Image: A woman in labor
Ariana Cubillos  /  AP
A woman in labor lies on a stretcher at the maternity ward of a Doctors Without Borders hospital in Port-au-Prince, Monday, Jan. 19, 2009.
updated 3/15/2009 3:33:04 PM ET 2009-03-15T19:33:04

The pain was different from before — deeper, sharper. Everyone else was sleeping in the banana grove shack, but Yslande Aristide could not bear it. She stood on the dirt floor and started to scream.

In rushed her sisters with candles and water. Then came the midwife, who made tea from a leaf called ti-zan and told the howling 23-year-old to drink it.

Then she looked under her patient and saw the baby’s foot. Aristide’s fifth child was breech, a life-threatening birth position that under normal medical care would require a Cesarean section.

Late at night, with no money to reach the nearest hospital, the midwife frantically tried to get the baby out by smacking Aristide in the rear.

Giving birth is dangerous business for Haiti’s poor, who suffer by far the highest maternal mortality ratio in the Western Hemisphere. Out of 100,000 live births, 670 Haitian women died of pregnancy-related causes in 2006, according to a UNICEF report issued last year.

In the United States, that number is 11.

Haiti’s maternal mortality ratio is more than five times the Latin American and Caribbean average. It is higher than any South Asian or Middle Eastern country except Afghanistan and Nepal. The worst rates are in West and Central Africa, where an average 1,110 women die per 100,000 live births. Haiti — closer to Miami than Atlanta is — has a ratio higher than four of the 24 countries there.

“The maternal mortality rate in Haiti is embarrassing to the Western world ... these are preventable deaths,” said Dr. Wendy Lai, an emergency obstetrician with Doctors Without Borders Holland.

Heart of the issue
The problem is heartbreakingly simple: Millions of Haitian women either cannot access health care, or cannot afford it.

Haitian health officials made significant strides last year with a program to waive entrance fees — the equivalent of 25 to 64 cents a day — for pregnant mothers at public hospitals. But the women must pay for almost everything else, from doctors’ gloves and syringes to medicine, food and transportation, said Jacqueline Ramon, a maternity ward nurse at Port-au-Prince’s General Hospital.

So many like Aristide still give birth at home, often with untrained midwives who administer traditional care using leaves made into tea, oil, smoke or steams.

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“It’s never, ever going to work unless we say some things are not meant to be sold, and safe motherhood is one of them,” said Dr. Paul Farmer, a Harvard physician. In rural towns where his nonprofit Partners in Health provides free health care, Farmer said the maternal mortality rate is less than one-tenth the national average.

Calculate your due dateMaternal health is one of the issues the Clinton Global Initiative and U.N. agencies are emphasizing, part of a wider call for increased aid and investment that Bill Clinton and U.N. Secretary-General Ban Ki-moon made in a visit to Haiti last week.

For $40 million a year, and likely even less, Farmer said, comprehensive care could be given to all pregnant Haitian women.

The issue is likely to be discussed at a long-delayed international donors conference on Haiti scheduled for April 13-14 in Washington. Haiti faces as much as a $100 million budget shortfall after large-scale emergency spending following four destructive storms in 2008.

Critical situation
Other steps are also needed in this country of nearly 10 million, including preventing unwanted pregnancies and lowering the highest birthrate in the Western Hemisphere — almost 36 births per 1,000 people.

The situation turned critical last fall when Port-au-Prince’s public hospitals went on strike during the fall peak birthing season — nine months after Carnival.

With mothers forced to turn to a handful of not-for-profits, the cramped, 66-bed Jude Anne maternity hospital run by Doctors Without Borders Holland in central Port-au-Prince became, in Lai’s words, a “war zone.”

Women were giving birth on the floor, in the waiting room, on staircases and in bathrooms. One died before doctors, caught up with other life-threatening emergencies, could attend to her.

“They had nowhere to go,” said Lai, a Canadian who previously worked in the Democratic Republic of Congo. “This has been described as a baby factory. On a normal day, we line them up and catch the babies.”

‘I really appreciate the service’
Some things are improving. Doctors Without Borders recently moved to a larger facility after 2½ years in a building so cramped, doctors could not walk around some patients’ beds.

At the old facility in January, women lay in rows, legs open and knees in the air, as professionally trained midwives chatted quietly and watched for signs that birth was imminent. Some of the mothers sang to get through the pain.

Jean-Francoise Marie Lucet was the next to start shouting in the delivery room. A midwife ran over. After just a few seconds of pushing and screaming, Lucet gave birth to a son who weighed a healthy 7.16 pounds. His father, waiting on the street outside, would pick out the name.

“I really appreciate the service I received here,” the exhausted and relieved 30-year-old mother said a few minutes later. The baby was her second — the first had died a year before after suddenly losing weight.

Haitian mothers are disproportionately threatened by the disorders of eclampsia and pre-eclampsia, which bring high blood pressure, excess protein and swelling, and can cause seizures, heart failure, brain hemorrhages and death.

Though seen all over the world, the incidents are much higher in Haiti — 14 in every 2,000 pregnancies compared to a rate of 1 in 2,000 to 3,000 pregnancies in the U.S., according to the National Institutes of Health.

Image: Haiti newborn
Ariana Cubillos  /  AP
A mother holds the hand of her newborn baby at a Doctors Without Borders hospital in Port-au-Prince.
Because they are caused by pregnancy, the only cure for the disorders is to deliver the baby.

Widelin Belance, 16, was suffering from pre-eclampsia when she was brought to MSF Holland’s Jude Anne Hospital. Her placenta had erupted and the baby had already died. Doctors were able to save her life by surgically removing it. She said she was exhausted and sad, but grateful.

‘We’re poor’
Just a few blocks away, deep in the Cite Soleil slum, things are different. Women depend on local midwives who, unlike those at the hospital, are untrained and unprepared for emergencies.

Lironne Jules, 35, decided to become a midwife after delivering her own seven children. She uses massage and the oil made from a locally grown leaf to deliver babies on a cloth mat. For each delivery, she buys a new razor blade.

Mothers pay her up to 250 gourdes, or about $6.25, for her services. But she says threats from midwives who charge four times as much are forcing her to quit the business.

“I can see these people don’t have the money and I just don’t have the heart to charge them more than they can afford,” Jules said.

For Aristide’s family in the banana grove of Pois Congo, on the slum’s outskirts, where to give birth comes down to the time of day and how much money is available at the moment.

“We’re poor. The medical doctors are much better but sometimes we have to use leaf medicine,” said Aristide’s mother, Katie Berkine, a slight, weathered woman who has given birth 16 times herself.

That October night, Aristide screamed for four hours as her sisters poured water over her and the midwife smacked. “It hurt a lot,” Aristide recalled.

Finally the child fell out. Then the midwife smacked it, and it started to breathe.

Aristide named the healthy-looking baby girl Nougenia Jean.

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