in low-resource settings there often isn’t the option to keep them in the hospital. Both Rwanda and Bangladesh has implemented strategies of “Kangaroo Care” which I don’t know much about aside from the premise of nurturing the baby by keeping him/her close to the body. I saw one mother give birth to a very tiny baby, and afterwards the mother needed a lot of medical attention from the nurses. The grandmother unfastened her sari, put the baby with a nose breathing tube to her chest, and wrapped her sari back around her. It was one of those startling precious moments that feels holy to witness. I am so thankful for my time in presence of those births.

After the week of building good friendships, we had to say “goodbye and maybe I’ll run into you somewhere else on this planet again!” I have already offered my home to so many people if they’re ever “passing through Phoenix,” which really means that my parents could be getting a lot of company!

Saidpur was beautiful and so quite compared to Dhaka, where I have been for the past few days. I shall leave these adventures for the next blog…

IMG_7127

Annie

on Rwanda, Charleston, loss, and resilience

I really love Africa. These two weeks have gone quickly, but every day has been so full. I resonate with the pace of life, the firm hand-slap-shakes, the way people greet with “welcome.”

I leave Africa with a few reflections on some heavy themes. The first is the call to bring life in the midst of loss. The second is the sorrow of war against our brothers and sisters. The third is resilience. Welcome.

Midwifery in Loss

When I arrived in Rwanda I had no definite appointments, but within one week I have had 11 interviews with 15 midwives. I have learned that the Rwandan midwife’s scope of practice is wider than both Dutch and Swedish midwives, based on their roles in maternal healthcare and their responsibilities. Midwifery has only been a registered career since 1996, so for this profession to encompass so many responsibilities in 20 years indicates that midwives are meeting severe needs in Rwanda.

When I asked midwives why they have chosen the profession, the answers have differed a lot from my findings in Europe. Five minutes into my very first interview last week I asked why this woman had chosen to become a midwife. She began to tear up.

“When I was 14 I was studying at boarding school. My mother was pregnant. One day, they came to me and told me, ‘The baby was stillborn. Your mother is in a coma.’ I went to visit my mother, and she never woke up. I did not understand why she died. I know it was negligence. I promised that I would not let this happen to other mothers. So I became a midwife.”

In these moments, the clipboard between us feels flimsy in my hands and all I can do it hold her gaze and nod. “Research” so quickly melds into raw heart. People and stories, not numbers and figures, motivate the inspiration in this field. A Swedish homebirth midwife told me that she believes that the way people are born and know the story of their birth affects the way that they give birth. I wonder if that is true with our vocations as well – the birth of calling.

Individuals here have shared so much with me. Each story holds the weight of a life’s challenges and hopes. I feel so honored to be entrusted with these stories.

I spoke with another midwife later in the week, and asked her origin story. She told me that her own mother had died giving birth to her. But she did not know this, because she was raised by her auntie whom she thought was her mother. When she was 6 years old, her auntie was killed in the genocide. She lost both of her mamas, she told me. She wants to help other mamas bring new life.

War Against our Brothers & Sisters

The Rwandan genocide which had been brewing for many decades reached its escalation in April 1994. Something that has always been striking to me is that the genocide broke out the week I was born – meaning that everyone my age and older in this country was present to the war. Those who are younger continue to feel its effects.

The genocide in Rwanda involved neighbors and family members suffering violence and death at each others’ hands due to ethnic disputes stemming from the colonization of the country centuries earlier. While this happened, the international community failed to respond. I would encourage individuals to educate themselves further about the causes and outcomes of the genocide. Rwanda’s acknowledgement of the horrors and their initiatives to remember the victims serve as examples of reparation and the desire to promote future peace. I provide a very brief synopsis because this history significantly impacts the people of Rwanda and reflects tragedies that are happening all over the world today.

I was sitting in a guesthouse with some Rwandan friends when the first reports about Charleston came on the local news. I read the English subtitles to try to figure out what was going on. Our Rwandan host shook her head. What is this?” she asked. “What is this killing of the black people?”

I didn’t know what to say. I watched with a new sense of shock and deep sadness, sitting as a white stranger warmly welcomed into the home of these friends of color, while back in my country a white man kills his neighbors of color. I don’t even know how to write about it. I know I must try – because we hurt as Americans, and we hurt as the world. Rwanda knows this story as deep and raw as any country. They name the hatred and bias, set up memorials, and build peace for the future.

A few days later I visited the Genocide memorial and sat in a room with photos of the victims. One million people killed. The hashtag surrounding Charleston kept echoing in my head: “Say Their Names.” I sat in this room with the victims and tried to see them – really see them. Feel the weight of their loss resonating with the fresh loss from my home country.

I don’t understand the violence humans inflict on one another. I don’t know what to say. When my friends asked me, I only shook my head in horror. I think what I have been feeling is that “our” pain is so much bigger than we assume. Pain is different for each person. Yet there is something about pain that is larger than all of us. What does it look like to step into that pain with one another? To listen and hold hands, to say their names and to really see them?

My first day at the prenatal clinic, an almost fully-term pregnant woman came for her initial check-up. Her body was tiny and frail with malnourishment, and as I helped her gently onto the mat I wanted so badly to will her my own extra strength to give birth. As she told us her history, she said that she was an orphan of the genocide and had taken care of her younger sister from a young age. Any medical events? A few years previous she had been hospitalized. She had been watching a documentary on the genocide, and went into PTSD-induced shock. Since she had no family to support her, she was hospitalized for over a month. I find it most easy and comfortable to categorize these kinds of atrocities as far back and long ago. But this is fresh, raw history that people embody and carry around with them. Life and death are not insular events to organize and manage, but so intimately connected. We must sit and listen and trust one another.

I went home and cried. I had no idea how to even approach this situation. The woman came too late for intervention to boost her nourishment. And I have absolutely no framework to help engage with genocide trauma. How does a person hold all this in her? Even just to know a small part of the story is nearly unbearable.

But the next week she came back. I saw her at the clinic and told her good morning and shook her hand. There is life in her – and in her child. Welcome.

Resilience

Another of my new good friends in Rwanda, Aimee, experienced much loss from the genocide. She has the opportunities and the visas to live in the US or Canada and says although she would like to leave, she feels compelled to stay. She has started two organizations: one for vulnerable divorced women, and the other for at-risk youth. She wants people to have the opportunity to work through their grief and discover themselves. “I want to write a book,” she tells me. “A book about resilience. I have seen and experienced many things in my life. And I have seen that all human beings have resilience.”

IMG_8672

My prayers are for Charleston. For Rwanda. For the midwives who lost their mothers and found their calling. For the malnourished woman with strength enough to grow a child. For all people who are suffering the pain of loss. These are prayers for resilience.

One of Aimee’s organizations is called “Living with Happiness” and can be found at www.icyemezo.netai.net

day in the life

Most of my blogs have been about rather general themes, broad impressions, and summations of my time. I thought it may be interesting to share a day in the life of a midwifery researcher in Rwanda: and today is that day.

This morning I woke up at 6am to the house helper knocking on my door for the modem USB I had been borrowing. I emerged from my mosquito net to give it to her, then fell back to sleep and had a dream wherein I was able to use my iPhone to connect to the outside world instead of just as a camera and alarm clock.

Later, I woke up at the appropriate time to get ready to leave the house with Aimee (my absolutely awesome local host), her friend and baby in tow. The plan was to leave me at a mall where I had my first meeting, and she would continue to her office. A few minutes after we left she said, “Annie, I think we may not be able to drop you.” As I was already in the car and we were on the way, I wondered how that was going to work. Fortunately, she was able to “drop me,” and I made it to the café in time for my meeting.

I met with a Rwandan midwife and clinical instructor. I ordered a French press and she ordered warm cow’s milk. We were both happy, and had a fantastic interview. I found a lot of the same ideas coming from her responses as other midwives: midwives serve women through their whole reproductive lives; barriers include a shortage of midwives, lack of resources, and deficiencies in training; and collaboration between midwives and doctors can be improved by midwives proving themselves through competency and keeping better records.

I told her I was going to Bangladesh next, and she told me that one of her instructors just moved there. “Is it Rondi?” I asked. “Oh you know her!” she said. Indeed – I first heard about Rondi in Sweden from a midwife and then from the Swedish Association of Midwives, then from Jocelyn in Rwanda, then from an email connection in Bangladesh, then from this midwife today. Rondi is a midwife who was in Rwanda and has just moved to Bangladesh, and has kindly offered for me to stay with her in Dhaka. With each new meeting of someone she knows I send her a message, and the anticipation is truly building. This is what I love about this trip so much – a month and a half ago before I left, I was planning to spend the whole 2 weeks in Bangladesh at a hospital compound. But now that I have gotten into the midwife network, I have rearranged my schedule to spend a week in the capital city Dhaka, staying with expats and meeting with people from the Bangladesh Midwife Society!!! Thinking back to my interview for this grant, a big question was why it was necessary to go to these places in person. Without all of these meetings face-to-face building trust and interest, I can’t imagine how this research endeavor could grow as much as it has. Also, just being immersed in each culture for a short amount of time has such a profound effect on the context for the research. And here I am back onto thematic elements of this journey…

After our meeting I took a taxi to Nyabagogo station to meet with another of Aimee’s house helpers Bosco so that he could take me to a hospital for a meeting in a far district. I could have taken a private taxi, which would have cost about $40, so instead I opted to take the bus route with guide, a total of $3. “It will be a good experience for you,” Aimee said.

The taxi dropped me at Nyabagogo, and I did not see Bosco. I headed into the gas station and asked the cashier if I could use his phone to call Bosco. “No minutes,” he said. Funny how nobody around here has minutes… I paid him 100 francs (15 cents) and then his phone was working! Only later in the day did I realize that I pretty much have just been bribing local people to use their phones…

Bosco showed up at the station and we pushed our way through crowded buses to get into a van with 4 benches across. The steering wheel was British – first one I’ve seen on the right side here – so that was special. We all started out with a fair amount of personal space, but by the peak of collecting passengers I counted 20 in the bus. It was during that time that the loud man in front finally noticed that I’m a mzungu foreigner, and began to chat about me with everyone in a language I didn’t understand. A man behind me introduced himself in English and asked if I could visit his NGO today. “I’m sorry, I’m very busy,” I said. When he asked for my email, I said I don’t give my contact info to strangers, and turned my head so that the awkward rejection could dissipate in the 30cm of space between us.

When we disembarked everybody laughed at us, so that was encouraging. We made our way to the hospital, where we knew to look for “Peace in Maternity.” I assumed Peace was a midwife. We found our way to the maternity ward, then were directed to the office. I shook hands with many people as we moved from office to office, and finally wound up in the director’s room. He looked just about as confused as I, but after we shook hands and I said I was a friend of Aimee’s, we both relaxed.

This was probably one of the most professional and diplomatic introductions I have had here. I carefully explained my project, and talked about how Rwanda’s maternal health development is so impressive that I have chosen this country out of the continent to visit. I saw a Swedish flag on his desk, and he explained that a Swedish mission helped build the hospital. I explained that I had just been to Sweden. Instant kinship.

After a few minutes of grilling me about the questions I would ask and flipping through my “which services fall under the midwife’s scope of practice?” flashcards, he was sufficiently satisfied with my intentions at his hospital to call in Peace the male midwife. Many parts of that entrance were rather surprising to me, but I was happy to be accepted. I took the director’s card, promised to send him my results, and went with Peace {and love & joy} to the maternity ward.

He showed me the facilities, which included a couple labor and delivery rooms and several postpartum rooms. There were three postpartum rooms: one for post C-section, one for normal deliveries, and one for other medical cases such as malaria. Each room had about 8 beds filled with women wearing colorful skirts and dresses. The most striking impression was the sea of floral and color in each room. In the last room, a toddler peeked around the door at me, I smiled, and she began to scream. Sorry, sorry recuperating mothers. I know my melanin levels are a little low today (and always…)

Peace asked how many midwives I wanted to talk with, and I said one or two is great. He led me into a room where the whole maternity ward staff of four other midwives sat across from me to talk. A mother labored behind a curtain, moaning through a contraction every ten minutes, and I encouraged them to attend to the moms. “No one is having an emergency,” Peace said. Needless to say, I kept the questions quite short.

When I asked why they became midwives, they all said because in the past many women were dying and maternal mortality was high. Such a startling difference from most of the answers in Europe, which followed along the lines of, “because I really love working with women, I wanted an autonomous medical practice, I’m so intrigued by the mystery of life.” Here, people are dying and they wanted to help.

After I had introduced myself, one of the midwives asked me, “how will this research help us?” I thought that was a brilliant question. The longer I am at this research, the more intensely I want this my work here to contribute, to actually make a difference. I am so new to the field of research, only an amateur at publishing, and don’t have any medical credibility or authority at this point. Yet my vision for this work is that through the stories of the actual experts in context, we will be able to provide a holistic vision of midwifery and the importance of the profession. “You are showing me how critical midwifery care is to the wellbeing of moms and babies,” I said. “This is such important work. I want to share this work so that midwives can continue to be supported.”

“Good,” she replied.

After our abbreviated interview, they each gave me their emails so that I could send them a follow up of the report. I am so excited that everyone I have talked to – from many hours to a few minutes – is so interested to hear “the results.” I feel like the stakes of this project grow with each encounter, but so does the knowledge and passion and life of the project. I not directing this project, I merely show up, ask, listen, and connect. I am daily experiencing the inspiration of connection.

After I left the maternity ward I {bribed} an office lady to use her phone to call Bosco, and we walked to find another bus. When we got to a station, a group of men began swarming me, “Sister! Sister! Take our bus – the best in Rwanda! Sister!!” Since I’m not in the habit of being treated like a nun (ay-oh), I took another van with Bosco and sat right behind the lady with the basket of live chickens. I passed the journey in subtle fear that a quick stop would send them flying into my lap, but they only tried to escape one time.

When people want to get off the bus, they rap on the windows or the roof. I was initially alarmed, but realize that is just one of the many examples of how complicated we make life in the west sometimes. I wonder how much the wiring for the signal buttons for every row of bus seats costs. Fist on glass is completely sufficient.

Bosco rapped on the glass, and we disembarked to walk down the road to Aimee’s house. We took a back route up a steep dirt path, where neighbor kids called out, “Good morning!” to me, and I called, “Good morning!” back. If any dear readers come to Rwanda to teach English, your students’ confusion of time-appropriate greetings will be entirely my fault, I confess. It was just so cute.

We made it back home, and now I’m drinking tea with Nido (vitamins! Calcium! Protein!) and sugar. I’m learning how to be a good guest in a local house. The other night I tried to clear my plate and Bosco took it from me and sternly said, “Bad.” So I stopped doing that.

Jocelyn told me that they often sleep early because it is so tiring to live intensively in this culture. I sincerely agree. I end each day with the heavy-lidded satisfied feeling of having lived a full-up bursting day. I have several more specific stories I want to share before ending my time in Rwanda this weekend, but I thought it would be interesting to provide a window into the daily life, which hopefully explains why I walk around constantly suppressing a giggle, always with my eyes open to what may unfold next…

Introduction to Rwanda

Rwanda and I are just getting to know each other. I came here about 6 years ago, when we were all still babies. It was my first time in Africa. We went on a breathtaking Kenyan safari, we stayed with our expat friends the Johnsons, and I got to explore this country from the perspective of a kid in the family. I am so grateful to have gotten to know a bit of the country so that years later when want to return to somewhere in Africa, I felt ok coming back to Rwanda solo.

carjohnsons in rwanda

see, babies every one

Fortunately, “solo” this time around actually means incredibly supported by wonderful via-via friends and families here. I have been staying with the Jelsma family who has lived here for the past 7 years. Jocelyn is a Canadian midwife, mom of four, and an absolute super hero. They have focused their lives on supporting the people in poor urban communities of Rwanda through quality maternal health care. She told me their story: they spent a few years providing health teachings in the village, and began to ask the community what their needs were. The community decided that one of their biggest needs was access to prenatal care, and so the Jelsmas worked with some other organizations to set up a prenatal clinic right in the village. This model of partnering with locals to address community-identified needs is such an inspiring model for respectful, effective, and sustainable health development work. As I have spent that past week with Jocelyn, I am blown away by the wisdom she and her counterparts bring to community health work: always focusing on the voices of the local populations and building alongside them.

IMG_8371

They have spent the past 5 years building a clinic that will serve the woman of Nyabisindu in pregnancy. The layout of Iranzi clinic is absolutely gorgeous – with triage rooms, labor and delivery rooms, training rooms, prenatal rooms, and postnatal rooms, a laboratory, pharmacy, and other rooms which I have forgotten. A ramp wraps around the whole 2-story building so that women can walk continuously during labor. They have solar heating and a water collection and processing system so that they can generate their own resources. The clinic will be open to all women of the community, regardless if they can pay. Income from postnatal private rooms will offset the cost of women who are unable to pay. It is all there: sustainable, accessible, and so intentionally designed to serve individuals and the community for years to come. The clinic is in the final stages of registration and staffing and will open this fall. The whole halls crackle with anticipatory energy, and I truly hope to come back to visit Iranzi in the future.

view of Nyabisindu from the wraparound porch

view of Nyabisindu from the wraparound porch

motivational caption about Jocelyn on the path to a successful beginning

motivational caption about Jocelyn on the path to a successful beginning

I spent a day at the Nyabisindu prenatal clinic with Jocelyn, where about 40 women came at different stages in pregnancy to get check-ups and referrals. Clients sit on a mattress in one of three curtained rooms, and the midwives sit beside them on a mat. I love that Jocelyn sits down on the clients’ levels, sometimes even kneeling before them. The posture is so humble and focused. She does not “do health” to the woman, but moves with the women, describing and asking permission. “It’s important to gain their consent, as in other settings that may not happen,” she said.

Nyabisindu clinic

Nyabisindu clinic

Jocelyn and I saw about 6 patients for their initial visits on that day. Most women were happy and healthy and ready to keep growing and soon meet their babies. Jocelyn caught risk signs of enlarged thyroids or high blood pressures and referred the women to health clinics with detailed instructions. I was able to witness how absolutely critical midwifery care is in these low-resource settings – midwives can be the main care practitioner in a woman’s life who can detect health issues for her that may be unrelated to pregnancy. Here, midwives are saving lives every day through spending the time to really see the whole woman. Midwives understand the realm of normal health and pregnancy, and have a keen sense when problems arise. Just as in Netherlands and Sweden, midwives are the first line of care for healthy pregnancy. But here, they are often the first line of care for women period. I’m blown away by how crucial their role is in this setting. We spent so much time with each woman that I feel so invested in their stories and curious about their futures.

The postnatal clinics on Thursday provided some happy resolution for the anticipation of childbirth. I joined Jocelyn for rounds to check up on moms and babies, where they come from the first few days after birth to when the child is 6 months old. Women came to the tent with babies nestled into cloths tied on their fronts and backs. One of the midwives said you can tell the age of the baby from the length of leg sticking out around mom’s waist. We congratulated mamas and cuddled sweet babies and Jocelyn reassured moms and referred for further care when necessary. Tuesday felt tight with anticipation, Thursday loose with life. It was such a privilege to be there amongst women bringing new humans onto this earth and women helping them through the process.

beautiful mom and baby <3

beautiful mom and baby ❤

This has only been my sixth day in Rwanda, which is hard to believe, and my third day doing interviews. I have really appreciated the time to shadow Jocelyn in her daily work, listen to both hard and joyful stories, and walk slowly to receive the cadence of life around here.

first midwife interview!

first midwife interview!

***

In the next few blogs, I want to share some stories that have been shared with me this week. I have been pondering them and crying with them. I want to offer the first to you today to sit with and to respond as you feel called, in thoughts or prayers or reaching out.

***

A tall and deeply beautiful woman with a white blouse and green floral skirt around her 6-month belly sits on the mattress and we fold our legs on the mat. This woman has come from special circumstances with International Justice Mission. She is 17 years old. Jocelyn asks the woman’s story.

She starts with her family – her elder sister and brothers. She says that she was going to school and was doing very well at math. She wanted to stay in school, she never wanted to be pregnant.

At the age of 16 a 24-year-old man coerced her to sleep with him, and afterwards he drugged her. She woke up in a brothel in Uganda. She was forced to service 12 men per day. Later on in the checkup when Jocelyn asks about drugs or alcohol, she says yes – constantly. Alcohol and marijuana were always provided, just to keep her together.

As she speaks, she ducks her head. Swipes her hand across her face. We lean in to listen as the IJM worker translates. Jocelyn’s hand is on the woman’s legs. We all cry. This is real life Half the Sky and Human Rights textbooks. She is here, in front of us.

She intentionally developed a sexual relationship with a guard so that he could help her to escape. She made it back to Rwanda. She is now pregnant and she is HIV positive. She lives with her family, but they do not support her. They are afraid that they will contract HIV so they do not share dishes. They are ashamed that she is pregnant. Her older sister was also involved in sex slavery, so their mother is devastated.

Her original attacker was in jail, but the jury claimed that the prosecution delayed evidence, so he has been released. He lives in her same district, and the guards are aware of him. But still, he remains in her neighborhood.

As the midwife, Jocelyn touches the woman, looks her in the eye, and asks many questions. Her role is to care for the health of the mother and the baby. And this whole story is of the utmost importance.

She says that she plans to breastfeed her baby and return to school. Jocelyn spoke to her with translation. “Thank you for sharing your story. You are the bravest woman I have ever met. What those men did to you was wrong. It was not your fault. There was nothing you could have done. You are not responsible for this. You are so brave. You are so beautiful.”

There are no words for the abuses and horrors this young, young woman has suffered. You don’t expect to write “sold” on a health history record.

Jocelyn plans to see this woman as her private client and is hoping to raise the funds to have her deliver in a private facility, instead of the government hospital. She can serve this woman with her presence and her skill. She will touch her gently and advocate for her and encourage this woman’s own power.

This has not only been my introduction to Rwanda, but to some of the bravest humans I have ever met. I feel so honored to have shared moments of life with them. I know that they will stay woven in my heart.

midwives in Sweden: dare to deliver

IMG_7293

I love having my GPS dots on Sweden’s map. Helsingborg – Gothenburg – Stockholm. From the south to the west coast to the east, I have learned so much in this beautiful country.

In April, when my school semester was at its peak I received an email from my contact in Gothenburg, a professor midwife named Helen. She invited me to stay with her family and also arranged a full week of activities. After interviewing 8 certified nurse midwives with PhDs who are senior lecturers at their university, I have a much deeper understanding of midwifery practice in Sweden. Some of the midwives I spoke with have been in practice for over 40 years and have experienced the restructuring of the maternal healthcare system. Others have worked in Ethiopia, Yemen, Afghanistan, Bangladesh (!!), and the US. I met another midwife who works with the UN to collaborate on strategies for the professionalization of midwifery in developing countries. I walked away from that interview in a delicious daze, thinking I’ve found my dream job.

My visit in Gothenburg coincided with the OptiBirth Conference about keeping C-section rates low in Sweden and Europe. I heard from researchers from Ireland, Germany, and Italy discuss how midwives and obstetricians can work together to facilitate more normal births and decrease the rates of unnecseaery C-sections. I loved hearing how different European countries are collaborating on research and development of practice to provide best care to women.

IMG_7418

Anna, Helen, and I

just giggling with some midwives

just giggling with some midwives

After my week in Gothenburg, I took a train to Stockholm bopping to ABBA Gold because I was born in the 90s and raised in the 70s. The train cross-sectioned the country from Gothenburg, and I’ve determined it’s the only way to travel in Sweden. The landscape is too breathtaking to miss by taking those metal bird contraptions. The countryside was gorgeous and my jaw kept dropping as we passed by another red house tucked away in a patch of trees, or a sudden expanse of sparkling lake. Travel by wilderness roller coaster with some catchy sappy tunes in the background – all about it.

I arrived in Stockholm, spent the night with a family friend that my uncle knew from college, and then came to the city to stay with one of their family friends. My next blog post will be about the wonderful relationships and travelly details – I’m going to focus on my expanding understanding of Swedish maternal healthcare in this one.

Here’s the down-low: Sweden has had educated midwives for over 300 years, and was actually the first country to keep official birth and death records. The maternal healthcare system is more medicalized here than in the Netherlands, with the majority of women giving birth in hospital. Midwives have a larger scope of practice than in the Netherlands, however, by providing primary contraceptive care to all citizens, especially through their youth clinics.

casual pee-testing station

casual pee-testing station in a youth clinic

While in Netherlands midwives have more continuity in their relationship with their patients, Swedish midwives have autonomy over a broader range of care. Many midwives have explained to me that through centuries of political negotiations, midwives have established responsibility for all normal childbirth. The strength of Swedish midwives has been derived from their organization in the Swedish Association of Midwives, global influence in connection with the International Confederation of Midwives, WHO, and UNFPA, and by midwives’ professional contributions to research. I have met so many midwives with PhDs who sit on medical boards and develop protocols for delivery care along with obstetricians. Sweden’s organization of the midwifery profession has been a model for countries all around the world. In Stockholm, I called up the Swedish Association of Midwives just to see if I could potentially talk with someone. Although it was last minute, they welcomed me to come in – and the secretary of the whole association spent 2 hours talking with me about their history and current issues in focus. Their headquarters is located in the building that used to be owned by Stig Andersson, the manager of ABBA, and we met in his old office. Talk about Mama Mia! (you know, because we were talking about mothers and their rights to excellent care…).

IMG_7911

with the editor and secretary

The ladies from the association were so welcoming and supportive of my work, and I can’t gush enough about them and this process of learning about the history of a noble and important profession that extends into the future of providing excellent care for the continuation of the species. So humbling.

I learned that Sweden is invested in many countries, including Bangladesh! They have written several publications together and have put me in touch with some people who are working to develop the profession in Dhaka. I am really hoping to meet with some of them in a few weeks. This web of connections continues to grow so organically – like a wonderful Swedish crime fiction novel with all of the intrigue but without the crime and it’s actually non-fiction!

Today I talked with a midwife who has worked in practice, research, teaching, and with the WHO in Geneva. She told me that Sweden has two especially important messages to contribute to global midwifery: The first, that midwives want to and should have the competence to broaden their scope of work to the comprehensive reproductive and sexual healthcare realm. The second, that midwives are not the second best solution for the healthcare of healthy, normal pregnancy and childbirth – they are the best option. The second best option is when countries abandon midwifery as they become more advanced. Midwives work with women to keep birth normal as long as possible through avoiding medicalization and intervention. She told me that other countries say to Sweden “you are a rich country, how do you still have midwives?” In response, Sweden realizes they need to continue to repeat the message that a country doesn’t have midwives just because they can’t afford doctors – a country has midwives because they can afford to invest in midwifery care for all women.

As I have spoken with over a dozen midwives in Sweden, a common term is often used: to dare. I spoke with an American friend who has spent her life in Sweden, and she explained that in Swedish the word “dare” does not carry quiet the same weight as in English. However, as the Swedes are rather shy people, actions that may shake up the norm or defy political correctness are considered to be daring. Here ideas that Swedish midwives expressed:

“With midwives, the patient dares to be sincere”
“Midwives dare to ask questions”
“Do we dare to increase women’s expectations for their birth experience?”

That last question especially resonates with me. What do we dare?

I have been invited to attend the graduation of midwives from Uppsala University tomorrow. I am so excited to celebrate the next cohort of midwives entering the world to serve both men and women during their reproductive lives, empowering the individual through competent care.

-Annie