Throughout the developing world, pregnancy is fraught with danger. There is little or no pre-natal care, hospitals and clinics are often far away, and mothers are often expected to pay to give birth. In the Americas, Haiti is the country with the highest rates of maternal and infant mortality. 600 women die in 100,000 deliveries.
Photos: Eric Beauchemin
Original broadcast: November 10, 2006
Throughout the developing world, pregnancy is fraught with danger. There is little or no pre-natal care, hospitals and clinics are often far away, and mothers are often expected to pay to give birth. In the Americas, Haiti is the country with the highest rates of maternal and infant mortality. It’s also the poorest nation in the Western Hemisphere. More than 500 out of every 100,000 pregnant women die; in Holland the figure is only 16. Infant mortality rates are also extremely high: in Haiti 74 out of every 1000 live-born babies die, compared to only 7 in Holland. In the Haitian capital, Port-au-Prince, one organisation is trying to help cut those alarmingly high figures: it’s the Dutch-branch of Médecins sans Frontières or Doctors without Borders. Eric Beauchemin recently travelled to Haiti and prepared this A Good Life special looking at obstetric care in the Caribbean nation.
I’m in Saline, one of the slums in Port-au-Prince. Even though I’ve travelled widely in Asia and Africa, I find the poverty here shocking: there’s one metal shack after another with far too many people living inside. The dirt paths are narrow and are so full of waste that it’s difficult to walk around. Pigs wallow in the filthy water, left by the rains the day before. Behind the slum, near the sea, for as far as the eye can see, there is garbage and it reeks.
Tens of thousands of people live in this slum. They’re among the 800,000 desperately poor inhabitants of Port-au-Prince who the Dutch-branch of MSF or Doctors without Borders is trying to reach here in the Haitian capital.
MSF teams head out into the slums every day to speak with pregnant women. They tell them that MSF is running an obstetric hospital in the city where they can go for pre-natal treatment and to have their babies…all of that, free of charge. Many women here and elsewhere have never been to hospital to give birth. There are a variety of reasons why women prefer to remain at home, says MSF’s Ernso Saindu. Most of the women don’t want to deliver in hospital because they come from very poor areas. They have been marginalised. When we try to explain that there’s no problem going to the hospital, in fact that this is normal when you’re pregnant, they don’t believe us. They think it’s better to deliver at home. We give them information and refer them to our hospital. Some eventually agree to go, but others refuse.
Most pregnant women turn to midwives, says Erline Germain, who also works with the MSF awareness team. They have rituals, she says, for example when a woman in labour is suffering, they gave her a type of bath with soap and water, and sometimes wine. That’s designed to relax the woman’s muscles. Before doing that the midwife also has to appeal to the spirits to make the delivery easier.
But traditional practices don’t help when the woman has obstructed labour or other problems. So the teams encourage all women in these slums to go to the MSF obstetrics hospital. The women listen but don’t appear all that interested. This doesn’t discourage the teams, who constantly go back to the neighbourhoods to raise awareness. They do so at great risk to themselves because of the violence in Port-au-Prince, and particularly the slums. 30 people a day are reported to be kidnapped in the city by gangs who control the slums. They fight amongst themselves, and with the Haitian police and MINUSTAH, the UN peace-keeping force in the country. Fighting can break out at any time, says Jean-Rony François, another member of the MSF team.
We’re never sure of anything. We can go out into the field. Everything will seem to be OK and then an hour or two later fighting will break out between the police and the gangs. Sometimes we have to hide until the shooting dies down. Other times, we hear that the UN is carrying out an operation, so our headquarters tell us to go to another area. Just to give you an idea: we’re speaking here, but when we finish, we could go out and hear shooting between MINUSTAH and the gangs. We might have to come back inside and wait for two or three hours. That’s the way it is.
The teams refer the pregnant women to the Jude Anne hospital, which MSF opened last March. It’s located near some of the most violent slums in Port-au-Prince, and security near and inside the hospital is a major concern. All the visitors and patients are screened. Petra Reijners is the MSF head of mission and she showed me around the Jude Anne Hospital.
Of course we do not accept arms to enter into our hospital. So everyone who is carrying an arm has to put it into a little box. We give them the key and they can get it back while going out. But they cannot go inside our hospital with arms. We have a metal detector for this, for detecting arms and knives on the front gate. EB: Jeez….
EB: There is a generator going on in the background. Why? Because there is just no electricity in this city. So there’s no electricity. There’s no water. We have to provide all the electricity ourselves with the generator working 24 hours on 24, which is very important because we do many surgeries, emergency surgeries, and the water too. We truck everything to the hospital. There is no water in the pipelines in this city. It must be an extremely expensive operation. Indeed it is expensive, but especially very difficult for the population. We as a hospital, need it but we have managed to get it. But all the people who are living in this city don’t have water and don’t have electricity except if you are very rich. Here’s the reception, where all the people are registered. They register all the persons arriving here for consultations. There you have the ones where they first take the blood pressure and other vital parameters and we check if they don’t present any risk. If it’s a very serious case coming in like who’s bleeding, who’s having convulsions, then she directly goes into triage and we decide what to do with this patient. EB: How many patients come in every day? We do a day about 150 out-patient consultations. We see about 1 or 2 cases of sexual violence daily and we do thirty deliveries. 70% of our deliveries are complicated deliveries, so this means they have a danger sign. This can put the life of the woman at risk. Several of them need C-section. If they wouldn’t get a C section they would die. EB: Why are there so many who have complications? One of the reasons is that there are more complications than back in our countries is that in our countries, you detect them on time. The woman is being pregnant go monthly for their check-up and every complication is directly detected and there is any action taken up, so that it doesn’t get into a complication, while here it’s not. Women are not used to go for a pre-natal check-up. Most cannot afford it, to pay for it. And that’s one of the reasons why you see here very severe cases that you would never see back home in Holland.
These are patients waiting for consultation and here you have the four different consultation rooms where there you have the triage for all the emergencies. Here you have two pre-natal and post-natal consultation rooms and also a room that we made especially closed because there we are seeing the sexual violence cases to make sure that all the conversations are really privately held between the doctor and the patient, and also there is the mental health department where we are giving mental health support to all victims of sexual violence, to victims of violence, because as you know unfortunately with the wave of violence which has hit Port-au-Prince we had to turn this hospital also into a traumatology hospital and we have received bullet wounded here, in emergency, so they too especially after amputations and very severe problems, they get mental health or also women who have lost their babies, who have very traumatic experiences while delivering. So there you see they’re going to take the blood pressure of the woman. Also some screams you are hearing in the back, these are women who are having contractions and feeling pain. There are a lot of screaming women in our hospital. And here you can see some women for post-natal check-up. And they are also in line for a counselling. We are doing counselling because we are offering an HIV test for women. And as you know this is a very difficult experience to go to an HIV-testing. We prepare them mentally for it and also if they are positive, we also do a counselling afterwards to learn them how to cope with the disease. And one of the very good things we managed to do in our hospital is that we have a special programme where we can prevent the transmission from the mother to the child and we have success rates of 95% in this. EB: And if the women find out that they are HIV positive, do you provide anti-retrovirals afterwards? We will send them to another NGO here who will provide their anti-retrovirals once the baby is born. What we do is provide anti-retrovirals or the three therapies if it’s a severe HIV case but once the baby is born and then the woman will be referred to another NGO who will follow her up for her disease, for her life. EB: And are the HIV rates here in Haiti quite high? Yeah. It’s 5.6% of the population.
And here we enter the laboratory….Bonjour! Comment ça va? So this is the lab where we are doing all the tests. They’re performing nearly 3000 lab tests per month here. Wow! In all the department. All this material had to be imported because you cannot find it here, and well, had to be adapted because the electricity back home is 220 volts. Here it’s 110 volts. So it’s a real logistical and technical challenge and of course with the high dust, the pollution, they’re working a lot these machines. They need very well maintenance. It’s a lot of logistical work in this kind of setting in Haiti.
So this is the pharmacy. We only have two weeks’ stocks here. One of the reasons why we only have few stocks is that we are afraid of getting looted. As you know, here we are close to the areas where there is fighting going on. Also we are close to the areas where there is local armed groups present. And medicine in this country is worth a lot of money. People have to pay very expensive for it. They cannot afford it. There are no insurances. So it’s worth a lot of money what you see here in this stock which can easily be sold on the street. So we keep limited amounts here because we are afraid of getting looted if violence increases. EB: Has that ever happened? So far not. Never.
EB: But do you have trouble getting supplies to the hospital? No, so far we never had any trouble but of course during tense periods when there’s fighting ongoing, we organise convoys to come to the hospital and we monitor very well by which streets we can go. There are different access which we can use to come to the hospital. And of course we do a lot of negotiations. I regularly see all the armed people involved in this conflict – so the local armed people, the police, the United Nations blue helmets. I explain them what we are doing here, and I tell them that it’s very important for us to have access. And so far this has been respected. When there is fighting, we have possibilities of organising humanitarian corridors, this means a ceasefire for 20 minutes so that our cars can pass. It has been respected by all parties involved in the conflict. And yeah, I always tell them when it’s very tense, I call them and I say ‘hey, an MSF car is passing by. There are patients inside or there are supplies who really need to come to the hospital. Respect them.’
And this is a lot of micromanagement I have to do, see them regularly to see that they really understand that they have to grant access to the patients. They have to grant access to the humanitarians so that we can continue this work here to help the population. So this is our emergency water stock because we are always afraid here that fighting starts and that we can’t go down, that we are stuck for a week here inside because of heavy fighting, so we have enough water for the national staff, for the expats and also for the patients.
Bonjour. So here you arrive in the ward for women who are going to deliver or for women who have a serious illness like eclampsia. Eclampsia is an illness which you see a lot here. 44% of the mortality is related to eclipse. EB: What is it? It’s a disease of high blood pressure where at the end, actually, the baby is poisoning the mother, where this can give convulsions and also make several organs to fail. The liver is not working. The kidneys are not working any more. It can create heavy brain damage because of the convulsions. So it’s extremely serious and it’s a cause of high mortality here. In Holland, these diseases exist too but they are discovered very early, so they are quickly under control but this is not the case unfortunately in Haiti. The only reason how to treat eclampsia is to get the baby out. This means we have to induce labour, but first beforehand we give some medicine to the baby in order to try to ripe the lungs as much as possible, but this is why we have many premature babies in our hospital. Babies who are born very early just because we had to save the life of the mother. And yeah, and that’s very difficult in these countries because there’s no neo-netological department in any hospital here and we try out best for these babies but many of these babies die while at home they would have survived. Here is something more sad. Here are two things: first it’s a morgue under the stairs. Maternal mortality in Haiti is very high. 600 women die in 100,000 deliveries. And we think that these figures have even increased with the latest violence. In Holland, it’s only about 7 women in 100,000. In Holland, in the career of a gynaecologist, he mostly will never have seen a woman dying in his whole career, and gynaecologists here in Haiti see every week women dying. And unfortunately also in our hospital, sometimes women die. They come in too late. The case is too serious. And they do several hours after arrival. And that’s extremely sad because these are mothers who often have children. Sometimes the baby is still alive when the mother died. It’s just extremely sad and not acceptable that women while giving birth are still dying in this country.
And here you can see when the babies are born. The five delivery rooms are just right next to you. As soon as the baby is born, we come here to check and if it needs resuscitation because it’s not breathing or it needs oxygen here then we can also warm up the baby with a lamp to make sure that they are not under-cooled. Here is where we are weighing how heavy the baby is. A scale. She’s sleeping. This is a mother who just delivered of a nice little baby. It looks a big baby. She probably only delivered about an hour ago, and now she’s trying to rest a little bit. So let’s not disturb her too much. Here they’re busy with treating a woman. There’s a woman being prepared for a C-section, and there’s another woman who’s in the late stages of delivery, who will probably deliver soon.
There you see some utensils coming back from decontamination. She decontaminated it so that all the blood is out going through chlorine so they cannot contaminate anymore the others working here. Here now they just did an operation, and they are coming out with the woman, and you will see of course there’s no lift in this hospital. So we carry all the patients up and down. You will see that now with a brancard [ed. stretcher] where they are lying on a bed and we are carrying them all up and down which is a very big hassle. Here you can see the operation theatre. It has to be cleaned now. The patient just came out. This is an operation theatre where we have everything, so where we have an anaesthetics machine, special lamps and where we can do all kinds of operations. So obstetrical operations, C-Sections, but we can also have more complicated traumas here, bullet wounds.
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EB: So here we are on the third floor. It’s big. How many patients do you have here? We have 60 beds. EB: Wow. We do 30 deliveries a day. It’s very big. Last month we did 750 deliveries and 900 admissions. EB: Why do you do so many deliveries at this hospital? Is this the only one in Port-au-Prince where there are deliveries? No, there are other hospitals also but the other hospitals or you have to pay. It’s very expensive delivering. They have to pay for a normal delivery about 10 or 20 dollars and knowing that about 80% of the population lives with less than $1 a day it’s just extremely expensive. And a C-section, a Caesarean section, costs about 100 US dollars. And they cannot afford it. It’s also the reason why so many women are dying at home. And then you have the ministry of health hospitals that they too are asking money or there is a lot of corruption ongoing, that they ask too much money to the patient because they know how vulnerable the patient is and often the system here is just not working. And neither is there no gynaecologist or anesthetise So there is just no good quality care for free outside our MSF hospital. EB: Does that meant that patients go from one hospital to another until they finally arrive here at MSF? This regularly happens and especially with emergencies: women who had obstructed labour. The baby is not coming out because it’s lying breech or a woman who are bleeding. They have been in one hospital. They told her we cannot treat you. You cannot pay so they go somewhere else. They go to another one. And sometimes they arrive here after visiting two or three or four hospitals before where they all refuse help to her because or she couldn’t pay or the staff was not there or there is no medicine. And it’s sometimes sad because we have patients who died here while they have been in several other hospitals before and maybe they could have helped her and she would have been there still on time while when she arrived here it was too late.
This is ??, our anaesthetist. Also British. Hi. What is this baby doing there lying lonely? The mother is in the OT? I think this is the one whose mother has died. She came here with eclampsia, severe eclampsia and apparently she died within a couple of hours of arrival here. I honestly don’t know the full history, but I know that the child is an orphan. EB: Didn’t the woman have any family? The woman has family but they were not there when the woman arrived. So we had a sister of hers coming later and we have told her that we are agreed to give her the baby, of course, to the sister, but then she needs to come up with some proof that she is the real sister of the person who died. So we are doing now some checks and this is why this is taking some time. Really sad. Yeah, it’s very sad. It’s extremely sad. EB: Does this happen quite a bit, this type of thing? Well, last month we had 5 women who died, where two the baby was still alive. Yes. But generally the family comes. Yeah, yeah. So far the family has always come. I remember one case where it was a street child of 16 years who was living in the street. And she had no family any more. And there we have given the baby to a local orphanage. And we are regularly checking on the baby to make sure that they’re treating the baby well. There’s a mother who tries that her baby sucks for the first time some milk. And he’s doing it. Look!
Sony François is 18, she says. She comes from Saint-Marc, 5 hours away from the capital. She explains that the hospital she went to referred to the MSF hospital because she didn’t have money for treatment in her local hospital. The hospital demanded 30,000 Haitian gourdes, the equivalent of nearly 650 dollars or more than twice the annual salary of the average Haitian. As a result of a fistula, she’s leaking urine and faeces uncontrollably. The worst thing about her case is that she also lost her baby. When you have the woman you see lying here, some of them have delivered but have no babies, because the baby died. This also regularly happens. We have a psychologist who will go through the wards and talk to them. That’s extremely sad but you know what also happens here is that women have babies and they are not happy because there is just no contraception. They have no access to contraceptive pills, to condoms and after a couple of babies, well they are very poor and they don’t want to have any more. So we have many women here who are not happy when they have their baby. And also there are a lot of women here who are happy but who are extremely worried because we know that with the Haitian statistics, one child on 6 will die before it will be 5 years old. So for normal deliveries they can come here and they can rest in the bed for 4 hours only because we have such a high rate of deliveries that we cannot afford to give him more longer the bed. Of course when it’s at night and fighting is going on they can stay longer. We will make space for them. But in a quiet day as today, they have to leave after 4 hours of rest. EB: But what happens when there is fighting and you have so many patients and you don’t have enough beds? Oh, then it’s chaos. What we will do is that we will try to squeeze in as many beds as possible. As you can see there are some other beds standing. And the ones who are doing fine, we will put chairs downstairs and ask them to wait downstairs, and they will not get a bed. Life is not easy. No, it’s not always easy in Haiti.
EB: Has the fighting ever gotten so bad here that you have had to evacuate the hospital? No, we luckily never had to evacuate the hospital. We have had fighting very close to the hospital, where in the current ward that you are seeing here, what we do then when there is fighting is that we put all the mattresses on the floor because we are afraid that the bullets can come in through the window. Something else that you can see on the windows is that we have all scotched them. We have taped them so that if there is a bullet impact not the whole glass is flying over the wards and hurting the patients and the newly born babies. So we are taking precautionary measures. EB: When there is fighting and the woman needs to come into the hospital. I mean the baby is not going to wait for the end of the fighting, what happens? Well that’s very difficult because when there is fighting, we cannot go and get the woman inside the area because we cannot take the risk of our medical staff, drivers, being hurt by a bullet. So then they have to find a way to come to the hospital. And some of them then decide not to come, to deliver at home. I believe also sometimes it happens that women die at home because they have a problem, an obstructed labour or are bleeding and the fighting is just too heavy and they decide not to come. Here we had to be a bit inventive because our hospital is so small. So for the kitchen, what we did is we rented the roof of another house and we build the kitchen on there so that we could create a little bit more space.
EB: Is this some typical Haitian food that she’s making? Yeah, she’s making some Haitian vegetables, and I see in there, there are some cabbage and you can see local spinach that they are putting together that they can make a sauce with goes rice. So all our patients in our hospital get three meals a day, and especially after a woman delivered, after difficult surgeries, they have to breastfeed, they need a lot of energy our women. So they get one meal and then if everything is OK within 4 hours, they’re gone. Normal deliver, yes.
EB: So we’re looking out towards the ocean now. Where did you say the slums were? Just in front of you. You see them there. There is the slum of La Saline. And some other slums are here to the right. I will show you from the roof. And the other area in front of us is Saint-Martin, and there’s Bel-air. Bel-air is not a slum. Bel-air is an area of the city where there’s even a cathedral, and where there has been really a lot of violence in the last two years. And it’s getting a bit more stabilised in Bel-air. We haven’t had that many fighting there recently. Saint-Martin is still very problematic. So when you look from here you only see the concrete buildings. But in there, there are a lot of metal shack buildings where people are living inside. So you can see also big flags of MSF all around the hospital. This is as protection because in front of you here is the slum of Cité Militaire, Village de la Solidarité, where there has been a lot of fighting recently. And sometimes they use also more heavy arms. Now I’m not at all an arms specialist but we are afraid that a bullet could reach until here. So we put big, big signs that from there they can see that we are here. EB: But if they’re bad shots they could miss, and they might hit here. Well, this is always a risk in these areas. Of course, you can always be victim of a stray bullet or that they are not taking attention. And this is why I’m doing this micro-management with them, and I regularly go and see them. I phone them, and every time when I hear shooting, one of the first things I do is I call them, and say ‘hey, guys, remember that we are there’. EB: For somebody from outside that sounds completely insane. Yeah. It is insane. It is not normal that in this city there is fighting, and I as a manager of an obstetrical maternity, I have to call people who are fighting, who are leaders of armed groups and tell them, ‘hey take care of our hospital and make sure you are not shooting on it’. It’s not at all normal. It’s very sad. It’s not acceptable. But I have to do it. This is the only way how we can reach the civilian population because there’s a lot of fighting, there’s a lot of civilians who are living here, and during this crisis I really want to help the civilians to come through this crisis.
You’ve been listening to A Good Life special on obstetric care in Haiti produced by Eric Beauchemin. This has been a Radio Netherlands Worldwide presentation.