Marvelous Misconceptions and Updates

Hello all, its been nearly a week and much has happened!

Besides my previous confinement from rain last weekend, this week has been the start of work, though mostly observation.

Monday:
My first visit at the office MANCORSARIC which is sort of an NGO that unites four municipalities: Copan, Santa Rita, Cabanas and San Jeronimo (the capitalized name is a mix of those “municipios” though I think SJ was a late addition). They have a few areas of interest: one the environment and water supply and another maternal and child health through 10 preventative medicine health centers and one 24hr birthing clinic with emergency care.   I met Kenia, who is my primary community partner and one of the directors who overseas the centers/clinic, as well as Leonides, who is the director of all of MANCORSARIC. The plan is to understand reasons why only 40% (or less in some areas) of births are not in the clinic or institutional births, even when the priority of the clinic is births, and they receive free care during pregnancy, for the birth, and for postpartum care with free care for children under 5 who were born there. Given the variety of terrain in the 4 municipalities, some have clear travel barriers while others do not.  In any case, the challenge is set.

As part of understanding the situation, the next part was to visit the clinic, which is 12-16miles away from Copan. For that trip, Kenia got tied up so myself and one of the office workers went out via one of the “motos” owned by MANCORSARIC aka a small motorcycle! That on cobblestone streets and over speed bumps was an adventure! Outside of Copan, the main is paved so its easier to go faster, though its a little windy with no painted lines. With the heat and humidity, it was nice to feel the wind on my skin as I clung to my driver, especially on a few curves.

The clinic was not what I expected in some ways. It was one story building with a front patio with chairs that people sat outside sometimes (though not to be patients). I had seen 4 or 5 pregnant girls outside together but not as waiting patients but as support network.  Just inside was a waiting room lined with chairs, a TV hanging and a front desk with a sign above saying “Administration and Statistics.” Behind the desk were shelves of medical records numbered in order of arrival, not name. God forbid anyone forget their number, though I am curious if there are duplicates. Nonetheless, to my surprise, I met a girl about my age or a little less working in front of a computer (Windows XP, Microsoft Office 2007, a decent Dell desktop). Her job is electronic record keeping of different kinds of statistics and registries from various information on the birthing moms, vaccinations and keeping track of 13-15 “standards of care” that are reviewed monthly by the whole staff. Honestly, there are not as many doctors offices/private Ob offices that do that, not even one where I worked on my Family Med rotation. I expected a lot less, and also did not expect a tracking system to be in place (which was part of my primary job in coming) so the project is taking a new direction. I returned back not by moto but by busita that went back to Copan quickly and easily (15 passenger vans that are a form of public transit).

Tuesday:

I returned to the clinic, though this time with proper shoes and my stethoscope. The road there was not as easy as anticipated as by busita, it took 2 busitas. There is one town between Copan and El Jaral (where the clinic is) called Santa Rita, which is a big connection point for  chicken buses and busitas.  Although the price was not different (just over $1 each way), it took longer so getting to clinic took ~1hour. I had just missed a birth as I came in, though I was able to go back to the birthing room. The baby was out and under a rather basic lamp and the nurse was doing the length, weight, Hep B vax#1 and maybe Vit K? All the while, mom was still in the stirups rather exposed. The room was tucked away and only the nurse and doctor (only 1 of each on duty per day) come back but I felt a little uncomfortable. I examined the baby some (yay newborn exam!) and watched as the nurse helped mom off the table to a wheelchair (with padding for the blood) and to the post-partum area. There were several moms there, as they stay 24hrs, with 6 beds, some separated by hanging Winnie-The-Pooh sheets. There were lots of paperwork and documents needing to be completed (I thought that was mostly happening here!) and mom was left to her bed while the nurse and doc completed the work.

Many were breastfeeding off the bat (things we love to talk about in the department of Maternal and Child Health (MCH). Sadly, something so natural is a struggle in our country for a variety of reasons, both from mom and from baby turnaround from the nursery. Breast-feeding friendly hospitals as supposed to return babies to mom within 1 hr, which didn’t happen as much in my time on Nursery, though that is partly my fault as a student learning how to bathe a newborn. Even though mom was tired, she laid on her side with her new son and her baby could suckle next to her. Not too much work. But because there are not too many alternatives for poor, rural indigenous people, they do what is recommended by BF advocates. Its sad that I was caught off guard by seeing 2 different women breast feeding in the street, one with a toddler and the other standing in the square holding her baby feeding while she appeared as she was going to keep moving down on street and continue on as normal. This is normal and yet, prude American culture gets offended by this since they can’t see a breast for more that a taboo sexual object vs the best choice for a baby. But I digress…

Wednesday: Not much, at home, researching questionnaire examples applicable to my question of why women are not coming to the clinic, such that I can hopefully interview people in this trip, once I can manage clearance from the US side of things. However, I am now “en comunicado” with a local pay-as-you-go cell phone and skype (when internet and power allow).

Thursday:

Meeting at the MANCORSARIC office with leaders of ~6 of 10 Health centers that do primary care. Again, surprised by the number of laptops, flashdrives, and excel files projecting stats of various MCH factors from vaccinations to birth plans to pregnant patients who did or did not come to the birthing clinic to contraceptive rates (which technically I hear that contraceptives are illegal in Honduras due to the church but somehow they are getting Depo shots, condoms and the occasional IUD). Some stats with percentages did not question make sense to me but they kept track of their indicators! Plus, for a “snack break” we were given pupusas, my first ever, which was soo good (think thick tortilla filled with some meat with a spicy beet juice-dyed pickled vegetables on top with cabbage, chilies and pink cauliflower). Other highlights of the meeting included a complete reading of the Honduran H1N1 vaccine campaign starting this month for first school children, then workers. The meeting, which was all day (a full Spanish immersion), ended with basically an M&M aka morbity and mortality report where the director went over cases where children died. Not the happiest moment, but Kenia drove home a) the need for good documentation and b) full analysis of what caused the death, since it makes a difference to them if it was preventable or not.  It was a rather heavy way to end the work day but really informative about how serious they are about quality and how passionate Kenia is about maternal and child health.

Friday: (almost done guys!)

Another meeting at MANCORSARIC but more to meet the other 4 health center leaders. However, these areas have the lower rates unfortunately due to many barriers outside of their hands, like impassable roads during the rainy season 80% of the time or 6 hour walking distances. These areas are very important, particularly to my work, since they are considering another birthing center in one of the areas and my research can help determine if that financial investiment is worth it (not to add any pressure!). I didn’t stay too long as it was mainly a repeat of yesterday’s meeting so I went to the clinic to start what I thought was a med rec survey of towns where people were from for births starting from scratch.  Yet, my girl Mariela the statistician had that information, but not quite in the form needed to answer my question about where in aggregate people came from for births. Nonetheless, with my flashdrive and laptop, I began mining that data from the spreadsheets and have begun part of my med record review, though fortunately not by reviewing >30,000 records (or well, in the last 2 years, its only about 7,000). What remains to be answered is whether people can to the clinic during the pregnancy for issues but never came back. Nonetheless, I do have sometime clear to work on while the other aspects of meet and greet of people I will likely visit continue.

Overall, this week was a fact finding and acclamation week, and even with this study, I get the sense that in my really short time, I am gathering info as part of a pilot to a more serious study and almost anthropological fieldwork project for accessing preferences and quantifying reasons for lack in utilization, maybe for another UNC summer student or a Duke Third year.  With IRB blessing, I hopefully can start to identify  short-term changeable factors and longer term changeable but harder to do plans (ie infrastructure, paved roads, etc).  But this is going to be a challenge. Still, I am glad there is data to be examined and that this group is so professional and passionate and put together (go USAID and the Honduran Health department!). Enough for one week’s worth

As a side note, my tourist event of the week was visiting a butterfly garden and capturing many beautiful wings.

– Kaitlin Rawluk