Besos & Home Sweet Home: Perspective

Cientos de besos

I've been struck by the warmth of the welcome we've received here.  We've been invited to dinner in family homes as well as restaurants with beautiful night views and been thanked over and over. But best of all, we've received hundreds of kisses, as it's the Guatemalan custom to greet and leave each other and us with a cheek to cheek kiss.

Yesterday was a day where we realized the fruits of our labors.  The second year Ob/Gyn resident physicians transformed from students to instructors in front of our eyes. After an often hesitant performance in the workshops the day before, Jacky, America, Feby, and Silvia lectured to their superiors with confidence and then tactfully corrected their errors in the hands-on workshops. These young women are now certified ALSO instructors - I am certain they will put their new found skills to great use.  Our hearts were bursting with pride for them!

The girls kissed us all goodbye and we were whisked away to a dinner hosted by the Chief of the Department!

Signing off with muchos besos,

Sarah M

----------------------
Home Sweet Home

It's late, and I'm tired. I look in on my daughter, fast asleep. She has
hair the color of wheat and is holding on to the dimples on her knuckles
for a little while longer, though she keeps getting taller. She's five. And
one quarter. Which is important when you're 5 1/4. I'm proud of all the
little ways she's making her mark in the world. Though she's shy, she's
making friends in Kindergarten and getting invited to play dates. Though
she's cautious, she knows her abilities well and climbs high into trees.
Though she just learned the sounds of the letters, she writes long
soliloquoys on pieces of printer paper, sometimes creating entire
illustrated books.

She is my inspiration.

She was born just after Mother's Day, and every year on her birthday I
renew my commitment to her, and to the women and girls of the world in her
honor.

All over the world girls grow up without an education, forced to work at an
early age, lacking access to clean water, nutritive food, and medicines. In
many countries they're married off as early as 9 or 10, but frequently by
15. Many of those same places offer very little to protect her from
unwanted pregnancy, and even if a pregnancy is desired, her chances of an
early death, or of losing the child due to complications, are very real.

800 women die every day in childbirth. In the nations with the worst
outcomes, the risk is 23 times higher than it is where I live and was born,
in California.

My daughter and I could have easily been born in one of these countries.
Statistically, we should have been.

But we were not, and so every year I am grateful. And every year I think of
ways I can save the life of another woman's daughter. Or share the gift of
education with another mother or child.

There are many ways this could be done. The challenge is to find the most
effective, and look for partners on the ground to support who will continue
the work. Maybe one day my daughter and I can do this work together. Maybe
someday I will have more than 10 days a year to spend on this work. But
this year something magical happened in just 10 days. Seven women, all of
them daughters, many of them mothers, traveled together with a shared
mission to improve maternal and child outcomes in rural Guatemala.

And I got to be part of this team!

My teammates were incredibly smart and organized, yet so warm and humble.
We partnered with the beautiful comadronas of Totonicapan and surrounding
areas to learn just as much as we were able to teach. We partnered with the
majority-female OB/GYNs and residents of Xela and Huehuetenango who work
incomprehensibly difficult shifts with almost zero resources for the
reasons we all share.

Women like Mercedes, younger than myself but already an accomplished
attending physician, who is pioneering a model that invites the lay
midwives to collaborate with the physicians to improve the health of rural
women. Who spends her rare off hours with her tiny precocious curly-haired
daughter Eva and her mother Norma who brought the ALSO course to Guatemala
years ago for all these same reasons.

Or like Pamela, a second-year resident who lives 2 1/2 hours away from her
7 year old daughter, so she can complete her training in obstetrics. She
sees her child just 3 weekends a year. When she's home it's all about her
daughter. But when she's at work, her life is about saving the lives of
others'.

These are just exactly the sort of women who can change the world.

We worked hard for those ten days. But it was the sort of work that never
feels like work, so full of laughter and relationship-building.

I hope one day I have this sort of opportunity again. I know I'll keep
searching.

But for now I look in on my little daughter and can't believe how much love
there is in the world. One more goodnight kiss. It's good to be home.
--Allison Bacon

Trial and Triumph…and Appreciation

Trial and triumph.

My first blog post ever, and also my first week as an ALSO teacher (actually I’m currently an “instructor candidate”, so not even official yet.)  While I’m talking about firsts, it’s also my first time in Guatemala, and I’m having a great time.

I have been so inspired by my colleagues both from the U.S. and here in Guatemala.  At the core we have a group of people who are passionate about women’s health/maternity care and who are all working together to share information and to improve outcomes.   Our first session was with the Comedronas (midwives) who provide care in rural areas with information passed down from generation to generation.  The ones who came to the course Mercedes organized are the ones who are especially eager to learn and improve.   We hear that 25% or so in the field don’t practice basic sanitation practices like hand washing.  This omission leads to higher rates of infection and sepsis and women at risk for critical illness.  This basic education is a priority for our colleagues as well.   Many of the GPs here also do deliveries (often home deliveries) – I had a great time learning about their management and when they refer. 

The OB/GYN specialists here in the hospitals work hard with long hours and limited resources.    They have a 40% cesarean section rate, which is likely because higher risk people end up in the hospital/and also that there is limited access for other options.  Our ALSO workshop on vacuum deliveries was very well received and doctors are very interested in this way to avoid some cesarean deliveries but for one problem – very few hospitals have access to the vacuum devices.    They are hopeful that the Minister of Health will continue to learn about the needs for the doctors and hospitals so funding will be improved.  We are also hoping that a protocol for amnioinfusion (putting fluid back up in the uterus when there is a cord being squeezed with contractions) might help decrease the c/s rate as well. 

Yesterday we taught the first ALSO instructor’s course in the past 7-8 years.  I’m currently watching one of the OB/GYN residents who took the course yesterday give a lecture on bleeding in pregnancy as an instructor candidate.  She’s rocking it.   They do the ALSO course very frequently here, but we have a different perspective as we are using many of the techniques being taught and can provide practical knowledge.  Ultimately the program is self-sustaining, with an occasional bolus of updates and new energy. 

Many of the instructors in our group have taught in several other countries (including the US) and are adapting to this curriculum with ease.  Many are faculty at our Kaiser program, or for Audra at Touro, and all of us teach residents on the labor deck.  It’s pretty amazing seeing what people have already done and their ideas for the future -- all with an inclusive and collaborative approach. 

I can’t help but think as well about the great amount of need that we have at home in the U.S. too.  The fact that we have so many resources and are such a wealthy country and STILL have Moms and children that are hungry and that have trouble accessing safety and care – well, we need to keep trying to improve.  I’m hoping to take some of this energy and use it in ways that count at home as well.  I challenge everyone to pick one thing to do to help improve the life of someone else – whether it’s keeping watch on an elderly neighbor, picking up medications for someone sick at home, bringing extra food/produce to a food bank, or writing your legislators to support a social program that you believe in.  And for everyone who does so much already – thank you for making this world a better place.   You inspire and humble me. 

Rebecca Darsey

PS: For my son Bryce – here is a bridge – I don’t think I can find you a roller coaster.  Love, Mom.

And from Audra Lehman:

Appreciations for my Team

Sarah J: Our den mother and the force behind this whole venture. An incredibly capable woman who makes things happen, and makes them happen to the highest standards. She’s always on: planning, monitoring, checking in and offering support (massages!) and feedback. Also, photographing continually! Improvising on the spot, she keeps the big picture and the littlest details in mind all the time.

Isabella: I couldn’t wish for a travelling companion with more warmth, intelligence, humor and grace. In addition to the nurturing attention she shows each of us, her dynamic translation is that kind that you always hope for: she has the medical knowledge and cultural awareness combined with such a strong commitment to making sure that students really get it. 

Sarah M: A perfect example of “don’t judge a book by its cover”. She’s an elegant, blond haired, blue-eyed surgeon who grew up all over Asia! Tough as nails, but lovely and kind at every step, I want her not only as my OB consult, but style consult too.

Candace: What a delight! She’s the only one among us that is still in her residency training, although her level of maturity and ability belie that status. She’s strong and smart, a problem solver with a passion for education. She’s “no drama”, but plenty of fun.

Rebecca: Steady and positive, always in good cheer and making heroic efforts to communicate in Spanish. I really admire that no matter how hard it is for her to be away from her little boy at home, she has traveled far because of her commitment to keeping women and children safe here, too.

Alison: My roommate, and that couldn’t be more perfect. Our neighbors say they hear us laughing at night. We have so many shared values and interests despite our completely different backgrounds; we could talk pretty much endlessly. And best of all, she sings me a beautiful lullaby at night.

Mercedes and Julio and Eva Marie: Our amazing hosts. Endlessly gracious, patient and attentive, it’s been truly precious to get to know these special people. I harbor a small fantasy of returning to study with Dra. Mercedes, then cover her service so she can have a vacation! I hope to stay in touch with this family and see how little Eva carries forward her amazing family tradition of love and service to community.

Audra invited edits to her post above--the only edit I have is to share my appreciation for Audra:

Audra is a born educator.  She is fun, smart, warm and dynamic, and she knows how to win an audience.  Committed to effective teaching, she incorporates various methods to engage learners and ensure a quality experience.  And…the woman can dance!  And sing!  She showed courage by joining an all KP-team, and she makes our team complete!  Hopeful this trip will be the first of many…thankful…sj

Worth the Effort: Getting to the "Mountaintop High"

It's the end of another day in Xela.  We are now 2/3 of the way through our 6-day teaching mission, and we were so tired by the end of the day, we skipped salsa lessons and chose a quieter evening instead.

I have to admit, the day started off a little rocky.  I'm not exactly sure I should blog about such things, but it's the truth.  And I don't want anything I share to be misconstrued--no complaining or criticizing here--but the pressure I felt trying to get the Instructor Course off the ground came to a head when the day-long course got started an hour later than scheduled.  Knowing that at least one of the participants would need to get to the hospital in time for overnight call, we knew we'd have to make some adjustments in the schedule.  Several students came over an hour late from the already-delayed start (fortunately, these were just a couple), and of course I was concerned that the quality of their experience would be diluted.  But I keep learning that there are some (many) things I cannot control and are not ultimately my responsibility.  I'm learning that sometimes, no matter how much I might want or prepare for something, no matter how much passion resides within--I cannot measure success by how beautifully a plan comes to fruition.  And I'm learning that often-times, the challenges become opportunities for creativity and grace and that things almost always work out in the end. I'm thankful to have friends who prayed with me, across the miles, in the moment.

And…I'm thankful for this group of volunteer teachers, who have the uncanny ability to adapt quickly, improvise and flex to meet the needs of the day.  No one of the teaching faculty (besides myself) had ever taught in an ALSO Instructor Course before, but they were more than willing to engage in this opportunity.  We felt the expectations were high, since the last Instructor course was in 2007 or 2008.  And watching them actively engage the participants--you would think they were old pros.  And since they all enjoy and have experience teaching, it's not surprising that they were so effective.  That's actually one of the things I appreciate about the ALSO Instructor Course:  it's less about the ALSO Content and more a faculty development course on such topics as principles of adult learning, preparing  & practicing"dynamic" lectures, complete with immediate verbal and written feedback (no head-nodding or constant iPhone checking!), working with "challenging learners" (via assigned roles not revealed to the teacher) in small group settings, teaching cases, teaching with mannequins, and teaching how to conduct and score the megadelivery exam.  There was AMPLE laughter as every single participant quickly transitioned into role play to make the learning experience richer.  There were insightful moments, times to share about prior teaching experiences, ideas shared on how to cope with "frustrating" teaching circumstances, and time to reflect on teaching philosophy.  Every physician is a teacher--of patients, families, and one another--and I'm sincerely honored to have the opportunity to participate in the course of lifelong learning that is medicine.  This transcends generations and cultures.

Over the next 2 days, 4 of the (22) instructor "candidates" will directly apply today's course as they teach alongside our team in the second ALSO Provider Course of the week.    Stay tuned!

 The first part of the Instructor Course involves short lectures and demonstrations by the teaching faculty.  Rebecca and Isabella discuss how to incorporate mannequins into hands-on workshops.

 Candace, serene and always at the ready.

 OB residents from 4 hospitals participated.  A few practicing obstetricians also attended.

 The participants practice their teaching skills on one another.  Such a joy to witness!

 Sarah M and Rebecca engaging in active role play with the participants.

 Allison (above) and Audra (below) facilitate the lecture/feedback workshop.  They are fantastic facilitators!!  After each student delivered a ~5 minute lecture, the student was prompted to give a self-assessment, and then the group invited to provide feedback. So meaningful--both for practice and especially in real life.  How often do we stop to reflect on our actions?  On our words? On how we're fulfilling our jobs/responsibilities?  And how often do we solicit or provide meaningful feedback?

 More practice teaching...

 Anny was enjoying her "assigned" student role!

Below: a few night shots of Xela's city center--the square is defined by picturesque buildings, and the narrow streets branching outward into the city lined with eye-catching windows.

A bumpy start culminating in an amazing ride--the Instructor Course was truly a success--that was topped with a tasty meal at Luna Cafe, known for its delectable chocolate (yes, we all enjoyed a chocolate beverage!) and eclectic antique/artistic decor, and finally the opportunity to FaceTime with some of my beloved.  With a heart full of gratitude and joy--sj

Flexibility

On Flexibility

Flexibility—it’s a concept I think we all subconsciously realize is essential for effective teaching, but these past few days here in Xela have really driven the point home, and pushed us to put it into practice. Whether it’s attempting to communicate (for me, anyway) in my kindergarten-level Spanglish, or adapting curriculum on the fly based on cultural or national differences in practice, I have been much more aware of our educational choices.  How we manage our time, what content to include or discard, how to structure group sessions—all of these become deliberate decisions as opposed to rote protocol. It’s an invaluable (and perhaps too rare) opportunity to come at teaching from a fresh perspective and consider ways in which we can improve our own skills. 

For example, during the practical examination yesterday, we found that many of the learners consistently forgot to consider anesthesia/pain control when preparing for operative vaginal delivery.  As it happens, regional anesthesia is not routinely used in labor here, in part because there is insufficient funding for this in the public hospitals—no wonder, then, that this isn’t something that the learners would normally think about.  Serendipitously, we are teaching another ALSO Provider Course tomorrow, so we’ll have the chance to make modifications based on what we have learned from our students. It’s been such fun to be surrounded by so many enthusiastic and talented educators—just the process of debriefing each day and brainstorming ways to improve is like a little master course in teaching and course planning.

I’ve also been impressed by the flexibility of our learners here. They have graciously and patiently allowed us to participate in the teaching of these courses, even when it means that the lectures run longer due to the translation process. Many of the residents have attended the course after 36-hour calls; most of them have had to round at their hospitals before arriving at the course each morning, and some have to return to the hospital afterward in the evenings. None have complained that we’ve asked them memorize lengthy English-based mnemonics—one in particular for vacuum deliveries, which few of them have ever seen or done due to lack of access to the equipment.  Instead, they have been curious, involved, and active participants, which makes it all the more exciting to have so many of them attend the Instructor Course and become the teachers for future generations of learners.

Now if only we could all get some more flexibility in our schedules to be able to have these kinds of experiences more often…!

--Candace Pau

Candace and Sarah M share a lively moment

 Allison engages learners practicing hands-on skills

 Audra is demonstrating suprapubic pressure

Active teaching! by Isabella 

 The students share sweet camaraderie

Dr. Maria Mercedes Ancheta Gonzalez hard at work--she is a passionate visionary with a busy OB practice!  She has made us feel very welcome, and it's a privilege to get to know her.

 As Candace alluded to in her blog post, vacuums are not readily available in most Guatemalan hospitals.  Still, some obstetricians have access to them, and ALL the students are interested in learning the indications and proper way to apply them.  With decades of experience, Sarah M demonstrated very effectively.

 I'll let Audra tell you why she's cracking up.

After a full morning, we took an hour "walk about." These photos are a brief glimpse of the people and colors we saw--hard to capture scents, but imagine bustling city streets with cars, buses, pedestrians, and motorcycles, the smells of fresh tacos and empanadas...

Yes, we purchased our fair share of fruit and vegetables!

And...

 Allison, in her healthy glow, got a papoose/colorful carrier for baby #3.

While we ooh'ed and aah'ed over the colorful fabrics stacked just so... 

 We returned in time for this group photo of the ALSO Provider Course 12-13 October.

The slide in the background highlights a "pilot" ALSO lecture from Colombia.

Candace and Audra facilitate the "megadelivery."

We had an excellent course! 

 Although we were pretty exhausted from such a long two days…

We were honored to be invited to dinner at Dra. Silvia's mother's totally cool/modern restaurant that boasted colorful balloons and thematic rooms surrounding a courtyard with a view of an historic church.  We are truly blessed.

And on that celebratory note, there's more to come following today's instructor course--22 participants--amazing interactions, lots of laughter as we hone teaching skills, role play, and provide timely feedback to one another.  

I could not be more thankful for this group of amazing women--fun, smart, creative, resilient. --sj

Renegade Scissors, Duct Tape, and Comedronas in Totonicopan

“If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”

-       Nelson Mandela

There were languages aplenty in the lecture hall at the Hospital Nacional in Totonicapan today for our first course for the midwives—between English, Spanish, and K’iche’, the process of communication was sometimes challenging, sometimes lengthy, and always intentional. Yet, strikingly, a common language emerged, which transcended national, cultural, and socioeconomic bounds. The love of obstetrics and the commitment to enabling safe childbirth for mothers and babies was obvious among the women gathered in the room today. 

Some had been delivering babies for over 35 years, others were brand new to midwifery and had yet to see their first birth. One had traveled 3 hours by bus to be with us for the day. All of them were undeniably dedicated to their profession and were eager to learn and share their experiences. 

In our small group sessions with the mannequins, one of the most seasoned midwives demonstrated for us what she would do when she attended a birth. The joy in her face, her eyes twinkling as she swaddled the plastic baby and meticulously cleaned off the mannequin—it was unsurprising that she drew a crowd of her peers, who gathered to watch her work and hear her share her expertise. 

In the end, I suspect that we learned much more from these resilient, passionate, and wise women than they did from us today. But as hopefully the first step in creating a lasting relationship between these midwives and the physicians and nurses in Totonicapan, this was an incredible opportunity to meet one another, break bread together, and get a glimpse in to each others’ worlds. That they were able to share with us their beliefs, concerns, and needs will be hugely helpful in determining how to design future programs to be most useful for their practices.

It is hard to put into words how humbling and inspiring it is to have spent the day in such amazing company, and also to be reminded of just how ancient and beautiful an art it is to bring life into the world--something we have practiced since the dawn of humanity, yet that we can continue to learn more about everyday. 

--Candace Pau

What a day! An early start – Chapin breakfast with frijoles, platanos, tortillas and salsa verde. Que rico!

Sarah M. shared information from an interesting article she found on lay midwives in Guatemala. The maternal mortality here is 140 per 100,000 pregnancies, which is 5 times higher than the US, but really, Israel and Belarus are the best places to be pregnant (MM 1-2/100,000)!

70% of births here are attended by lay midwives, and occur at home. Instead of trying to suppress midwifery practice, the government has instead tried to improve outcomes by increasing the capacity of the midwives through certification and ongoing education! The midwives usually speak one of the 24 different Mayan languages, often no Spanish, which complicates the government efforts for standardized education.

Dr. Mercedes arranged a course with a group of midwives who have brought patients to the hospital before, and went through an application process. When we met the women, we were enchanted by the beautiful embroidered huipiles they wore, the years of experience they carry, and the dedication they demonstrate by coming all the way to Totonicapan from their villages: Momostenango, Santa Maria Chiquimula, and Canton Poxlaqui to join with us in the class. Each introduced themselves formally with their full names, their region, an expression of gratitude for our being there and their eagerness to learn.

They wanted to learn about prenatal care, were concerned about the poor nutrition of their Moms, about their observation over the years of increasingly difficult labors and complicated pregnancies. They wanted to learn about causes of hypertensive disorders of pregnancy, late pregnancy bleeding and newborn anomalies. They also want to bring this information to their colleagues that don’t have the capacity to come to trainings like this.

These are women that are more than willing to bring their patients to the hospital when complications arise, but also face significant barriers in doing so. Logistical barriers seem obvious, but even moreso, they describe patient resistance. The women want to deliver in their homes, in whatever position feels right to them, with all their people around, and they don’t want vaginal exams and episiotomies.

The midwives shared stories with us about their experiences: Dominga was probably in her 30s when she got her calling to midwifery. It happened in a  dream where a long haired woman in a long white gown insisted that Dominga attend her labor, even though she had no experience in this. This woman talked her through every step, teaching her everything she needed to know, from how to massage and position her, to how to manage the placenta. Dominga awoke disconcerted, but 3 days later put all this information to use when a neighbor asked for her help in an actual delivery. She’s been a midwife ever since.

We learned about the herbal baths they prepare on the first postpartum day that brings in the milk, the cleansings in the temezcal, how they help Mom to nurse, etc.

We were especially impressed with their amazing palpatory skills: one woman diagnosed triplets with her hands, later confirmed by ultrasound; another described diagnosing oligohydramnios; others found malpresentations such as footling and frank breech. These women are on the frontlines, they provide prenatal and pediatric care in addition to attending deliveries, and even field questions about general medical care. No wonder they are anxious to increase their knowledge base.

The midwives that were present today feel a sense of obligation to share the information they have with their colleagues who can’t access the hospital. Some have over 3 decades of experience. They care deeply about their communities, love what they do, love the Moms and babies (even cuddling the mannequin babe and treating it tenderly!), and love, and are proud of, the traditions that they continue. We all felt inspired by these women and hope to return to work with them more in the future.

This training was the first of its kind. It wasn’t sponsored by the government, but by the Totonicapan Hospital. Dr. Merecedes is dedicated to serving this community, much like her older sister who is a radiologist and her incredible mother, Norma.  Norma is a Family Physician who trained in Albequerque and returned to her home country to teach and practice medicine.  She continues to teach at the University and brought ALSO here in the first place in 2004 after learning about it in Albequerque and helping to introduce it to Ecuador!  Her vision is far-reaching--ALSO is well-established at the medical school in Xela, and she is now considering ways to sustainably teach comodronas.   She welcomed our entire group over to meet more family and enjoy a delicious pepian – traditional Guatemalan chicken stew. And maybe a michelata or two.  

--Audra Lehman

Introductions--THANK YOU Isabella, for serving as our interpreter much of the day!

Providentially, Rebecca's scissors made it through security…AND she thought that "having duct tape might be a good idea" on the trip.  Well, both came in handy when we learned that the comodronas wanted to learn about exams.  A few snips here and lots of wrapping…and we ended up with great ad lib teaching models (see Audra demo).

Audra and Allison set up for the hands-on practice.  

Isabella in action!  The comodronas were eager for the opportunity to share their knowledge and demonstrate their skills.

Sarah M is fully engaged as she helps two comodronas deliver this baby (mannequin).  

Rebecca and a comodrona share a happy delivery. 

The comodronas--who serve in different areas--teach one another.  Love this collaboration.

Las manos de vida--these are some of the hands that welcome life into the Totonicapan community.  The stories they tell...

Dr. Mercedes gave us a tour of the hospital--here's  view of the delivery room.

A shout out to Harrison, who asked about the Guatemalan skies…brilliant blue with dramatic clouds.

Keep looking upward. --sj