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MSF Briefing Paper | May 2008

A perilous journey:

The obstacles to safe delivery for vulnerable women in Port-au-Prince

Š Julie RÊmy


In 2002, a young woman, her husband and her brother were on their way to a hospital in Port-au-Prince to deliver her baby, when they were caught up in crossfire between the police and a Port-au-Prince gang. The woman’s husband was shot dead in front of her, and her brother was so frightened that he ran away with the money he had brought to pay for the hospital. She was in complete shock. “I felt the pain as much in my belly as in my heart.” She arrived at the hospital alone and penniless. She was told by the doctor that, “Money is a must. We don’t receive poor people here!” Her brother eventually showed up with the money at the hospital a few hours later. She needed a caesarean section to deliver her babies, but sadly one of her twins had already died. Despite her brother’s money, she still had to sell her belongings for 2,000 gourdes1 ($54 USD) and borrowed 3,000 gourdes ($81 USD) to clear the hospital bills. Because her husband had died, she no longer had any means to repay the debt, so she decided to try to find work in the Dominican Republic. The journey was dangerous. While crossing a field at night, some men tried to rape her. She ran to escape and got lost, but eventually found her way to her destination. She worked in the Dominican for two years on the beach, selling goods to the tourists. In the end however, she fell sick and was forced to return to Haiti. Her mother spent everything she had to care for her. “I don’t think about having children anymore. Being pregnant is a huge responsibility, you need to have a lot of money.” - A 29-year-old widow living in a slum community, October 2007

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© Pep Bonet/Noor

Gourde is the local currency in Haiti


CONTENTS

Introduction 06 The critical moment: Delivery 08 Step 1: Insecurity and violence (past and present) 10 Step 2: Transportation issues 12 Step 3: Economic problems 14 Step 4: Poorly functioning health care services 16 Step 5: Stigma and discrimination 18 Conclusion 20 Annex 22

Š Julie RÊmy


For a pregnant woman living in the slum communities of Port-auPrince in Haiti, each step she takes in her journey to give birth is fraught with life-threatening perils.2 In Haiti, life expectancy of women is estimated at 58.8 years (whereas in its neighbour country the Dominican Republic, life expectancy is 68 years), while the maternal mortality rate is estimated at 630 deaths per 100,000 live births3 (in Dominican Republic, the maternal mortality rate is 92 per 100,000 live births4) – the worst in the western hemisphere. In the capital city of Portau-Prince, less than half of the pregnant women deliver their baby in a health care institution, while the rest of them deliver at home without skilled assistance, usually with the help of a traditional birth attendant.5 Over 1.5 million people are living in the poor and violent slums of Port-au-Prince, and this number is ever growing. Life is harsh for the overwhelming majority and it is even more difficult for women, especially pregnant women. Most pregnant women stay at home when it comes time to deliver. For many, there are no complications and they are able to deliver relatively safely. But when and if there are complications, women are forced to make a difficult decision. The lack of adequate health facilities in their neighbourhoods – partly as a consequence of violence – and the limited skills of traditional birth attendants, force women to seek assistance elsewhere. Leaving their homes after dark is dangerous: Many women are reluctant to risk encountering gangs or other violence on their way. They

Introduction

experience similar risks with hiring a taxi or a tap-tap (local means of transportation), as this form of transportation is hard to find in the slums after dark. There are also financial barriers and other security risks. They must spend money on transportation, hospital fees and drugs which imply that a family must live without other essential things (such as food, or paying for shelter). If a pregnant woman does manage to arrive at a hospital in time, there is no guarantee there will be room for her or quality healthcare for her and her baby. She might also be discouraged from going to a clinic outside her community due to derogatory comments made by health care professionals, hospital workers and other community members. Given the alarming maternal mortality indicators and pervasive violence, Médecins Sans Frontières opened Jude Anne Hospital in March 2006 to provide free emergency obstetric care to this most marginalized population of Port-au-Prince. Since the opening of the hospital, the monthly number of deliveries has been growing steadily. In 22 months, MSF has provided free and quality obstetric care for over 21,000 births, almost 60% of which were with complications that had potentially life-threatening consequences for the mother and the child. After two years of experience in such a demanding context, MSF feels compelled to share its experience and to raise awareness about the desperate situation of vulnerable pregnant women in Port-au Prince. MSF calls for an urgent and concerted action to reduce the unreasonably high maternal mortality in Haiti.

A slum, as defined by the United Nations agency UN-HABITAT, is a run-down area of a city characterized by substandard housing and squalor and lacking in tenure security. Confidence interval range: 479 /100,000 to 781/100,000 4 http://www.unicef.org/infobycountry/domrepublic_statistics.html 5 The figures are from “Enquête de Mortalité, Morbidité et utilisation des services (Survey on mortality, morbidity and utilisation of services), 2005-6, (EMMUS IV), carried out by the Ministry of Public Health and Population with the financial and technical support from various international agencies including UNFPA, USAID, Centre for Disease Control and Prevention, etc. 2 3

06 © Julie Rémy

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For pregnant women living in the violent slums of Port-au-Prince, it is not easy to find health care. Women can find some antenatal care available in the health care structures within slum communities, mostly run by churches and NGOs. Yet none of these provide care during the actual delivery of the baby. Seventy-five percent of maternal deaths occur during delivery or during the first few hours afterwards. Most of the health facilities have suffered from insecurity in the past few years: Some were victims of armed robberies, were caught in crossfire, were directly threatened at gunpoint, or had their staff attacked. Some are still suffering from the lack of health care personnel and other repercussions.6 Some health centres closed down or had to relocate outside the slums for months during the worst times. Insecurity has been the major obstacle to the provision of health care.

The critical moment: Delivery

“Now our health centre is hardly functioning because the medical staff have left. We had closed down for two years from 2004 because of insecurity. Now it’s a problem of staff. We still don’t have a doctor.” - A nurse working in a health centre in a slum community, November 2007

Over half of the deliveries in Port-au-Prince occur at home. Matrons (traditional birth attendants) play a big role in taking care of pregnant women, especially at the time of delivery. Yet when they encounter an obstetric emergency, traditional practices can do very little to help, and what the pregnant woman needs most urgently is comprehensive medical care by skilled birth attendants (midwives and doctors). At this critical moment, facing the inadequacy of health structures within the slum communities and the limitations of matrons, pregnant women begin their perilous journey to seek health care outside their neighbourhood.

08

According to the MSF survey on the maternal health care services available in the slums.

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09 © Julie Rémy


“Since about a month, there are bandits who disguise themselves as ordinary people in the nearby neighbourhood. They stop people by surprise and rob them. If they don’t find anything valuable on you and you are a woman, they rape you. Normally a lot of people pass by there, but now, you have to take other routes after dark.” - A woman living in a slum community, October 2007

Even during daytime, some women state they would not dare to go to other areas in their vicinity because they are afraid of being identified and associated with their own neighbourhood, which may make them a target of revenge attacks. The MSF mobile clinics in La Saline, Solino and Pelé Simon do not treat many women from surrounding areas even though they are all situated within possible walking distance. Women have had to find other ways to seek health care, such as taking another road or going to another clinic in order to avoid certain neighbourhoods. MSF is addressing this security constraint by trying to provide consultations in a convenient and neutral location for these women.

Step 1: Insecurity and violence (past and present) “There is no security around here; only God can protect us.” - A patient, MSF mobile clinic, November 2007

© Julie Rémy

the violence that has ravaged Port-au-Prince in the past few years has not spared women and their families and has prevented pregnant women from seeking appropriate health care. Being surrounded by insecurity and violence has been a collective experience of these women. Many patients and their families have been direct targets of violent attacks at least one time: Many have been victims of gunshots, beatings and rapes. Some had their houses burnt down, destroyed or seized, and a number of them have been victims of kidnappings. The vast majority of them have been eyewitness to violence being inflicted upon somebody else.7 Some women told shocking stories of being stranded at home during labour while fighting was raging in the streets; others recounted terrifying experiences while on their way to the hospital.

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“The women here do not go to the neighbouring zone because if we go, we will be interrogated, threatened or we may be sexually assaulted… because of the conflicts between the [armed] groups in the past, it is the ordinary people who are the victims. We still don’t go now. We are afraid.” - A 23-year-old patient, Jude Anne Hospital, October 2007

“I was caught up in the shootings [end of 2005] when I went to the hospital for delivery and coming back home … since then, I always have headaches. I really can’t stand the stress anymore.” - A 30-year-old patient, MSF mobile clinic, November 2007

Despite a reduction of open fighting in the slums since January 2007, women report that insecurity still hampers access to health care: People do not dare to go out at night. Sixty-five percent of the rape survivors who presented themselves at Jude Anne Hospital were attacked during the night; drivers of public transport do not work at night for fear of being attacked.

Rape is a problem for women living anywhere in Port-au-Prince. While it remains a taboo subject for discussion, health caregivers, especially those in reproductive health, are often in a special position of proximity with their patients that allow survivors to discuss sexual violence. Between March 2006 and December 2007, Jude Anne Hospital received 200 girls and women who had been raped, many of whom live in the poor areas of the city. Approximately 20% of these rape survivors were pregnant from the rape when they arrived at Jude Anne Hospital, some of them already at an advanced stage of pregnancy.8

“Once my [adoptive] mother called the godfather of one of the kids to come to watch over the house [while she was away]… he wanted to rape me, I resisted, then he punched me, threw things at me, and threatened me with a gun… I was exhausted and scared, so he raped me… Later I found out that I have become pregnant of this… I suffer a lot in my body. I’m not going to the police because I’m afraid he’ll take revenge or even kill me, he showed his gun when he raped me… I don’t have any friends; the girls here said I’m in trouble because my mother was saying bad things about other people. My father used to give me some money to buy food, but now he refuses to see me because my big belly makes him feel ashamed in front of his friends. My mother even asks me to pay for my food, my sister tells me to get water by myself. Last week I was sick, my mother took me to MSF but she asked me to pay her back the transport money… I’m so sad. How could I possibly take care of the baby when it’s born?” - A 16-year-old patient, MSF mobile clinic, November 2007

Apart from the direct consequences of violent attacks on physical health, the psychological impact of violence on the women’s health is also alarming. Approximately 50% of them - either after having been the target of violent attacks or having witnessed it - expressed that they feel anxiety and fear; another 20% feels emotional strain or have become sick (e.g. headaches). 104 women - MSF patients – took part in a survey. 8 For more information about the comprehensive psychological and medical treatment programme run by MSF in Port-au-Prince, see article “Treating sexual violence in Haiti”: http://www.doctorswithoutborders.org/news/voices/2007/10-30-2007.cfm 7

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Step 2: Transportation issues

Many women living in the slum communities claimed that they are stuck at home at night during labour due to insecurity and fear of being attacked in the streets even though they want to go to a hospital to see a doctor. Data on the registry in Jude Anne Hospital echoes what the women claim - the last woman in labour normally arrives at around 10 p.m. Between 10 p.m. to 6 a.m. there are seldom any admissions. On the following day, the first woman arrives at around 6 a.m. If the birth is imminent, they mostly call for help from a matron living in the neighbourhood, but if possible, they will wait until dawn before leaving their area. Some ask for help from people who have a vehicle and pay the fuel money to the driver and some even risk going to the hospital on foot even though they are already in active labour. Some women reported that they have to be brought to the hospital by their family and neighbours using a wooden cart, and some have ended up delivering the baby on the way.

“I had difficulty in delivering the baby last year. It was almost midnight and there was no transport, so I walked to the hospital.” - A woman living in a slum community, October 2007

Such delays can be fatal for the mother and the baby during an obstetric emergency.10 For example, eclamptic seizures can cause brain damage. The longer a patient suffers from eclampsia11

© Julie Rémy

WHEN a woman from the slums decides to undertake the dangerous journey to seek medical care, transportation is the next obstacle she must overcome. Ambulance services are almost non-existent, so women must pay for private transportation, which is too expensive for the poorest ones. It is even more difficult to find public transportation at night, because drivers of tap-taps9 (minibuses) reportedly do not work after dark due to fear of violent attacks, such as kidnappings and armed robberies. Some drivers are willing to take the risk, but they may ask for a much higher

without proper medical care, the lower the chances of survival for the mother and the baby. If the patient suffers from abruptio placentae (when the placenta detaches from the uterus) or ante-/ post-partum haemorrhage, both the mother and the baby will die if they do not get immediate proper medical care, which may include blood transfusions and surgery. Although some slum communities are not too far away from the hospitals, even small delays can be very dangerous for the patients.

“A pregnant woman arrived at the hospital at 9 a.m. and she died 15 minutes later. Her two cousins who lived with her brought her here. They said she had lost consciousness since 2 a.m. in the morning and had had several seizures. There was no transport available at night and it was probably too dangerous for them to come out. She didn’t have a partner, they didn’t know what to do with her… they came too late.” - An MSF nurse, Jude Anne Hospital, November 2007

Obstetric Emergencies The most common obstetric emergencies encountered in Jude Anne Hospital: • Severe pre-eclampsia: a serious condition that sometimes develops during pregnancy characterized by development of high blood pressure, protein in the urine, and swelling of the feet, hands and face.

price, which can be up to 50 times the normal transportation fee of ten gourdes (25 cents). “I was looking for a tap-tap in the street [while I was about to deliver my baby], it was about 9 p.m. so there wasn’t a lot of traffic. One tap-tap drove by but the driver was asking me for 500 gourdes ($13.50 USD)!” - A 24-year-old woman living in a slum community, October 2007

• Eclampsia: when a patient with pre-eclampsia develops convulsions. • Prolonged obstructed labour: Excessively long labour which can be due to cephalopelvic disproportion (the

baby’s head or body is too large to fit through the mother’s pelvis) or due to inadequate contractions. • Haemorrage: excessive bleeding which can occur before the baby is born (antepartum) or after delivery (post-partum). • Abruptio placentae: detachment of a normally located placenta from the uterus before the foetus is delivered.

See text box “Obstetric emergencies” for the definition of eclampsia, and the most common obstetric emergencies encountered in Jude Anne Hospital. Eclampsia is not common in most places but it has a high prevalence in Haiti.

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Local public means of transport

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12

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Because of economic problems, vulnerable pregnant women living in the slum communities seldom think about undertaking the journey to seek maternal health care in a hospital. As of 2007, the fee for vaginal delivery in the public referral maternity hospital of Port-auPrince12 is 500 gourdes ($13.50 USD) and, for a caesarean section, 3,000 gourdes ($81 USD), which is respectively seven times and 48 times the minimal daily wage13 in a place where over half of the population is unemployed. Moreover, the cost of drugs is not included in these fees. Drugs can be as expensive as the delivery fee itself, and can easily go up to $40 USD or more when the woman needs a caesarean section. Because an overwhelming majority of women have no job, they state that they must rely on help from their partners, family or friends for economic assistance, making the unpredictability of health care costs a major obstacle for them. Many of them are also in a very precarious situation because they receive no support from their male partners. Insecurity also has socio-economic consequences. Armed robberies occur frequently, further jeopardizing whatever meagre savings women might have had to pay for health care.

Step 3: Economic problems

“I had absolutely nothing. Some people who came to pray in the hospital paid the bill for me, and other women gave me some sanitary napkins.” - A woman living in a slum community, October 2007

“I bought a lot of drugs [when I delivered] at the General Hospital, it cost about 5,000 gourdes ($135 USD) in total. So my husband borrowed money from a neighbour… we have been trying to pay back once in a while, every time a few hundred gourdes [a few dollars]… It’s been two years now, but we haven’t been able to pay back everything.” - A 36-year-old woman living in a slum community, October 2007

Women state they cannot afford the fees for health care, drugs, or transport to go to a hospital. Many of them simply stay at home

to deliver their babies, perhaps calling for help from a matron, and hoping for a smooth delivery. When they decide to go to a hospital because they encounter difficulties or suffer too much during labour, the most common solution is to borrow money from friends or relatives or sell their belongings to get cash to pay for maternal health care. Some women even have to ask for help from strangers because they have absolutely no one who can help them.

“[At first, I went to Isaie-Jeanty Hospital for delivery] because I had already followed pre-natal consultations over there. But they asked me to pay before I could stay there to deliver the baby… [so in the end, I came to Jude Anne Hospital from there because]…I didn’t have money to pay for the delivery because I don’t have any work to do. The father of the baby helps me sometimes, but when he doesn’t have work to do, he doesn’t give me anything.” - An 18-year-old patient, Jude Anne Hospital, September 2007

Because of its offer of free obstetric care, Jude Anne Hospital has quickly become the only place these vulnerable women can turn to. More than half of the patients who come to Jude Anne Hospital do so because the care is free of charge or because they feel they have no other option.14

“They said [sarcastically] that because I still haven’t paid, I should still have no pain [so no need for care]! (Her previous pregnancy in 2003)” - A 22-year-old patient, MSF mobile clinic, November 2007

The referral maternity hospital of Port-au-Prince is the Maternity Isaie Jeanty. The price of delivery in the public hospitals in Port-au-Prince varies between 300 to 1,000 gourdes for vaginal delivery, and between 2,500 to 3,750 gourdes for caesarean section. In January 2008, the Ministry of Public Health and Population promised to provide free obstetric care in public hospitals. 13 The minimum daily wage is 70 gourdes ($1.90 USD) per day. 14 Interviews with randomly selected patients of Jude Anne Hospital (182 interviews were conducted between September and November 2007) 12

14 © Julie Rémy

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Some women manage to overcome barriers and leave their neighbourhood to reach a hospital. Nonetheless, the hospitals they get to may not be able to take care of them. Lack of quality care is one of the key factors discouraging women from going to the public hospitals to deliver their baby even in case of emergency. Women claim that the most common problems they face in the hospitals are general lack of care or negligence by the personnel towards those who cannot pay. Some women have been denied care altogether, due to a disruption of services caused by the absence of doctors or anaesthetists, strikes, or power cuts. The public hospitals are struggling to meet the maternal care needs of pregnant women. The hospitals attribute the problem of quality to their lack of capacity. Staff interviewed complained about the lack of materials and equipment, such as delivery kits and drugs. Very often, surgical operations cannot be carried out because there is no electricity due to problems with the hospital’s own generators and interruptions of city power supply. Doctors and nurses are often absent because, with their low salary, many of them maintain parallel jobs or private practice to pay the bills. Surgeons and anaesthetists are rarely present because they only work part-time. Trained staff only work during the day and residents and interns manage patient care at night. This poses a particular risk when C-sections need to be performed. Employees on contract receive their salary only once every three to four months, and when they receive their salary, it is usually only 50 to 60% of what they are supposed to receive. This inability to pay salaries consistently has been one of the major reasons for the numerous strikes in the public hospitals in the past few years.

Step 4: Poorly functioning health care services

“(Last year) we went to five hospitals but none of them received us.” -A woman living in a slum community, October 2007

“The women are badly received there. There is not enough staff, the resident physicians are not yet qualified but they

are often left alone to manage all sorts of situations. The doctors on duty are never present.” - A nurse who is working both in a private hospital and a public hospital, October 2007

General Hospital, Isaie-Jeanty Maternity Hospital, La Paix Hospital, Carrefour Hospital, and St. Catherine Hospital are the public hospitals with maternity services in Port-au-Prince where women can go to deliver their babies.15 However, despite MSF’s efforts to focus on women with emergency obstetrics problems, since Jude Anne Hospital opened in March 2006 it has been performing nearly as many deliveries as all these hospitals combined.16 When asked, 28% of the patients of Jude Anne Hospital reported that they came after having failed to obtain care elsewhere, while the remaining 72% came directly from home. Sixty-seven percent said that they chose Jude Anne because of its quality of care or reputation.17

“[I came to Jude Anne Hospital directly to deliver my baby] because at the General Hospital I would not find a doctor to take care of me, especially at such late hours.” - A 33-year-old patient, Jude Anne Hospital, September 2007 Such circumstances further shed light as to why the Jude Anne hospital has been performing a huge number of deliveries per month. Between March 2006 and December 2007, Jude Anne Hospital has provided free and quality obstetric care for 21,009 births, or a monthly average of 955 births.18 Almost 60% of these presented complications that can have life-threatening consequences for the mother and the child.

Isaie-Jeanty Maternity has 80 beds and Jude Anne Hospital has 75 beds (increased from 55 last year), both are specialised in obstetric care. Number of beds for the obstetrics and gynaecology section of the following hospitals is: General Hospital - 93 beds; Carrefour - 40; St. Catherine Hospital – 29; Hospital La Paix – 19. MSF worked in collaboration with the Ministry of Public Health and Population in St. Catherine Hospital from September 2005 to December 2007. 16 See annex for the table showing the number of deliveries assisted in these hospitals per month in 2006 & 2007. 17 Interviews with randomly selected patients of Jude Anne Hospital (between September and November 2007). 18 Figures include vaginal deliveries, caesarean sections, deliveries assisted by a vacuum extractor or forceps. 15

16 © Julie Rémy

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Step 5: Stigma and discrimination

“I am scared of public hospitals because they humiliate you there and you suffer.” - A woman living in a slum community, October 2007

Vulnerable women’s fear of being looked down upon – either by their own community or by hospital staff – is also a major obstacle to overcome during this perilous journey. Women living in the slums are often discriminated against because of their origin, status or appearance. This accentuates their self-exclusion and discourages pregnant women from seeking health care. Some women feel ashamed of going to the hospital and decide to deliver at home because they do not have clothes or materials for their newborn babies. Some referred to being ashamed of going barefoot to the hospital because they had lost the only pair of sandals they owned; other mentioned that they suffered from skin diseases and felt uncomfortable about their appearance. “A fourteen-year-old girl who was nine-months pregnant refused to come out from her home for fear of being seen as pregnant at such a young age, despite having swollen feet and eye-sight problems, which are clear signs of pre-eclampsia. We found her and brought her to the mobile clinic.” - An MSF outreach worker, August 2007 The attitude of the personnel in health structures is also not encouraging. A number of women referred to being insulted and humiliated in hospitals for being pregnant at a very young age, having been abandoned by their partner, being poor or coming from the slums. Our patients told us that some health personnel in public hospitals did not properly receive them because they were not wearing clean clothes or looked very thin when they presented themselves at the facility. “It’s a question of appearance. Some people go to the hospital and are not taken care of because of their appearance, because they are dirty for example. Those who go looking nice are seen quickly.” - A patient, MSF mobile clinic, November 2007 Stigma and discrimination, whether enacted or perceived, can also be a cause of maternal mortality. It leads to delay in presentation to health services, prolonged health risks and compromises the quality of health care.

18 © Julie Rémy

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For a woman living in the slum areas of Port-au-Prince the journey to giving birth is filled with obstacles. Insecurity, violence and transport problems limit her physical access to health care and even if she can reach a health facility she can hardly afford the services, which anyway may not be of an adequate quality. To add to her distress, the very people who are meant to provide care and compassion may treat her poorly because of her status.

Conclusion

When vulnerable women become pregnant, they have no choice but to face these daunting challenges. The distress, destitution, discrimination and risks they endure at the moment of giving birth in particular, are unacceptable. If their pregnancy fails to run smoothly, it may cost their lives. In January 2008 the Ministry of Public Health and Population announced the introduction of a free obstetric care plan. MSF welcomes this initiative and is looking forward to its full implementation. However, the reduction of the extremely high maternal mortality affecting pregnant women in Port-au-Prince requires a more comprehensive approach. The challenge for the Ministry of Public Health and Population is to make obstetric care more accessible to women from the slum communities. Strategies are needed that offer quality basic obstetric services in or near the slums with the ability to provide timely transfer of emergency cases to public secondary health facilities. Public hospitals need to be able to provide comprehensive obstetric emergency care (which includes the ability to perform cesarean sections and offer safe blood transfusions) 24/7. Maternal death is not a natural death. Reducing the risks of death during childbirth must be made an urgent priority in Haiti.

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21 © Julie Rémy

© Julie Rémy


Annex

Monthly number of surgical interventions including caesarean sections in Jude Anne Hospital from March 2006 to December 2007

Médecins Sans Frontières in Haiti Obstetrical care provided by Jude Anne Hospital and its mobile clinics others

Since March 2006, MSF has been running an emergency obstetrical care programme at the Jude Anne Hospital, Delmas 18, Port-au-Prince. This programme aims at contributing to the reduction of maternal mortality by providing free obstetrical care, targeting in particular pregnant women living in the slum communities in Port-au-Prince. The specific objectives of the programme are: 1. Providing 24h / 7 days access to free and quality emergency obstetrical care to women who have been followed up at MSF’s mobile clinics and cases of complicated pregnancy requiring medical or emergency surgical intervention during delivery. 2. Providing access to free and quality antenatal and post-natal consultations, including voluntary counselling and testing on HIV (VCT), to pregnant women living in the areas covered by MSF’s mobile clinics. The number of deliveries and consultations per month has been continuously on the rise. Since the beginning of the programme until December 2007, the programme has achieved: • 21,009 deliveries (or 955 per month), more than half of which presented complications with life-threatening consequences for the mother and the baby • 12,581 antenatal consultations (or 572 per month), of which 46% are first consultations • 14,860 post-natal consultations (or 675 per month) • 185 patients have benefited from prevention of mother to child transmission of HIV (PMTCT)

curettages laparotomies (including hysterectomies) tubal ligation caesarean sections

Monthly number of perinatal consultations in Jude Anne Hospital and its mobile clinics from June 2006 to December 2007

antenatal consultations

Monthly Number of Deliveries in Jude Anne Hospital: March 2006 - December 2007

post-natal consultations

Jude Anne Hospital has an absolute capacity of 75 beds, an operating theatre, a delivery room, a triage area, a laboratory and a pharmacy. There is also an outpatient department that provides antenatal and post-natal consultations and VCT (voluntary counselling treatment for HIV patients). MSF also has mobile clinics three times a week to provide antenatal and post-natal consultations and VCT in the following slum communities: Solino, Pelé Simon, La Saline.

Other delivery procedures caesarean sections vaginal deliveries

Number of beds (maternity and obstetrics) and average monthly number of deliveries in Jude Anne and five major public hospitals in and around Port-au-Prince (vaginal and caesarean)19

Isaie-Jeanty Maternity

General Hospital

Carrefour Hospital

Hospital La Paix

St. Catherine (MSPP/MSF)

Jude Anne (MSF)

Total

Beds

80

93

40

19

29

75

336

2006

134

270

218

104

225

780

1731

2007

200

375

350

150

318

1090

2483

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MSF has been working in Haiti since 1991. Currently, MSF runs also the following programmes: • Trauma emergency centre with surgical capacity, Hôpital de la Trinité, Delmas 19, Port-au-Prince • Rehabilitation centre with a specific program to assist sexual violence victims, Pacot, Port-au-Prince • Stabilisation centre for trauma victims of violence and emergencies, Martissant 25, with mobile clinics in various zones of Martissant and ambulance service, Port-au-Prince • Training for nurse anaesthetists at national level, Cange, Port-au-Prince In December 2007, MSF handed over to the Ministry of Public Health and Population its programmes at Saint Catherine Hospital and the CHAPI health centre in Cité Soleil after two years of presence. The numbers for 2006 are the official figures submitted by each respective public hospital to the World Health Organisation; however, only estimated numbers are available for 2007 based on interviews with the persons in charge of the maternity service or the registry of the public hospital. The numbers of beds (maternity and obstetrics) are also based on interviews with the responsible persons in each respective hospital.

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A Perilous Journey