According to the 2017 Demographic Health Surveys (DHS), approximately 23.5% of women in Haiti reported sexual and physical violence committed by a partner. Many experts feel that the statistics about gender-based violence in Haiti are even greater than the numbers reported by DHS. Haiti, like many other developing countries, has structural socio-economic inequalities and barriers that implicitly enable gender-based violence (GBV).

The unsafe living conditions in the temporary displacement camps set up after the horrific 2010 earthquake are major contributors to the increase in violence against girls and women. After the earthquake, many non- governmental organizations (NGOs) “set up house” in Haiti to provide services to victims. Despite some progress in assistance and resources that were organized to fight violence against women following the earthquake, conditions have deteriorated for women during the months prior to June 2015. At that time many post-earthquake NGOs left Haiti, resulting in the decrease of services and resources over time.

As trusted health professionals, midwives play a critical role in supporting and caring for victims of GBV. The Association of Haitian Midwives (AISFH/Association Infirmière Sage Femme d’Haiti) recognizes GBV to be a significant problem facing their patients. Given that GBV is a complex issue with multiple layers of consequences that can be psychological, physical, economic, social, legal, and cultural, AISFH requested to have additional training in this area in order to improve their skills in performing trauma-informed care for victims.

Midwives are often the only care provider that a woman will seek care from in her lifetime. Empowering Haitian midwives with the knowledge, skills, and sensitivity required to work with GBV victims creates a sustainable model of care. Haitian midwives are part of the community in which they live and work. They are in the optimal position to provide culturally sensitive and evidence-based care to Haitian victims and survivors.

From November 6th to 9th, FAHM (Foundation for the Advancement of Haitian Midwives) hosted a four day conference for Haitian midwives on GBV in Port-au-Prince Haiti. Twenty two midwives from 7 of Haiti’s 10 departments were in attendance. The topics and discussions of the conference required self-reflection and examination of personal ideas and biases related to violence, sex, and barriers to seeking care. These included cultural and societal norms affecting health, sexual and reproductive health, respectful and privacy-protected care, principles of trauma-informed care, types of gender-based violence, human and women’s rights according to Haitian law, medical exam of victims, the medical-legal aspects of reporting and ethics, and professional development.

We were honored to have formative presenters, including SHOG (Société Haïtienne Obstétrique et de Gynécologie) and Monique Manigat, a Haitian psychotherapist based in Haiti with Billion Women Rising Ayiti. We thank our partners: AISFH, Every Mother Counts, Rona Jaffe Foundation, Global Health Action, and NYC Midwives.

The Foundation for the Advancement of Haitian Midwives (FAHM) works to improve maternal health through a model that promotes leadership, networking, empowerment, and education for Haitian midwives. They have been a partner of Every Mother Counts since 2017.

At the intersection of midwifery and gender-based violence was originally published in Every Mother Counts on Medium, where people are continuing the conversation by highlighting and responding to this story.

Here is an update from Robin Lim, Founder of Bumi Sehat, who traveled to Sulawesi as a first responder to help mothers and families in desperate need of water, food, and basic medical care.

Today began with a loud bang, caused by a 3.0 earthquake tremor…some 6 miles beneath the Budi Agung hospital in Palu, Indonesia, where I was sleeping.

Two weeks ago a 7.5 magnitude earthquake struck Donggala, Sulawesi, Indonesia. Minutes after the Indonesia’s National Disaster Reduction Agency declared that there was NO tsunami hazard, a tsunami of 3–6 meter waves funneled death and destruction through a narrow Sulawesi Island channel. It decimated the cities of Palu (population 350,000) and Donggala (population 300,000). Liquefaction followed: huge areas of loosely packed, sandy, waterlogged soil were transformed into quicksand. Houses floated like barges. Villages of 1,700 families were swallowed into the liquid earth. The underreported numbers of missing is staggering. Search and rescue efforts are hopeless. Next, as if Sulawesi had not already suffered unimaginable sorrow, Mount Soputan in the North erupted.

Due to the kindness of people who donated to support Bumi Sehat’s work in Sulawesi, I found myself traveling to Palu. Two midwives, three nurses, a doctor and 280 kilos of medicine and disaster relief supplies arrived with us at a heavily damaged airport. Staircases were jimmied up with expansion rods. Walls missing large chunks of cement wobbled while a generator grumbled. The air traffic control tower looks like Godzilla stepped on it. Dozens of Military C130 Hercules airplanes, helicopters and what appeared to be armored tanks were all over the tarmac.

Representatives of Budi Agung Hospital had arranged a truck to pick up our luggage, and Gordon of Direct Relief was waiting with a 4-wheel drive vehicle. We were soon laying eyes on a city betrayed by nature. Buildings left standing teetered on the verge of collapse. Multi-level shopping malls were pancaked. Thousands of people camped in fields under blue tarps and plastic bags. Many still hoped missing family would be found alive. Most are too full of gratitude for having survived the multiple disasters to yet realize the scope of their losses. Shattered lives, sleep shivering cold, equatorial heat in the day hours, scavenging for food and potable water. Now it rains in torrents. The speed with which the Indonesian government has restored road access and phone communications to Palu though is astounding, considering the intensity and enormity of the disasters.

Team Bumi Sehat organized the medicine and supplies into two huge waterproof duffel bags. I found a group of early responders camped by the coconut vendors, young men from Bandung Java, with maps and satellite photos, pinpointing areas too vulnerable to Liquefaction to enter. I asked where medical relief was most urgently needed and they said Sigi. “Relief teams ran out of medicine and food as soon as they come to Palu. Sigi is hard to reach. Yesterday they suffered a tornado. “A tornado! You must be kidding!” I yelped.

Sonia, an early responder from Jakarta, organized a vehicle to bring us to Sigi. On the way the tire blew out. We had Arjuna and his trusty 4-wheel drive Jeep, with broken windows. But we needed one more vehicle. We actually found a willing driver and 5-passenger sedan via Grab, as it began to rain again.

The devastation was astounding. We passed areas devoid of buildings, where Liquefaction left only a trampoline-like skin of earth, grafted from somewhere kilometers away. We stopped to allow the vehicles to fuel, not easy, and impossible just days ago. As we drove up country, the rain let up, and the air became chilly and foggy.

We inched by landslide after landslide. Broken bridges caused us to take many detours, we got lost many times. As we climbed the mountain, earthquake damage was less apparent. People lived in wooden plank houses made by the farmers themselves. Someone had introduced cocoa trees to the region, but the people had yet to tap the market, and fruit fell to the ground, unharvested. The main food crop seemed to be singkong, aka cassava.

After 3 1/2 hours on the road, we arrived at an only slightly damaged community building where dozens of people waited.

They suffered the common illnesses of poverty and trauma. Elders sat calmly, seeking vitamins for emaciated grandchildren, only admitting to headache and blurry vision when we found their blood pressure was frighteningly high. There were wounds to dress. Conversation included the shock and damage done by the tornado that rampaged through the village of Uenuni in Sigi, only yesterday.

The day was long and hot as patients crowded into the small room. People politely left their rubber slippers at the door, they laughed easily, Muslims leaned against Christian neighbors in the plastic chairs, we knew they were dressed in their best dusters.

Nearly all of the pregnant mothers had lost babies in the past, most also suffered hypertension, all were malnourished. We dispersed vitamins and advised them to eat more of the leafy greens from their gardens. Fish from the ocean was not marketed at all since the tsunami, anyway it’s too expensive.

It was dark night and still raining when we finished. We had helped 200 patients before the hypertension medication and children’s vitamins had run out. There was a 3 hour drive back to Budi Agung hospital, in Palu. The road winded steeply downhill, punctuated by landslides, which we skirted while we spoke of some of the patients. Another main bridge was washed away, another detour.

Then a traffic jam loomed, as people backed away from a rushing river where a main road was only this morning. Considering the bridge was out, our only route to Palu was to ford the flood waters. Our four wheel drive would of course make it but the rented sedan was a risk.

The driver Bapak Sar had warmed up as he saw our efforts: he had never seen medical care dispersed freely before. He laughed and hollered, “Time to pray!” as he backed up then hit the gas. Waves higher than the car parted, and we actually screamed. The car smoked but we made it. A few meters later, another flooded roadway, smaller, less water, and we had more courage. At last we arrived, to a surprise warm meal provided by the hospital crew.

A cold bucket bath, an honest bowl of rice, some mosquito repellent and rest in tents. Tomorrow, we begin again at dawn.

Ibu Robin Lim is the Founder of Bumi Sehat, which works in Bali, Indonesia, to reduce maternal and child morbidity and mortality and to support the health and development of communities. Bumi Sehat provides general health services, emergency care, prenatal, postpartum and birth services and breastfeeding support, as well as healthcare and youth education, environmental and disaster relief programs.

Updates from Sulawesi, Indonesia was originally published in Every Mother Counts on Medium, where people are continuing the conversation by highlighting and responding to this story.

Today, International Day of the Girl, complications from pregnancy remain the leading killer of girls ages 15–19. In Haiti, about 14% of girls this age are already pregnant or have children. Many girls experience violence and sexual abuse: about 70% of girls and women have been exposed to some sort of violence.

At Grace Community Birth Center in Grand Bassin, Terrier Rouge, in northeast Haiti, midwife Ninotte Lubin works with adolescent girls and young women, teaching them about their bodies through comprehensive sex education, organizing crafting workshops, and distributing cloth menstrual kits in coordination with Days for Girls.

Ninotte is a Certified Professional Midwife who trained for five years with midwives in Haiti and the United States before achieving certification with the North American Registry of Midwives in 2015. Since that time, she has been working to develop a three-acre plot of donated land into a fully functional birth and community education center. So far, the property has a well, a covered educational facility, an extensive garden (with peanuts, plantains, beans, moringa trees, lemon and orange trees, cherry trees, and coconut trees), and twenty-five bee hives.

Ninotte currently conducts prenatal and post-partum visits for pregnant women, but the main focus of her work thus far has been on the educational program for girls aged 13–20, in response to requests from the community to help its adolescent girls.

Since January 2017, Ninotte has been teaching sexual education classes to groups of 70–90 girls twice a month. In the classes she covers topics such as the female reproductive system, nutrition and teen health, identification and prevention of sexually transmitted infections, teen pregnancy, healthy relationships, and sexual and intimate partner violence.

As of June 2018, Ninotte has also been coordinating crafting workshops, where the girls learn skills and create products that they can sell. These workshops give value and enrichment to the girls’ lives and help to discourage them from falling into prostitution, which is very common among this age group.

In partnership with Days for Girls, Ninotte has also distributed nearly 100 cloth menstrual kits, which help the girls to go about their daily lives including school and work without interruption from their menstrual cycles. Without the kits many of these girls would use any piece of cloth or rag they find to deal with their period, without concern for hygiene and their own health. The kits, and the education that Ninotte provides along with them, encourage the girls to take care of themselves and to practice healthy habits.

Grace Community Birth Center is currently raising funds to build their birth center, where Ninotte and other midwives will be able to hold prenatal and postpartum visits and deliver babies, and continue working with adolescent girls, to help ensure they have a bright and health future.

Tara Mulder is on the Board of Grace Community Birth Center.

Celebrating the International Day of the Girl in Haiti was originally published in Every Mother Counts on Medium, where people are continuing the conversation by highlighting and responding to this story.

Common mental health problems, such as depression and anxiety, that occur during pregnancy and in the year after child birth are highly prevalent globally. In developing countries, the rates are much higher than in high income settings. Women and girls who live in poverty and who experience violence are particularly vulnerable. In South Africa, about 1 in 3 women will experience depression or anxiety during or after their pregnancy.

Poor maternal mental health not only has adverse effects on mothers, but may negatively impact their children. Mental health problems in mothers is linked to maternal and infant mortality. Poor maternal mental health jeopardises the development of the foetus resulting in premature births and low birth weight infants. Social, behavioural and emotional development of children is also affected by the mental health of the mother. Many of these effects may be buffered by the presence of another supportive and well adult caregiver for the child. However, many mothers in resource scarce settings are socially and emotionally isolated.

In South Africa, more than 40% of the population lives below the poverty line. Recent statistics show that two in every ten South African families run out of money for food before the end of the month.

The Perinatal Mental Health Project (PMHP) provides a maternal mental health service in Hanover Park, an area with high rates of unemployment, alcohol and substance abuse, physical and sexual violence, child abuse and neglect. Recent research from the PMHP shows that 42% of pregnant women attending the antenatal clinic were food insecure, with 21% diagnosed with depression. Food insecurity was also associated with suicidal behaviour.

One of the women seen by a PMHP counsellor is Carol.

Here she tells her story:

It’s very hard… it’s… sometimes I feel I can explode because I am alone. while I was pregnant, … one of the sisters [nursing staff] approached me and asked me to complete a form. I didn’t know what it was about, and then after completing the form and answering all the questions they scored my points and then they told me that I needed to see a counsellor. I was always a person that would tell myself, when I was younger, I want to get married, and you know, buy a house and then start a family. But then I got involved with the wrong guy… ’.

The day I told him [that I was pregnant], over the phone actually and I never saw him again. He never saw me pregnant, he never saw the baby. Thinking of why did I get involved with him, how could I be so stupid, you know. I punished myself a lot.

I’m the sort of friend, no one sees my sensitive side, or no one knows what I was going through. So I didn’t want them to know, you know, and talking to someone I didn’t know [the counsellor] was actually a good thing because I knew no one would look at me, she wouldn’t judge me.

I felt much better that it was someone that I didn’t know.

All those hurts, feelings inside, you know, it’s not a good thing. It just made me an unhappy person and I didn’t want to be an unhappy mother actually. I just thought to myself, when I talk to the counsellor I don’t know how but I felt much better.

Last year the PMHP screened more than 1300 pregnant women at the Hanover Park midwife obstetric unit for mental health problems and for risk factors. Out of those, over 200 women, like Carol, took up the offer of free, on-site counselling.

The PMHP’s aim is to ensure that all pregnant women, particularly women from disadvantaged communities, have access to quality mental health services routinely integrated in to all public services for mothers.

The PMHP research agenda arises from real world service design and health systems problems that have emerged over 16 years in the field. We then translate the scientific evidence to engage collaboratively with local and international policy makers and programme managers. We develop a range of open access resource materials and build capacity among health and social development workers to provide empathic support for pregnant women and new mothers.

Find out more about the PMHP on their website: https://pmhp.za.org/

Maternal Mental Health: A South African Story was originally published in Every Mother Counts on Medium, where people are continuing the conversation by highlighting and responding to this story.

As the Grants Program Director for Every Mother Counts, I love going into the field and seeing firsthand the work that we are supporting, as well as learning what other organizations and people are doing around women’s health in the country. Haiti is also just a beautiful, historic country to visit. Haiti has been identified as one of the top countries suffering from a critical shortage of health workers, and women face serious challenges trying to access care that is nearby, timely, high-quality, and well-resourced. Since 2012, EMC has funded the work of Midwives For Haiti. Midwives For Haiti is having success helping to close the gap of skilled providers, as are a number of other small organizations in the country.

Last week I hit the road with Jessica Jordan, Executive Director of Midwives for Haiti, traveling around Haiti to visit a few other organizations working to improve maternal health in the country, hear about their challenges and approaches, and identify opportunities.

Our first stop was Les Cayes, in the southwest part of the country. There, we met up with a group of supporters and friends of Mimsi International, an organization founded and run by Dr. Winfred Tovar, a Haitian-American Ob/Gyn. Mimsi has a small, well-trained team of community health workers delivering prenatal care through 13 mobile clinics deployed to rural villages outside of Les Cayes. Dr. Tovar founded Mimsi in 2015 after his cousin in Haiti nearly died from eclampsia and hemorrhage giving birth to twins. She had limited access to skilled prenatal care and emergency obstetric care.

We tagged along to two of Mimsi’s monthly mobile clinics, the first held at a government dispensary in Les Cayes, the second at a church up in the mountains. We watched as Mimsi’s team of 17 Haitian health workers piled into the back of a small pick-up truck to trek to the next destination. At each, the team got to work with efficiency, giving women pre- and post-natal check-ups, administering pregnancy tests, vaccinations, and Depo shots, testing and treatment for sexually-transmitted infections (STIs), taking blood, testing for HIV, and providing referrals. Sixteen of the 17 workers are women, including a doctor and 2 nurses. Mimsi focuses on hiring women, and wants to build the pipeline of women health workers at all levels in Haiti.

Mimsi’s lone man — a community health agent named Pierre — travels on his moto to rural villages in the mobile clinic catchment areas to recruit pregnant women and women who suspect they may be pregnant, to come to the clinic for free pregnancy tests and services. Because of that active recruitment, they have been able to get nearly 38% of their patients to come in their first trimester — an unusually high rate for low-resource and underserved settings.

Mimsi patients have two paper records — one that Mimsi hangs on to, and a smaller pocket-sized one that patients carry with them. This way they ensure continuum of care and that wherever they give birth they will have their records. On the pocket-sized record is a hotline number that women can call in-between visits if they have questions or concerns. Mimsi workers take turns with a shared phone and are on-call to (wo)man the hotline.

Low-risk women (about 75%) deliver where they want, usually with a matwon (traditional birth attendant), and Mimsi distributes clean birth kits to the women for their matwons to use. The other 25% deliver at a hospital, which Mimsi covers. They are growing quickly — seeing 1,200 patients/month, adding 250–275 more patients each month.

(Side Note: This post would be incomplete without a huge shout-out to Madame Jeanine Tovar who generously hosted us and fed us delicious Haitian food).

Mimsi hopes to build a maternity hospital with a birth center across the street from Jeanine’s house, and wants to eventually expand their model beyond Les Cayes into other parts of Haiti and, eventually, globally.

The following day, we visited REMODEL Development, an NGO founded and run by a Haitian woman and her husband living in Canada. REMODEL is doing work in Nippes department, in the mountains near Saint Louis du-Sud, and in Carrefour. We drove far up into the mountains near Plaisance, climbing rocky dirt roads filled with crater-sized holes, to see their mobile prenatal clinic, held in a community church. REMODEL had funding from the UN to do health and nutrition outreach in underserved rural communities. As happens too often with international aid projects, the projects last a few years and then close up shop, failing to leave communities much better off than they started and instead, arguably, fostering aid dependency instead of supporting communities to realize their own self-defined long-term goals on their terms.

Since the end of REMODEL’s UN project, REMODEL has worked hard to continue the work so that women and babies continue to receive care without disruption. We watched as a community health worker handed out prenatal vitamins, nutrition supplements, and led the women in a song to educate them on identifying health risk signs in themselves and their children. Song and music are powerful in every culture, and this is particularly true in Haiti. Song can also act as a great memorization tool in places where literacy levels might be low.

Check back in over the next couple days for Notes From the Field: Haiti (Part II).

Notes From the Field: Haiti (Part I.) was originally published in Every Mother Counts on Medium, where people are continuing the conversation by highlighting and responding to this story.

Last week a massive 7.5 magnitude earthquake shook the island of Sulawesi, Indonesia and surrounding regions. The ensuing tsunami and numerous aftershocks have contributed to wiping out entire villages and towns in Indonesia. Over 1,230 people are confirmed dead, with the death toll expected to rise.

Our friends at Bumi Sehat in Bali, Indonesia have endured a number of natural disasters, and are often some of the first to show up to offer assistance. The ongoing challenges associated with climate change mean that these disasters show no signs of future decline. In the meantime, people are desperate for food, water, and shelter, and so many women are homeless and pregnant, also in need of food water, basic supplies, and health care.

Donate today to EMC’s Emergency Fund to help victims of Indonesia’s earthquake and tsunami. Every Mother Counts will match every dollar raised up to $10,000 for our partner, Bumi Sehat.

Here is an update from Ibu Robin Lim, midwife and Founder of Bumi Sehat, describing what it has been like since the earthquake:

“Bumi Sehat has had a medical relief team in Lombok, since the earthquakes in late July/early August. Our midwives, nurses and doctor experienced the second 7.0 earthquake…it taught us how very terrifying it is for the families there. How can they begin to imagine a normal life again, when the earth keeps trembling? Lombok is as terrible as Haiti was in 2010, Nepal in 2015….Bumi Sehat is doing what we can to establish safe birthing units in tents. All the tents in Indonesia are sold out. We are awaiting two tents from Direct Relief International… being air freighted now. Meanwhile we have seen over 3,000 injured and sick patients. Malaria is now upon Lombok, and the rains have come, while most families in the northern half of the island — hundreds of thousands of people — are sleeping in the open.

[In September], Typhoon Mangkhut devastated the northern part of Luzon, Philippines, where my mother’s family lives. My family is safe, but so many are not. Fortunately, people heeded the evacuation warnings, therefore much loss of human life was prevented. The issue now is hospitals, clinics, homes, and schools are destroyed. I am raising money for the efforts to rebuild and restore hope.

On September 28th, when the 7.5 earthquake struck Sulawesi, there was a tsunami warning. Then the warning was revoked…young people were gathered on the beach, for a music concert, then the tsunami struck! Much of my Balinese son-in-law’s family lives in Palu, Sulawesi. We are still trying to find Aunt Dewi…she lives in an area where there is liquefaction — loose sandy soil giving way, swallowing entire houses.

Sulawesi has no electricity, the cell phone towers are felled, and communication is impossible. The bridges are out, gas stations are all destroyed, no fuel can be had, so people cannot travel, even to try to locate lost family. Running water pipes are all broken. Food and drinking water are desperately needed. The bodies of the dead have been heaping up in front of damaged dark hospitals and broken mosques.

We thank heaven international help is now being accepted for the Sulawesi disaster. Bumi Sehat is seeking donations to begin working with the local midwives, to establish safe birthing tents — all the while we fear people will forget the disaster situations in Philippines and Lombok, due to this new crisis in Sulawesi.

We need solar lights, water filters, tents (all tents in Indonesia are sold out), and money for medical supplies. We are establishing partners on the ground in Palu. Getting to the areas with the most need is still impossible. The military is helping to bring relief workers and supplies into Palu by Hercules C130 planes. They have asked me to come, but I must first organize supplies and another medical team, as I won’t show up empty-handed.

Meanwhile the effects of climate change disasters are profoundly felt by the expectant and birthing mothers. We see more complications of pregnancy, much more. It is a knife in my heart day and night, that hundreds of thousands of mothers-to-be are homeless, hungry, thirsty and have no safe clean place to birth.

It’s been so difficult responding to Lombok’s earthquake disaster. Our head midwife there, Budi, is originally from Lombok, and her family home is only rubble, but she keeps working. And, yet another disaster in the Philippines and now…utter devastation in Sulawesi.

Love, Ibu Robin and the Team Midwives of Bumi Sehat”

—

Please donate here to EMC’s Emergency Fund to help victims of Indonesia’s earthquake and tsunami. Every Mother Counts will match every dollar raised up to $10,000 for our partner, Bumi Sehat.

Disaster in Indonesia was originally published in Every Mother Counts on Medium, where people are continuing the conversation by highlighting and responding to this story.

For over 40 years, it has been illegal for Certified Professional Midwives (CPMs) to deliver babies in Alabama. In the midst of a maternal health crisis in which Alabama has some of the worst maternal health outcomes in the country, Alabama is now poised to begin licensing midwives and stop criminalizing their work. We asked a couple of our friends in Alabama to share their thoughts:

Dr. Cooper’s story:

I am a physician who loves midwives. Midwives were kind to me during the dark days of residency training. They supported and comforted me on the journey to physician-hood just as they nurtured other women on their pregnancy and childbirth journeys. My midwife colleagues now support me with understanding and validation, often picking me up and setting me squarely back on my path. It’s what good midwives do. The midwifery model of care is both empowering and compassionate. It is low cost and high touch. This model is the solution to Alabama’s current maternity care crisis — if we have the political and financial will to support it.

Alabama has an access problem. We have both an access to care problem and an access to quality care crisis. Access problems lead to outcome problems. In Alabama, 33 of our 67 counties have NO maternity care providers. It should, therefore, not surprise anyone that we have poor infant and maternal health outcomes with disparities clearly delineated in black and white.

White/ Black

Infant Mortality: 6.5/15.1% per 1,000 live births

Preterm Birth: 10.4/15.2%

C/S rates 35.6/ 37.2%

These statistics are more in line with the outcomes in Bahrain, Sri Lanka and the Ukraine than with the more developed countries of Canada, U.K., and Japan. The crux of our access/ outcome problem lies with where we invest our healthcare dollars. We spend enormous amounts on maternity care. But, the majority of those costs go towards 2–3 days of hospital care. Meanwhile, the bulk of maternity care occurs outside the hospital — pre and postpartum.

So, we have an access to quality care problem because we don’t invest in the largest portion of maternity care. In Alabama, we don’t invest in providers and models that have been shown to improve access and outcomes. There is no reimbursement for group prenatal care, doulas, IBCLCs (International Board Certified Lactation Consultants), CLCs (Certified Lactation Counselors), peer counselors, or mental health services (including Ob-Gyn visits for peripartum mood disorders.) There is low and inconsistent reimbursement for midwives, physical therapists, and medical care required outside of the very narrowly defined “pregnancy related” care. What is covered? Delivery! The majority of the bundled provider payment goes to delivery — the quickest, most easily scheduled delivery will make those reimbursement dollars go the furthest. And that is an important calculation because outpatient practice is becoming unaffordable. Overhead costs go up, reimbursement goes down and physicians look for other ways to pay back their school loans.

Physicians are pushed into hospital employment. And, hospitals are profit driven, not quality driven. Spending the majority of maternity care dollars on hospital care exacerbates our quality problem. It also exacerbates our access problem. Hospitals want to invest in the high intervention, high intensity care that pays the most: laborists, OB-EDs (Obstetric Emergency Departments), and NICUs are all good for business. Physicians can earn more providing this type of care and leave their practices to become laborists. In Alabama, this leaves no one to provide prenatal care which creates an even greater need for the OB-ED. Providing high intensity care is expensive. So, hospitals consolidate service lines. Here, this means moving services from black areas to white and from lower income zip codes to higher. It means closing hospitals in rural areas as well as “urban deserts.” It means we have 7 full service L&D (labor and delivery) hospitals with NICUs fighting for business within a 15 mile radius and 33 of 67 counties with no maternity services at all.

Alabama needs reimbursement and legislative reform that supports a pyramid structure of maternity care. The base of that care is formed by community health workers bringing home based care to our rural areas and urban deserts: CPMs, doulas, breastfeeding peer counselors, home health RNs and physical therapists. The next layer includes CNMs (Certified Nurse midwives) and CLCs providing group prenatal care, birth center care and lactation support. A significant portion of our maternity care dollars should go to supporting these base tiers. The next tier includes pediatricians, Ob-Gyn generalists, and family medicine physicians backing up CNMs in a hospital setting with c/s capabilities, nursery support and IBCLCs. The top triangle of the pyramid includes MFMs (Maternal-Fetal Medicine Specialists), OB-ED laborists, intensivists and ICUs, psychiatric units, and NICUs. We need telemedicine and transport services so that every mother/ infant dyad is cared for in the appropriate setting. These services are the mortar holding the pyramid together.

If we continue to only support and reimburse services at the tip of the maternity care pyramid, the system will continue to be structurally unsound, and we will find ourselves digging sick and dying mothers and babies out of the rubble.

Access to Maternity Care in Alabama: an Ob/Gyn’s Perspective was originally published in Every Mother Counts on Medium, where people are continuing the conversation by highlighting and responding to this story.

Senators Cory Booker (D-NJ), Kirsten Gillibrand (D-NY), Tammy Baldwin (D-WI), Ben Cardin (D-MD), Richard Blumenthal (D-CT) and Kamala Harris (D-CA) have announced groundbreaking new legislation to improve health outcomes, access to care, and health equity for women and infants in the United States. The Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act– the “MOMMIES Act” — takes a comprehensive approach to fixing a system that too often isn’t meeting the needs of childbearing women in the U.S. Despite spending more on health care than any other country, women in the U.S. are more likely to die from pregnancy and childbirth than in any other developed nation.

The MOMMIES Act is part of a renewed focus on maternal health in the U.S. Senate and House of Representatives and is one of the most far-reaching bills to address this issue. The legislation proposes extending postpartum coverage, expanding on models that work, and improving reimbursement rates, which would have a powerful impact on the health of families at a critical time. By focusing on improving Medicaid services, this bill takes an effective strategy to overhaul the maternity care system, given that Medicaid covers about half of all births in the U.S.

A close look at poor maternal health outcomes in the U.S. has demonstrated dramatic disparities — most notably by race, but also by socioeconomic status and geographic location. Not only are non-Hispanic Black women three to four times more likely to die from pregnancy and childbirth than non-Hispanic Whites, but women living in poverty and in certain states also have much higher rates of maternal deaths than the national average. While issues of race, socioeconomic status, and geographic location are invariably intertwined, Medicaid provides a valuable avenue to close gaps in provision and experience of maternity care.

Extending Medicaid Coverage

The MOMMIES Act would extend Medicaid from the current 60 days postpartum to 365 days, recognizing that the postpartum period is a critical window for preventing maternal deaths and reducing complications.

Nearly half of all births in the U.S. are covered by Medicaid — with some states surpassing fifty percent. Medicaid for pregnant women is required to cover, at a minimum, all care related to pregnancy, delivery, and any complications that may occur during pregnancy and up to 60 days of the postpartum period. Reports from state maternal mortality review committees, however, have consistently indicated that 60 days of postpartum care is not enough. Nearly one in five maternal deaths occur between 6 weeks and a year following childbirth. Of these deaths, 58% are considered preventable.

Additionally, the MOMMIES Act would expand full scope Medicaid coverage to all pregnant and postpartum women, rather than coverage that can be limited to pregnancy-related services. This is particularly critical for reducing disparities as benefits for pregnant women covered by Medicaid vary depending on their eligibility group and also vary across states.

Maternity Care Home Pilot Project

The MOMMIES Act would establish, implement, and evaluate a Maternity Care Demonstration Project in 15 states to serve as a maternity care home model aimed at Medicaid. Similar to pilot programs in other states, such as North Carolina, maternity care home models provide care coordination and support services with the goal of improving quality of care, improving birth outcomes, and providing continuity of care. With a focus on identifying and treating high-risk pregnancies, maternity home programs facilitate access to personalized, comprehensive and integrated care and have shown early successes in reducing health care costs, increasing the number of prenatal visits, and a reduction in low birthweight infants. This is critical because for many pregnant Medicaid recipients, coverage and access does not equal quality. Beyond ensuring that pregnant women on Medicaid are receiving care, maternity care home models have the potential to ensure that this care is timely, tailored, and holistic.

Expanded Access to Doula Care through Medicaid

The Mommies Act would also increase access to doula care for pregnant women on Medicaid. In the U.S., fewer than a handful of states report having Medicaid coverage for doula assistance for women. The benefits of doula support are numerous and have consistently been documented across settings. Doulas not only help improve a woman’s childbirth experience, but also help reduce C-sections, the length of labor, and decrease the use of pain relief medications, which can lead to added interventions or complications. This bill directs the Medicaid and CHIP Payment and Access Commission (MACPAC) to generate a report on the coverage of doula care under state Medicaid programs, the barriers to coverage, strategies and recommendations to increase the utilization of doulas. Following this report, the Centers for Medicare & Medicaid Service (CMS) will issue guidance to states on how to increase access to doula care for Medicaid recipients. The implementation of doula services for Medicaid recipients is a tremendous step toward ensuring that everyone, regardless of socioeconomic status, has the emotional and physical support they need for a healthy pregnancy and childbirth.

Other Improvements

Finally, Sen. Booker’s legislation proposes two additional components — 1) for state Medicaid programs to increase access to maternity care through telemedicine, and 2) to require Medicaid to adopt mandatory minimum reimbursement levels for pregnancy and childbirth care.

Every Mother Counts supports the MOMMIES Act, which, true to its name, would maximize outcomes for moms.

Groundbreaking Legislation Introduced to Improve Maternal Health Outcomes in the U.S. was originally published in Every Mother Counts on Medium, where people are continuing the conversation by highlighting and responding to this story.

Every Mother Counts’ grantee partner, HOPE Foundation for Women and Children, is inaugurating a new field hospital this week. Located in the world’s largest refugee camp, where nearly one million refugees reside, the Hope Field Hospital for Women (HFHW) will be based in the Cox’s Bazar District of Bangladesh — a setting where approximately 70% of refugees are women and children. The HFHW will be the first field hospital of its kind, delivering inpatient and outpatient care 24/7 to women and children of Rohingya settlements and surrounding communities.

Fleeing religious and ethnic persecution, Rohingya refugees arrived in the Cox’s Bazar District over a year ago in what was considered the world’s fastest-growing humanitarian crisis since the Rwandan Genocide. Facing an uncertain future, Rohingya refugees today continue to live in dire conditions, with limited access to safe drinking water, adequate food, transportation, schools, and basic health services. From June through October, during the monsoon season in Bangladesh, heavy rains and mass flooding exacerbate the challenges this population already experiences by threatening their fragile shelters and further limiting their access to basic needs.

Rohingya refugee women and children, like most displaced women and children in humanitarian settings, experience added barriers. Children in Cox’s Bazar are at higher risk of waterborne diseases, suffer from acute and chronic malnutrition, and have a stunting rate of nearly 40%. For women, access to essential maternal and reproductive health services is a major concern; at the end of February, the World Health Organization (WHO) estimated over 50,000 pregnant Rohingya refugee women in Cox’s Bazar, a disproportionately high number for the size of the total population in the area. Despite humanitarian efforts in place to address immediate health needs of Rohingya refugees, health facilities are limited in number, hard to reach, and are often not adequately resourced to provide services to women and children.

Built in response to growing needs of Rohingya refugee women and children, the construction and inauguration of the HFHW is a striking first step towards health improvements in Cox’s Bazar. As a field and gender-segregated hospital, the HFWH will be centrally located in a critical area of need within the camps, and will create a safe health care zone for women and children. The hospital will focus on providing quality maternity care and will also work to scale up sexual and reproductive health services by increasing knowledge and cultural acceptability. The HFWH will have an operating room and lab, x-ray, pediatric, sexual and reproductive health services as well as provide emergency transportation services when needed. In a setting where women are also at an increased risk of sexual and gender-based violence and often do not seek health services due to safety concerns, the impact of a facility that specifically provides a safe space for them can be immeasurable.

Every Mother Counts (EMC) has been working with HOPE Foundation since 2015, supporting their efforts on the ground to advance maternal health improvements by providing pregnancy and safe delivery care, as well as postnatal and newborn care, including immunizations, health screenings, breastfeeding support, and family planning. Prior to the beginning of the Rohingya refugee crisis, Cox’s Bazar had among the worst maternal health outcomes in Bangladesh; With a large population influx to this underserved area prone to extreme weather conditions, existing high rates of maternal deaths may only worsen. With two grants in 2017–2018, EMC continues to work with HOPE Foundation to specifically support emergency preparedness training and response, in addition to the growing health needs of Rohingya refugee women.

EMC applauds HOPE’s invaluable efforts to advance the health and well-being of women and children.

Learn more here about the HOPE Field Hospital for Women.

HOPE Builds Hope for Rohingya Refugee Women and Children was originally published in Every Mother Counts on Medium, where people are continuing the conversation by highlighting and responding to this story.

I recently attended the DC Mayor’s Maternal & Infant Health Summit in Washington, DC. The turnout at the summit and the variety and level of stakeholders demonstrated the magnitude of this issue and how many people want to create change. There were about 800 attendees, predominantly African-American, standing-room only.

The reason for the summit was clear: While the United States overall has a serious maternal health problem (we are the only industrialized nation with a rising maternal mortality rate), Washington, DC has it twofold. Marked by tremendous inequality, Washington DC’s maternal mortality ratio is nearly double the national average and the highest maternal mortality ratio in the nation, yet at the same time their non-Hispanic white patients have the lowest maternal mortality mortality ratio in the U.S.

Many women in the District of Columbia do not access care until late in their pregnancies, or not at all. The maternity care deserts that exist in rural areas across the country (shortages of providers and facilities nearby) exist in urban areas as well. The last two hospital maternity wards that served the poorest areas of the city closed in the last two years. The District has identified this crisis and recently ordered the creation of a mortality review committee.

The summit’s panels featured U.S. mayors (from Baltimore; Flint, MI; Gary, IN; Rochester, NY), local community-based organizations (CBOs) (Mary’s Center, Community of Hope), national organizations (March of Dimes, Campaign to Prevent Teen Pregnancy), DC government officials, private health sector leaders (MedStar Washington, CareFirst, Kaiser Permanente) who came ready to examine the trends and discuss and learn about solutions.

Some of the most informed and insightful remarks came from the leaders of community-based organizations and others who have been working to advocate for and implement maternal and newborn health solutions for people living at the margins for decades. The call was clear: the only way we will make progress is to engage and involve the community, and work through and with community organizations and leaders.

Some of my favorite quotes from the day illustrate a few of the key takeaways from the summit:

“To really affect pregnancy outcomes you need to start early, and to start early you need to engage the community.” — Dr. Hugh Mighty, Howard U. College of Medicine. Alternative forms of care that are located at the community level (doulas, other community-based care workers, etc.) tend to be more accessible and provide women with a bridge to better access formal health services. Meet women where they are, even if it’s locating services and providing information through churches and other community spaces.

“We need to stop acting like mental health is different from physical health.” — Mayor Karen Freeman-Wilson, Gary, IN. Going beyond just physical care and looking at the whole woman is critical for positive mom/baby outcomes: mental health resources and wraparound support systems are invaluable and should be part of any maternal health care package.

“We need to deal with implicit bias and make sure all providers are treating women equally.” — Stacey Davis Stuart, President, March of Dimes. Structural and systemic racism is a significant and harmful barrier. Training and educating providers early should be part of their training, and building the pipeline of providers of color is an important investment.

“If women have a good experience, they will tell all their friends, if they have a bad experience they’ll tell EVERYONE!” — Cherie Craft, CEO/Founding Executive Director, Smart From the Start. We need to consider the importance of customer service — if people are treated badly, they are unlikely to want to return for care — it’s that simple.

The solutions aren’t simple, but they are out there. Plenty of great programs and organizations out there are doing incredible work — they just need support, resources, and a seat at the table to be able to scale and continue doing what they are doing. As one panelist said, we need to build on what already exists in the communities.

The DC Mayor’s Maternal & Infant Health Summit was originally published in Every Mother Counts on Medium, where people are continuing the conversation by highlighting and responding to this story.