Jenifer Sawchenko, CPM... I like the look of that!

I'm a Certified Professional Midwife!!

Word of my official certification arrived in the mail this week to my parent's house. I am delighted to say that I'm a bona fide midwife and it feels good.

In case you were wondering, I have included a description of a CPM from the NARM website:

A Certified Professional Midwife (CPM) is a knowledgeable, skilled and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM) and is qualified to provide the Midwives Model of Care. The CPM is the only international credential that requires knowledge about and experience in out-of-hospital settings.

The Midwives Model of Care is based on the fact that pregnancy and birth are normal life events. The Midwives Model of Care includes:

• monitoring the physical, psychological and social well-being of the mother throughout the childbearing cycle;
• providing the mother with individualized education, counseling and prenatal care, continuous hands-on assistance during labor and delivery and postpartum support;
• minimizing technological interventions; and
• identifying and referring women who require obstetrical attention.

The application of this model has been proven to reduce the incidence of birth injury, trauma and cesarean section.

Copyright © 1996-2001, Midwifery Task Force All Rights Reserved

What a Great Day!

Twenty minutes before our social worker was set to arrive for our home study update this morning, I got a call from my parents that a letter from NARM arrived. I gave them the go ahead to open it and they read me the happy news that I passed!!! Yeeehaw!! How fun to have Andrey here to share in the joy. Even our helper cheered. I jumped up and did a happy dance. I did not expect to get word so soon! Wahooo!!!

The home visit with our social worker went fabulously - better than expected. We were able to ask lots of questions and now have a much clearer picture of how this whole thing works. This is what we learned:

• Our social worker really likes us and is hoping along with us that we'll get matched soon
  
• Our application has been released and is indeed available for matching (we thought this was the case but couldn't confirm it till now)
• Very few children come from foster families. The majority come from institutions varying in size and quality.
  
• How matching works: ICAB informs children's homes when a child in their care has been approved for matching. The social worker appointed over that child has to travel to ICAB in Manila and look through the list of available approved parents. The SW chooses a list of 5 parents who's parameters fits the criteria of the child in their care. The files of those five sets of parents gets pulled and the SW is able to look through them in detail. Out of those five, the SW chooses a first and a second choice. Every Tuesday, ICAB holds a meeting in which the SW presents the reasons for choosing those particular parents. Every Thursday, ICAB meets to determine if they agree with the choice of the SW and chooses the parents they feel are best out of the two options (or I suppose none if they disagree). Then the proposed match goes to the board and if the board approves it then they inform the adoption agency and the agency informs the parents. Now, our SW told us that because social workers have to travel, sometimes long distances to get to ICAB in Manila, they will wait until they have several children in their care up for matching before they go. This really does help me understand why this process takes so long.
  
• According to our SW, we shouldn't have to wait the usual 4-6 months from match to custody. That period of time is how long it usually takes for the processing of the immigration papers needed to take the child out of the country. Since we live in Cebu and once we are matched, it could take 1-2 weeks for the match to be approved by ICAB and at that time, we would be able to pick up the child right away. It was hard to contain my excitement at hearing this! (We still need to check with our agency that this is in fact true so even though I'm excited I'm reserving a space in my mind for this to not be the case in the end)
• Apparently for children under age 2, parents can take them on the same day they meet the child, whereas for older children parents must visit a few times before taking the child?? I find this strange. From what I've read, even children under age two benefit from a more gradual transition (less traumatic), getting to know the parents at least a bit before being taken away by them as strangers. She told us we'd be able to visit over several days and spend time first before taking custody if we want.
  
• Once we take custody, there is a 6 month post-placement period, during which we will have three home studies. At the end of this period the adoption will have to be finalized in the US.
  
• Because of the recent change in the determination of an orphan from a legal process to an administrative process, children are now becoming available for adoption at younger ages. For domestic adoption, children as young as 3 months may be classified as orphans and become available for matching and in international adoption, children as young as 6 months may become available, whereas before, it was 6 and 9 months, respectively. So far, the youngest age of child at time of match that I've heard about was 9 or 10 months.
• Even though we requested a single child age 0-36 months or a sibling pair ages 0-48 months, our SW thinks that the most likely scenario for us is that we'll be matched with a single child under age 2 yr 0 months, including a decent possibility of a match with a child under age 1. She thinks this because of the fact that we are still "young" (relative to other applicants, I guess) and childless.
  
• If we were to get matched with a sibling pair (less likely but still possible), she said it's more likely we'd get twins over getting non-twin siblings, since the sibling groups of two that she sees have an older sibling who is most often over 4 years old.
• We should prepare a book with photos of us and our home so it's ready when we get matched and can be sent directly to the child so he/she can at least see our faces before we meet in person and take them home with us
• Apparently we need a crib. We showed her our baby room with it's double bed and she said, "Uh... I think you need to get a crib." Ha ha, yes, we had thought of that but weren't sure we should in case we get a three year old.

So about the crib... Now that we know (think) we may not have much time between getting matched and taking custody, maybe we should get a crib! Until how old does a child use a crib anyway? We were just thinking a mattress on the floor because we've been expecting a toddler but now I realize maybe even that is a dumb idea. Somebody please inform me because I have no idea and it appears I need to get a move on here! Advice anyone??

Breaking the Blogging Fast

I'm back! My trip to the US is over and more importantly, my midwifery exam is over. I've been home for a week already. The trip to Seattle/Portland was successful on all accounts. I had quality time with my closest friends and some really fun mother-daughter time with my Mom. (I must give props to Matt & Colleen and Danny & Taj for hosting my Mom and me. Thank you SO much. I am so blessed by you!) Colleen and I even drove up to BC to see some more good friends. We had a gathering for dinner with 8 children and 7 adults. It was nuts but fun. I'm bummed we didn't get a picture.

I still don't know if I passed my test (should know some time next month, I think) but I did walk out of the test feeling relieved because it wasn't as difficult as I had feared. In fact, it was quite reasonable in regards to the material it covered. There was a lot on management and on being able to recognize the line between normal and a complication in which referral or transport is needed. I guess it really tests the midwife's judgment and I realized during the test that I feel pretty confident in my judgment. That was a refreshing realization for me. So assuming my judgment is in line with that deemed appropriate by NARM, I should be fine - but I won't know for sure until I get that result.

Just a quick word about Portland. I loved hanging out in that city. It's a lot like Seattle but smaller, cheaper, less traffic and friendlier people. I was surprised by how friendly people were. It is easy to get around Portland - lots of public transport downtown and very walkable - and my Mom and I had some of the most tasty food we've ever had at a little place called The Country Cat. We ate there twice. I'm not articulate enough to describe how amazing the food was. All I can say is I had the very best eggs Benedict I've ever had. My mom and I also popped in to one of the many local breweries for a beer and a pretzel. We even caught some Olympic action on the TV while hanging out in the pub. Oh and Cuban food. Who knew? But this place called Pambiche came highly recommended and it did not disappoint. You could say food was a real highlight of our time spent in Portland. And coffee of course. A favorite being Stumptown. We also spend many hours in Powell's Books, "the largest independent used and new bookstore in the world." One could easily spend all day there. Portland is a city I could definitely see myself living in should I ever have the option.

Andrey and I are having our home study update tomorrow. Our social worker from Manila is flying in for the day and will be in our home for a few hours going over any changes from the last home study. We found out only last week that we needed to prepare several documents. There is no reference to this in the materials given to us. Thanks to the Yahoo Philippines adoption group I belong to, I read about a family rushing to get all sorts of documents together in time for their home study update, and that tipped me off to ask our agency and our social worker what we should prepare. Both of them said, oh yeah, you need new police clearances (background checks), medical clearances, and copies of tax forms from the past two years. Tax forms, no problem but the other two things may not be possible to get together within a week. For example, in order to get a police clearance we have to get something called a barangay (neighborhood) clearance and then something else called a cedula (tax identification number). Each require a trip by both of us to a different government office requiring their own documents, so I was a little worried at first. Thankfully, acquiring these things have gone smoother than expected.

I'm happy to say we have our police clearances and tax forms and I have my medical clearance printed on the required letterhead. Andrey will have to mail his medical clearance to our social worker after he sees his doctor early next week (he's already been once to the office but there was no computer and no letterhead so not possible). We've accomplished a lot in just a week considering how long these things took the first time we tried to acquire them. Experience in this case is on our side. Assuming those are the only things we need, we are in good shape but we have learned to expect things to not go as planned or hoped for. I won't be surprised if we find out tomorrow that there is more paperwork to prepare. Yikes. I sound jaded.

We are praying the home study update report will not take nearly as long as the original report did. (Home study done in March '08. Report accurate and complete 9 months later.) Frankly, we can't afford for it to take months. The current home study expires on April 27 so this must be submitted by then or the whole adoption is off. Prayers for this report to be accomplished in a timely manner are greatly appreciated.

We are about 15 months into our 12-24 month projected wait to be matched. I hear of families with Filipino heritage getting matched closer to the low end of the wait time and non-Filipino families waiting on the longest end. Every day inches us closer.

Prepping for the NARM and getting more than I expected

It's been a while since I posted. I have decided today is my errands day so my posting won't be displacing any studying, which is why I've taken a blogging break lately. With less than a month until the NARM exam, I am doing everything within my power to study as much as I can. (this is also because I didn't get as serious about studying until much later than I had planned). Now with some caffeine in my system after a not-so-busy-but-still-didn't-sleep-much shift at the clinic (wah wah wah, I'm such a whiner! Isn't this what I signed up for when I decided to become a midwife?), I am hoping a quick update post will follow...

I booked my flights to the US! I'll be flying in/out of Seattle and staying with friends before and after the test, which will take place in Portland on Feb 17. My mom is coming to Seattle to see me and will join me for our two-day trip to Portland plus a few days before and after. I'm so excited! I think it will be really fun. I will have about 4 days in the states to get over jet lag before we drive to Portland and then 5 days after we get back to hang out and enjoy time with friends. It's going to feel great to have this test under my belt!

In anticipation of the trip, I recently emailed a nurse-midwife contact I have in Seattle to see if she'd meet with me while I'm in town. I had met her years ago back when I was getting my nutrition/doula business going. She was going to refer some of her patients to me - until I soon decided to leave the country. Oh well. She was very kind to give a chance back then to an inexperienced "professional" trying to get her feet wet and so I was glad when I remembered her and decided to email her. She quickly responded and she is willing to meet with me next month. I told her how I am just dying to speak to a midwife practicing in North America (she's the only one I know) and be able to discuss my experience in the Philippines and how it compares to birth in the States. I have already started a list of questions!

As it turns out she has a licensed midwife working with her now who apparently also trained in the Philippines. I bet she has some interesting perspectives to share as well. I'm hoping I'll get to meet her, too. And who knows? If I ever get to practice midwifery in Seattle, these will be good contacts to have. It's never too early to start networking.

This meeting will be timely. Especially since lately, I've been pouring over every detail of the book, Heart & Hands by Elizabeth Davis, an American home birth midwife. Mel, you should check this book out. It is seriously inspiring me to want to be a home birth midwife! It is the most holistically-balanced midwifery book I've read so far. It includes all the pertinent evidence-based medical material (without it being overly technical) plus almost as much information on the impacts of emotions on pregnancy and birth and how to deal with them. This aspect is underestimated in medical texts yet plays an enormous role in the pregnancy, labor, delivery, and postpartum experience. It also includes much on non-allopathic (herbal, homeopathic) remedies, and the impact of nutrition is not underestimated. There are maneuvers to correct malpresentation (such as when the baby's head is deflexed) and so many "tricks of the trade." This book epitomizes what is called, "the art of midwifery," something that is getting lost in our culture. I have learned so much stuff that I haven't gotten out of any other midwifery text.

I suddenly feel equipped with so many tools and I'm excited to try them out. Just last night, the way I dealt with our patient in labor was different because of what I've recently read. Too bad I don't get to be there for her whole labor to really play an impactful role. And so it goes with shift work. You only get to experience a slice of the labor sometimes. There's another reason why I'd really like to provide continuity of care as in a home birth practice. Besides it's hard to detect and help correct emotional issues/barriers in a laboring woman you've never worked with before! I think I could really enjoy the experience of caring for a woman from start to finish. There really is much benefit to that.

So I'm working two more shifts this week and then I should be off until I travel. I had all last week off, which was great as I got a ton of notes taken, ready to be committed to memory (I hope!)

Lately and Some Venting

I've grown remiss once again with the blogging. Sorry about that. I just have more than enough on my plate lately and I'm trying to prioritize accordingly. I still haven't even posted about Thanksgiving! I still plan to share the recipes that worked out so well this year. I will get to that... For now I just have time for a quick update on what's going on lately.

Just yesterday I finally got word that I have permission to take the North American Registry of Midwives exam. Yeah! Today I will submit my written intent with my chosen test site. Once I get confirmation, which is expected by the first week of January, I can then make travel plans. On the intent form there was an additional test sight - Portland, Oregon. I had planned to travel to Eugene but Portland would be even better (closer to Seattle where I'll be driving from) and a really cool city to hang out in. Hopefully enough people sign up to test in Portland. For now I have to wait and see. I've been struggling to find time for studying but with this new development I'm starting to feel like I really must get serious. I've requested to only work one shift per week next month so that will really help.

I'm on call these days for my first home birth. Have I mentioned that? Our pastor's wife is due any day now (she's 39+ weeks) and I'll be assisting at her birth with a midwife friend who used to work at Glory Reborn and now lives in Hong Kong. She is in Cebu just to attend this birth. She delivered this woman's first baby five years ago. I'm really looking forward to it!

Tomorrow I'm teaching the second class in my series on Women's Health to young women and girls recovering from some really tough challenges in their lives. I have learned that most of them have already had a baby and one is pregnant. Tomorrow's topic is the female reproductive system and well-woman care. I continue to be shocked at how little young women know about their bodies in this country.

Earlier this week I had the opportunity to pray with an 18-year-old girl who tried to abort her baby (unsuccessfully) after finding she was pregnant. She's in her 3rd year of college and the father is also a student who may or may not even know she's pregnant, as they are no longer in contact. She had absolutely no intention of getting pregnant. So why did she choose to have unprotected sex? Is it because she didn't know? Or did she know but didn't have access to ways to protect herself? I really wonder if she knew that getting pregnant was what happens when you have unprotected sex (among other things!).

Also this week we sent a 19-year-old woman for an ultrasound because the size of her belly did not correlate with how many weeks pregnant she thought she was. As it turned out she wasn't even pregnant. I saw this as an opportunity to discuss whether she had planned this pregnancy and if so, why would wanted a baby. She's single, only reached high school level education, and has no job. When I asked her she said that she wasn't planning to get pregnant but was happy about the idea of having a baby. Why? I asked her. With a childlike grin she shrugged her shoulders and said she didn't know why, she just want to. I noticed on her intake form that she had no history of using any contraceptives. I informed her of what she was exposing herself to every time she had unprotected sex and I'm telling you her face was as if she had never heard that you could get an infection or God-forbid HIV from having unprotected sex, not to mention get pregnant. I encouraged her to not have sex because men tend to use women in this way but if she were going to have sex, at least protect herself!

I also discussed what having a baby would be like. How much is costs and asked her how she would care for a child when she has no job. I told her how hard it is to raise a child without a partner and that God's plan for family is such because it is hard work! Babies need a father and a mother who have work to provide for them in the context of a loving committed marriage relationship. That is God's design and it is that way for a reason. As I shared she started to cry and told me that this guy she had temporarily hooked up with had talked her into having sex and she didn't really want to do it.

After you live in the Philippines and work with pregnant women for a while it becomes clear that men here just don't like to use condoms. Not single men. Not married men. They don't like it and so they refuse to use them. I mean, why would they? It's not their problem if their woman gets pregnant. It's not their problem if the asymptomatic chlamydia they are carrying is spread to god knows how many other women. And besides women will still have sex with them even without a condom so why would they use one?

One of the guards at the clinic the other day was wearing shirt that had a picture of a condom on a yellow traffic yield sign and a big X over it. Below it read, "Protection. What every man is afraid to see."

Back to the 19-year-old.... Trying to hold back my emotions I tried to explain to her how she has a right to make her own choices based on how she wants to live her life and that any guy that will be with her only if she's having sex with him is no guy she should be with!

I entreated her to take care of herself, to protect herself and to make good choices by thinking about consequences. Honestly, I told her, do you really think having a baby is a good idea? She agreed that it was not.

I get so worked up about these things! These young, ignorant girls living in a culture where men seem to have so much power! It's so frustrating because if only the women would step up and exert their own power, men wouldn't be able to take advantage of them as much. This all starts, I believe, with education. Education is power. How can we expect people to make good choices if they don't have information!?

And here is where I may get offensive to anyone who is Catholic or anyone who is against sexual education and information on family planning and contraception. I just get so pissed off that these issues are ignored in an attempt to not give approval to anyone having sex outside of marriage but the fact is EVERYONE IS HAVING SEX ANYWAY!!! Hello! And they are doing it without the knowledge of the consequences and are subsequently not protecting themselves and it is the women especially who suffer here as they are the ones who have to put their lives at risk to keep having babies and who's infections actually potentially damage their reproductive systems and can wreak havoc in their unborn baby's developing body. It is the men who can spread their seeds and infections without any apparent harmful effect. Argh!!!

Another t-shirt I saw on a man in the Philippines sums this up pretty well. It read, "Who are all these kids? And why are they calling me Daddy?"

So what do we end up with? Young, single girls trying to dangerously abort their babies. Unwanted pregnancies. Impoverished children who grow up malnourished and ignorant and uneducated who end up in the same situation as their mothers - young and pregnant. And the cycle of poverty goes on and on and on. I just want to scream!

There is this reproductive health bill in the Philippines that is very controversial and of course, the catholic church staunchly opposes it. Meanwhile the maternal mortality rate is not improving. Rates of STDs and HIV are creeping up and the population is growing very fast. If I remember this correctly, nearly half of the population are urban poor and living on less than $2 a day. Young girls are pressured to provide for their poor, struggling families and end up in sex work and eventually get pregnant. Mothers leave their children to work overseas, desperate for a way to climb out of poverty by being able to afford an education for their children. Broken families. And the entire nation suffers.

Whatever comes...

Do you ever just sit down to blog because it's been several days but you don't where to start because your head feels all jumbled and busy? Well there you go. That's how I'm feeling right now. I figured if I just start writing, a post will come. I'll give it a shot.

I sent off my NARM application today. That feels good. There was quite a bit involved in getting it together so it is quite satisfying to have it no longer in my hands. Hopefully, it's not missing anything and I'll get word in a few weeks that I am able to take the test. I'll go ahead and make travel arrangements at that time. The test is in Eugene, Oregon so that means I'll get to see my friends in Seattle, where I will fly to/from. My mom is going to meet me and then drive with me to Oregon. I'm so glad she's coming and I won't have to make that trip alone. It will be good to have some moral support before the test. Afterward I'll spend several days in Seattle to celebrate and relax and enjoy being with my dear friends there. I love going to Seattle! Oh yeah, that's happening in February.

For the application I had to determine total numbers of birth experiences including births I delivered, assisted or actively participated in, births I observed, and births that were transported to hospital. It's quite interesting to see it quantified and I thought I'd share what I've gotten to experience in two years at Glory Reborn so far.

Births I've observed: 14
Births attended as an assistant midwife: 41
Births attended as primary midwife: 32

I wonder what these numbers will look like in another year?

Here's some fun news - Andrey's sister had a baby girl last night. I don't know many details yet but hope to get them soon. This is a pretty big deal for our family. Mike & Lisa haven't had the smoothest road to becoming parents and God knows Andrey's Mom & Dad have waited a long time (patiently) to be Grandparents. We are so, so happy for our family! This is quite the significant event and even though it's been hard being so far away while it took place, we have been able to be in pretty close contact and feel like we participated. Part of that was because she was overdue so we were constantly praying and calling and eagerly checking email to see if there was any news.

I am a little too busy for my liking these days. I have a feeling these next few months are going to go by very quickly. I think I might ask for a slightly lighter schedule at the clinic, especially while I'm studying for this test.

I've been thinking about Thanksgiving lately. What I will prepare. Who will come. The nerdy trivia we will do. I'm getting excited. I love this holiday. I just wish I could invite everyone! I think I'll put our Christmas decorations up soon. Of course in the US we never did this till after Thanksgiving but it's been Christmas here for months already so I'm willing to budge by a few weeks. Strangely, I found myself enjoying the Christmas music in the grocery store today. Weird, I tell you. This is not like me. I was just in good spirits. And I was finding Thanksgiving/Christmas-type products. There's already Butterball turkeys and canned pumpkin and cranberry relish on the shelves. Well, the turkey was in the freezer. Anyway, I realize that a happy part of these holidays for me is the food prep involved in them and how naturally, a trip to the grocery store to buy all the stuff needed is a big part of those memories of past holidays for me. I recall trips to the store with my mom and buying tons of butter and potatoes and granny smith apples, and yams and the cart being super full. My mom always cooked for huge crowds around the holidays, especially Thanksgiving. It's just how it's done and I love it.

I'm also trying to be a bit more prepared this year so I think I'm not feeling stressed at all and am hoping it will continue. I am learning that this is key to enjoying the holiday season, especially as it relates to gift-giving. It seems we've waited till the last minute in years past and I'm determined to do it differently this year. So far so good.

I made pita bread this week. That's a first. How delightful to pull it out of the oven to discover the air pocket formed like it's supposed to. Okay, well only some did but it was still very exciting. We enjoyed them hot out of the oven with some home-made hummus, feta, cucumbers and fresh basil from the garden. (We're eating a lot of basil lately.) Tonight I roasted some red peppers and plan to make a chicken filling for the leftover pitas and of course, some more fresh basil. I think we'll have some salad on the side. Speaking of which, it's time to get dinner together. Andrey will be home soon and I'm getting hungry.

I really want to try to blog more about food and share recipes that I try and like. I put a lot of time and thought and effort into what we eat each week that it would stand to play a bigger role here. I do promise to share some of the Thanksgiving recipes I mentioned before. So look forward to those.

See, I knew something would come if I just started writing... I'm determined to keep this frequent blogging up. I am continually inspired by my blogging mentors. Unfortunately though I think that the more often I blog, the less interesting my posts may be as they are sure to include more day-to-day details of life. Oh well, hopefully there's something interesting in it for you. If not, you can always skim. ;-)

Learning and Teaching

Andrey's coming back tonight. Yay! He's been in Manila all week for meetings. I really prefer having that guy around and I'll be happy to pick him up from the airport later.

I worked last night and was delighted to get to rest for half the night because Tuesday night I was up till 5 a.m. with an 18-year-old first-time mama whose baby's father is considered 'unknown.' I find it sad on so many levels. The good things about this birth included a beautiful, precious little baby girl named Allyson and the fact that I felt really confident managing her labor and delivery. I'm starting to arrive at this place I couldn't imagine before. A place where I feel like I might actually know what I'm doing. There are still many-a-births when I don't feel this way but the number in which I do feel confident is increasing. I'm starting to feel like a real team member who contributes nearly as much as the nurses and midwives I work with that already have many years of experience.

The past few days I have been looking through tons of charts at the clinic of past births trying to find births that I either observed or managed and needed to be transported to hospital. I haven't kept of record of these because I didn't think I'd need to but turns out the North American Registry of Midwives (NARM) wants to know these in addition to the births I attended - delivered or assisted - as part of my application for the licensing exam. So I've been looking through charts. I found a few things that surprised me. In the past 5 months or so I have had the opportunity to instruct a couple of our newer staff-members (nurses getting trained in midwifery). There was a day when we had several births and Hilary was busy in the other room when a patient progressed faster than we expected and it was just me and one of the newer nurses in the room. Next thing we knew the baby's head was out and it's cord was wrapped around it's neck loosely. She panicked a little and I got to talk the her through what to do and I was surprisingly calm and relaxed (probably because cord wrap isn't that big of a deal, I may have reacted differently if it were an emergency or something serious) and was able to talk her through it instead of just taking over.

Then there was another birth I had forgotten about when a different nurse was handling the birth and she had trouble facilitating the birth of the baby's body after the head was out. I was able to instruct her and then stepped in to get it done after being instructed to do so by the supervisor on duty.

The reason I am mentioning these things is that I realize that I LOVE teaching! I love it! Who doesn't like to feel like they know what they are talking about? It's a good feeling and I'd love to do more of it. This is perfect as far as midwifery goes because there is a saying in midwifery (actually it's Midwifery Today's motto) - "Each one teach one." I have often thought about what it would be like to work as a midwife in another developing country on my own and how that would likely include training local midwives. There is a part of me that thinks it would be hard to not do births myself but I think I could really enjoy teaching.

One thing that has come out of becoming a midwife that I didn't expect is coming to understand and appreciate the significance of my father's two-decade career as a paramedic. When I took the Pediatric Advanced Life Support (PALS) class recently it occurred to me that this was the kind of stuff my Dad did knew how to do and did for so many years when I was a kid - handled trauma cases and managed a rescue car in a busy city, worked on a CareFlight helicopter. And then my Dad told me that he used to teach the PALS class. Wow! I had no idea how amazing my Dad was! I mean, I knew he was pretty great but I had no idea how skilled he was medically.

When I was a kid and somebody in my family got a bad cut or gash (usually one of my brothers), my mom and I immediately knew they needed stitches and always felt quite disappointed when my dad would say something like, "Na, it's fine. Just throw a butterfly bandage on it and it will be fine." My mom and I would usually think he was crazy and that he just didn't understand the seriousness of the laceration or we felt that the accident required more pity and babying (because that's what we would have wanted). Well, now I understand! It really wasn't a big deal and if it really were, it would have been handled appropriately. And even if there was a lot of blood, of course it wasn't a big deal considering the things my Dad saw and handled all the time at work. Sorry I underestimated you, Dad!

It's been so fun lately chatting with him about emergencies and trauma cases and growing as a care provider faced with these things or the possibility of these things. I love hearing his stories about starting out as a rookie and then growing into a confident paramedic that was able to sleep in the rescue car because by that time he had seen just about everything and was able to confidently slip in a few zzzz's on the way to a call. I learned also that he did quite a lot of teaching after he became an expert in his field. My Dad is extremely patient, kind and encouraging and I can clearly imagine him teaching a younger paramedic on the job. I feel like I may have some of these same skills. My mom is pretty great with these things, too. She teaches nurses to do ultrasound in pregnancy crisis centers around the US. I have seen her in action (she trained the GRC staff last year) and she's a great teacher, too - very patient and encouraging - so I've had great models.

My dad retired from the City of Tampa Fire Rescue department after he herniated two discs in his back from all the lifting over the years. I think these kind of jobs have a shorter life span than other careers and from what I can tell, most paramedics don't work as long as my dad did. I still don't know how he did it. I have a lot of respect for paramedics (like my friend, Melissa!), but I know I'm not called to that career. I am quite satisfied with the possibility of the rare, serious emergencies that midwifery brings and needing to be ready to handle them effectively should one arise. I never saw it before but given the careers of my parents, this midwifery thing seems quite appropriate. I never knew I'd get such enjoyment out of medical stuff but as it turns out some of my favorite things are poking people with needles to hook an IV or spending an hour suturing!!! Ha ha! The immediate, tangible result is so satisfying!

A New Approach to Blogging and Likely Much More than you Bargained For!

I have recently been inspired by fellow bloggers to post more. I have a few friends who are so good at blogging. They blog almost every day and they include a lot of day to day stuff, which I really enjoy reading. I realize I could do more of this and not limit my blogging to what I consider to be the most significant things. I can include the details of the week or day - even if it doesn't seem that interesting to me. After all, people can choose read it or skim it or skip it! (although every blogger hopes her posts are read and commented on!). The fact is, when I sit down to write I realize there is some noteworthy stuff going on and I'd like to remember more of it. Time goes by fast and when asked I can't always say what I did in a week but I know I was busy. So I'm gonna try to take better note of what goes on in a week - even if it's just for me. Take or leave it friends. Here are a few things from this past week.

Midwife?
I started referring to myself as a midwife this week. On Monday I received this (long awaited) email from the National College of Midwifery:

You have completed all your clinical and academic requirements for your NCM program. We have issued your Certificate in Midwifery. I have reviewed your file for eligibility to take the NARM exam. You are eligible and we will be happy to grant permission to take the exam.When you send us verification that you have passed the NARM Exam we will issue your Associate of Science in Midwifery Degree.

I shared this with Hilary before our weekly clinic meeting and she immediately said, "You're a midwife now!" It hadn't occurred to me. She then announced to the staff, "Hey everybody! Jen's a midwife!" Everyone cheered and congratulated me and it felt really good. On my student record I noticed a little something - "Graduation date: October 19, 2009." So sure, I'm not licensed yet but I have apparently graduated and am going to start calling myself a midwife.

On a side note. One thing I find funny is when patients at Glory Reborn call me or another staff member "Doc." It happened this past week while I was stitching up a patient. I used to say 'No, no, I'm not a doctor. I'm a just student midwife.' And then I realized there is no reason to say 'just a student midwife' because I do value my profession - student or not - so it's value shouldn't be minimized. So then I started saying, 'I'm a student midwife.' Now I say 'No, no, I'm not a doctor. I'm a midwife' (smiling on the inside). I still can't believe it. I wonder when I'll start feeling like I'm a real midwife. I don't feel it yet but I think it will come.

I started prepping the application for my licensing exam. I plan to take it February 17 in Eugene, Oregon. Now that I got the "go ahead" from NCM, I can now apply and get registered to take the exam. That also means I have to start studying. I plan to officially start once November arrives - so I have a week left of post-midwifery-program, pre-NARM exam, time to do what I want. FYI: NARM stands for North American Registry of Midwives. They grant the Certified Professional Midwife credential.

Still a Nutritionist
The past few weeks have been fun as I've taken on a few nutrition projects. I realize once again how much I enjoy nutrition work. It's nice to remember the work I have put into become a nutritionist (not so nice to remember that student loan every month though!) and that I can help inspire people to take better care of themselves. It occurred to me recently that I should take the opportunity to do more with nutrition now that I'm finished with my midwifery degree. Several opportunities have come up at the right time.

Hilary wanted some brochures made for the clinic so I made a 'Nutrition in Pregnancy' brochure specifically geared toward our clients. I put a lot of emphasis on the importance of nutrition during pregnany and less on the specific dos and don'ts (although it did include basic nurition principles and the components of complete meals). Our women need to understand why it's imporant before they will put effort into improving their diet during pregnancy. I find many have yet to see the value in it.

As I made the brochure I was further convinced of how important it is! The main points of the brochure are 1. Nutrition may save your life (2 of the top 3 causes of maternal death in the Philippines are nutrition-related!) and your baby's life (low birth weight babies have higher risk of death and poor growth and development and a whole host of other negative things) and 2. Nutrition saves money in the long run by preventing expensive complications and need for hospital delivery. I felt good about it and hope it inspires and compels women to do what they can to improve their diets during pregnancy. It's going to be translated into the local language. I also made a newborn care brochure and I would like to make a breastfeeding one as well. These are all topics that are covered in our health teachings during prenatal check ups but what is taught is not firmly established and really just depends on which nurse or midwife does the teaching. Also, it is good to have something in writing that our women can take with them.

I'm also creating a meal plan for my neighbor who is battling cancer and needs help gaining weight. It's a really tough situation for our her and her family so it feels good to be able to help in a practical way.

Other projects in the works include creating a meal plan for an American guy we know who is in a boxing training program and is training for a fight in December. He needs to gain weight, which is not easy since he exercises intensely 6 days a week, and wants to do it without having to rely on fast food all the time (good on him).

Also, recently I was asked by our church leaders to teach a nutrition class to the families in our community. Most of the children (and many parents) are quite underweight and I see a lot of packaged junk food going around all the time. I love teaching and I have tons of fun ideas for the class, which will probably take place sometime next month.

What fun to have two careers that I absolutely enjoy. I was quite happy and content to work in nutrition - especially if it included working with moms and babies and getting to do some doula and breastfeeding education work. Midwifery is the icing on the cake. How did this happen? I feel so blessed to not be limited to only doing jobs that pay. What freedom to be able take on whatever I have the desire and time for. It's really a joy to be doing such practical, useful work. Years ago I could have never guessed I'd be living in Asia doing what I do. The longer I am in Asia, the more thankful I am for this opportunity to live overseas and learn so many new things.

Our Weekend So Far
Yesterday (Saturday) Andrey and I (along with many other IJM staff members) took part in an anti-human-trafficking awareness walk and concert put on by MTV EXIT (End exploitation and human trafficking). Three very popular Filipino bands played and they were so good! It's great that MTV is taking a stand against trafficking and using their popularity among young people to do something about it. I wish I could post a few photos but I forgot our camera.

I also wish I could share in some detail about Andrey's work on this blog but I can't. What I can say though is that in the past two weeks, there has been some exciting work that has gone on that has resulted in arrests and rescue. We are thankful for the success that has occurred on behalf of the oppressed and pray for the work of healing and transformation for those involved.

It's Sunday morning and Andrey left for church a little while ago. I'm so tired this morning. I pulled an all-nighter Friday night at the clinic, then yesterday was busy all day and this morning I'm just not feeling so great so I decided to stay back. I'm gonna have some quiet time and do some journaling and reading and resting. So nice.

The Coming Week
Andrey will be in Manila all next week. He leaves early Monday morning. I've decided I'm going to eat vegetarian all week. I've pulled out some old Bastyr University recipes from my whole foods cooking classes. Some very Fall recipes as that was the season I took the class but hey - it's Fall in many places in the world right now. This week's menu will hopefully include:

• Curried lentils with cauliflower and sweet potatoes with spicy raita (yogurt sauce) and brown rice
• Rosemary red soup (beets, carrots, red lentils), green salad and whole wheat buns
• Mexican bean/corn casserole
• Sweet squash corn muffins
• Honey-glazed tofu

Well, at least the first two meals are sure to be made as I've already bought the ingredients for them. If any of these sound good to you and you want the recipe let me know and I'll send it to you. They are generally pretty easy and very perfect for Fall weather. I'm not going to let the lack of Fall weather stop me from enjoying these foods. I'm working Tuesday and Thursday night shifts this week so we'll see if I have the energy to cook later on but at least I'll get the week started out right and then have leftovers all to myself.

I've really been enjoying meal planning and lately I've been challenging myself to plan meals utilizing stuff I already have in stock instead of always buying more. This month, I have successfully began clearing out our pantry and refrigerator/freezer. Meal planning results in healthier meals and less waste. I buy the produce I plan to use, not hope to use. I only have to shop every 3 to 4 days - sometimes I'll make the meal plan for a whole week with two different shopping lists of what to buy now and what produce I will need to pick up mid-week. I love cooking and the satisfaction it brings knowing I am eating well and using less.

I have uncharacteristically started planning already for Thanksgiving and Christmas. What's wrong with me? I'm slowly conforming to Filipino culture as I plan to put up Christmas decorations BEFORE Thanksgiving this year. Gasp! Our family never did this but Christmas in the Philippines started almost two months ago so the idea of mid-November Christmas decorating is growing on me. I'm so excited about Thanksgiving this year (after all, it IS my FAVORITE holiday of all!). I can't wait to roast a large bird after it sits in brine for about a day. I have learned (from my skilled mother with little credit to Martha Stewart), that this produces the most juicy and flavorful turkey of all. I have been tweaking my recipe the past few years to include some dark beer and brown sugar. Oh Lordy it is good. Maybe in a few weeks I'll post a few of my favorite Thanksgiving recipes. The others that I must make and just can not delegate to others is apple pie (adapted from my Mom's famous recipe!) and a new addition whole wheat butterhorns (thanks Lonna and Mennonite bakers from Intercourse, Pennsylvania - yes that is a real town and yes, that is it's real name. Isn't that awesome?).

Well now that I've gotten started I'm just rambling now so I'll stop here for fear that no one will read or comment on this extremely long post. Hope you all are having a great weekend!

Busy Baby Season & the Making of a Midwife

September and October are the most busy months at Glory Reborn clinic. Last night was a good example of this. When I arrived we had six inpatients plus a woman in labor. Three patients had delivered the day before and two had delivered earlier in the day. The woman in labor was already active and lying on her left side since her blood pressure was borderline high. While we were doing endorsements (explaining of charts from one shift to the next), the woman in labor exclaimed that she was ready to push. I quickly checked her and determined that she was fully dilated. We transferred her upstairs and within 15 minutes her baby was born. Our postpartum room was full, which has three beds. Our delivery room was full (two beds) and our prenatal area was full (three beds). Thankfully, after the delivery we were able to send one of the postpartum patients home, giving us one free bed. That turned out to be exactly what we needed because at 9:30pm another woman in labor arrived and she too was fully dilated! I ran upstairs to tell my coworkers to hurry and transfer the last patient off of the OB table so we could bring the next one upstairs. They moved her and the bed was cleaned just in time.

I got to deliver the second baby, "Baby Jane," at 9:54pm. Whew! Both deliveries were so fast! After that, we ended up with 9 patients for the night. We had to transfer two to the annex in the back of the clinic so that our delivery room would have two free beds.

I feel like I am becoming better equipped to serve the women we see at GRC. For a long time I resisted the active management of our patients in labor as I believed that most births should be normal and would not need intervention except in a minority of cases. Because of this I have missed some key interventions/preventative actions that resulted in a few of my patients losing a bit more blood than they needed to. A few weeks ago I had a patient that hemorrhaged and it sobered me to the very real danger of excessive blood loss. It can happen so fast!

Hemorrhage is one of the top three causes of maternal death in the Philippines as is the case in most developing countries with poor maternal mortality rates. I have become aware of the necessity in changing the way in which I view my patients at Glory Reborn. By far the majority of our patients are high-risk and my management should reflect that.

I have written about this in the past - my need to reconcile the birth stories I read about in the West and my experience in midwifery in the Philippines. I have come to the following conclusions:

• I still believe that birth is a physiological process that should not be interfered with as long as it continues within the realm of normal. Expected management should be implored in known low-risk women.
• Most women will have normal pregnancies and deliveries if they enter pregnancy with a certain level of health, which sadly and in the majority of women, corresponds with socioeconomic status and level of education.
• Impoverished women, who have lower levels of education, less access to health care and family planning services, and know less about health and nutrition, tend to enter pregnancies malnourished with iron-deficiency anemia, and as is the case in the Philippines, higher parity (having had a greater number of pregnancies).
  
• These women end up with very poor nutrition - with numerous states of deficiency in the least including deficiencies of protein, iron, vitamins A & C, calcium, folic acid, zinc...
• The impact of poor nutrition is understated and is often overlooked.
  
• When compared to women in developing countries, the women in the Philippines have a MUCH greater risk of dying from infection, hemorrhage or pre-eclampsia.
  
• This warrants a different approach by me as a midwife as long as I am working among the poor in a developing country. (Numerous resources put forth by the World Health Organization further confirms the appropriateness of this.)
  
• Doing this will not ruin my ability to appropriately support healthier women in pregnancy and childbirth but will better equip me to handle life-threatening emergencies when they do occur.
  
• It is very appropriate and possible to "be on the safe side" for the women we serve at Glory Reborn while remaining in the realm of evidence-based practice.
• I must continually challenge myself to further improve my skills and judgment so that I can better discern the line where interventions become unnecessary and harmful.
  

So, the birth I handled last night confirmed to me that this approach is an appropriate one. Even though the patient's hemoglobin was normal (so was the last patient I delivered who hemorrhaged), I decided to hook her to IV fluids before she delivered just in case she hemorrhaged. This was only her second baby, but her labor was precipitous, which increased the risk of hemorrhage. I delivered her placenta actively (within several minutes) and sure enough her uterus did not contract well and she had a steady trickle of blood until the pitocin that we immediately infused into her IV took effect. She lost at about 400 cc of blood in those few short minutes. I believe it would have been worse had I not hooked IV and had to give pitocin intramuscularly, which takes longer to take effect and is less effective than pitocin administered via IV infusion.

Her placenta showed signs of poor nutrition. It was small with a very thin cord. Come to find out her husband is a smoker which further reduces the health of the placenta. In the end, her baby transitioned well to extra-uterine life with a birth weight of 2800 grams (only 300 grams away from being considered low birth weight. Babies who weigh less than 2,500 grams at birth have significantly increased risks of mental retardation, learning disabilities, stunted growth/development, and death when compared to babies in a normal weight range. Babies in the 2,500 - 3,000 gram category have lower risks of the above but are three times more likely to experience one or more of those things than babies who weigh more than 3,000 grams.

So, I am practicing a different kind of midwifery than I initially envisioned, but I am choosing to embrace it, learn as much as I can and do the best that I can. Who knows where this experience and will lead me? For now I am quite content and thankful for the opportunity to volunteer at Glory Reborn to grow in my skills as a midwife.

Midwifery Paperwork Complete!

As my mother would say, "Hallelujah! Pass the biscuits!"

This is what ran through my mind last night after I finished scanning the completed paperwork for my midwifery degree. What a happy feeling to have all assignments and tests completed and graded and every form completely filled up with all the signatures I need! The midwifery college has even received my transcripts and applied the needed transfer credits.

So with this, I am happy to report that I have completed all coursework and clinical requirements for my Associate of Science in Midwifery from the National College of Midwifery! Except... there is one thing I am missing: my newborn resuscitation certification. :-(

Hilary and I erroneously assumed that my infant, child, adult CPR certification with the Red Cross was the only necessary requirement because when Hilary was a student that was the only one she needed. Unfortunately, the college recently asked for my NRP (newborn resuscitation program) card. Shoot. After inquiring further and after I waited two weeks for a reply, I learned that I will need to take a class in line with the training of the American Academy of Pediatrics or the American Heart Association. My deadline is October 15 to complete and submit this last requirement.

Yesterday, I called Red Cross in Cebu and they do not offer the class, nor do they know who does in Cebu. So I looked online and found a class in Manila scheduled for today and tomorrow. The class is only offered three times a year through the Philippine Heart Center and this was the last training of the year. The office closed at 5pm and it was 4pm. Shoot. I scrambled to the phone and prayed that maybe they'd still have space, I could register late over the phone and somehow get to Manila by this morning. I was relieved to learn that the class had been postponed and is scheduled for October 5-7. Whew.

The man I spoke to was kind and willing to work with me given my unique situation of registering outside of Manila. So, all I have to do is find some way to send payment to Manila in the next few weeks and arrange for them to mail me the manual so I can do the required study preparation for the class, then confirm one week before the class, buy a ticket to Manila, and find a place to stay for 3 nights. If all goes well, and the class is not postponed again, I will likely accomplish this last requirement. Then I will truly be relieved.

It is so fun just to work at the clinic like everyone else, knowing that any experience I get is just bonus and is helping me gain the skills and confidence I need to be a good midwife. Although not 100% done, I still feel very satisfied having made it this far. Once I get the NRP certification and get the okay from the college, I will apply to take the NARM exam in February in Oregon. Once passed, I will receive the credential of certified professional midwife (CPM). I am looking forward to that!

Back to Work, A Birth Story, and the Practice of Midwifery Among the Poor

Yesterday was my first shift at the clinic since our trip to North America. I felt a little nervous about going back, as I usually do after a long break. I'm typically a little nervous that I will have forgotten how to do something or that I'll be a little rusty from being out of practice, but after a busy labor and birth-filled day, I am happy to report that I didn't forget and I didn't feel rusty. I just slipped right back in to sweaty, busy clinic life.

A 24-year-old woman in labor with her third child arrived just before 10. The rest of the staff was in our weekly meeting so I was the one to receive her. This meant I would be the one to deliver her baby and I was quite happy about that. I wondered if I would get a birth on my first shift back.

She said her contractions were coming every five minutes. She was 39 weeks and 3 days. Her blood count was uncommonly good and she didn't report any major complications in her previous pregnancies. All very reassuring things. Upon examination and monitoring her I found out that she was 3 cm dilated, her blood pressure was slightly elevated and her contractions were indeed coming every 5-6 minutes and they were moderately strong. She was very relaxed even though it was apparent that her contractions were painful.

After I hung out with her a while timing her contractions and noticing her blood pressure was borderline high between contractions, I asked her how she was feeling about giving birth, which would likely be this afternoon. Was she excited? Nervous? Worried? I tried to get an idea of what was going on inside her mind. I find it's not easy to read some of our moms. Most are very reserved with their emotions and I was trying to see if there was an emotional reason for her B/P to be on the high-side. She didn't say much at first, then as I asked her again she just shrugged her shoulders and said something to the effect of, Whatever, man, totally fine. Like what's the big deal? Okay right. No big deal. At least she wasn't worried about anything. That certainly can't hurt while in labor. (Assuming she's telling me the truth.)

As the day went on she progressed well. Four hours after she was admitted she was 6 cm dilated and her contractions were every 4-5 minutes. Within an hour after that, I knew she was reaching transition as her contractions grew stronger and were coming every 2 minutes. Her blood pressure continued to rise. I transferred her upstairs and had her lie on her left side. She continued to do an excellent job of keeping her body relaxed through the intensely strong and painful contractions but she clearly appreciated support through each contraction. Between me and her boyfriend rubbing her back and talking her through, I think we were able to give her the support she needed.

As her labor intensified, her blood pressure rose and became disconcertingly high. I called Hilary in who was busy with lots of new patients downstairs. (Each month we offer free labs in order to fill our available space for patients so there were numerous new patients waiting to have their interview and first check-up.) Usually we would transport a patient with high B/P but I knew she was getting close and at the public hospital they would likely leave her unattended without monitoring her properly. Since she was progressing well and was asymptomatic, we decided to keep her at the clinic and do what we could to help her deliver safely.

We hooked her to IV fluids just in case it became a true emergency and we either had to take her to hospital or infuse hydralazine to bring her B/P down. I did an IE and she was 9cm and the bag of waters was at +2 station. After a contraction I rupture her bag of waters. The water was a dark brownish-green color, "moderate meconium stain." She said she wanted to push but I doubted it was a physiological urge since she wasn't instinctively bearing down and also because I knew she wasn't yet fully dilated. It was best to let her uterus do its job and wait for the physiological urge to push. She would have to continue breathing until she really had the undeniably strong urge to push. And when this happens, it will be undeniable. So she stayed lying on her left side and we encouraged her to breath deeply through each contraction and try to stay relaxed. She did this well although we could tell it was very difficult.

Within 20 minutes it was clear that the baby's head had reached the pelvic floor as she couldn't do anything else but begin bearing down. Her B/P continued to rise beyond what is normal. We tried to get her to only push as much as she had to but to breath when she was able. Again, she did such a good job trying this and I knew it was extremely difficult to do, but I knew the baby's head was coming down and all we had to do was wait a couple more contractions, get her to breath and the baby's head would be visible. And soon it was.

With the next contraction and with her doing more breathing than pushing, the head was emerging. Her perineum was taut and bulged with about a 2-inch circle of the baby's head just behind it when her contraction ended. I wanted her to stay as relaxed as possible in order to keep the tissues oxygenated and give them a few moments to stretch. I have read that this can help prevent a tear by letting crowning happen slowly (when possible!). I was amazed at her ability to relax and breath! I thought, this is amazing! This will really help. We waited for the next contraction. At the beginning of the next contraction and with a small push, the head was out but I could tell that she tore. The body followed and the baby was placed on its mother's belly just as the room filled with the sound of his first cry. Another baby boy! (Their third.) He weighed 7 pounds 6 ounces. It was almost 4 pm.

I waited for the cord to stop pulsing before we clamped and cut it. The baby was placed at the breast while our nurse dried him, put a dry blanket over him and checked his vital signs. The placenta was delivered after eight minutes and pitocin was added to her IV. Hilary said in her experience that women with high B/P in labor tend to bleed.

I was surprised to discover that this mom had about seven first degree tears. Five of them would have to be sutured. I spent the next two hours suturing! Poor gal! Don't worry, we do give local anesthesia. It was a challenging suturing job for me and I was grateful that Hilary was there to guide me. I learned a lot with this one but I'm am disappointed and confused why she tore so badly. First baby, okay maybe but the third? Most of our women tear and I still wonder why it happens so often. What are we doing wrong? Hilary says a simple episiotomy would have prevented all those tears but I keep believing that it shouldn't have to be this way. But after tear after tear after difficult tear I can't help but wonder. But you never know that a woman will tear so badly until after and at each birth I am always hoping for the best! Do our moms tear more often? If so, why? Of course I don't know what is normal because at this point I don't know any different. Anyway...

What a way to come back to work! By the time we got mom and baby settled, got everything cleaned up and I finished the paperwork, my shift was over and it was time to go home. Even though there are many elements to this birth that I need to process and evaluate in my mind, I feel very satisfied to have gotten the chance to work with this young mother. I did a lot of praying for her throughout the day and so I give glory to God for helping us and helping her safely deliver a healthy baby without a trip to the hospital!

This is exactly the kind of situation that is clearly out of the scope of practice for midwives in N. America. There are many reasons for that and it's good that that's the way it is, but I am beginning to realize that working with the poor in a developing country is practically a different career than practicing midwifery in a developed country. It's just so different. I know the midwifery I am able to practice in the Philippines is not possible back home. I am starting to wrestle with this reality as I develop in my mind where and how I'd like to use my midwifery skills. Do I want to be limited to working with low-risk women, many of whom have several options available to them? Or do I want to work with women considered to be "high-risk" because of their age, their high fertility rates, their poor nutrition levels - who have little to no options for giving birth in what would be considered to be a safe place? I'd say the majority of the women we see at Glory Reborn would be considered "high-risk," but we are compelled to work with them because of their lack of options and we are able to work with them and care for them beyond the scope of midwifery in the West because we have two obstetricians who have agreed to oversee our cases. I'm glad for this. It's good for the moms we serve.

In the spectrum of developing countries, the Philippines is not as bad as many other countries like Afghanistan and Haiti, and those in West Africa. I'm not saying it's not bad here because it is, considering how much better it could be. I was recently looking at maternal and infant mortality rates in Haiti and it's so much worse than the Philippines! Although about half as bad as West African countries and Afghanistan, Haiti's maternal mortality rate is three times that of the Philippines. And the infant mortality rate is ~2.5 times that of the Phils. Haiti is clearly the worst in the Western Hemisphere, which is not a surprise since it is the poorest country in the Western Hemisphere.

We have friends who are working with orphans in Haiti and I hear stories about how bad it is there and how they need midwives! One of the babies our friends adopted was orphaned because her mother died in childbirth. I can't help but dream (am I crazy?) of working in a place like Haiti where only 26% of all births are attended by skilled health personnel (only 6% are attended among those in the lowest wealth quintile!). This figure is 60% of all births in the Philippines, with 25% attended births among the poorest, versus 92% among the wealthiest! This is outrageous! It is well documented that one of the best ways to improve maternal and infant mortality rates is to have access to and utilize a trained health care provider during pregnancy and birth. Midwifery saves lives!

I am compelled to use midwifery in the developing world but to do that is to choose to practice a different kind of midwifery. Different than the dreamy natural birth stories I hear of friends in North America attended by midwives, which are wonderful and great and well, that's why I call them dreamy. I must, I believe, in order to be a good midwife, experience natural birth in the West. Learning what those midwives know will enable me to only intervene when it is really necessary. I try to do this now but it is hard without experience on my side and those with experience telling me this is what is needed to keep our moms and babies safe. I don't want to lose my trust of birth and God's enabling of women to give birth. I get sad expecting, trusting things to go as they should and then they don't. Fine, if that is the case in the minority of cases. But the majority? I struggle with this.

I understand that our women aren't birthing under ideal conditions. Malnutrition is rampant and I think its effects are underestimated. Plus lack of access to decent health care must play a role in their health level coming into pregnancy and birth. I am learning in the health care debate in my own country that those without health insurance access less health care and are subsequently sicker and have higher mortality and morbidity rates. This has to be a factor here as all medical costs are out-of-pocket. The only social insurance is for those with full-time jobs who pay taxes and the health coverage they get is not worth much. Arg! It's just so frustrating!

Other factors that I can see include lack of basic education regarding how the body works, cultural factors that keep poor women from thinking for themselves and being empowered to affect how her pregnancy and birth is handled, and simply poverty. Not having the money to treat basic infections, buy nutritious food, get care when it is needed to even maintain a minimum level of health. We do provide education at Glory Reborn but just a few teachings here and there is simply not enough to change the way people think and approach the births of their babies.

Okay, that's it for now. Just needed to vent a little and process some of the stuff running around in my head.
p.s. I took these photos last week at the monthly Glory Reborn baby party. We had a photo shoot so Hilary could get photos for some upcoming Christmas cards she's making that will be for sale on the GRC website. They're just so cute I had to add some. I'll post more later.

Sleep

What? I haven't posted in 9 days? Time is racing by lately. I was seriously surprised to see that May 5 was the last time I posted. Busy. BU-SY right now. May is a busy month because I am working ~40 hours a week at the clinic plus I am finishing one of my last major midwifery modules - all the about the newborn, which has 4 very long assignments. The two I just finished totaled 56 pages with 10-point type. Yesterday I took two of the four tests in this module and it felt great to be done with those. So today, I'm allowing myself to get caught up on a few things - like grocery shopping and blogging. I also met a friend for coffee this morning, which was nice.

Starting tonight I'll be working every other day until a week from Saturday - alternating 12 hrs on with 24 to 36 hrs off. This happens to be a very common schedule for most of the Glory Reborn staff and frankly I don't know how they sustain it for years and years. Granted, they're not working on a degree at the same time, but I think I would be nearly just as tired with or without the studies. It's just hard having inconsistent sleep patterns. It just feels harder on the body. In my lowest tired moments I wonder if midwifery is really worth it, I long to feel rested so bad but then I realize that this is probably quite similar to how parents of young children feel all the time too. So it's not like giving up on midwifery will make it all better, which I don't plan on doing anyway.

I have always been a good sleeper. Always. Until I started working night shifts two years ago. The frustrating thing is the fact that the pressure of really needing a good sleep when I have the opportunity to sleep makes me unable to SLEEP! How stupid is that? I seriously work myself up so much that I lie there feeling angry about still being awake. It's madness!

Andrey tells me I just need to not care about not getting sleep, that way I'll be able to sleep. Believe me, if it were that easy I wouldn't be struggling with this to begin with. Make myself not care? Fine. Maybe, if it were every once in a while. And I told him he is sweet for trying to help but I simply don't agree. Yes, I (now) agree a night with poor or little sleep isn't that bad (I used to be WAY worse!) but I'm talking about the importance of a night of sleep after a previous sleepless, work-filled, tiring night. Or a night of sleep after a previous night with only 3 hours of sleep. Humans need sleep. God created sleep. I am not crazy to feel like I REALLY just need to sleep sometimes. When I don't get sleep I don't make much progress on assignments! I sit there at the computer, spacing out, taking way too many breaks to pee or eat or check email... again... and then get sucked in to facebook (I know it's nobody else's fault but mine) for 20 minutes and then I check a blog and then another and then suddenly hours have gone by and oh shit, I still haven't gotten any assignment done! And then it's time to make dinnner. I could try to push through with lots of coffee. I'd probably get more done that way but then that is a recipe for an inability to go to sleep later.

I haven't exercised in weeks which I know would probably help me sleep better. I've tried herbs - skullcap, passionflower, sleepytime tea. These help sometimes. I've taken magnesium maleate, which helps sometimes. What really works are anti-anxiety sleeping pills but they are habit forming so I save those for only my most desperate times. I've also started a bed-time routine to help get me relaxed for sleep. I dim the lights, put on soft music, no computer or TV is allowed, do some reading, journaling or praying. That helps sometimes too. Maybe I do just have to find a way not to care about sleep. If so, how the heck do you do that???

I'm surprised Andrey suggested this. Ever since we've been married he has remarked at my silly habit at counting hours of sleep. He calls me the sleep-counter. This is how it goes...

Ok, let's see. What time is it? It's only 10. I have to get up at 7, so that's at least 8, almost 9 hours. Great! It's going to be a good day tomorrow. (My body's favorite number is 9)

-OR-

Oh crap it's late. And I have to get up 5. Five hours? Oh tomorrow is going to be awful.

And that was back when I got to sleep every night. No night shifts. No midwifery training.

Now it's even worse. I say to myself... I got 3 hrs last night and I'm exhausted. Damn I'd better get at LEAST 8 hours tonight! Oh no but it's already midnight and I've been lying here for more than two hours! I'm screwed! My hours are chewed down to almost 6! Oh God no! Help me, please! Why can't I sleep?! This is so ridiculou! I'm so tired! And this is when I either feel like punching the wall or crying.

So this whole thing isn't about the sleep lost when I'm working. It's about sleep lost when I theoretically can and should be sleeping. That is the frustrating part. I know it is all in my mind but that is a very tough battlefield. It also has to do with anxiety and the stress hormones that are released when I am lying there analyzing my day. I sometimes lie there and run through scenarios of things I said to people and realize things I didn't notice before or realize a mistake I made a work or that I forgot to do something and maybe so-and-so is mad about me or because I said the wrong thing...all the while I feel this surge of adrenaline going through my body. I'm going to have to get a handle on this because stress is very damaging to the body (knowing that doesn't help). At least I am eating well. I still make the time to prepare dinner almost every night and we eat pretty well when I do.

I also realize that this temporary. Once I finish this module things will slow down a little bit - not much, but a little. And hopefully we'll get more staff at the clinic (we're currenly short-handed and that's why i'm working a little more than usual) soon so I won't have to work quite so often. I just feel this is a common life challenge that I need to learn to overcome.

That's it. It's out there. It's really out there.

At some point today the Philippines government became aware or our intention to adopt a Filipino child or two. Our home study, which was recently completed and more recently approved and endorsed by our adoption agency was submitted to the Inter-Country Adoption Board of the Philippines. That's it. Now they have it. It's out there. Out of our hands.
I'm finding the uncertain nature of the time-line until we actually become parents unsettling. Although it's not likely (so we are told), we could technically be matched with a child in 6 months! Alternatively, it could be 12 months, 18 months, or even 24 months. How do you prepare for something like this?

Maybe it's like living with the awareness of your mortality. Sure, we all know we should love today as if it were our last - oh boy, now I'm comparing adoption to death, not at all my intention just stick with me. My point is that we don't usually live today as if it were our last but if we actually knew for a fact that we were going to die tomorrow we would certainly live differently - taking advantage of every opportunity and not wasting time on things that aren't important.

What I'm getting at here is my midwifery degree. I REALLY want to complete my program (set end of 2009) and pass a licensing exam (set for early 2010) and become a midwife. Even if I won't be able to practice as a midwife for a while - at least I will have the credential that will allow me to step into it when the time is right. Completing my degree is very attainable if our adoption is typical of other Philippines adoptions. It's attainable if I continue to work at it at a reasonable pace. Now let's say that I become a mommy sooner than I think (prior to 2010). I would have to work much harder at getting it done sooner.

The other thing is that with the midwifery stuff I have very little time to delve deeply into adoption preparation resources right now. Up until this point I've felt like I have some time so it's okay if I don't dive into it right away. But if I knew I was getting a child in a few months I think I'd wished I did more reading earlier. I really should be focusing more on that right now just in case.

I think I may have a hard time switching gears from one time-consuming goal to another. It's hard to go back and forth. At least with midwifery, I get more assignments done when I build up some momentum but once I take a break because of travel or a visitor in town or something then it really takes me a while to get back into it. Isn't multi-tasking a prerequisite for successful parenting? What does that say about me? Obviously with kids it will be different as you can't just leave a kid on your desk and pretend you don't see it.

I am so excited about having children that I am more than willing, at that point to throw midwifery out the window - at least for a little while until we adjust as a family. I know I'll still be able to finish my degree at a later date if we do get a child before the end of '09 - but will I want to? I really have no idea what I'm going to want later on. I know I will want to take care of my kids and not have to squeeze school in somehow. I think midwifery will be an excellent way to serve the poor in other places we may live or to have a practice in North America should we live there again. But I don't envision myself working a lot while our kids are young. A little at some point would be great but not a lot. And then when our kids are older then I might consider a midwifery practice. Oh heck I really have no idea. Normally I am totally fine with uncertainty and not knowing what is next - but that's when it was only me and Andrey in the equation. Having kids is going to change everything. The question is, how much do I change now - in the anticipation of having kids at some unknown date?