The country has the highest maternal death rate in the Americas. But there’s a new solution: putting care in the hands of midwives
Sylvie Delice was born on a hot, slow March afternoon in a clinic in Marigot, a coastal town in south Haiti. The labour was seven hours; her mother, Natalie, 24, a seamstress, was stoic throughout, helped by two midwives in pale pink scrubs. Sylvie arrived strong and healthy, and was named after her mother’s cousin. Natalie recovered well and went home the next day. There was nothing unusual about Sylvie’s birth – yet it was far from typical.
Haiti has the highest maternal mortality rate in the Americas; higher than much of Africa, including Sudan and Rwanda. According to the most recent figures available, Haitian women have a one in 280 chance of dying due to pregnancy or childbirth – a death rate, relative to the country’s population, 40 times greater than the UK, 26 times more than the US and almost on a par with Afghanistan. And while the neonatal mortality rate has dropped from a high of 82.9 deaths per 1,000 births in 1967 to 28.3 in 2017, 3.1% of newborns die within a month, according to the Haitian ministry of health.
Many of these deaths are caused by events that occur during, or shortly after, delivery. A mother may haemorrhage. She or her baby may suffer an infection. Some babies can’t take their first breath without help; newborns, particularly those who are tiny, can quickly become cold, making them weak and less able to breastfeed. Simple, life-saving treatment has been available for decades in income-rich countries. But not in Haiti.
Part of the problem is that, although Haiti has a relatively large number of hospitals ( 390 for a population of around 10 million) many are understaffed, underequipped and not open 24 hours a day. Haiti has 2.7 million women of childbearing age and only 600 obstetricians. About 36% of births occur in clinics or hospitals; the rest take place at home, often in remote villages with no running water or transport. Most Haitian women give birth with the help of “matrons”, traditional birth attendants, a role passed from mother to daughter through the generations. Matrons charge around 500 gourdes (£5.23) to deliver a girl and 800 (£8.36) for a boy, because sons are more valued. But they may not have the equipment or know-how to identify high blood pressure (pre-eclampsia or eclampsia), conditions that are easily treatable in an equipped hospital, and that account for around 17% of maternal deaths in Haiti. There is also a lack of awareness about the importance of washing hands for vaginal examinations and delivery, and cutting the umbilical cord with a sterilised blade.
But Haiti is working on a solution: the country is training a new generation of midwives, working in dedicated birth centres. This is radically transforming the prospects for mothers and babies even in the most hard-to-reach areas, and turning birth into an exhilarating rather than deadly experience.
Marigot’s Centre de Santé, where Sylvie Delice was delivered, is 60 miles south of the capital, Port-au-Prince. Set on the seafront, among hibiscuses and lime trees, the clinic serves a rural population of around 25,000 who live in the town and the surrounding lush forests and thatched hut villages. Women in labour arrive in tuk-tuks or sitting side-saddle on the back of motorbikes.
“The midwives make you feel safe, because you have someone watching over you,” Natalie says when we speak the morning after Sylvie’s birth. She is married to a fisherman, and they live in Raymond les Bains, a village farther along the coast. “I wasn’t scared about the labour,” she says. With her son, now two, she had an epic labour – five days – and was able to stay at the clinic throughout. “The midwives did not send me away,” she says. “They were very patient.”
Visitors can stay overnight, and Natalie was supported by her cousin and a neighbour. “They held the baby at night so I could sleep,” Natalie says. “They brought me food: meat and plantain.”
The Marigot centre delivers around 800 babies a year. It has few of the amenities you would associate with a modern maternity clinic, such as ultrasound, or even a reliable supply of catheters. There is no pain relief, not even paracetamol. “We recommend a shower [warm water can help ease the pain of contractions],” says Stephanie Roche, 30, the midwife who heads the clinic. Labouring women deliver alongside other women in a room with three beds; each has a detachable plastic cover and a bucket. While the clinic has basic plumbing and sanitation (fewer than a third of Haitians draw water from public or private taps; the rest comes from wells, bottled and bagged water, and cisterns filled by trucks); there is no air-conditioning, even though temperatures routinely reach 30C. It might not be obvious why women are better off delivering here rather than at home in a village, but the centre has not lost a mother or a baby since it opened in 2013. “Not one,” Roche says.
Staffed by two midwives and an auxiliary nurse, and funded by the UNFPA (United Nations Population Fund), it provides antenatal and maternity care, all free of charge. Most healthcare in Haiti is paid for, with the average cost of a first antenatal visit ranging from $6 to $25. The clinic also offers family-planning services and post-abortion care. Abortion is illegal in Haiti, and complications from unsafe terminations are another cause of maternal mortality.
“Women are well taken care of, and that is very rare in this area,” Roche says. The oldest of three children born to a single mother who worked in a shop, Roche started her career as a nurse, inspired by her grandmother who worked as a hospital assistant. “She gave me real equipment to play with,” she says. “I used to practise giving injections to the lizards on my bedroom wall. My sister and aunt are both nurses. I come from a family where all the women are nurses.” After studying nursing in Port-au-Prince, she worked for 18 months in a hospital in Marchand-Dessalines, in the northern region of Artibonite.
She was at the hospital in 2010 when one of the deadliest earthquakes in history levelled Port-au-Prince and much of southern Haiti, killing more than 220,000 people. As the shock waves surged through the country, the hospital started shaking, even though it was more than 130km from the epicentre. “At first, I thought it was a bulldozer or truck going by,” Roche says. “I only realised it was an earthquake when I saw one of the directors screaming, ‘Get out!’”
But, actually, she says, it was the catastrophe that befell Haiti barely a year later that really changed her: the cholera epidemic that, to date, has killed around 10,000 people. It highlighted how ill-equipped Haiti was to deal with a public health emergency, and sharpened her resolve. “It was shocking,” Roche says. “In other countries, this would not have occurred. It made me want to teach women how to keep themselves clean, and how to protect themselves from disease.”
This came at a time when Roche was becoming dissatisfied with nursing. “As a nurse, you have to run from gynaecology to cardiac to orthopaedic wards. As a midwife, you are doing a specific job with specific results.” It’s a job she describes as “beautiful, because you are really taking care of someone”. In 2011, Roche enrolled at National Midwifery School in Port-au-Prince and then, after various internships, joined the clinic in Marigot in 2013. She has since delivered well over 1,000 babies.
Since 2013, the National Midwifery School has occupied a shiny new building, near Cité Soleil in Port-au-Prince. The previous building was devastated in the earthquake. Many student midwives would have been killed had lessons not finished less than an hour before it struck. When the rumbling started, some were at the nearby Lumière University, attending a lecture on obstetric care by Quettely Chevalier, then a teacher at the midwifery school and now its director. The students and Chevalier escaped unharmed.
Chevalier’s “personal fight” is to lower the maternal mortality rate so it’s at least on a par with other countries in the Caribbean. “Why is it that so many women in my country have to die while giving life?” she asks.
Outside the midwifery school, a group of students are sitting on steps reciting the causes of sexually transmitted diseases (having an STD during pregnancy can create potential complications for both mother and baby). They are dressed in a smart, grey uniform (“I want the midwives to stand out from other medical professionals,” Chevalier says). The atmosphere is jovial, enthusiastic.
“I want to help women in difficulties,” says Edeline Pierre, 19, who has moved with her mother to Port-au-Prince from Pilate, an eight-hour drive away, so she can train to be a midwife. “I want to be informed, successful in life.” The school has 38 students in the first year, including two boys. Oliver, a former law student, switched to medicine and then midwifery to “do my bit for Haiti”.
Before the earthquake, Haiti had around 350 midwives; by 2013, fatalities and emigration had reduced that number to 211. However, the intake has doubled in recent years, thanks to a change in structure that makes it easier to retrain nurses in midwifery. The college also offers a three-year direct-entry course for school leavers.
A recent report by the WHO estimates that at least 2,200 midwives are needed to significantly lower maternal deaths in Haiti. Chevalier remains hopeful that they will reach this target. “The plan is to open satellite midwifery schools to increase numbers,” she explains. “There is a long way to go, but still, things are improving.”
Back at the Marigot clinic, Roche’s colleague, Pascal Darline, 30, also a former nurse, explains why she switched to midwifery five years ago. “I like the idea of helping a woman give life.” Darline grew up the second oldest of four in Grand Goâve, near Léogâne, in south-west Haiti, where her father is a soft drinks salesman and her mother a seamstress. She qualified as a midwife in 2013, working in a hospital in the Artibonite region. But the 90-minute commute from her home in Port-au-Prince was “too far, so when a job came up here, I applied,” she says. She has been here for a week. “The biggest challenge for me as a midwife is to watch a patient dying. It is very painful.” She says in each case it was a home birth. “It’s not that they don’t want to come into hospital; it’s because they can’t afford it, or they can’t get there.”
Haiti’s terrain is marked by high mountains and deep troughs. On the northern side is the Massif du Nord; in the south-west, the Massif de la Hotte and Massif de la Selle. Over half of Haitians live in remote countryside. Chronic underfunding means there are few roads, little public transport and much of the country is inaccessible.
“Many of these women [who died] have seen their mothers give birth at home, so they follow their example, but they weren’t as lucky as their mothers,” Darline says. “Lack of education is a problem.”
Roche is single; Darline married. They board together at the clinic (Darline’s husband lives in Port-au-Prince). Their official working day runs from 8am to 8pm, but the clinic is open 24 hours a day, and they help whenever required. They’ve seen and learned to deal with countless complications: twins; babies whose umbilical cord is wrapped around their neck; stuck shoulders.
More complex cases requiring blood transfusions, say, or caesareans, are transferred to Saint-Michel hospital, a 45-minute drive away in Jacmel, or to Port-au-Prince. The ambulance, a 4×4, is parked outside. Darline has just sent a women who is eight months pregnant to Jacmel. “She is severely anaemic. Even if we gave her iron tablets, she would still need a blood transfusion.” Other patients include Marie Carline, 21, who is three months pregnant and suffering from severe morning sickness, and is lying in bed on a drip receiving much-needed fluids; and Dionese Exil, 18, who is having a long and difficult labour with her first baby. She kneels and rocks, her voice exploding through the air: “Whoah, whoooah.” With each contraction, she grows louder, “O Lord! O Papa! Where are you!? The pain! God, I’m dying!” (Haitians subscribe to two religions: Catholicism and Voodoo.)
Laurette, 36, a mother of two daughters, aged 18 and 14, is sitting in the outdoor waiting area in the clinic’s courtyard with several neighbours to support Exil. Laurette knows firsthand how birth and death are interlinked. Her cousin died of a haemorrhage a few hours after giving birth in 2007. And her baby son died when he was one month old in 2004. “He fell ill with a fever.” She says she would have gone to the hospital in Jacmel, but her only means of transport was her husband’s boat – he’s a fisherman – which had been seized by Dominican Republic authorities. “They said he was poaching.” Lokun died in her arms.
Laurette and her friends eat a packed lunch of fish and fried plantains. “We love babies,” she says, sticking her head around the door of the labour room to cheer on Exil, who later gives birth to a boy in the hospital in Jacmel.
Motherhood may be a dangerous experience in Haiti, but it is highly valued, even revered. “Being a mother gives you a lot of status, you are seen as someone important in the community,” says Moetsi Duchatellier, assistant representative, UNFPA, Haiti. “It’s better to be married and divorce two or three weeks later than never to be married at all. The next level is to be married and have children. If you have a boy, you win it all.”
“If you don’t have babies there is no possibility of change in your life,” says Myrtha Magloire, 26, who lives among almond and mango trees in the lush hills above the village of Peredo, a 20-minute drive from Marigot. Married to a gardener and over eight months pregnant with her second child (her son is eight), her belly strains out of her dress; she is blooming. She chose the Centre de Santé, even though it is at least an hour away, because her local clinic only offered antenatal appointments from seven months. The midwives in Marigot see women monthly during the first and second trimester, then twice a month. Magloire explains why some women die in childbirth. “This happens when you have extreme complications or some voodoo. It can be a spell someone has put on the woman. For example, someone might not like the man you’re with, so it can be an act of jealousy.”
“We have to work with traditional beliefs,” Darline says. “It’s all about education.”
The midwives have created a safe sub-world in this poverty-stricken part of Haiti. But still, out of around 300 pregnant women currently registered, only 30 will deliver at the clinic. “You have to be really motivated, because getting here can be really difficult,” Roche says. Women who live in the village of Guillermond find it particularly hard. “They are separated by a river. There is no bridge. It takes at least an hour to walk down the river. The only option is a boat.” Continue reading