San fanm pa gen lavi
This Haitain proverb, which means 'without women there is no life', has a particularly literal meaning in the context of maternal health. Protecting this source of life requires well developed health services for pregnant women, something which Haiti has sorely lacked. Though no local data are available for maternal health indicators in Thomassique, the national statistics paint a concerning picture:
- Haiti has by far the highest maternal mortality ratio in the Western Hemisphere: 670 women die from pregnancy-related causes per 100,000 live births. To put this in perspective, the ratio is 11 deaths per 100,000 live births in the United States.
- Overall, the lifetime risk of maternal death for a Haitian woman is 1 in 44. In the U.S. the risk is 1 in 4800.
- 85% of pregnant Haitian women receive antenatal care at least once, but only 54% have 4 or more visits. The actual statistics for St. Joseph's patients are probably much lower because we serve a rural and largely uneducated population, which are characteristics associated with poor antenatal coverage.
- Only 26% of births in Haiti are attended by skilled health personnel (doctors, midwives or nurses). Compare this with the U.S., where skilled health personnel are present at 99% of births.
Her suggestions centered on three main themes:
(1) improving supply management; (2)
enhancing cooperation with other clinics and hospitals; and (3) increasing community outreach for maternal health services.
If you've read our earlier posts, you know that keeping the clinic stocked with necessary medicines and supplies is a huge challenge. We were dismayed last month when we exhausted our supply of iron supplements, which is prescribed to virtually every maternity patient to prevent anemia. Though we had placed an order months ago, a received word in June that a large shipment of medications (including iron) had arrived for us in Port-au-Prince, tracking this shipment through Customs and after has been a nightmare; we still do not have the medications. In the meantime, Mis Ketna and our Clinic Director Doctor Casseus have been pulling strings and going the extra mile to obtain crucial prenatal medications from other sources. To avoid future shortages we are implementing a new system for tracking maternity supply use, and looking into sources for purchasing medications on a short time frame in the Dominican Republic. This problem may also be alleviated by working on Maggie's second recommendation of networking with other clinics, through medication exchanges or sales.
The area where we are making the most progress is in Maggie's third recommendation, community outreach. Several of Maggie's suggestions centered on accessing the extensive local networks of matwòn (traditional birth attendants). Many women opt to deliver at their homes under the care of matwòn rather than coming to the clinic. This means women give birth in poorly sanitized conditions, without access to medical technology, and without medical professionals that are properly trained to handle complications. Ironically, women pay for the services of matwòn, while delivery services at Klinik Sen Jozef are free. We are planning a study to examine why many women choose the services of matwòn over coming to the clinic, but previous research and discussions with Mis Ketna suggest that motivators could include cultural norms, habit, lack of knowledge about the risks of delivering without a skilled attendant, lack of transport to the clinic, distance from the clinic and mistrust of medical care. Thanks to a recent grant through the Soins Obstetricaux Gratuits program ('Free Obstetric Care' – a collaboration between the World Health Organization, Pan American Health Organization and the Haitian Ministry of Public Health and Population), we are implementing a new initiative in which matwòn are given financial incentives for referring and accompanying patients to our clinic. Mis Ketna also has plans to implement a Klib Matwòn, where matwòn will come together to share about their work, and receive education from clinic staff.
Our ajan sante, who staff the 4 newly established Community Health Centers in outlying areas of Thomassique, are another important source of maternal health outreach efforts. Their role is to encourage pregnant women in their communities to access the clinic's many maternal health services, and provide relevant education and support. The ajan sante refer any pregnant women that come to their Community Health Center to the clinic, and also conduct home visits to actively seek out women in need of pre or post-natal care (above, our ajan sante Jude, Mary Madeleine, Jean Reluse and Anya review the home visit guidelines and forms). Additionally, Mis Kenta will be speaking on the radio to widely disseminate educational messages and promote the use of our services.
Many thanks to Maggie for all of her excellent work. All of St. Joseph's wishes her the best in medical school and beyond!
