Can Haiti’s young midwives save a new generation?


The full title of this article is “’We have a shower for pain relief’: can Haiti’s young midwives save a new generation?” Sally Williams (The Guardian) reports on midwives in Haiti: “The country has the highest maternal death rate in the Americas. But there’s a new solution: putting care in the hands of midwives.” Williams writes:

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.” [. . .]

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. [. . .]

[Photo above by Elena Heatherwick: Stephanie Roche, the midwife who heads the center.]

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