Located in the small double island democratic republic of Trinidad-Tobago is one of the most unique birthing practices, possibly in the world. Named Amicus Maternity Center, from the Latin words for love and friendship, it is located on the island of Trinidad, seven miles off the east coast of Venezuela. Amicus has flourished as a result of the strength and perseverance of one midwife who founded it 35 years ago.
Venus Mark, a brilliant and dynamic nurse-midwife, opened this full-service birth center on July 23, 1970. She continues to mother it and to work there. Often only one strong, tenacious individual is needed to manifest a great idea. In the world of midwives, doulas, and activists, many such determined people are working with heart and soul for the good of motherbaby. That is certainly true in the case of Amicus, which is a replicable model.
Trinidad is a country rich in natural gas, oil, and asphalt. Pitch Lake, on Trinidad’s southwestern coast, is the world’s largest reservoir of asphalt. Because of the petroleum and natural gas reserves, the country is one of the richest in the Caribbean. As a result, many of its citizens are fairly well off monetarily.
Trinidad and Tobago together have a population of over a million people. They have a birth rate of just under 13 births per 1000 population. Despite the fact that the birth rate is higher than the death rate, the islands are losing population due to emigration. Twenty-one percent of the population lives under the poverty line. The infant mortality rate is approximately 24 deaths for every 1000 live births—more than three times that of the United States. Ninety-six percent of babies are born with midwives.
Trinidad is also multicultural. It has been said to be “one nation, many people.” Nobel laureate Desmond Tutu, first black General Secretary of the South African Council of Churches, called Trinidad a “rainbow nation.” The scourge of slavery-transplanted people from many African nations to this and other Caribbean islands. That abhorrent practice was abolished in 1834. The island was then further populated when laborers from India, China, Portugal, and the Middle East came to find a better life by working there. All of these people have contributed to making Trinidad a culturally rich country. Interestingly, the people of these diverse cultures appear to have great respect for one another.
We attended a conference during the Hindu Festival of Light, called Divali, and found that everyone was celebrating. Divali represents the triumph of light over darkness, good over evil, justice over injustice, and knowledge over ignorance. It is a time of rebuilding and rejuvenation.
This respect that Trinidadians seem to have for each other is reflected in the midwives who work there. The midwives in this island nation have great respect for one another, despite how they may have come to the profession; this is extremely rare around the world. Reflecting that, the midwifery organization invites all midwives as members, regardless of whether they are traditional, direct entry or nurse-midwives.
Academically-trained midwives have a great deal of respect for their traditional sisters. At both of the conferences I attended in Trinidad traditional midwives were at the forefront teaching classes. The audience reaction was one of great respect and interest in these women and their knowledge. This was a joy to witness. I believe that something within the respect that people of Trinidad have for each other carries over into midwifery. This respect for people is one of the driving factors for Amicus as well.
Venus began Amicus in 1973. She was dissatisfied with the limitations on midwifery care that she was able to provide.
My motivation for starting Amicus was that I was not doing full midwifery care. During the 1960s where I worked in the US, midwives did more maternity nursing, while the interns and residents were responsible for the deliveries. Only in the case of an emergency or when they were not available could the midwives practice.
I had always known when I was in the United States that I would return home and do something meaningful. The catalyst was the death of my good friend. I felt I needed to dedicate my life to something really important. I didn’t like the politics and how we were treated as midwives in the United States.
So many things were going on in 1968 and 1969, both in me and in the society. My father and mother both had died. I wanted to take control of my life. I was just working but not really doing births. I wanted continuity of care and births with no obstetrician present. I was not experiencing continuity of care. I was teaching residents and doing an occasional birth at night.
I wanted to come back to my country where I could do birth the way I wanted and knew was right. You can’t do births like they do in the hospital. I hated it. I didn’t want to burn out. I needed to give complete care, not fragmented, doing just births or just prenatal or postpartum care.
“Jean Claude” helped me design Amicus. He was an architect in New York from Mt. Sinai hospital. The doors, theater, and equipment were shipped through him. He gave me a special deal on this work. We redesigned an existing house. His wife knew kitchen, sheets, and all that part of the project. The whole process took nine months.
From the look and function of Amicus the collaboration was successful. Amicus is situated in a neighborhood among nice houses with trees, bushes, and landscaped yards. When you walk in you feel the warmth and joy of the place and people. You are greeted by a staff member in the waiting room.
The rest of the house is comfortable and spacious. It is an eight bed center, with a small birth room and operating theater to handle emergencies, as well as a fully-maintained kitchen. They have eight movable baby bassinettes, a small incubator and Kreisleman Rescuscitare for emergencies, and a utility area for autoclaving, storage and washing and drying. There are two staff offices. Covering the walls are pictures of the thousands of babies who have birthed there sent in by happy and proud families. Amicus as a place definitely reaches out and welcomes as surely as the staff does.
At the time Amicus was started the issues were different than today. Although not firmly entrenched, the medicalization of birth had not gone as far as it has today. Venus found the biggest obstacle was financial.
The problem in getting started was money. In the 70s there was no medico-political opposition to starting the birth center. These were the years of black power. The larger society in the United States was into helping women and getting blacks into banking. Radical changes were taking place in Trinidad and Tobago. Banks could not see a woman asking for a loan. Barclay’s Bank finally loaned the money to start Amicus. It was heart-wrenching for a woman to get a loan. Barclay’s representative met me in my little garden and gave me a loan in the form of an overdraft. This loan was given for running of the business and overdraft purposes. When I left the United States I never thought to have fear. I went about my tasks in hippie clothes and got a loan!
Ultimately Amicus received a loan from the Small Business section of the Industrial Development Company (Ministry of Industry and Commerce) which paid all of the bills in the US, including the contractor and mortgage. That left just one bill to pay—the government Small Business Loan.
One of the most unique aspects of Amicus is the mother-daughter midwife-obstetrician team. Since 1999 Dr. Lisa Mark, MD, FACOG—Venus’s daughter—has worked at the birth center. In contrast to the obstetricians who were previously associated with the organization, Lisa’s office is located at Amicus. In addition to routine gynecological and obstetrical care, she performs high-risk care, including doing cesareans, when necessary. Because she is able to provide onsite care for women who feel more comfortable with a doctor, the clinic is fairly autonomous.
Until Lisa came on board, clients chose an obstetrician with whom they had at least one prenatal visit and who agreed to provide backup. Because Amicus staff see their role as working with women regarding their births, at times they had problems with obstetricians when their soon-to-be-mothers asked questions about their care and recommendations made by these physicians. According to Venus:
Working with Lisa is like a living partnership. When you are working in such situations doing very visible work you can feel quite alone. Sharing responsibility for this important work is very helpful.
For example, if a woman was referred for induction for elevated blood pressure with a history of 110/80, we would ask her if she understood why they suggested induction; if she did not then we would suggest that she ask questions of the obstetrician so that she could understand. Some of the obstetricians did not like that, but Lisa shares in the Amicus philosophy and believes in educating women about their health care and births.
Prior to working at the birth center, Lisa spent most of her life in the United States where she obtained most of her higher education. Before returning to Trinidad she worked in an obstetrical practice that employed midwives. Her office always had two midwives and two nurse-practitioners. She grew up around midwives and spent an intense residency working with midwives. The midwifery model of care is very much a part of her style.
Lisa also has a master’s degree in public health, which gives her a distinctive perspective of care. In addition to her work at Amicus, Lisa also specializes in Teenage Counseling. This allows her to go into all the schools in the area and in surrounding areas to give lectures to both boys and girls.
With Lisa’s expertise, the center is able to provide essential services including gynecological surgery such as hysterectomies, tubal pregnancies, and myomectomies, as well as dealing with other complications. This ability to provide other women-related services makes Amicus more of a full service clinic. According to Venus:
Only if we need neonatal intensive care do we transfer. Having Lisa come back has been such a blessing. She has such a midwife’s heart and such confidence. She makes our work so much easier.
The nearest hospital is only 15 minutes away, so on the rare occasions when a transfer is necessary they can get there quickly.
Like other private health care facilities in Trinidad, Amicus is reviewed by the Private Hospitals Board of the Ministry of Health to ensure that they are meeting the statutory requirements of the Private Hospitals Act.
Amicus employs three other full-time midwives, an LPN for the operating theater, three auxiliaries, a cook, and a cleaner. Maintenance is performed by contract staff.
All staff receive continuing education, attend workshops and conferences and receive inhouse and community training. They use the Internet for research a lot. In addition, they have a very comprehensive library and travel in the Caribbean to network with other midwives.
Debbie Lewis is one of the midwives who works at Amicus. She has been there since 1991. Debbie notes:
I visited most of the public and private institutions and did a four month rotation through the public hospital. I did not want to work at any of these places. Then I got pregnant and went to Amicus to check it out for my own birth. I was trying to arrange a homebirth. I hadn’t gone there for a job. I knew Lisa in New York. I had one prenatal visit. Venus and I chatted. Venus said “We’ll hire you.” I said, “Can I start tomorrow?” Venus told me to take the weekend off. I put my CV on her desk but she never read it! I got hired and have been there ever since.
I felt the warmth when I walked in looking for a midwife. Mary was at the desk. I thought, “this place is fabulous.” I wanted a homebirth but didn’t insist because I knew Lisa and Venus and trusted them. I went home and told my husband, “I’m going to work.”
Debbie and the rest of the staff members at Amicus exude warmth and caring. Debbie believes it all comes from Venus and trickles down to the rest of them because:
Venus obviously has a gift for leadership and bringing the best out in others. This is something the world needs a lot more of.
Debbie has admitting privileges at Amicus, but also does homebirths and can transfer clients to the Center when necessary. She feels her role is “to provide women with what they want. I ask what they want, what experience they are looking for. Women and their partners know what they want. We let them bring all their things to the birth center.”
Confidence in Birth
Mary Ellen was referred to us from a midwifery service in Boston, Massachusetts, USA, for a vaginal birth after c-section (VBAC). Amicus staff took a complete personal history and reviewed referral notes regarding her c-section from her prior obstetrician.
Mary Ellen received prenatal care and she and Joe (her husband) were instructed to be realistic about how the birth might go. They were required to participate fully in childbirth preparation, including nutrition, dance exercise, work habits, family life, sex education, and relationships with siblings. The family willingly participated.
The key to our relationship and the events that took place during this pregnancy and birth was that the family had total confidence, love and respect for themselves that the midwives and obstetrician found contagious. They were aware of possible complications as well as positive results.
Mary Ellen was admitted with her family to Suite 1 at 41 weeks gestation. Upon early onset of labour, Mary Ellen, Joe and their son settled in for the night. They received nutrition when needed, and lots of foreplay and love games were encouraged.
Early the next morning the Venus performed a complete evaluation. Mary Ellen’s height and size (under five feet) and Joe’s (over six feet) were reviewed.
She received a trial of labour and a scan—she had a very excellent Bishop’s Score Cervical Status descent and position of vertex. An IV line R/L with 10cc Syntocinon commenced, to be absorbed to 5 dpm to increase every half hour until 40 dpm.
She walked, continued interaction with her husband, maintained hydration and ate.
An Amicus belief is that music, good company, and conversation soothes the soul and encourages the production of endorphins. The one-on-one interaction with her husband appeared to truly work a miracle. Mary Ellen’s labour to birthing was eight hours; she delivered a 7lb 8 oz baby boy vaginally.
This family was not Trinidadian—the father was Anglo Saxon European and the mother was Trinidadian/Hawaiian/Chinese. Everyone had a great time.
I believe they trusted and believed in us at Amicus because we had an obstetrician inhouse and an operating theatre on standby.