A Long and Winding Road

My last days in Nicaragua were spent adventuring deep into communities of the north atlantic coast. Cody was sent on a mission to inspect a small saw-mill operation in the pine wood savanna, and I eagerly accompanied him for a chance to explore and get out of the city. We boarded the sleek grey truck that virtually has no shocks left, leaving us bumping up and down the road as if we were in a truck pimped out with hydraulics in a live action hip-hop video. The road is bumpy, but our driver, Chaparo, is skilled at dodging the large craters that abound. It has been raining the past couple of days so at least the road is moist, no dust to cover us from head to toe, filling the gaps in our teeth as I have experienced in past adventures on the roads of the north atlantic coast. We wound our way through the grasslands, stopping to pee and realizing that the small yellow flowers that are populating the green fields were minuscule orchids. We head deeper and deeper into no-mans land. we pass communities from which women who have stayed at the Casa Materna live: Ena in Santa Marta, Tasba Raya, Tasba Pawni... At some point hours down the dirt highway we turn off and begin our ascent into pine, mahogany, and madrone covered hills with views of the mountains of Jinotepe in the distance. The scenery is breath taking. Eventually we weave our way up and down, over and through dark, earthy-mud to arrive at the saw mill. Now, i'm not the kind of girl that knows alot about saw mills...I leave that kind of knowledge of machines and engines to Cody...my interests are in health. What struck me the most about this saw mill and the small communities around it were how isolated they actually were. I finally understood the importance of a place like the Casa Materna. I could conjure up images of medical emergencies, sense the urgency, and palpate the despair of feeling trapped. What if someone cut their arm off on the saw mill? would they make it to the small clinic in Francia 1 hour away by vehicle in time? would they then make it to the hospital before it was too late? Just a few days prior a log (basically a tree) fell on one of the employees crushing him. A makeshift cot was made out of sheets and branches and then fashioned to the skidder (the only available vehicle) and he was then carried down to the health center, later to be transferred to the hospital. There are no emergency plans in place, and what happens if you have no access to any form of vehicle. I guess the answer was seen in my previous story of the man carrying his seizing wife on a bicycle to the medical post.

It was standing in a small community like this, drinking coconut water, and watching the women herding their many children when I really got it. I really understood how difficult it must be for a woman to a) make the choice to leave all her children, walk the 8 hours to the highway to then find a ride to Port, and then spend an indeterminate amount of time at the Casa Materna, or b)stay at home, birth her baby and pray that there are no complications. Access to healthcare is a common theme of discussion in the academic world of nursing/medicine, but we are usually talking about how to market medicine to encourage patients to engage in preventative health, or reach populations that are on the fringes of society (i.e. prostitutes, IV drug users, homeless, etc.); but in this case access to health is a strictly logistic issue. How on earth do you get to the hospital when you have a long and winding road separating you from it and no money to get there. How do you get medical care when your personal knowledge of risks, emergencies, and your own body is as limited as your access?

My last days in Nicaragua were spent in the lush tropical town of Waspam contemplating these questions. Waspam is the second largest city in the North Atlantic Coast. They have no super market, no gas station, they only sell tomatoes, onions, and cabbage in the market. What they do have is a fabulously long river that separates Nicaragua from Honduras with unknown quantities of indigenous people living along its borders. I had gotten to thinking back in Port about how we could provide better access to people, specifically women living out in these distant communities...Sonja and I had come up with a fabulous idea that has started to take more shape and became more important to me as I visited communities and sat in my hotel in Waspam listening to the rain patter outside. So the conception of our next project has taken place...it may be a pregnancy of more than nine months but it will be nourished and fed until the birth of Mairin Karna (Strong Woman) a one hour radio program on Women's Health is broadcast in Spanish, Miskito, and Mayagna throughout the North Atlantic Coast! Knowledge is power, and if we can reach the women out in the communities hopefully they will in turn be able to reach us!

Well I have ventured down my own long, winding road and have arrived once again in the US. I am on the brink of beginning my official studies to become a midwife and am ecstatic for the opportunity to learn more and become more skilled. I hope that all of my beloved readers have enjoyed this leg of the journey...stay tuned for more!

Last Day at Casa Materna Bilwi

The Little Icebox that Could

One of the goals of this adventure in Nicaragua was to assist the Casa Materna in establishing a small business to help them gather funds to send laboring women to the hopsital in taxis. As far as a business plan goes, this business would seem as complex as setting up a lemonade stand. Easy...buy one refirgerator (icebox in Miskito), buy many pounds of sugar, some fresh fruits, mix them up in buckets, store in aformentioned fridge, sell to the public...voila! The only problem is that this lemonade stand is in Nicaragua...and as I have come to learn, nothing is as easy as it seems here. I know I elaborated a bit on my struggles trying to purchase the fridge before: various trips to El Gallo mas Gallo, a blue and yellow facade that has become so familiar to me I could probably arrive at it sleepwalking; my battles with the credit card machine, and my frustration with the sheer lack of customer service required to don the yellow polo shirt and blue pants of an El Gallo employee. Well, a few weeks ago I acomplished the unthinkable... I bought the fridge. I felt like a super power, or some exotic bird puffing my chest out and wagging my tail feathers with success. I mounted the blue flatbed truck that would deliver my shining white pride to the Casa Materna, all the while ensuring that the delivery boys did not lay her on her side thus destroying the cooling mechanism. I circled the machine as they laid it down on the cement floor of the Casa. She was beautiful: a classic freezer on top, fridge on bottom model...white-white, and the cool air would just pour out of the freezer when you opened her door, exposing her to the heat and humidity of Port.

The day after the purchase I did what only any right minded Nicaraguan would do. I went to buy locks to put on my fridge. Obviously you cant just give anyone access to the fridge, otherwise she would stand empty, sad, in the corner. So Cody and I headed to the Casa Materna with two hinged closures, two locks, several screws, and a drill. The first drill hole went in smooth as ice. My success was growing by the minute...soon we would have the fridge and it would be on lock down. The next two holes didnt seem to go as deeply...it was impossible to put the screw through. I poked around a bit with the drill bit and said to Cody "it seems like there´s something there...you just need to drill in a bit more" he said "are you sure you want me to drill in more" and I said "definately...go for it!". Within 4 seconds the hole was drilled and a forceful stream of Frion emerged from the hole until my poor, beuatiful fridge was sucked dry of life. I was in a panic...was it possible that just 12 hours after finally purchasing this machine that it was dead? what could I do, who could help me? This sentiment ended in a long string of disinterested repair men who have left my ice box half functioning...but better than dead. First there was the old school sandanist, fidel castro-esque hippie who came to fix my fridge. rather than patching the hole and refilling the tubes he decided to cut the line and build a new system behind it. so confident was he in his work that after quoting me an exoribtant gringo price to fix the fridge he did not charge me for the work. I returned to the casa the next morning to find the fridge hot and bothered. This repairman returned the next day with a young man that we will refer to as the "welder". He repaired the work of the first repairman...again not charging me. Then there was the chubby, metal head that took one look at the work and never came back. Lastly was the "contractor". He assured me a working fridge and an under the table situation in which he would certify the work so that I could still use the 5 year additional warranty that I had bought with the fridge which was rendered nul after piercing the tubing with the drill. It was a deal too good to be true...1000 cordobas and five days later the work was never done. After a wild goose chase the money is back in hand, but my fridge will never be her glorious, chilling, original self.

So...as of today, the fridge is working...kind of. If the freezer isnt opend for two full days everything fully freezes. The fridge will keep frozen stuff cold. The women all tell me that they like their boli more luck slush than frozen solid anyway...maybe its for the better! As far as the business side of it goes we are selling boli, and frescos, and cold water (rather than ice) to the community and the women at the Casa Materna. We have made over 500 cordobas, and have re-invested three times to purchase pounds of sugar and nancite fruits to make more fresco and boli. I guess all-in-all its working; working as well as any business could possibly work here in puerto cabezas. We have officially sent three laboring women to the hospital with money from the business. Given everything I would call it a success. As for my little icebox...I hope she keeps on chugging along...she has a strong spirit. And I blame her loss of frion not on me, or Cody, but on Nicaragua...a country in which its necessary to put a lock on a fridge.

More Photos

The faces of birth in Puerto Cabezas

In matters of birth the outcome is generally positive. A woman labors, a baby is brought into this world and it is celebrated. In a place like Puerto Cabezas you not only have the joy and beauty of birth, but you must also contend with the reality of when birth goes wrong. I have this personal or spiritual beleive that at the moment of birth a veil lifts between the worlds of life and death...mostly the baby passes through into the world of life...but occassionaly the veil falls on the side of death and either mom or baby leave this world.





On Monday I went to the hospital to volunteer. I arrived in my freshly cleaned, line dried scrubs. I walked back to the sala de labor y parto and waited as I engaged in the usual conversation with the nurse: where are you from, are you a nurse, how many kids do you have...oh when you do have a baby it will come out blanco, blanco, blanco, etc. After about three hours with no action and no one in labor in the maternity ward I decided to visit Dr Aragon who was on call in emergency. I sat with him for about a half hour as he reviewed children all suffering from the same litney of symptoms: cough, fever, lethargy, vomiting and/or diarrhea. After about the tenth child screamed with tears streaming down their face when he asked to see their belly I felt exhausted. It was in that moment that an ambulance arrived and a stretcher was quickly guided into the emergency room. One minute later a white clad nurse peered her head through the door and yelled nervously "we need a doctor". Aragon was on call so he left the weeping children and scurried into emergeny...with myself tailing behind to see what was going on. On the stretcher was a young woman pregnant with her first baby. She looked possessed as her dark, milky eyes rotated back and forth in her head, as her thick tongue proturded from her mouth, and her black, silky hair billowed about her face. She wore a green hand sewn top and a yellow skirt that was soaked through with urine and feces. Her husband had carried her on a bicycle early in the morning to the town of Rosita, several hours away by ambulance. He thought that when she began convulsing in the morning that it was a normal progression of labor. He later began to fear for her life and placed her on the bicycle. We received her in the emergency room with full blown eclampsia, a disorder of high blood pressure that can occur in pregnacy that almost never evolves in the US which manifests as convlusions, extremely high blood pressure, and at its worst coma and death. In a disorderly fashion the nurses began grabbing the womans arms and legs to prevent her from falling of the stretcher as she seized; her blood pressure read 220/140 (normal is 120/80); the doctors started shouting orders to hang normal saline with doses of magnesium sulfate to stop the convulsions, and I started cutting the womans clothes off to prepare her for surgery. The only way to truly treat eclampsia is to deliver the baby STAT in order to save the mothers life. As I cut through her skirt that was hand altered to fit her growing belly I was swept by a tidal wave of emotion that brought tears to my eyes. how does a woman become so ill in her pregnancy and not know it? how is a disorder that is treated in the US able to manifest in to such a life threatenng state? The emergency room was tense with the severity of the situation. tubes were running into her arm carrying the magensium sulfate, a nasal cannula was held against her nose to provide oxygen, and a tongue depressor was shoved into her mouth to prevent her from biting her tongue. After three boluses of magensium sulfate her body finally quieted. Her limbs lay at her sides, her head tilted upwards, her eyes empty. She was rushed to c-section. In the morning I found out that she had survived. I counted it as a miracle, never having seen someone in such an acute obsetric emergency. Sadly, her baby did not survive.

I was overwhelmed by the experience. I headed back to labor y parto to gather my things and walk home to clear my head. As I started down the hallway a woman was being pushed towards me in a wheelchair in full blown labor. I figured this birth had to turn out okay...so i turned around and followed her back to the room. She wore a fitted, red, v-neck shirt and a camoflouge mini skirt. There wasnt time to get her out of her cloths. We had her get onto the birth table, setting her legs in the black leg supports. I donned a glove and checked her. My fingers barely entered and grazed the babies head that was just about to emerge. The mother screamed with fear that she had had an ultrasound that showed the cord wrapped around the babies neck, and the doctor had prophesed that she would require a c-section to save the baby. I explained to her that it was okay; that we would just lift the cord off of the babies neck like pulling off a necklace. She shot me a pleading look and told me that she had seven boys and this would be her only girl...she had to live. With that she bore down and her little girls head was out. The cord was quickly lifted from around the babies neck and the rest of her body slipped into the world. Tears flooded the mothers cheeks as she heard her little girls first cry. In a moment that I will never forget, the mother grabbed my hand and said thank you. A thank you is hard to come by in this side of Nicaragua, and I will always remember it as a testament of how important it is to be caring and understanding of a patient, particularly in their most vulnerable moment, no matter where they are or in what language you are speaking.

This day in the hospital showed me the faces that birth can have...the fears that women bear, the real ife emergencies that can occur; the joy and the saddness that can ensue. It was a powerful day to say the least!

Funny, Fantastic, and Frustrating

In this blog i decided to take the opportunity to relay some of the things that have been said to me that made me laugh out loud, or that seemed really interesting to me, or situations that were down-right frustrating...yet all illustrate what day to day life in puerto cabezas is like...

fantastic...cody´s amazing connection with a man named chico down at the pier. on any given day we can drive down to the pier, pull up in front of his small, yellow painted, wooden shack and collect pounds of fresh caught monster crabs, or lobster tails. chico has also been known to hook us up with half of a red snapper or some delicious fresh conch meat! all we need to do is get the butter, cody cooks it up, and we are feasting of giant claws!

funny...Ena and i were talking about our families one day. She asked me how many sisters and brothers I had, and nodded politely as i told her i had one of each. she then asked me if i get confused when i would see my sister, mistaking someone else for her, because all white people look the same! I explained to her that i am pretty confident of who my sis is! Earlier in the year I had attended a global health conference and during one presentation the lecturer mentioned a study that was conducted in which people of a similar color are able to distinguish between people of the same color better than those of a different color....case in point!

funny...Dr. Aragon likes to ask me all kinds of questions about the United States. I think he is either trying to flex his knowledge to impress me or to dispell myths. One day he told me how people in the US dont have sex. He then said that all we do is work and so there isn´t any time for sex. He explained that this was different from latin america where everyone makes time for it. I told him it wasn´t true...its just that people in the US use more birth control than in Puerto Cabezas!

fascinating...Miskito women follow many tradtional practices related to birth, post partum, and care of the newborn.
-Several of the women at the casa materna have not participated in learning to crochet or embroider. come to find out these women have a beleif that if you crochet or sew during pregnancy that this will cause the babies cord to wrap around its neck.
-Many woman are known to use teas of commonly found herbs to stimulate labor. this is the oxy-casera that i refered to in an earlier post. They also protect themselves from wind/cold entering their body after birth. This is a common preocupation of women throughout all of latin america, yet their preventative practices are different. Women here put cotton balls in their ears and cover their head for 9 days postpartum to prevent wind from entering their body and affecting their uterus. Similar to other latin american cultures women will make tea from rosemary in a large pot and sit over it to steam the uterus and release any wind or retained placenta.
-As far as newborn care women put a red plastic band that has a large brown seed as large as the newborns fist, around the babies arm to ward of the evil eye which is known to cause diarrhea, dehydration and death. the baby is also fed 1oz of a tea of cumin or fennel 3xdaily after birth to help expell all of the meconium (babies first poop) and prevent colic. Women are also advised not to do any sewing post partum because this can prevent the babies umbilical cord from drying up and falling off.

frustrating...trying to start even the smallest business in puerto cabezas! since my arrival i have been planning on starting a small business to sell frescos, ice, and boly at the casa materna to gain more funds for them and help provide money for transportation of the pregnant ladies/new moms. Everything moves in slow motion here...you make a plan to go look at fridges and it ends up taking a week before it happens. then you find out that the store is waiting for a new shipment that must be hauled through the mud and crater like pot holes of the "road" from managua, so you want to wait to see what they will bring before you commit. the shipment of course will be in at 4pm that same day...but one week later it finally arrives. then when you finally try to make the purchase the credit card machine line is down. it will be fixed by 4pm. its fixed 4 days later. then they arent sure how to use the credit card machine...then they learn...then you find out that they don´t take master card. then you use your debit card...but a block has been put on it...then you have to go to the internet cafe and use skype to unblock the card, and after four attempts (because the connection gets lost) you finally get it unblocked. then you realize it has been 3 weeks and 9 hours and you still havent got the fridge...but you are close, closer than ever before!

now we will see how long it will take to make the frescos and sell them. my goal is to sell just one bag of fresco before my little plane takes me back to managua then once again to san francisco! All frustration aside, if it was as easy to run errands and accomplish goals here it wouldnt be puerto cabezas...it would be the states and it would lose all of its charm and tranquility!

Oxy-casera

After last Sunday´s experience I made two decisions: 1) to return to the pile of used clothes to search out some scrubs, and 2) to return to hospital Nuevo Amanecer Bilwi to work in the labor and delivery department in the evenings. I was successful and found two pairs of lavender scrub pants, both of which were worn out in the crotch that I later repaired on the sewing machine at the Casa Materna, and one green and one blue scrub top. I excitedly donned my mismatched outfit, feeling quite professional and ready for any action that the hospital might show me. My first day at the hospital Cody dropped me out front of the locked chain link fence that encircles the teal blue painted hospital. My scrubs were the lock to the door as the watchman ushered me through. I walked through the maze of open aired halls, peeking my head into the various rooms filled with 4, 5, 6, or 8 beds in which whole famiies languised with their sick loved ones. I kept walking until I found the aluminum framed glass doors of the Labor y Parto wing, the only part of the hospital aside from the surgery suite that is air conditioned. Just inside the door I met Julia, who has been an obstetric nurse for a hundred years at Nuevo Amanecer. Within two hours my first scrub clad birth took place, as a slight twenty something year old woman pushed her third baby out into the world. The birth was fast and the contractions fierce...later I came to find out that the girl had been drinking a birth promoting tea that many women in the community are known to consume. It is compared to the hormone Oxytocin, a synthetic version of which is given in the labor room to stimulate birth, both concoctions are known to increase the strenght and frequency of contractions. At the hospital the tea is refered to as oxy-casera...casera means homemade! After the birth I quickly scooped up the baby and did all the basic Puerto Cabezas nursing practices including Vitamin K injection, Antibiotic eye cream, weight, temperature, and measurments of head, thorax, and length. A very exciting day at wrok indeed!

Even more exciting was my next day at the hoispital. I worked with nurse Clara who is reknowned in the community for her years of service to birthing women. She trains the new resident doctors and is often called on at home by poor Miskito families that don´t have the money to reach the hospital. She told me stories of being called to homes when a girl had been convulsing for two hours, due to bad spirits per the family, but due to eclampsia for those who beleive in western medicine; of breech babies with their legs dangeling out of their mothers, and babies so big that it took all her strenght to pull them out; and lastly of her baby that she adopted when a young mother abandoned her child in the labor and delivery wing thirteen years earlier. When I arrived to the hospital one of my patients, Luciana, from the Casa Materna was dilated to five centemeters and pacing in the Labor y Parto room. Swipe from your mind any image of a high tech labor ward, and replace it with concrete floors often covered in blood spatters as the cleaning crew has yet to clean up the remnants of the previous birth, imagine two cots in one room with a curtain as a door rather than a private room with sweeping panoramic views of the san francisco bay, and then picture the birthing room as a concrete floored operating suite with three brithing tables from the 1950s with leg supports, but no foot supports, lined up side by side in the event that three women are in labor all at the same time...its a bare bones kind of birthing center if you get my drift. Although the birthing room lacks certain comforts there is something about its simplicity that seems to traslate to the births that I have seen. Granted, I´ve only seen three births in that room, none of the women had any pain medication, because its not an option, but the women were so elegant and graceful in their birthing. No moaning, no crying, no hours of pushing. There would simply arrive a moment when the women would climb up onto the birthing table, ask for their dilation to be checked, be at 10cms, and pushing their babies out 5 minutes later. Quite striking! Well, back to Lucianas birth...the obstetric nurse Clara was checking Luciana and said that she was 9cms. She told me to glove up, that I was going to attend to the birth. I told her "uh-uh, I don´t know how to do that"...then she said "there´s only one way to learn" and thats how I ended up catching my first baby! She had me check the neck to see if there was a cord and then pull down and then up on the babies head (with alot of force which was unexpected!) and then grab under the babies arms as I pulled him from his mother and laid him on her belly! It was totaly exhilirating! Its wonderful to be in a place like Puerto Cabezas where I have the opportunity and freedom to learn in this hands on way.

There are so many things that I want to say about birth at hospital Nuevo Amanecer...but I´m still putting words to my thoughts...right now there is a lot of blood, dirty floors, stoic mothers, legs agape, arms akimbo on the birthing table, and then there´s me drying off the babies, bringing them to their mothers, and feeling so much hope and very low expectations all at the same time. I think that as I spend my evenings at the hospital my feelings will become more articulate....right now I´m still riding the wave of having caught my first babe!

The Casa Materna

Sonja, the nursing director, and Burse Magda at the Casa Materna with the new doppler



Luciana, Jessenia, and Hazel at the Casa Materna listening to Ena tell her birth story.



Ena and her new baby with a hat that I crocheted...Ena taught me how to make the hat!