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Message Global Birth Models By Kay Sandberg, Director for Global Force for Healing & Shane Carnahan, BSN Published September 20, 2014 Published in three segments in Midwifery Today in 2015 ∼ Global Force for Healing, PO Box 428, Ashland, Oregon 97520; EIN #80-0739258

1 TABLE OF CONTENTS Introduction 2 One Heart World-Wide Mission and Model 8 Sustainability 12 Cultural Sensitivity 13 Respectful Care 13 Competency in Care 14 Love and Compassion in Action 15 Future Plans 18 Yayasan Bumi Sehat Mission and Model 19 Sustainability 21 Cultural Sensitivity 22 Respectful Care 22 Competency in Care 23 Love and Compassion in Action 24 Future Plans 25 Mother Health International Mission and Model 26 Sustainability 28 Cultural Sensitivity 29 Respectful Care 29 Competency in Care 30 Love and Compassion in Action 31 Future Plans 32 CASA (Center for the Adolescents of San Miguel de Allende) Mission and Model 34 Sustainability 37 Cultural Sensitivity 37 Respectful Care 38 Competency in Care 39 Love and Compassion in Action 40 Future Plans 40 Conclusion 41 List of Organizations and How to Reach Them 43 References 46

2 EFFECTIVE GLOBAL BIRTH MODELS: INNOVATING FOR MATERNAL & INFANT HEALTH AT THE GRASSROOTS LEVEL INTRODUCTION On behalf of the Global Force for Healing, it is an honor and privilege to convene a global network of projects and birth centers focused on healthy, compassionate birthing for marginalized people in remote and indigenous areas. Three of the four programs featured in this article belong to our Healthy, Compassionate Birthing network (www.globalforceforhealing.org/project-one/). All are led by courageous women founders who, with their staff and volunteers have been on the frontlines of providing loving care to mothers and babies for a decade or more. This article is dedicated, with appreciation to these women and the families they serve in remote and indigenous global locations. GOAL OF THE HEALTHY, COMPASSIONATE BIRTHING PROJECT The overarching goal of the Healthy Birthing Project and of each participating group is to dramatically reduce the number of preventable deaths among mothers and newborns, and to honor the power of love and compassion in the intimate setting of birth. We believe that birth, including what leads up to the event and the weeks immediately following, are a human’s first opportunity to experience unconditional love. Since love is a hologram, every loving birth extends love and healing to a much wider circle—parents, communities, and the planet. In short, “As we are in birth, so we are with Mother Earth.” According to the World Health Organization (WHO), approximately 800 women and 8,200 newborns die daily from preventable causes related to pregnancy and birth. Ninety- nine percent of these deaths occur in resource-limited global settings, and an estimated 90% could be avoided by proper care and nutrition before, during, and after birth. (World Health Organization, May 2014). The Healthy, Compassionate Birthing project is in service to United Nations Millennium Development Goals (MDG’s) established in 2000, to be achieved by the end of 2015.

3 Goals 4 and 5 are respectively, to reduce infant deaths worldwide by 2/3 over 1990 levels and global maternal deaths by ¾ over 1990 levels. While great progress has been made in many countries, many underserved populations are not likely to meet these targets, especially without the global community stepping up its efforts to all who request support. We have included individual program initiatives to fulfill the MDG’s to the extent that they speak about their own work in these terms. PURPOSE OF THIS ARTICLE The purpose of this article is to highlight effective organizational models for healthy childbirth in particular cultural settings, in order to provide guidance, inspiration, and ideas that may be applicable to other cultural environments. It is our hope that by articulating why these organizational models have been successful, others may avoid reinventing the wheel and better serve remote and indigenous, underserved communities. We also highlight why particular strategies and each model as a whole leads to successful birth outcomes and reduction of maternal and infant deaths. For example, the Network of Safety model pioneered by One Heart World-Wide, illustrates a holistic approach to education, training and treatment by a wide range of healthcare providers, both for prevention and in response to birth events. Local staff members work with government entities to improve health facilities and clear the path for long-term program operations. Bumi Sehat Foundation’s model is focused on and well suited to sending midwives to respond to natural disasters such as the earthquake in Haiti in 2010, the tsunami in Aceh, Indonesia in 2004, and in 2013, Typhoon Haiyan which devastated parts of the coastal Philippines. They have been early responders over the last ten years, applying wisdom gleaned from providing midwifery and holistic health services for underserved families in Bali, Indonesia for more than 20 years. Mother Health International has achieved an admirably sustainable model of care. For example, the birth center in Atiak, Uganda has been constructed with dedication to the preservation of natural resources. Their ‘Earth Birth Center’ model is actively working

4 toward financial sustainability in a number of ways, including selling items crafted by new mothers, who also maintain a garden that feeds laboring and postpartum women. Mother Health demonstrates its commitment to the preservation of cultural traditions by advocating for the active involvement of Traditional Ugandan Midwives in all births. CASA (Centro Para los Adolescentes de San Miguel de Allende) has created an exemplary model of midwifery education, with proven effectiveness in training midwifery professionals who demonstrate a high level of care and professionalism while offering mothers and families culturally sensitive support. All projects embody the Midwifery Model of Care, meaning woman-centered, gentle, non-invasive approaches, which view birth as a natural act. The midwifery model is based on a deep respect for women’s “voice and choice” in childbirth. That said, not all projects rely on midwives. In fact, the birthing professional may be a birth attendant, traditional midwife/skilled birth attendant, a physician, nurse midwife, community health worker, or a combination. These choices are based on the practicality of what works best and is most realistic given the remote regions where services are delivered. We hope this article helps to bridge any gaps in understanding and contributes to a climate of mutual respect among birthing professionals participating in the biomedical (‘modern’ medicine) frame as well as those who operate independent of it. KEY FACTORS SHARED BY FEATURED PROJECTS We have chosen five key factors that cut across all projects featured. All of these key ingredients are aimed at reducing maternal and neonatal mortality rates. If you are interested in a particular factor, we trust the article will be helpful in accessing a variety of perspectives and practical wisdom on for example, sustainability. And, in order to fully grasp the “secret sauce” of each model, the five factors combined with other innovative aspects will paint a picture of what has been effective and why.

5 *Sustainability--the ability to meet basic commitments and needs on an ongoing basis for the communities in which they work. Note that the ability to be self-sustaining is a goal of some projects and a fulfilled promise for others at this point in time. *Cultural Sensitivity—a commitment to working in harmony with and appreciation for local cultural traditions, rituals, and organizational structures, often as a result of years of research prior to project inception, and always based on respectful learning from and responsiveness to requests by community leaders and birthing mothers themselves. *Respectful Care—dedication to universal rights of childbearing women to high-quality maternity and newborn care, and to avoiding disrespect and abuse of women that sometimes occurs in resource-poor settings. Some projects featured subscribe to the International MotherBaby Childbirth Initiative’s “10 Steps to Optimal MotherBaby Maternity Services” (www.imbci.org), which we also endorse. *Competency in Care—Each project adheres to clear standards for training birth professionals and the services they provide. Each focuses on ensuring consistent practices, attitudes, and behaviors that are life-affirming and that reflect the highest quality of care for mother and baby, whether they be midwives, (skilled) birth attendants, doctors, nurse-midwives, doulas, etc. while taking local constraints into account. *Love and Compassion in Action—by their very way of being with birthing families, communities, staff and volunteers, each project embodies its own unique expression of love and compassion. Even if not stated in published documents or performance guidelines love is at the core of what these projects are about, starting with the way of being of the founders/executive directors. Expressing love and compassion in action is also the guiding purpose of the Global Force for Healing and a hallmark of our projects. MODEL PROJECTS FEATURED The four model projects are:

6 1. One Heart World-Wide (Nepal; formerly in Tibet and Mexico; technical assistance to projects in Ecuador, Peru & Mexico; www.oneheartworld-wide.org) 2. Yayasan Bumi Sehat (Bali and Aceh, Indonesia, the Philippines; formerly Haiti; http://www.bumisehatbali.org) 3. Mother Health International (currently, Northern Uganda, training midwives in Haiti and advising the government of Guinea; formerly in Senegal; www. motherhealth.org) 4. CASA (Mexico; also trains global midwives; http://www.casa.org and http://www.empowercasa.org). COMMON CHALLENGES *Ability to be financially sustainable in order to maintain current commitments and expand beyond present locations; there is an ongoing need for materials, funding for key staff, and transportation *Bias against traditional ways of giving birth on the part of ‘modern’ medical providers *Lack of local, state and national government support for the profession of midwifery *Challenges in creating structures that serve all and are affordable, accessible, and welcoming; it is often also difficult to remain fully staffed *Communication linkages with remote locations, both during birth emergencies and for staff on an ongoing basis *Remoteness of the rural location in and of itself often presents many logistical challenges for project staff and birthing mamas. FUTURE POSSIBILITIES Through further collaboration within the network, expansion of alliances with other nongovernmental organizations (NGO’s) and public-private partnerships, all hope to become self-sustaining if they are not already, and to thrive. This includes expansion of the number of birthing houses in countries where projects now work, extending services to include full-spectrum continuity of care (for example, family planning where there are no existing programs), and fulfilling the missions of founders with all their uniqueness and commonalities.

7 OTHER PROMISING MODELS IN PROCESS Other organizations in earlier stages of development are also providing valuable services based on the Midwifery Model of Care in Africa and Asia. The list includes four members of Global Force for Healing’s Healthy, Compassionate Birthing network: 1. Buiga Sunrise—serving several villages in central Uganda; buiga-sunrise.org; 2. Jungle Mamas—serving mothers and families in the Ecuadorian rainforest; www.pachamama.org/advocacy/jungle-mamas 3. Pemako Health Initiative—serving tribal people in the northeast Himalayas, India; pemakohealthinitiative.org; 4. Sukuli Project—serving selected villages in Sierra Leone; www.themoonlodge.biz/sukuli.html. GRATITUDE We are very grateful to the Executive Directors and staff of the four organizations featured here, who generously offered suggestions for the article. We also offer deep gratitude to Dr. Robbie Davis-Floyd and her co-authors of the main text for the article, Birth Models That Work (2009). Other source material came from the projects themselves, interviews, and online research. All of these courageous, brilliant women embody love and compassion in action and infuse this spirit into their work on a daily basis. Any errors in facts or interpretation are the responsibility of Global Force for Healing. Please see the References section for other valuable source material and contact information for the organizations featured. With love as the force, Shane Carnahan, Global Force for Healing Intern, and Kay Sandberg, Global Force for Healing Founder and President http://www.globalforceforhealing.org September 2014

8 ONE HEART WORLD-WIDE One Heart’s Mission and Network of Safety Model One Heart World-Wide (OHW) is a 501(c)(3) organization with seventeen years of experience implementing maternal and newborn mortality prevention programs in remote rural areas of the world. The mission of OHW and the Network of Safety model is to reduce maternal and neonatal mortality in rural areas of the world by ensuring that all women have access to competent prenatal care and a safe, clean delivery. Implementing the model and eventually transferring program maintenance to local partners ensures that this important work will continue and long-term sustainability will be accomplished. The Network of Safety is a comprehensive, culturally sensitive, replicable, and sustainable model aimed at addressing maternal and neonatal mortality within rural communities in developing countries. It is a community-based model that builds a network of equipped and staffed facilities, educates and trains local providers and Community Health Volunteers to provide maternal and child health care and attend all deliveries, and empowers local communities to take responsibility for the project’s success. The model involves the integration of local resources and people, including political leaders, religious leaders, and healthcare providers, while respecting cultural norms and practices within communities. An annual report is published by OHW containing detailed progress made in applying the Network of Safety, along with future plans in three major categories: 1. Health education programs for medical providers; 2. Health facility improvement; and, 3. Community empowerment/health education for families. Work in Tibet In 1997, OHW Founder and President Arlene Samen met His Holiness the Dalai Lama, who asked her to help women and children in Tibet. The following year, Arlene launched a maternal and neonatal health program in Tibet through the University of Utah. Arlene

9 discovered a great need for a local training program for community members willing to go into remote areas to assure that all pregnant women had clean birth kits, life-saving medications, safe motherhood education and a delivery plan. These community members in Tibet became “foot soldiers” for community health. Ten years after initiating a pilot program in Medro Gongkar County (Tibet Autonomous Region), the rate of unattended births decreased from 85% to 20%, and maternal and newborn death rates decreased from 10% to 3% (www.oneheartworld-wide.org). During this ten-year period, 140 midwives and 1,500 foot soldiers were trained. In 2009, OHW turned the Tibet programs over to a local team of Tibetans they had trained. The dedicated Tibetan staff have continued to implement the OHW model after establishing a new nonprofit organization called Lhasa Prefecture Maternal Child Health (LPMC). Applying the Network of Safety in Nepal Successful implementation of the Network of Safety model in Tibet inspired OHW to open a new site in northwestern Nepal, another remote region with extremely limited healthcare and access to resources. In Nepal, the One Heart model provides training courses for Skilled Birth Attendants (SBAs), Community Outreach Providers, and Female Community Health Volunteers (FCHVs) in the Baglung and Dolpa regions. In addition, there are plans to train more Master Trainers in Dhading on One Heart’s Network of Safety. As part of the Network of Safety, the Master Trainers are trained in safe motherhood, newborn care, the use of the drug Misoprostol to prevent postpartum hemorrhage, and to recognize complications and danger signs. To date, 100% of Baglung and 80% of Dolpa have benefitted from the Network of Safety model. One Heart World- Wide is happy to report there have been no maternal deaths in Baglung and Dolpa since their work began (One Heart World-Wide, 2013 Annual Report, p.24). To varying degrees, these trainings teach interested individuals the basic principles of anatomy and physiology as it relates to pregnancy, labor, delivery, and postpartum health. Nutrition is emphasized and instruction is provided on the use of interventions to prevent and treat postpartum hemorrhage. Postpartum hemorrhage is a major contributing factor

10 to maternal mortality in low and middle-income regions across the globe. (United Nations Children’s Fund and World Health Organization report, 2014). Skilled Birth Attendants (SBAs) complete the training program with sufficient knowledge regarding proper nutrition, screening tests/procedures, labor and delivery assistance, and best practices concerning the recognition of high-risk situations and birth emergencies. The training program includes basic life-saving techniques and access to transportation for women who need emergency assistance from medical providers in hospitals. Several volunteers in Dolpa have also been instructed on proper use of Misoprostol to treat postpartum hemorrhage. Misoprostol is a medication that acts on the musculature in the uterus, encouraging contraction to reduce postpartum bleeding (Vallerand, Sanoski, & Deglin, 2013, p. 870). Instruction in various life-saving skills to treat postpartum hemorrhage and uterine prolapse has been essential in indigenous communities, where excessive bleeding is a leading cause of maternal mortality (Haeri & Dildy, 2012, p. 49). Existing governmental health centers in Baglung and Dolpa have been upgraded and equipped as a key component of OHW’s work in Nepal. These upgrades include basic renovations such as bathrooms, insulation, roofing, water systems, paint, solar power, flooring, and doors. Once renovated, OHW works with the Nepalese District Health Office to have the buildings certified as official birthing centers. In 2013 alone, over 530 deliveries took place at these newly upgraded birthing centers, with no loss of mothers’ lives. One Heart World-Wide has implemented a Master Trainer education program in Nepal to specifically address the prevention and management of uterine prolapse. Uterine prolapse is a condition of the uterus descending into the vagina and can be life threatening if it is not treated as an emergency. Uterine prolapse can lead to postpartum hemorrhage or conditions related to alterations in bladder, bowel, or sexual function. In collaboration

11 with Karuna Schechen, a Pelvic Organ Prolapse (POP) prevention program is currently being implemented in Baglung and Dolpa. On the Leading Edge: Mobile Phone App to Improve Health Outcomes in Nepal One Heart has piloted the use of low-cost SMS texting-based mobile phone technology to improve data collection and ensure provider communication, positively affecting the continuity of care for mothers and babies. In conjunction with Medic Mobile and SamaHope, the cell phone program has been implemented in four Village Development Committees in the Baglung region of Nepal. This creative partnership provides Community Health Workers and volunteers with the ability to capture patient data, communicate with patients, make referrals for treatment, and alert healthcare personnel of mothers and babies in need of treatment. To date, there have been 265 pregnancies and 49 births registered in the Medic Mobile database (One Heart World-Wide Annual Report 2013, p.18). One Heart’s Work with the Tarahumara of Northern Mexico In 2011, OHW began implementing the Network of Safety model in Chihuahua, Mexico with the Tarahumara indigenous people. The Tarahumara reside in a remote area of the Copper Canyon. Though their population represents only 3% of the area, 34% of all maternal deaths in the state have occurred here, representing a strong need for One Heart’s birth model implementation. After three years of implementation of the Network of Safety there, the maternal mortality rate has dropped to zero in the communities in which One Heart has worked. The program in Chihuahua has recently been transitioned over to a local nonprofit organization. One Heart will continue to be expert advisors in this region as needed. Technical Assistance for China, Liberia, and Ecuador’s Jungle Mamas Program OHW has provided assistance to Direct Relief International and the Amitabha Foundation by designing and implementing maternal child health programs and improving data collection in China. One Heart has also provided assistance to Tiyatien Health in Liberia, where they helped design and implement community-based maternal

12 and child health services based on needs assessments of community members and facilities. In January 2013 One Heart World-Wide conducted a complete needs assessment of the existing Jungle Mamas program of The Pachamama Alliance and provided recommendations to improve program activities. Since January 2013 the OHW team has successfully helped the Jungle Mamas team develop a three-year plan; design and implement a new training curriculum for community volunteers; develop appropriate indicators, data collection tools, and a program database; and, help raise needed program funds for next the three years (One Heart World-Wide 2013 Annual Report, p. 22). KEY SUCCESS FACTORS: THE ONE HEART WORLD-WIDE EXPERIENCE Sustainability Long-term sustainability is a fundamental component of the One Heart model. The Network of Safety advocates local sustainability by teaching community members how to care for women and babies and creating partnerships with local stakeholders, thereby allowing local villagers to directly influence the lives of the people in their region. One Heart World-Wide also collaborates with existing non-governmental organizations, government agencies, and officials in the countries where they work. A key component of One Heart’s model is to avoid creating a parallel system wherever they work; by partnering with the government, the model becomes incorporated into the healthcare infrastructure. Community birth center volunteers in Nepal are given food incentives for getting involved. The food trade system fosters sustainability in these rural communities. According to a systematic review across several cultures, it is suggested that community participation largely has a positive impact on maternal and newborn health (Marsten, Renedo, McGowen, & Portela, 2013). By integrating local resources and collaborating with local providers, the One Heart birth model is a shining example of community sustainability.

13 Finally, the Network of Safety model empowers local communities to take responsibility over time to ensure the project’s ongoing success. Long-term sustainability and improved birth outcomes are based on the integration of local resources, collaboration with key local religious and political leaders, participation of local communities and providers, and respect for cultural norms and practices. Cultural Sensitivity The birth model created by One Heart World-Wide is tailored to the needs of specific local cultural contexts to ensure that appropriate methods of teaching and empowerment are implemented. The One Heart model places community members at the very heart of creating positive changes in their communities, encouraging social cohesion and long- term sustainability. Prior to introducing programs within a community, the Network of Safety requires a needs assessment of the population. These assessments are considered by One Heart to be a fundamental step in creating a culturally competent model. Assessments are done locally, allowing community members the opportunity to express their thoughts and concerns regarding maternal health, while pinpointing specific areas of need. Inclusion of community voices helps built trust, rapport, and mutual respect. The community at large is also involved in the implementation process, creating long-term “survivability.” Respectful Care Caring for mothers and babies focuses on educating the mother in ways that empower her. Mothers are provided with choices, interactive learning, and opportunities for personal growth through education. In Nepal, One Heart’s trained Skilled Birth Attendants and Female Community Health Volunteers are also trained in culturally appropriate and respectful communication to promote safe motherhood. One Heart’s philosophy is to go to the people, love them, and respect them. This core value empowers women to seek appropriate care at the time of delivery. After four years of implementing the Network of Safety model, maternal and

14 neonatal mortality were reduced by 80% in the Baglung district. Likewise, after three years of implementation in the Dolpa district, both maternal and neonatal mortality were reduced by more than 50%. Another example of respectful care comes from implementing the Network of Safety among the indigenous Tarahumara population of Copper Canyon, Mexico. The initial needs assessment found that a language barrier and misunderstanding about cultural beliefs and practices was contributing to increased maternal and infant mortality rates. Tarahumara women were increasingly choosing to give birth at home without assistance because they felt that there was a lack of understanding by the healthcare providers of their cultural practices and beliefs. Confusing medical language compounded the problem. Prior to the Network of Safety model, almost 90% of Tarahumara women were delivering their babies without a Skilled Birth Attendant, a key contributing factor to the dismal maternal and neonatal survival outcomes of the region. The One Heart team, including a male Tarahumara nurse-midwife, provided culturally sensitive, compassionate education in their own language, another contributing factor to reducing preventable deaths of mothers and babies. Competency in Care One Heart’s mission is to decrease maternal and infant mortality in remote and rural areas of the world, particularly where no one else has gone. All programs focus on competent care delivered in a culturally sensitive manner. The vision is to implement a simple, effective, replicable, and sustainable intervention to reduce maternal and neonatal mortality by at least 50% in areas served. Based on program data from the two regions where One Heart World-Wide has operated for over three years, One Heart demonstrated that their programs are able to reduce maternal and neonatal mortality 50-80% or more after implementing their model. Depending on location, programs include: • Teaching various skills to Birth Attendants, Master Trainers, and Female Community Health Volunteers within indigenous communities via Community

15 Outreach Programs: prenatal and newborn care, delivery with a skilled provider, prenatal supplements and nutrition, recognition of danger signs, clean birth kits, and emergency evacuation • Provider Trainings for local health clinics and hospital staff • Renovation of existing health posts to become certified birthing centers, and, • Partnership with other organizations to determine emergency evacuation plans. Love and Compassion in Action Love and compassion permeate the One Heart World-Wide approach and are a cornerstone of their work, even if not explicitly stated. One of the many stories that illustrate the commitment to compassion in action: The Story of a Mother and Baby Saved Written by Ashira Satya with the help of Mary Richards There was a knock at the door. "Yes?" "My mom was just invited to assist a home birth, would you like to come?" "Coming!" I yelled throwing on my recently taken off clothes. Amma, is the mother of Krishna, who is the head of SWAN Nepal an NGO that is collaborating with One Heart World Wide to help women and babies in the remote village of Narayansthan in western Nepal. Amma is a strong and powerful woman, and is a well-trusted traditional birth attendant of both humans and animals. She is often invited to assist with births in the village. Tonight it was a young woman's husband who came, asking for help with the delivery of their first child. Amma lead the way with her flashlight as there are no street lights in the village. We walked straight to the new One Heart home and gathered Mary, the midwife, Anji and Surya, the new Master Trainers in the area. They quickly grabbed their birth kits and we were on our way. The night was dark and cool, and the moon was waning with fullness as we walked to the young girl's home through the small paths in the fields of corn. I realized what an amazing experience was about to take place and prayed for both the mother and the baby to survive this sometimes dangerous journey of homebirth.

16 We entered the young mother's room and those of us not trained in assisting births were invited to sit on her bed. Sita's a 23-year old Nepali woman who was in the beginning stages of labor of her first child. She was lying on a straw mat on the cement ground with a few pillows behind her. While Mary and Anji assessed her progress in labor, I noticed the posters hanging on her walls. She had one of Avril Lavigne, a Canadian musical artist and a few with inspirations messages, including one with a picture of a baby with the message, " life is meant to be lived." Mary and Anji assessed that she was in the beginning stages of labour, that everything seemed well, and that it might be a long night ahead of us. After a cup of tea from Sita's mother in law, I was invited to lie down and rest. I fell asleep while Mary and Anji stayed up with Sita. Sometimes I would wake up when Sita was in pain, and sometimes I would wake up and think it was time, but the labor was slow. While sleeping in this young mother's bed, I had an auspicious dream. There were angels above Sita's head, shimmering beauty and peace, and as Sita was giving birth, magic was in the air. She was lying in a bed covered in white, with her legs spread wide open. When the babies head began to show, I could see a full head of hair, and the next thing we knew, the baby pulled herself out of her mother, stood and fell into her mother’s arms. I woke up not sure if that had actually happened or not, but quickly came to see that Sita was still in labor and in pain on the floor. A few more hours passed by and the sun was now shining into the room. Arlene Samen (One Heart) came by to see how the labor was progressing. It seemed that she would be giving birth soon; she was having good contractions, and was fully dilated. Arlene got behind her and held her, helping her to breath and push. However, after a lot of pushing there seemed to be little to no progress, the contractions became less often and less intense. Anji listened to the baby's heart rate and found the heart rate had gone down following the contractions and was showing signs of early fetal distress. The mother and baby were tired after a long night in labor and there was no further descent of the baby's head in the pelvis. Labor was not progressing. Mary, Arlene, Amma and Anji all agreed

17 that she was having an obstructed labor, and that it was time to arrange for an emergency evacuation via stretcher to take her to the nearest hospital. All of a sudden there was fear in the air. Would she make it to the hospital in time and would she and her baby survive? Quite quickly people gathered with the stretcher to take her to the hospital, and there was strong sense of the community really supporting one another. The nearest road is over an hour walk down the mountain, and it was arranged for Sita to be carried on a stretcher by a group of strong men who would take turns carrying her carefully but quickly down the mountain path. While the District hospital is not so far away, every second in this situation is life threatening. There is a high risk that the baby will die along the way and if this happens it also puts Sita's life at risk. After the hour-long walk to the road, an ambulance was waiting and takes Sita the last 30 minutes to the district hospital in Baglung. The district hospital was informed about the situation and prepared for Sita's arrival. On arrival, the expert midwife quickly assessed Sita and her unborn baby, the baby is still alive. Quickly the midwives decides a vacuum extraction is possible and is the best plan to save the mother and baby. The team immediately and expertly swing into action, and within a short time the baby girl is born alive and crying. Both Sita and her baby are exhausted but thankfully alive thanks to the recognition of obstructed labor, one of the danger signs in labor and the quick community mobilization of emergency evacuation to a hospital. I sigh with relief and gratitude, when the news reaches us that the mother and baby have survived and are well, I wonder what would have happened if the One Heart team had not been there to recognize the danger signs of obstructed labor? Two Weeks Later... Two weeks after the birth, Mary, Surya, Anji and I made a trip to visit the mother and baby. We again walked through the small paths between cornfields and found their comfortable home. Sita's mother and father in law seemed happy to see us and placed a straw mat and a few chairs for us to sit down. We were told that Sita and the baby were sleeping and that they would come out in a moment. It was nice to be back at their home

18 and to see the family's smiles, knowing that had the baby and/or Sita died, their would be a different feeling to our return visit. After a few moments of casual talk, Sita and the baby came out of the room where she spent the night in labour. Sita looked beautiful, healthy, strong and glowing with the warmth of motherhood. The baby girl was wrapped warm in a few blankets and also looked healthy and radiantly alive. It was a joyful moment, to see them both doing so well! Anji and Surya asked the mother a few questions and she said that she and the baby were doing very well, and feeling good. Sita passed the baby to the mother in law who was holding the little girl with so much love. I asked if she had a name yet and they said no, they are still thinking about it. I suggested Sundari, the name of the Goddess of beauty, but I also found out is the name of a female monkey. Anji and I both took turns holding the baby. I felt so grateful that she and the mother had surivived, and sang the little girl sweet songs. This experience made it so clear to me that One Heart World-Wide is desperately needed in the world, because every mother should feel supported when giving birth, knowing that there is at least one person there that is trained and will help her survive if there are difficulties. One Heart's assessment of the obstructed labor saved Sita and her sweet babie’s life and I am sure will save many more lives in this rural area of Nepal. Future Plans In 2014, the One Heart World-Wide Nepal program is expanding its coverage to at least 80% of the population and offering refresher courses for local health providers in the Baglung and Dolpa regions. They have already conducted a needs assessment in their next district and will be undertaking a needs assessment of two additional districts that will be implementing the Network of Safety model in 2015 (Darchala, and Sindhulpalchowk). Their long-term intention is to offer Network of Safety services and education to all of the remaining underserved districts of Nepal, and to eliminate all preventable deaths of mothers and babies.

19 YAYASAN BUMI SEHAT (HEALTHY MOTHER EARTH FOUNDATION) “Gentle Birth Heals Mother Earth” When Robin Lim’s sister died from complications with her third pregnancy, Robin, her husband, and their children left their home in Hawaii and relocated to Bali, Indonesia. She decided to take this difficult time in her life as an opportunity to become part of the solution to the tragedy of dying to give life. Ibu (“Mother”) Robin, who has eight children herself, started volunteering to help midwives in Bali in 1994 (bumisehatfoundation.org). After strong encouragement Robin decided to become a certified professional midwife via the North American Registry of Midwives (NARM). In 2003 she and many concerned Balinese people went on to open a birth clinic for Bali’s underserved called Yayasan Bumi Sehat (Healthy Mother Earth Foundation). Yayasan Bumi Sehat’s Mission and Model Currently, Yayasan Bumi Sehat Foundation International, a 501c(3) nonprofit foundation operates two birth centers in Indonesia--in Ubud, Bali and Aceh. A third center was recently opened in the heart of the Philippine disaster zone, Dulag, in the aftermath of super typhoon Haiyan. The clinic in Aceh was founded in 2005 in response to the devastating tsunami that killed so many in December 2004. The mission of these centers and the Foundation behind them is “to provide access to quality healthcare to families; and kind, hygienic and culturally appropriate childbirth to traditionally under-represented populations.” To fulfill this mission, Bumi Sehat provides health services, emergency care, environmental, and disaster relief programs (Bumi Sehat Foundation International, 2013). Bumi Sehat offers a model of cost-effective, loving care that encourages replication. Services are free (donations are accepted by those who are able to pay), and patients are never turned away, including those not accepted by other healthcare facilities. Everyone receives the same loving, hygienic, evidence-based medical care, a truly amazing and rather unique way of operating. The model is also unique because of its holistic (blending allopathic and alternative/complementary care), integrated community programs unified

20 by the foundational goal of providing all people access to a safe, loving world. The large volume and range of global services—more than 500 births and 20,000 health consultations annually at the original clinic in Bali alone—and their ability to be early responders to natural disasters, including a tsunami (Aceh), an earthquake (Haiti), and the largest typhoon to make landfall in human history (central Philippines)—are truly remarkable. Bumi Sehat’s Response to United Nations Millennium Development Goals for 2015 Most of us are aware of the United Nations Millennium Development Goals and their target of fulfillment by the end of 2015. Team Bumi Sehat is most involved with attaining • Goal 4: Reduce the child mortality rate—the global goal is 2/3 reduction over 1990 levels o Infant and under 5 mortality rates in Indonesia are 32 and 40 deaths per 1,000 live births, respectively (per Bumi Sehat) o Sixty percent of infant deaths occurred during the first month of life (neonatal period), and eighty percent of child deaths occur in infancy, from birth to age 1 (The World Bank, 2014) o Infant mortality rates are highest among children whose mother gave birth at age 40 or older, had 3 or more children, and who became pregnant after a short birth interval (less than 24 months) (Indonesian Ministry of Health, 2013) o Infant mortality rates are higher in rural areas, whose mothers have no education and whose children are in the lowest wealth quintile (Indonesian Ministry of Health, 2013) • Goal 5: Improve maternal health—the global goal is ¾ reduction over 1990 levels o Maternal mortality rates in Indonesia are 190/100,000 (WHO). • Goal 6: Combat HIV/AIDS, malaria, and other diseases.

21 First and foremost, the clinics are responding to the need for improved maternal health and reduced infant mortality. By also providing free general healthcare to resource-poor women and families, the model strengthens community and promotes a healthy start for children. In addition, Bumi Sehat has youth education programs and environmental programs, adding grassroots solutions to address even more of the UN Millennium Development Goals. Unfortunately, the world is not nearly close enough to reaching these goals, which advocate for the basic human right to decent healthcare. Women and families come to Bumi Sehat to receive excellent prenatal care and be supported by midwives throughout pregnancy, labor, delivery, and the postpartum period. Women and children experience a continuity of care that is extremely rare for low- income groups worldwide. The nurses, doctors and midwives at Bumi Sehat have specific and unique, culturally sensitive programs for educating families in the areas of conscious conception, birth control, family planning, HIV/AIDS and other diseases, and caring for their children’s health. A new lab supported by Every Mother Counts and Sokasi Banten has opened to provide screenings for HIV, malaria, complete blood count (used to monitor a person for many health conditions), and anemia. Additional programs available at Bumi Sehat include educating youth and providing scholarships for girls with dreams of becoming midwives and nurses. Human rights and equal care for all people are an integral part of the mission. In fact, there is a strong promotion of gender equality and women’s empowerment by the staff at Bumi Sehat as they work every day to reach UN Millennium Development goals. All programs at their clinics also emphasize the importance of sharing love and compassion with the world. KEY SUCCESS FACTORS: THE BUMI SEHAT EXPERIENCE Sustainability Bumi Sehat works in partnership with local communities to improve the quality of life for each member, regardless of cultural/religious background or ability to pay. In their words: “We are devoted to working in partnership with people to improve the quality of life and to build peace—one mother, one child, one family at a time”

22 (bumisehatfoundation.org). Local partnerships allow Bumi Sehat to implement important community-related environmental sustainability programs in Bali. Bumi Sehat Foundation International’s donor assistance allows them to implement a successful community recycling program. Several other environmental awareness programs and ecological initiatives have been put into place as well. For example, Bumi Sehat staff and volunteers practice organic farming and offer an Earth-friendly food supply. Educating and engaging Balinese youth in growing food and saving seeds has the potential to eradicate food insecurity and provide a sound nutritional foundation for each person. Programs like community gardens and recycling create community cohesion and encourage environmental responsibility (Bumi Sehat Foundation International, 2013). Cultural Sensitivity It is a strongly held belief at Bumi Sehat that all people are entitled to information and resources needed to improve their lives according to their own cultural principles and faith. A deep commitment to cultural sensitivity is vital to their work whether it be in Indonesia, a country with a wide diversity of religious and cultural traditions, or in adapting rapidly to a new cultural milieu in places like Haiti after the earthquake in 2010 and most recently, coastal Philippines after Typhoon Haiyan in 2013. Respectful Care The mission of this organization is to provide access to kind, gentle, hygienic, culturally appropriate childbirth as a human right made available to all. Bumi Sehat’s Founder, Robin Lim believes that peace begins at birth. By caring for babies and mamas with love and kindness, peace is encouraged, quality of life is improved, and society moves toward this peace. At Bumi Sehat Foundation International, the team provides kind and gentle care for women, providing choices and encouragement as they traverse the path of motherhood. Kind and gentle care is also extended to babies, who are sung to at the time of birth by midwives and families. Babies are not separated from their mothers and umbilical cords

23 are kept intact, providing newborns with their full blood supply to prevent future problems and provide vital nutrition from the mother (Bumi Sehat Foundation International, 2013). Competency in Care Bumi Sehat Foundation International offers an array of programs aimed at addressing child mortality. They provide free pediatric clinics and support for healthy pregnancies through high-quality care including prenatal check-ups, childbirth services, postpartum care and breastfeeding support. Bumi Sehat has a breastfeeding rate of 100% at this time. The caregivers at Bumi Sehat are breastfeeding advocates because they know that in Indonesia, an infant who is fed infant formula is 300 times more likely to die in the first year of life than breastfed babies (http://www.gmanetwork.com; search “Robin Lim”). All the Bumi Sehat clinics are open 24 hours a day, 7 days a week. Providers at Bumi Sehat transport women in need to emergency facilities via ambulance, finding ways to pay for their care if the family does not have funds. Other services provided by Bumi Sehat include nutritional support, prenatal yoga, acupuncture and natural family planning. In 2013, the clinic in Ubud completed construction on a building that serves as a laboratory for testing, research and data collection. This lab gives free confidential access to each mother to screen for sexually transmitted infections, HIV/AIDS, complete blood counts, anemia screening, and urinalysis. These tests demonstrate competency of care by recognizing potentially complicated situations ands greatly reducing risks during pregnancy. Bumi Sehat is committed to providing educational capacity-building programs aimed at encouraging community members to engage in peaceful practices to improve their lives, and the lives of their families while caring for the Earth in a sustainable way. The organization also actively supports education and internships for midwives-in-training from across the globe as well as within Indonesia and the Philippines.

24 Love and Compassion in Action “Every baby’s first breath on earth could be one of peace and love. Every mother should be healthy and strong. Every birth could be safe and loving, but our world is not there yet. The situation is bad…babies are unattended, deliveries have become commercialized, and mothers die from hemorrhage after childbirth because they can’t afford proper care.” Robin Lim The courage and willingness to respond to devastating circumstances in the wake of natural calamities is another illustration of staff and volunteers’ commitment to being a force for love and compassion to help heal our world. Wherever these early responders are called, the focus is on assisting birthing mothers & infants, and supporting local midwives by a cadre of global midwives. In the Philippines alone since fall 2013, 100 local midwives have been supported and given supplies after their clinics were destroyed by the typhoon. More than 600 mamas received free childbirth services from midwives, and 11,500 medical relief appointments for families have been provided since fall 2013. (www.onehealthorganization.org). To illustrate the commitment to loving kindness and compassion, a story from the field: Ibu Juniarti, having her second baby was in the birth tub, pushing. We scattered flowers in the water and sang the Gayatri mantra with Juniarti’s mother and husband, as the baby was gently born. Due to the large episiotomy that Juniarti suffered at the hospital when her first baby was born, she had a large tear. Bidan Suastini sutured it masterfully. “Thank you for numbing me first,” was Ibu Juniarti’s tearful comment, as she was being sutured, while breastfeeding her baby, smiling. She had been sutured after her first baby was hospital born, without local anesthesia, and still cried when she told the story four years later. At Bumi Sehat we do not cut episiotomies unless for emergency care. (only one in 4,000 births). We always are gentle and careful not to traumatize mothers or babies with our actions or our words. (http://www.bumisehatfoundation.org/masterfully- birthed-in-a-tub/)

25 Love and compassion are also extended to Mother Earth through practices surrounding birth and the care taken with environmental programs. The high degree of integration of environmental and maternal/family health is a hallmark of the Bumi Sehat model. Future Plans To meet the growing needs of community members in Bali, a new clinic is being built using traditional Balinese temple design. The building will be earthquake resistant and is being designed in attunement with the way that midwives, doctors and nurses prefer to practice. Ground was broken in March 2013, and funds are being raised to complete the building and create an endowment to fund full-time salaries for local healthcare providers and staff. They also plan to continue working in the Philippines as long as needed. Bumi Sehat needs assistance to complete and sustain these ambitious projects, which stem from a belief that healthcare is a human right even in the lowest resource, highest risk areas of the world. They need the world’s support to make this a dream come true. Donations by check are to be sent to their 501c(3) nonprofit account in the US. For the mailing address, see the list of organizations at the end of this article. “Healthcare is a human right and every mother, every baby, every family is a piece of Peace.” -Ibu Robin Lim

26 MOTHER HEALTH INTERNATIONAL (MHI) MHI’s Mission and Model Mother Health International (MHI) is dedicated to responding and providing relief to pregnant women and children in areas of disaster and extreme poverty. MHI is committed to reducing the maternal and infant mortality rates by creating healthy, sustainable holistic birth centers using the midwifery model of care. Mother Health International was founded in 2007 after midwife Rachel Zaslow spent several months working in a government-funded hospital in Northern Uganda at the end of the civil war. The hospital was functioning at what the WHO estimated to be over 10 times its capacity. Women were turned away in labor or sent to walk home minutes after giving birth, often bleeding to death on the road home. Women who were admitted to the hospital were often treated violently by the hospital staff for not ‘pushing fast enough’ or failing to bring their own piece of plastic on which to give birth. These conditions made the hospital a traumatic, dangerous place to give birth in an area already ravaged by war. Over the last six years, MHI has worked in coordination with local midwives who serve their own communities. They work to build ‘Earth Birth Centers’. Earth Birth Centers are country-specific maternity centers run by local midwives. Mother Health International helps to physically build structures, develop culturally competent protocols, work hand in hand with traditional midwives to develop skills, and create sustainable methods for obtaining supplies and emergency equipment. Each clinic provides: comprehensive prenatal care, both on site and through mobile outreach programs into rural areas; education and support groups for pregnant women; labor support; postpartum care; transport to and from the clinic for laboring mothers and postpartum families; ambulance services for emergencies; postpartum follow-up of babies from birth until 6 months; and education and support of traditional midwives.

27 “Creating spaces where women can access comprehensive care and also join in community restoration efforts is intrinsic to our mission. Our outcomes make it clear that our model works to reduce maternal and infant mortality. Simultaneously, we are combating the violence and trauma that women often experience giving birth in overcrowded and understaffed hospitals. When women do not see pregnancy as a potential death sentence they take care of themselves and their children differently. Our model allows women to participate actively in their daily health care. Women are treated with respect and given one-on-one attention.” –Rachel Zaslow Pilot Clinic: Ot Nywal Me Kuc (House of Birth and Peace) Birth Center MHI’s pilot clinic is in Northern Uganda. This birth center called Ot Nywal Me Kuc (translates to House of Birth and Peace) is located in Atiak, 20 miles south of the border with South Sudan. The closest hospital is 50 miles away in Gulu. The birth center itself is government approved and employs traditional midwives. On average, 45 women give birth each month at the clinic, and many come every week for antenatal care. In Northern Uganda a woman has a 1 in 25 lifetime chance of dying during childbirth. The infant mortality rate is 10 times higher than anywhere in the Western hemisphere. The MHI clinic in Uganda has seen over 2,700 deliveries in the last three years. They have never lost a mother and their infant mortality is 12/1,000, compared to the national average of 54/1000. They attribute this to one-on-one care that integrates nutrition, counseling, and holistic support throughout--from prenatal through labor & delivery and postpartum care. In 2013, 1842 women gave birth at ‘Ot Nywal Me Kuc’. Among them were thirteen sets of twins. Additionally, they saw 1776 women for prenatal care, and 182 women received family planning. They employ three full-time Traditional Midwives and two full-time nurse midwives. (http://motherhealthinternational.org and Rachel Zaslow) Haiti’s Soley Lavi Birth Center Mother Health International also introduced its presence in Haiti following the 2010 earthquake. The need for comprehensive health care in Haiti is clearly established. More

28 recently, data collected and interpreted by UNICEF found that Haiti has the highest infant and under-five mortality rate in the entire Western hemisphere. Maternal mortality rates soar at 360/100,000 (rate at this time in developed countries is 16/100,000) (UNICEF, 2013). Mother Health developed a birth center in Haiti, named Soley Lavi, where services offered included antenatal care, nutritional support, labor/delivery support, and postpartum care in Jacmel. Over the past few years in this region, women have increasingly chosen to birth their babies in the home. This increase in home birth caused a shift in need and a decline of the need of birth services at Soley Lavi. In response, Mother Health International shifted its focus to provide support and collaboration with Traditional Homebirth Midwives. These midwives (called Matrons) provide support to Homebirth Midwives in Jacmel and surrounding communities. Soley Lavi remains open to now provide resources and outreach to community members, and is supported by Direct Relief International. KEY SUCCESS FACTORS: MOTHER HEALTH INTERNATIONAL’S EXPERIENCE Sustainability Cultural and environmental sustainability are the cornerstones of MHI’s birth model. Ot Nywal Me Kuc in Atiak, Northern Uganda is a solar powered and self-sustaining birth center. The work of Mother Health International is governed by the conventions of local leadership, renewable resources, and clinics that financially sustain themselves. The model works to combine renewable Western practices with traditional methods. Services at Ot Nywal Me Kuc are offered free of charge, and women are asked to contribute to a project that helps to sustain the clinic. Women have choices when fulfilling their volunteer hours. They can work in the garden, participate in a sewing collective or a beading project. The food grown in the garden goes into the clinic kitchen to feed pregnant, laboring and postpartum mamas. Other projects include sewing Moon Pads (reusable menstrual pads which are sold locally and internationally), baby slings, maternity and baby clothes, creating local crafts and jewelry. Each of these projects are

29 earth-friendly, fair trade and organic. The products are sold and the proceeds go back into purchasing supplies for the clinic. Cultural Sensitivity: The Role of Traditional Midwives Traditional Midwives are women who practice midwifery as it has been handed down to them from generation to generation. Replaced over several years with a biomedical approach to childbirth, traditional midwifery has almost been eradicated in many places around the world. MHI is committed to preserving traditional midwifery knowledge and valuing its importance as culturally specific approaches to women’s health care. “Most NGOs and models of formal education function along a continuum of colonization and charity, which assume a ‘West is best’ mentality. Despite government pushes towards hospital births, it is estimated that 80% of births in rural areas take place with traditional birth attendants, which makes them critical health care providers and crucial to community restoration efforts. We believe that holistic and restorative reproductive care is essential to a future of peace and development.” – Rachel Zaslow In response to this, Mother Health International works closely with Traditional Midwives to create a model of midwifery that combines renewable practices from the West and practical traditional methods as well. The result are culturally competent, government- recognized birth centers. MHI works closely with a group of over 30 Traditional Midwives who come monthly for workshops, meetings and support. The TBAs bring their clients to the clinic in labor, stay with them and support them hand in hand with nurse midwives until after the delivery. Respectful Care A large population of clients at Ot Nywal Me Kuc is made up of displaced people with severe past war trauma. Chronic stress affects mortality rates of mothers and infants, as does exposure to war and suffering. Rape and sexual violence are often used as weapons of war in times of civil unrest. In one study, the women refugees who have experienced rape and sexual violence in this context reported higher incidences of health concerns

30 such as perinatal health problems, impaired mental health, lack of appropriate health services, and discrimination (Berman et al., 2014). Midwives at Ot Nywal Me Kuc are attuned to possibly dangerous manifestations of trauma during pregnancy, labor, and delivery. They have found that approaching women affected by war violence, trauma and poverty with dignity, respect and gentle, loving care is much more effective in the long run than the hierarchical and controlling treatment that has become commonplace in some nearby hospitals. There are many explanations why this compassionate birthing assistance is not as widely practiced in the government hospitals. The nearby government regional hospitals in Uganda are not equipped with enough supplies or providers to serve the number of people who need care. Often there is no water, access to gloves, medication, scant electricity and other resources needed to make a facility successful. Comprehensive healthcare is difficult if not impossible to offer in this setting. Gentle birth has not been an option in the hospital setting, and sometimes, attended birth is not an option. There simply are not enough care providers for patients. The Mother Health birth model sees gentle birth as a human right to which every woman should have access and has founded its birth center on that basis. Competency in Care In Uganda at Ot Nywal Me Kuc, Traditional Midwives (also known as Skilled Birth Attendants) provide prenatal and postpartum care for women by travelling by bicycle or motorbike out to the homes of these families. Mother Health International’s Founder, Rachel Zaslow has asked the question, “How do we train people to become professional midwives without undermining the wisdom of traditional midwives?” In asking this question, she pioneered a brilliant tool allowing Traditional Midwives to flag complications or potential complications for the fetus during pregnancy. The HeartString, a color-coded bracelet that allows birth attendants who cannot read, write or count, to monitor fetal heart tones in pregnant women and infants. Using a sand timer that is set to 15 seconds and a Pinard Horn or fetal stethoscope, birth attendants listen for the fetal heart rate (FHR), pressing a bead each time they hear a fetal

31 heartbeat. When the sand timer is emptied, the birth attendant observes where she has landed on the HeartString. If she is in the white section, the FHR is depressed; the Green, the FHR is in a range of normal; the Red, the FHR is high. The HeartString is a low cost, easily produced, culturally adaptable tool. It is a solution for Traditional Midwives to accurately assess fetal heart tones and ultimately determine fetal distress, and to initiate appropriate plans to improve fetal status. By working within local infrastructures to offer practical tools for TBAs to improve outcomes, MHI believes that they will have the long- term capacity to increase women’s ability to access care and thus radically reduce perinatal mortality. Mother Health has a ‘Mobile Midwives’ program that sends midwives into rural villages each week to care for women who are unable to travel to the clinic. Reaching out to women in this way has facilitated a decrease in maternal and neonatal mortality in the area. Regular prenatal care ensures that mothers are nourished, STIs and other illness are treated, baby’s growth and wellbeing are tracked, and issues are noted before they become emergencies. This makes the population of women automatically ‘lower risk’ for seriously life threatening emergencies at the time of birth and postpartum. Tracking children who are born at the clinic in this same way means that the wellness of each child is followed to make sure they are part of a network of support if and when illness occurs. Love and Compassion in Action In addition to the many tangible examples of love and compassion in action such as Heartstrings and the various fair trade projects, here is a story of Acen Agnes Lanny, a 20 year-old Ugandan woman reflecting on the birth of her first daughter at the birth center in Atiak. This story has been translated from Acoli to English. I came here several times when I was pregnant. They tested me, they gave me tea and I went with it home. And then on the 11th of May at night I started to feel pains very strongly. I called these people at the birth house around 2:00am and I told them what was going on. They came immediately and picked me up. When I reached here there were 3 midwives here that helped me. They walked with me and told me I was going to make it

32 through. They fed me and gave me tea, which gave me strength to continue. I gave birth around 5:00am. Giving birth was not easy. I felt like I might die but these people helped me. After I delivered they massaged me and gave me something under my tongue. It really helped me; the pain and bleeding stopped. They gave me clothes for the baby to take home. They even give free water and we don’t have to haul it ourselves. They also give food. I don’t know of any other hospital in Uganda that gives food. I ate so well and it gave me strength to feed my baby. When I got back to the village I gave the phone number out to 2 women. We called and they also came here when it was time for them to give birth. I like this place. I came back for postpartum care and to work on beading because they really helped me and I want them also to help others. Before this place, most women gave birth at home alone because if you go to the government health center there is no hope, no care. They will leave you alone or even beat you. Even my husband was happy that I was there. He said, “Go to them! They will care for you!” I encourage some people from home to come here. I had not gotten any clothes for my baby yet, so they helped me make my baby beautiful. The midwives really think about our people’s problems and share with us. They really help. I am now proud of being a mother. Now some people respect me. Even my husband respects me more because I gave him a baby and we love her. I am 20 years old and proud to be a mother. This story illustrates Mother Health International’s dedication to applying loving practices as their primary strategy in transforming the lives of women, babies, and their families in Uganda. Future Plans In the case of an emergency, which constitutes a need for the woman to go to the hospital during labor, delivery or postpartum, the birth center arranges for a ride to the hospital. The nearest hospital is three hours (50 miles) away and the ambulance for MHI is no longer functioning. MHI has recently launched a campaign to raise money for a new

33 ambulance to fulfill the purpose of transporting women in this situation. To find out more about this campaign, follow the link to the Mother Health International Facebook page: https://www.facebook.com/Motherhealthinternational.

34 CASA (CENTRO PARA LOS ADOLESCENTES DE SAN MIGUEL DE ALLENDE) CASA’S Model CASA, or Center for the Adolescents of San Miguel de Allende, is located in Guanajuato, a state in central Mexico and was cofounded by Nadine Goodman and Alejandro Gonzalez in 1981. This non-profit grassroots, youth-driven organization is aimed primarily at providing care for disadvantaged youth and women in vulnerable rural communities. The mission of CASA is to improve the quality of life for Mexico’s most vulnerable communities by empowering youth to make a positive impact in their lives, and the lives of those who surround them, through employment and education opportunities. CASA’s programs are focused on the promotion of family planning, human rights, gender equality, basic health care, professional midwifery, prevention of violence, and child development. Midwifery Training In 1994, due to a need noticed in the community, a maternity hospital was opened and in 1997, the midwifery school was opened. The midwifery school has become a beacon to attract international students--particularly those who desire an education in both Spanish and English--and because of the high quality of culturally relevant educational experiences offered. The CASA school of midwifery has international interns but the midwifery student body has been made up of Mexicans, Central Americans, and one person from Germany. The CASA midwifery school remains Mexico’s only government-accredited midwifery school. CASA trains professional midwives using the midwifery model of woman- centered care and cultivates experts in primary preventative care, as well as normal pregnancy and birth. Midwives trained at CASA accompany women throughout their reproductive cycle and are trained to promote gender equality, cultural sensitivity, respect

35 and empowerment. The CASA model was established with the hope that a vast majority of these midwives, upon completion of the program, would live and work in rural outlying communities, where the maternal and infant mortality rates are highest. Achievements To Date As of 2014, a total of 91 students from 13 different Mexican states, Guatemala, and Germany have graduated from the CASA midwifery school (www.empowercasa.org). Together with teaching staff, students have attended more than 8,000 births in the CASA teaching hospital with clinical results exceeding state and national statistics, such as lower maternal and infant mortality and morbidity rates, lower cesarean rates, and notably lower rates of low birth-weight babies. With such superior outcomes, CASA has a growing degree of government support. For example, Mexico’s Ministry of Health and National Congress supported a local initiative to amend Mexico’s General Health Law to fortify the position of traditional and professional midwives, guaranteeing their inclusion in the national health system. Along the same lines, a recent collaboration has formed between the National Center for Gender Equality and Reproductive Health (CNEGSR) and CASA. This organization (CNEGSR) provided scholarships to women in need so that they may study professional midwifery at CASA and is looking to increase the participation of midwives in the public health system. In August 2012, the government of Guerrero opened the first public school of midwifery in the country using the CASA academic model, verifying the high quality education midwifery students receive at CASA (www.empowercasa.org). Maternity Hospital The CASA maternity hospital provides family planning, gynecology services, and midwifery services. More specifically, the services provided include contraceptive counseling, pap smears, HIV/STD testing, cancer screening, ultrasounds, prenatal counseling, professional midwife-attended births in one of six private birthing rooms, two

36 water birth tubs, interventions for complicated births (including cesarean), lactation consulting, and postpartum care (DavisHFloyd, Barclay, Daviss, & Tritten, 2009). Opened in 1994, the CASA hospital is the only one in Mexico that employs traditional midwives, professional midwives, and doctors working together to provide services to the public. Fees for many services at the hospital are offered on a sliding fee scale to thousands of patients, and no one is denied services for lack of funds. Services at the CASA Hospital are most often used by young people, families, and seniors. Achievements to Date 1. In 2010 the CASA Hospital became the only private hospital in Guanajuato state to be accredited by the Federal Health Ministry and designated a public healthcare provider. Low-income people with government health insurance (“Seguro Popular”) will have free access to the CASA Hospital’s midwifery team. Third-party government reimbursement of midwifery services has enormous potential to increase access to needed obstetrical care throughout Mexico, especially in remote areas and for disadvantaged populations. 2. In the first nine months of 2011, the doctors, midwives, and CASA Hospital team assisted 186 births, provided 6,712 consulting appointments and 7,238 laboratory tests. 3. CASA’s maternal and infant mortality rates are lower than state and national rates. For example, the perinatal mortality rate at the CASA Hospital from 2002–2006 was 5/1,000 for 2,440 deliveries while in Guanajuato state overall the rate was 18/1,000 for the same period. The national rate for Mexico in 2009 was 18.42/1,000. Between 2002 and 2005, there were 5 maternal deaths in San Miguel de Allende where CASA is located, and 58 in the state of Guanajuato. There were no maternal deaths in the CASA Hospital during this period. 4. In both Mexico’s private and public sectors, the rate of medically unjustified caesareans is very high and represents unnecessary health risks for mothers and babies, in addition to the questionable use of public health dollars. Between 2002 and

37 2005, the average rate of caesarean sections at the CASA Hospital was 13% compared to the average rate of 35% in Guanajuato state. The caesarean rate during deliveries by midwives at the CASA Hospital was 9.33% (2010) (Source of statistics for Achievements #1-4: www.empowercasa.org). 5. The Hospital has distributed free birth control to 21,737 people (Centro para los Adolescentes de San Miguel de Allende, CASA, 2013). KEY SUCCESS FACTORS: THE CASA EXPERIENCE Sustainability The vast majority of the Mexican population only completes primary education (grades 1-6), and those who complete a higher level of education seldom stay in the rural communities. The need for care is great in the rural communities where maternal and infant mortality rates are highest. In order to meet this challenge, CASA only requires the completion of the 9th grade to be considered for admission to its midwifery school. This policy was instituted to sustain and improve care of mothers & babies likely not be served because of the inability to attract and retain trained personnel in outlying rural areas. This technical level midwifery education plan has been met with much criticism among professionals in the medical field and government officials. That said, during certification processes at the midwifery school, performance of staff trained at CASA has often exceeded standards, showing that the acceptance of lower education levels in the beginning of the program has not decreased the quality of care. Retaining midwives where the need is highest helps ensure sustainability of care and longevity of the midwifery profession in Mexico. Cultural Sensitivity The role of the midwife, as taught at CASA, is not only to provide health care to women and babies, but also to become involved with the social and political sectors of the community, advocating for the rights and health of women and babies.

38 Upon graduating from CASA, the expectation is that midwives take with them an evidence-based professional midwifery skill set in combination with a more traditional model of care they learn during the required portion of their schooling that takes place “in the field” with traditional midwives. This component of the CASA program is referred to as terrenos practicos (practical field experience). Midwives-in-training at CASA receive a woman centered, culturally appropriate education with medical literacy and professional midwifery proficiency that also embraces parteras traditionales (traditional midwives’) wisdom. Evidence-based biomedical information is taught in the classroom and traditional practice is experienced out in the community. The purpose of all training is to create a group of professionals who are well versed in medical knowledge with a firm understanding of anatomy, physiology and obstetrics, while providing culturally sensitive care in the home settings of the people they are serving. This component of the model ensures the building of rapport with women and families, a vital aspect of respectful care. Women enrolled in the midwifery training program go out to rural areas for two to three week periods with parteras traditionales (traditional midwives) five or six times during the three-year midwifery training. During these terrenos practicos (practical field experience) periods, trainees observe parteras traditionales in the ways they care for women in exchange for sharing ‘modern’ medical knowledge with the traditional midwives. Respectful Care CASA is a nonprofit health and social service agency offering diverse services that focus on the needs of disadvantaged youth and women, with a combination of science and care (Davis-Floyd, Barclay, Daviss & Tritten, 2009). The CASA program began by offering family planning services and contraceptives through peer counseling programs in the state of Guanajuato. The goal at that time was to reach all women across the reproductive spectrum and inspire them to ask specific questions about family planning: when to have children, what type of birth they would like, how they want to be cared for, and whether they would want to work after the baby is born. These peer counselors would empower women to understand that there are many choices for each of these

39 questions. The idea was to awaken within these women a deep awareness that planning a family is full of choices and is the result of these choices, whether they are consciously or subconsciously made. The CASA hospital currently provides a wide range of reproductive health services, as well as a dental, pharmacy, and laboratory services. A day care center is also available for the children of working families in the region. There are also youth ecological awareness teams, a large public library, and a theater group involving local adolescents. These theater groups perform dramas dealing with gender issues such as domestic violence. CASA also has a weekly radio program run by young people and midwives, with a potential audience of more than 5 million people. This large audience is made possible through a network of nineteen government-funded radio stations overseen by indigenous groups. Midwives trained at CASA practice respectful care because they are able to honor woman’s choices. These midwives receive both medical knowledge and traditional wisdom in their midwifery training at CASA. “If a woman wants one thing and we give her another, she is not going to believe in us, she won’t have confidence in us,” (midwifery student at the Casa) (Davis-Floyd, Barclay, Daviss & Tritten, 2009, p. 319). Competency in Care Mexico as a country currently recognizes CASA midwifery school graduates as independent health professionals qualified to practice in any state. Midwives trained at CASA are taught to recognize risk factors and become skilled at locating local community resources for emergency transport and referral. The education women receive is intended to train them as midwives, so that they have awareness and knowledge to find solutions to every situation within the scope of their education. CASA graduates are also able to provide information about and access to the closest hospital services available. For many women, emergency transport is not a viable option. Therefore, the CASA model involves precise and adequate prenatal care, with a focus on performing screening

40 for risk factors so that early transport and planning for hospital admittance becomes a more viable possibility. Love and Compassion in Action A CASA tradition is to hold the baby up at some point after the birth and ask, “Que ves?” (What do you see?). The mother can express her pride and say, “My baby!” and all present can share in that happiness. Another example is the strong advocacy for the rights and dignity of all people from a place of “fierce love” and out of regard for the sanctity of human life. Future Plans CASA’s long-term goal has always been to ensure that there is at least one professional midwife in every rural village in Mexico and Guatemala. With the help of an international coalition headed by philanthropic leaders in Mexico, along with support from the government and private sector, CASA works to educate the country regarding the benefits of professional midwifery and advance the recruitment of midwives by the government. CASA also hopes to make sure that free birth inns are created around the country and to open two new midwifery schools in Mexico and Guatemala (www.empowercasa.org). Glossary of Terms 1. Parteras tradicionalesHHtraditional midwives 2. Terrenos practicosHHperiods of two to three weeks where CASA midwifery students leave San Miguel and go into rural areas to apprentice with traditional midwives. These happen five times during the threeHyear midwifery training program at CASA.

41 CONCLUSION We live in a world where the disparity between those with access to health care services and those without is all too apparent, with few bright lights on the horizon. Decreasing the number of mamas and babies who die needlessly in childbirth or soon thereafter is an area where dramatic gains could be made, and recent progress could be leveraged to eliminate all preventable deaths for mothers and babies. The global community knows how to do this, even for the most vulnerable global citizens who happen to live in extremely remote, indigenous, low-income, or poverty-ridden communities. There are models such as those featured that shine a light on what is possible with appropriate cultural adaptations, resource allocation, and political will. The opportunity to transform the experience of birth is not merely a matter of allocating financial and human resources. What is at stake is a matter of human rights—the right to be born in a loving, caring, safe and affordable manner regardless of where you live, what your parents’ income or education level may be, or other circumstantial differences that have no place in defining the fundamental experience of being human and being loved. Each of the four exemplary programs—CASA in Mexico, Yayasan Bumi Sehat (Healthy Mother Earth Foundation), Mother Health International, and One Heart World-Wide— demonstrates leadership, courage, vision, and the ability to implement successful models in a variety of cultural settings with well-chosen healthcare professionals. We hope the “secret sauce” of each is offered in enough depth to stimulate creative ideas of replication, with modification to fit the unique needs of particular locations. Each program began at the invitation of local partners in a variety of remote communities, fellow global citizens who knew what they needed and reached out in partnership. Each organization featured is a testament to global collaboration and respect for the autonomy of the communities that issued a call for support. The ability to respond to locally defined needs is another cornerstone of robust, sustainable programs, and a hallmark of our work at the Global Force for Healing.

42 Behind each of these models is what is often called the “midwifery model of care”, which is based on a simple-yet-profound knowing when, or if, to intervene and a respect for each woman and her choices. As Vicki Penwell, the Founder of an exemplar program in the Philippines, Mercy in Action puts it so well: “It is really so simple: reduce interventions in the normal physiological and social process of birth, be prepared to perform advanced emergency life-saving skills in the event of an emergency, and be nice…Unfortunately, kindness and compassion are too often ignored during the delivery of maternity care in both developing and developed countries.” Vicki Penwell in Birth Models That Work, 2009 The Healthy, Compassionate Birthing Project exists to amplify both the gains and particular needs of people who have been marginalized. As an advisory organization and convener of a network of birthing clinics and grassroots organizations in countries in Africa, Asia, Central and South America, we hope to contribute “wind behind the wings” of those on the frontlines of reducing maternal and infant mortality. Each project in the current network shares our vision to put love and compassion at the heart of the birth experience, in service to eliminating all preventable deaths of mothers and babies worldwide. We also share ways to measure progress toward this vision and criteria for participation in network activities. We invite other grassroots initiatives to join us at our in-person and online global gatherings and sharing of educational/training resources. There is leverage in the power of a network to support each other to become sustainable and collaborate on mutual concerns, share fundraising ideas, and best practices. We also offer consulting advice on organizational and developmental concerns. There is no cost for grassroots organizations to participate in the Healthy, Compassionate Birthing Network. We welcome your inquiries about the article and invite you to join us. This is an opportune time for a breakthrough in supporting existing programs, and in nurturing future generations waiting for their moment in the sun.

43 LIST OF ORGANIZATIONS AND HOW TO REACH THEM Organizations Featured in the Article One Heart World-Wide Website: http://www.oneheartworld-wide.org For donations: visit website or contact Ellen Eoff, Development Manager: ellen@onheartworld-wide.org Addresses: San Francisco Headquarters 1818 Pacheco Street San Francisco, CA 94116 U.S.A. Office: 415-379-4762 Fax: 415-742-4814 Kathmandu Office House No. 496 Dhara Marga, Ward No 4. Maharajgunj, Kathmandu, Nepal Office: 977-1-4416191 Email: info@oneheartworld-wide.org Yayasan Bumi Sehat Foundation International Website: http://www.bumisehatfoundation.org For donations: 25 Colby Street Barre, VT 05641 USA Account #: 1321649980 RBS Citizens N. A. (Citizens Bank) 1 Citizens Drive Riverside, RI 02915 All transfers must include Bumi Sehat Foundation’s name, account # above, and either a routing # or Swift Code--Within the USA: ABA/Routing #011500120;International Transfers use Swift Code: CTZIUS3 Email: iburobin@gmail.com. Mother Health International Website: www.motherhealth.org; www.facebook.com/motherhealthinternational For donations: http://motherhealth.org/donate/ Address: Mother Health International 8004 Trevor Place Vienna, VA 22182 Email: info@motherhealthinternational.org CASA Website: http://www.empowercasa.org/donate-now/general-donations/

44 Address: Mexico: Santa Julia 15, Colonia Santa Julia, San Miguel de Allende Guanajuato, Mexico 37734 USA: San Miguel CASA, Inc. C/O PMB 264 220 N. Zapata Hwy #11 Laredo, Texas 78043-4464 Email: Antonia Weber, Development Coordinator, development@casa.org.mx Global Force for Healing Website: www.globalforceforhealing.org For donations: www.globalforceforhealing.org/donate/ Address: PO Box 428 Ashland, OR 97520 Email: kay@globalforceforhealing.org Other Organizations Mentioned Amitabha Foundation: an organization working to preserve and promote Tibetan culture and provide for the needs of Tibetan people. http://www.amitabhafoundation.us Buiga Sunrise: a community-led program in the Mukono District of central Uganda working to provide healthcare, schooling and sustainability to surrounding villages. buiga-sunrise.org Direct Relief International: a nonprofit organization that provides medical assistance to people affected by poverty, natural disasters, and civil unrest globally. http://www.directrelief.org Every Mother Counts: nonprofit organization dedicated to making pregnancy and childbirth safe for every mother. http://everymothercounts.org International MotherBaby Childbirth Initiative: a ten-step guide to improving maternity care globally that is offered in several languages. http://www.imbci.org Jungle Mamas: offers workshops teaching best practices of midwifery and obstetrics while valuing indigenous Achuar motherhood traditions to promote safe, healthy birth. http://www.pachamama.org/advocacy/jungle-mamas

45 Karuna Schechen: a non-profit humanitarian organization which provideseducation, health care and social services in the greater Himalayan region. http://www.karuna-schechen.org Medic Mobile: a non-profit organization advancing healthcare in the developing world by using open source SMS software, which allows health workers to use mobile phones to gather health data. Mobile phones are used to increase patient follow-up, care plan compliance, and continuity of care. Medic Mobile is currently used in fifteen countries, largely in sub-Saharan Africa. http://www.medicmobile.org North American Registry of Midwives (NARM): sets certification standards for Certified Professional Midwives (CPM). http://www.narm.org Pemako Health Initiative: currently working to address the healthcare needs of women and children in the remote Himalayan region of Pemako. http://www.pemakohealthinitiative.org SamaHope: a crowdfunding platform that raises money for medical providers in global underserved regions. http://www.samahope.org Sokasi Banten: association created in 2009 to promote health and education services to the most resource-poor families in Indonesia. http://sokasibanten.org Sukuli Project: improving health in remote villages of Sierra Leone, West Africa through education, research, midwifery training and community recovery. http://www.themoonlodge.biz/sukuli.html Tayatien (currently called Last Mile Health): an organization that trains and equips many health workers in rural areas of Liberia. http://www.lastmilehealth.org The Pachamama Alliance: a nonprofit organization working with indigenous people of the Amazon rainforest to preserve their lands and culture, and offering educational programs globally to bring forth a thriving, just and sustainable world; sponsors Jungle Mamas. http://pachamama.org UN Millennium Development Goals: eight international development goals that were established in 2000 at the United Nations Summit, to be achieved by 2015. http://www.un.org/millenniumgoals/

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