Just a few field notes...

      So a tropical storm has hit Majunga and it has been rainy rainy rainy for the past like four days. It was nice for the first few days because it was not as unbearably hot here but now I am wishing for some sunshine and heat. I need to start working on my tan! Anyways, aside from that it has been a pretty exciting few days here in Majunga with many visits to local organizations and authorities. Yesterday we got to visit a clinic, which specialized in women’s health, maternal health especially. Later that day we got to visit a doany which was a sacred site for Sakalava kings (the group of people that lives in the region of Majunga). This was pretty cool in that we were invited into a very sacred site for them and had to wear special clothing and respect local "fady" or taboos related to that culture. For example, wearing the special clothing, taking off shoes upon entering the sacred site and letting our hair down without elastics or anything.  Today we got a visit from a local divanatore and the afternoon was free to work on some of the projects we are currently doing. The fortune teller, "divanatoire" was interesting... he told our fortunes and horoscopes and some of them were pretty ridiculous. Apparently according to him I spend lots of time worrying about the things going on in my life and what I need to do all the time that it gives me heart palpitations and nightmares (which is actually pretty valid) then he proceeded to tell me that I will get diabetes because of it... Which doesn't run in my family and I hope to God that it is not true. Anyways, after everyone got their future read for them we had the afternoon free, during this time I got the chance to visit another health center.

            Just a background for you all: I have spoken briefly earlier about the schoolwork components of this program but to reiterate… Right now we have a thematic seminar paper due in about a month. This will be done while the regular program activities and classes are in session and requires some fieldwork and research but is not super in depth. I am doing this paper on women’s health and family planning, which will involve me visiting various health centers and family planning centers and interviewing the individuals in charge of them. 

         So part of my homework here is to keep a field journal full of field notes and information I have gained from special visits and interviews and such. Since I have been super busy this week with work and writing I really do not feel like summarizing my experiences at the health clinics again. So, instead, I will provide you with entries from my working field journal. So excuse me if they are more schooly sounding or if they don't make any sense... I was up late last night writing many many things and by the end of it I could not write in french or english... let alone think in either language... 

So here it is: the in-depth clinic visits- 

February 29, 2012: Visit to Centre de Sante Base

Study Questions:

1.     Quelles sortes d’education est-ce que vous avez sur le sujet de planning familliale?

2.     Quelle methods de planning familliale est-ce que vous avez?

3.     Comment est le centre fonder?

4.     Est-ce les services du centre a gratuite pour les gens?

5.     Qui peut utilizer les services du centre?

Upon the visit to the center, we were greeted by the chef medecin who was very friendly. She showed us around the clinic and introduced us to her coworkers and answered any questions we had. These questions above were questions I was planning on asking during my visit. Some of them were already answered by the doctor’s explanations and others were asked by me or other students. We were brought into the vaccination room first. We met another doctor in there and he went on to explain the vaccination process for infants. He said that there were 5 vaccinations given to every child between the ages of 0 and 11 months and that there was a 98% vaccination rate in the community served. The community served in this case includes 4 fokotany (divisions within the city of Majunga).

We were then brought into the family planning room. They explained the types of family planning that they gave out. All of this is free and funded by NGOs. They gave out two different types of pills, spermicide, the shot, condoms and the natural necklace method. One student asked the percentage of women in the area that use the family planning services and they responded that 97% of women use their family planning services. We were then shown around the maternity ward. They explained that there were 50 births per month and that women stay for 3 days after the birth and if there are any complications then they would get moved to another clinic. It is also necessary for the women to bring their own bedding, food and clothes.

      I was surprised when we walked into the maternity ward that there was a women lying on the table with her belly out being examined. It seemed as well that there were too many people in such a tight space in this section of the clinic. There were like five nurses helping out this one lady. When we went into the recovery room there were about five beds, one of which was occupied by a very young woman with a baby in her arms. She was trying to breastfeed the baby and was not doing it right and the doctors that were with us rushed to her side to help her breastfeed correctly. Our last stop was the clinic pharmacy. It was well stocked with the basic medicines.

      This visit taught me a lot about the basic health centers in cities in Madagascar. I am interested in writing my thematic seminar paper on maternal and child health so it was very cool for me to see a working clinic that specialized in maternal and child health. The statistics given surprised me. I could not help but think critically about how the statistics involving the amount of children vaccinated and the amount of women receiving family planning services were gathered. I was also surprised at the amount of births that happen in the clinic each month. This clinic serves only a section of a city and there are one plus children being born each day in this clinic. I was impressed with the relationships between the staff at the clinic. It seemed like more of an intimate setting than some public health clinic. By intimate I mean, while we were in the recovery room there were about 5 staff helping this poor woman nurse her baby and you could tell that they really cared.

Looking back at this, I was very impressed by this center. It seemed like they worked together as a community and gave basic health needs to mothers and children. I was impressed by the amount of free services they gave. I cannot help but think about how long that will be in place. I hope that someday the government in Madagascar turns into more of a democracy and is able to fully fund these free services rather than depending on aid from elsewhere. I also cannot help but be critical of the statistics they gave us. How were these measured and who was involved. In reference to the family planning statistic, 97% of women receiving service, what would constitute a “service?” Also, on the subject of family planning, it was interesting to see that the “natural” necklace method was offered. I would be interested to delve more into that and to see how educated people are about methods such as those. Do they offer it as an alternative for women who do not wish to use other methods for religious reasons? Or are they promoting it as something that provides protection against pregnancy? These are just some questions that have come up for me during my evaluation that I hope to have answered in time to write my thematic paper.

March 1, 2012: Visit to CSI (Centre de Santé Intégré) à Mahabibo

Rendez vous avec: M. Rakotozanany Pascal; Médecin- Chef

Study Questions:

1.     Quelles choses est-ce que vous faites pour les services planning familliale?

2.     Qui fondes ça?

3.     Quelles sortes d’education de communité est-ce que vous faites? (pour le planning familliale)

4.     Quest-ce que c’est le percentage de femmes qui utilize les services de planning familliale? Comment est-ce qu’on ce trouve cet statistic?

5.     Est-ce que le planning familliale et l’education a une decision seulement pour les femmes ou est-ce que tu emploies l’education pour les hommes aussi?

6.     Quelles sortes de choses est-ce que vous faites pour les services prenatale et pour l’accouchement?

7.     Est-ce que vous employez les services pour les STDs?

This was my first visit to an organization by myself so it was a bit nerve wracking at first but it turned out to be a wonderful experience! I learned so much about child health, maternal health and family planning in regards to this center and for all of Madagascar. I acquired lots of information about these topics so I will first try to give a detailed account of what I learned, and then I will interpret and evaluate my findings as a whole.

I met with the Medecin-chef or head doctor of this center. He started out by giving me an overview of what the center is responsible for and then I explained that I was interested in hearing about specifically child and maternal health and as well, the health of sex workers. He began to explain to me that this center unites many aspects of health and there are many specialists that reside here as well. The center unites mothers and children; it unites transmissible diseases as well as being a diagnostic center for TB and leprosy. Prostitutes come here to receive services as well as those living with HIV including the vulnerable populations of homosexuals and sex workers as stated before. One of the goals of the HIV program is to eliminate the discrimination and stigmatization, that of which he brought up a bit later. There are many different doctors who specialize that work at this center such as psychologists and other doctors that one would get referred to from a base clinic.

When I told him I was specifically interested in child and maternal health, he explained that they have three categories of child and maternal health child and maternal vaccinations, prenatal consultations and maternal care and family planning services. He went on to explain the vaccination process for infants. He explained that each population (this center was in charge of 8 fokotany) has a number o f children that they need to vaccinate. These population projections however, are not exact numbers because it has been difficult during the times of the crisis to acquire an accurate census. There are around 2,000 children in the area aged 0-11 months (which is the priority age for vaccination) and the objective is to vaccinate all of them. 

Each child receives five vaccinations before they reach one year of age. These include: BCG, which is given for tuberculosis and is given at birth or within the first fourteen days of birth. If this does not happen the child must get the vaccination at six weeks. The next vaccination is DTC, which includes Diphtheria, Tetanus, Meningitis and Hepatitis B. this is given in a series of three; one at 6 weeks, two at ten weeks and three at fourteen weeks. The child also receives the influenza, polio and VAR vaccinations. I need to enquire more about the details of these.

To explain the vaccinations more clearly, the chef medecin brought in the vaccination doctor with their charts to give me a visual representation of the kind of vaccinations that were given and at what age. They then showed me special cards that each child had to show which vaccinations they received and when. They also showed me a book in which all the vaccinations were recorded. The vaccines are mostly given out every day, except for the BCG vaccine, which is not given on Tuesdays and Thursdays. Once the child has completed all of his/her vaccinations, he/she gets a vaccination diploma (which they showed me) with their name on it and they also get a free bottle of insecticide to use against malaria. In addition to just vaccinating the children at the center, if the child has not completed their series of vaccinations, the healthcare workers will actually go to the home of the child (their address is written on the cards) and give the vaccination there. I also forgot to mention that women of procreating age receive a tetanus vaccination.

 As far as other child health goes, the vaccination specialist and the chef medecin showed me a special armband that goes around the child’s right arm that they use to measure malnutrition in a child. This measurement is used from six months to five years. If the child is malnourished then they are given special food provided by UNICEF for a period of six weeks until they reach a healthy weight.

The chief doctor (chef medecin) then moved onto the topic of maternal health. There were four prenatal consultations. The first is at 24 weeks in which they perform diagnostic tests to make sure that everything is right on track. The second is within the fifth month of pregnancy in which they make sure that there is no risk for a premature birth. The third is in the seventh month where they do diagnostic tests to see if there will be any complications as well as check the placement of the baby. The fourth consultation takes place within the eighth or ninth month and goes over the details and prognosis of the birth.  Like the infant vaccination cards, the mothers have cards as well which outline the risk factors for the women, her vitals at each visit, observations and the back of the card is devoted to notes about the actual birth. The doctor also showed me a women’s book of health, which one can acquire if they go to the head of the region. These are free as well and they are unique to Majunga.

The doctor then went on to explain in detail some of the tests and diagnostics they some during the prenatal consultations. The women receive malaria prevention medicines in addition to free HIV and Syphilis testing which is required. When the baby starts to move, the mother is given another round of anti-malaria medication in addition to insecticides. The health workers observe the woman taking the antimalarial meds to make sure that she just does not go home and throw it away.  At the seven to eight-month gestation period the women is also given anti-parasitic medication. This is all free and provided by the clinic. I asked the doctor who funded these services and he answered that an organization by the name of Cooperation de Fanomiale funded it. I am not sure if I caught the name correctly, I will have to look into this subject a bit more. These services are also standard for health clinics all around Madagascar. I am sure that they vary by region, especially in the poorer and more rural areas. 

Front side of the Maternal Card that would be filled out with the information gathered in the four prenatal visits

      Giving birth at the center is also free. It is open 24 hours and there is always a midwife on duty. The doctor explained that the midwife is obligated to follow the chart on the card for the birthing. There is a zone as you can see, which is like a “red zone” if the woman reaches this zone then the nurses are obligated to send her to a specialist complex for birthing complications. He explained that recently there has been regulations put in place to follow these obligations and since then, the number of child and infant deaths has dropped drastically. After the birth, the mother stays in the recovery center for an average of three days; it is sometimes less depending on the mother and infant’s health and the number of beds that are available. There are normally four beds in the recovery room but sometimes it is necessary to add a fifth. When I toured the center, there was only one bed occupied with a woman who had just given birth that morning.

I asked the doctor if it was necessary for the women to bring their own bedding, food and clothes for the baby. He explained that there used to be a complimentary pregnancy kit given to all women but because of financial troubles they are unable to provide funding for this. He hopes that they will be able to bring it back because one of the largest problems that the clinic face right now is the problem of very poor women that do not have any family to bring food, bedding or clothes for the baby. The clinic will provide the woman with clothes for the baby but this is not sustainable if it continues for a long period of time. Something must be done about this problem.

Just to add a bit more about maternal care and my tour of the maternity ward, I got to meet with one of the midwives and have a tour of the consulting rooms. There are two beds in the consulting room in which the midwives meet with the pregnant women for their routine consultations. The midwife told me that they see on average thirty women a day and each woman has a respective midwife that she continually goes to see for her four visits.

Opposite side of the maternal card that outlines the safe zone and danger zone for women in labor. This is the card that the midwives use to judge if they need to send the woman to a special clinic for complications. 

The chief doctor then went on to talk about the next topic of family planning in relation to women’s health. All women in their reproductive years are eligible to receive family planning services. This means that all women between the ages of 15 and 49 are eligible. The contraceptives offered are the oral contraceptive, an injection every two weeks, implants which are changed every two years, intra-uterine devise, condoms, spermicide and the natural necklace method. These are all free for women and paid for by a combination of NGOs and government.

As far as the utilization of these services goes, the doctor explained that about 4,500 women use the services which accounts for about 65% of the population of the 8 fokatany served. I asked the questions about which method is most used and if men are educated at all about the benefits of family planning. He explained that the injectable method was the most popular because it doesn’t require a taking a pill every day and the women can go in every two weeks to get the shot without their husbands knowing. Many of the other methods require the knowledge of the husband/partner (ex: condom, taking a pill every day, spermicide etc.).  Many women who have seen poverty see the benefits of birth control because they know that having many children and no means to support them will lead to poverty. They see the benefits of family planning to abortions because in this society, abortions are not accepted and often very dangerous.

The clinic works to try to educate the community on the benefits of family planning but often times there is a cultural mentality and belief to have many children as well as a religious belief to not use method of birth control.  As far as deciding which method to use, the nurse midwives educate the women on the various methods of birth control, the patients have some say in which method they would prefer but it is ultimately up to the midwife to decide which method would work best with the woman’s health.

Sheet filled out for every woman who receives family planning services with their information and the methods outlined by the midwives that would work best for them 

In addition to family planning services, the health center provides STD testing as well. They provide free HIV testing to vulnerable populations such as pregnant women, homosexuals and sex workers. The chef medecin stated that HIV is becoming a growing problem in these vulnerable populations and they are trying to catch it early by providing these people with free testing. They are trying to provide early testing and education in reference to the STDs but unfortunately eery year they are seeing increases in STD and HIV rates. This is very disconcerting to the population and about every month there is a newly tested HIV positive woman.

On the subject of the sex workers, the doctor provided me with some limited information regarding to services provided for the health of sex workers. There are associations of sex workers in which they belong to they are also provided with peer educator which aim to educate them about the dangers of sex trafficking and the other options they have in life. In regards to their health, there is a paper that is given to the sex workers, which outlines the tests that they could receive, HIV and Syphilis testing every three months for free. A German cooperation also will provide them with free medications if tested positive for any of these diseases. Also, they are given free condoms but many do not use them because the men that they have sex with do not want to use them.

The doctor then briefly touched upon the social implications and difficulties that sex workers face. Sex workers are present in all sections of town and can range from 13 to 50 years old. On average a woman gets 1,000 Ariary per customer (that is equivalent to 50 cents in USD). Ten men pass by a woman each night on average and usually the girls are about 14-15 years old. He explained that this is a subject that needs lots of patience and is a great social problem that needs to be addressed.

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So that is that for the health visits. I am sorry if that was super long but its what I have written in my field journal and didn't feel like doing anything about it. Let me know if you have any questions! I would be happy to clarify! This is also an ongoing project for me so I will be conducting more interviews within the next month as well as gathering more information. As far as my large ISP project goes, I am thinking about doing it on the socioeconomic factors playing into the jobs of sex workers and the public health problems that they face. I am so excited to start learning more about both of these topics!

Well, thats it for today! I will update more on Sunday to give you all a last weekend in Majunga update and my plans for next week! It is going to be like a mini SIT spring break! We are going to Nosy Be for five days which is a major tourist destination and will be spending most of the time at the beach!