Week of 1.29.10
Transcript: Saving Haiti's MothersBRANCACCIO: Here's a number that will stop you in your tracks: Around the world, more than a half million women die during pregnancy every year. Five hundred thousand, in pregnancy. Our reporters were covering this story in Haiti when the earthquake leveled much of the capital. Our story focuses on new and innovative efforts to make sure women survive childbirth—and how that's gotten ever so much more difficult after the earthquake. NOW's senior correspondent Maria Hinojosa and the Bureau for International Reporting have our story.
HINOJOSA: When a magnitude seven earthquake hits Haiti on January 12, the world responds to the disaster with whatever help it can... rushing in soldiers, doctors and humanitarian aid. The emergency is huge, and so is the relief effort. But at the same time, outside Haiti's destroyed capital, another life or death emergency is playing out. A woman is in labor.
BETTE GEBRIAN: Simone Eustache. She comes from Abricot, She is 43 and this is her sixth pregnancy.
HINOJOSA: Because Simone lives in a village several hour's walk away from town, odds are she wouldn't normally be on her way to the hospital right now. It's 1:00 a.m. when they arrive at the front door of the hospital. Fortunately for Simone, there is the tender hand of Bette Gebrian, an American from Connecticut who has worked in Haiti for two decades.
BETTE GEBRIAN: First time in a hospital, she's delivered all her other babies at home. She's here because of her advanced age because she's 43 and that's a risk.
HINOJOSA: Bette works for the Haitian Health Foundation, or HHF, which has made it its mission to reduce the numbers of women dying in childbirth. HHF has brought Simone here to the public hospital, to make sure she doesn't become part of an astounding statistic.
ANN STARRS: The estimate is that over half a million women die each year from complications of pregnancy and childbirth. And that's ten million women per generation.
HINOJOSA: Ann Starrs is the president of Family Care International, an organization that advocates for safer pregnancies around the world.
ANN STARRS: Think about that. You sit in a room full of schoolgirls, and five of those are going to die from pregnancy and childbirth. But you also can't forget the problem of women who suffer serious complications. For every woman who dies, there are at least 20 women who suffer a serious long-term illness or a disability.
HINOJOSA: There are lots of parts to the puzzle. Even though Simone has come to a hospital, she's at the mercy of a notoriously weak government-run health system. There's blood all over the floor signs that the birth before hers might not have gone so well. The reality is that while great strides are being made with other global health issues, like HIV/AIDS, maternal mortality figures worldwide have flatlined with virtually no improvement in the death rates in 20 years. Starrs says it shouldn't, and needn't, be this way.
ANN STARRS: I think people are sometimes put off by the sense that you need to fix the entire health system in order to solve the problem. But there are interventions that can be implemented, you know, within a year or two that are really going to have a measurable impact on saving women's lives.
HINOJOSA: Why has it been relatively easy to get governments, for example, to take on the issue of HIV/AIDS but not so easy for them to take on the issue of women who die in childbirth?
ANN STARRS: There's a number of reasons. One is that, sorry, but it's a problem that affects men directly. So I think since decision makers in these countries are often men, they see it as a personal threat. But I think another reason that HIV and AIDS has gotten so much attention is because there was a movement. There was a people's movement of advocates and activists who took this issue on, who made noise around the world. And there hasn't been that for the issue of maternal health.
HINOJOSA: While this is a global problem, with over half of all deaths from childbirth occurring in Africa, the situation in Haiti stands out. Pregnant women here are 70 times more likely to die than their American counterparts, only a two hour flight away.
ANN STARRS: It's a country where there's tremendous poverty, poor infrastructure, poor roads, the isolation of many of these rural villages, there are a lot of similarities between Haiti and much of sub-Saharan Africa.
HINOJOSA: To document the problem but also the fragile signs of promise, our film crews set out for Haiti; the timing? Just days before the earthquake... deploying to different parts of the country: following a midwife trainee team in the agricultural heartland of Petite Riviere... and embedding with HHF in the far western reaches of Jeremie. Women in these places are the most at risk. And to understand why, we can break it down to something Ann Starrs describes as the three delays:
ANN STARRS: The first delay is the delay within the family, within the household. And that's the delay in decision to seek care. So a woman is bleeding, a woman is having fits, the family doesn't know what to do, so they delay in making the decision. The second delay is the delay in actually getting to the health facility. Do we have money to pay for a taxi or for a vehicle? Is there a vehicle available? Sometimes there's a river in the way. These issues of transportation can be huge. The third delay is the delay in actually getting treatment once a woman gets to the hospital.
HINOJOSA: Haiti is a place where these three delays play out on a daily basis. Early one morning, the staff from the Haitian health foundation makes the bumpy ride into the mountains around Jeremie. They are here for two purposes: to bring health care to remote communities; but perhaps more importantly, to challenge cultural perceptions. Like those of 29 year old Beyoneze Basil.
BETTE GEBRIAN: She has not yet had a pre-natal consultation. She is 9 months pregnant. She came in December from Port Au Prince on the boat. So that's a 12- hour boat ride from Port au Prince. She has had no pre-natal care, she's come home to deliver, the story we have heard before, and so it is critical that we see her now and see if she has any high risk.
HINOJOSA: Beyoneze had never seen a doctor during either of her two pregnancies. So the HHF team jumps into action. It's a combination of low tech solutions... and surprisingly high-tech service. Beyoneze gets a clean bill of health today, but it comes with a message: don't be afraid to seek trained care. Most Haitians deliver at home. Families are too poor to pay for care, and on top of that, hospitals have a terrible reputation. And there's more. Elderly matriarchs, known as traditional birth attendants, wield a great amount of sway in women's decisions.
ANN STARRS: Traditional birth attendants have been, too often, seen as a problem in the issue of maternal mortality because they can't really provide the medical treatment that is necessary to save a woman's life if she's ha—if she's having a life threatening complication. But traditional birth attendants often play a very important role culturally in the family and in the community. So what a number of organizations are really focusing on is to try and work with traditional birth attendants to educate them and get them linked in to the health facilities.
HINOJOSA: We see this in action in the tiny village of St. Denis, in central Haiti. Our team of trainee midwives has come to bring their knowledge of life-saving birth techniques.
MIDWIFE VIRGINIE: So everyone who delivers in this area, you are the one who delivers them?
TRADITIONAL BIRTH ATTENDANT: Not everyone, but almost.
MIDWIFE VIRGINIE: Ok, are there other attendants in the area?
TRADITIONAL BIRTH ATTENDANT: There were but really it is just me.
AMIONNE JEAN-CHARLES: Can you tell me how many babies you think you have delivered in your life?
TRADITIONAL BIRTH ATTENDANT: I've done so many deliveries I can't count!
HINOJOSA: Villagers gather around. But this entertainment carries important lessons about delivery techniques and hygiene. There's even a fake placenta.
MIDWIFE VIRGINIE: OK, now the placenta has come out. How do you cut the umbilical cord? What do you use?
TRADITIONAL BIRTH ATTENDANT: With a Gillette that I boiled.
MIDWIFE VIRGINIE: Before you cut it you don't tie it or anything?
TRADITIONAL BIRTH ATTENDANT: Yes, I tie it with a string.
HINOJOSA: By the end of the session, the traditional birth attendant has gotten the message: a big deal when 75% of Haitian women give birth at home. Amionne Jean-Charles leads the delegation. She's with the United Nations population fund, and is bridging the gap between traditional health care practices and those being offered at a nearby maternity hospital in Petite Riviere.
AMIONNE JEAN-CHARLES: At nursing school I assisted with a birth, and after that it clicked and I found myself in love with this profession and I have been doing this for 13 years.
HINOJOSA: In fact, Amionne adopted a baby whose mother died in childbirth. Now she is fighting to eliminate the reasons why a woman might choose to avoid life-saving help.
AMIONNE JEAN-CHARLES: They say that in Haiti there's the belief that it's cultural that the women prefer to stay at home for birth. And that was very much how it was in Petite Riviere before. But when we overcame the financial barrier and more importantly when women realized they would not die in the health institution, that we would do everything in our possibility to stop her from dying, that gave them confidence.
HINOJOSA: Midwife trainee Francenette Defonce says it's very important to create a bond with the woman giving birth.
FRANCENETTE DEFONCE: There is a psychological aspect. You have to reassure the patient. For example, if you have a woman at risk of a premature birth, the baby might need to be resuscitated. The woman could be worried, so you reassure her, tell her everything will be OK, that you will do everything for her.
HINOJOSA: The hospital in Petite Riviere is run by the Haitian government with financial support from Dr. Paul Farmer's group Partners in Health. Dr. John Denis directs the hospital.
DR. JOHN DENIS: Not long ago we were doing deliveries in a tiny room, by candlelight. And it used to be that upon arriving at the hospital, we asked the women to go out and buy a Gillette blade to cut the umbilical cord.
HINOJOSA: But while the hospital has come a long way and now more women want to give birth here, Dr. Denis says the second delay - the physical difficulty in reaching that care - still puts lives at risk.
DR. JOHN DENIS: Distance is also a factor that increases the death toll. We have women who have to walk 6 to 8 hours to get to the hospital.
HINOJOSA: Haiti's roads are notoriously bad. Over in Jeremie, the Haitian Health Foundation, serves 100 remote mountain villages. It's a logistical nightmare. But working with local rural leaders, the organization has come up with an ingenious response. Community evacuation teams, seen here in a practice drill. Health agent Jowel Romulus explains how it works.
JOWEL ROMULUS: In an emergency, we have a whistle. We have a committee and when the whistle blows, that announces that there is a woman in the village who has an emergency. Immediately we assemble. I call HHF for the ambulance to come, the other people in the committee get the stretcher and bring the woman to where the ambulance can meet them.
HINOJOSA: HHF has done more than set up evacuation networks. In town, near the hospital, it has created a place where at-risk women from remote areas can come and stay towards the very end of their pregnancies, before they become emergency cases. It's called the center of hope. Camseuze Toussaint rode thirty miles on the back of a motorbike because she had learned about the center of hope from her sister. She is worried she might have trouble giving birth because of her anemia. Still, the decision to leave home wasn't easy.
CAMSEUZE TOUSSAINT: Even this morning as I was getting ready to come, my mother was so upset, she went and took her bed, she started crying and said what are you doing, you should be staying home instead. And I told my mother I need to be closer to the doctor instead of being far.
HINOJOSA: And remember Simone Estache? She's benefited from solutions to the first two delays - she knew to seek help thanks to HHF's community outreach, and was even brought here in HHF's ambulance. But now, Simone's labor is getting complicated. The public hospital in Jeremie is basic, lacking in many supplies. But the good news is that there is a trained midwife. The lives of Simone and her baby are at stake, because the baby has its umbilical cord wrapped around its neck, and it's not coming out.
GEBRIAN: She says she's not pushing hard enough. They'll add Petocin to the IV because that will make her contractions stronger.
HINOJOSA: The medicine kicks in and the midwife is able to untangle the umbilical cord... and Simone gives birth to a large, 9 pound baby girl named Naomi.
GEBRIAN: She'll go back to the Center of Hope because most hemorrhages happen in the post partum period of the first 7 days. We want to make sure she's not going to start hemorrhaging.
HINOJOSA: Right after Simone gives birth, the power at the hospital in Jeremie cuts out. She is led back to her bed by the light of our camera. But Simone is delighted to have a healthy baby - and to have survived childbirth. Many women in Haiti and all across the developing world are not so lucky...and this brings us to what is known as the "third delay": globally there is a severe shortage of doctors, nurses and most importantly, trained midwives, especially in rural areas.
ANN STARRS: Midwives are lower cost to train. And they cost less to maintain. So, they're really, in many ways, the answer to this problem.
HINOJOSA: Before the earthquake, the government of Haiti was expanding a program that was already graduating almost 40 midwives a year and, with the help of the U.N. Population Fund, sending them across the country for rural internships. Its model was pioneered back in our hospital in Petite Riviere. Francenette Defonce and two classmates were sent here for their training rotations.
FRANCENETTE DEFONCE: We have two months of courses on theory and then four months of practical training on the hospital level. And then we come for a stage in community health. We work in the prenatal clinic, in family planning, in the delivery room, and in post partum after the woman delivers. We're teamed with a senior midwife, if there's something you can't do as a student, you refer it to the senior midwife.
HINOJOSA: The delivery room is buzzing as the midwife trainees deliver three babies in less than two hours: two boys, and a girl, all safe - and their mothers too. But the night is not without its drama, as a pregnant woman arrives with swollen feet... the tell tale sign of Eclampsia. It's a top killer of pregnant women Haiti.
AMIONNE JEAN-CHARLES: It's a multi-symptom sickness, the whole body is sick, there is a problem with the kidneys, there is a problem with the heart, there is a problem with breathing, everything. So when she comes here we might give her magnesium sulfate to prevent convulsions. Because with each seizure, she is closer to death.
HINOJOSA: After a night of observation, the woman is moved to a larger, nearby hospital for a caesarian section. Almost immediately another woman arrives to take her bed. Even with the best efforts, not every death in childbirth can be avoided but there are lessons to be learned from every tragic loss. HHF convenes what they call a mortality review: in this case, a woman in a remote village who started to hemorrhage after giving birth to twins.
DR DADY MONTINOR: At that point the family called for the voodoo priest, so that the voodoo priest could stop the hemorrhaging. Unfortunately the patient didn't hold on. She died going from the village to the clinic.
NADEGE PIERRE: We're going to determine the responsibility of everyone who is part of this mortality case. Definitely this is a death that could have been avoided.
HINOJOSA: HHF has shown tremendous progress in serving its community. But it is an internationally-funded program, the brainchild of an American orthodontist, Dr. Jeremiah Lowney, who wanted to make a difference. The real challenge, says Ann Starrs, is to scale up these successes to a national level.
ANN STARRS: Donor interest, donor investments, come and go. They wax and wane. Women are not gonna stop getting pregnant and having babies be—depending on whether donors are giving money for services or not. So it's really something that governments have to prioritize.
HINOJOSA: Would your sense be that, right now, countries like Haiti, in a crisis, but essentially that there was a will, that there was the political will to—to open up to this?
ANN STARRS: Yes, there is a significant increase in recognition by heads of state, by ministers of health, of the importance of investing in and supporting training programs, for example, for—for maternal health. We've seen that—we saw that starting to happen in Haiti before this crisis. We've seen it in countries like Ethiopia and Rwanda and India, where governments are trying out some really innovative ideas.
HINOJOSA: What Starrs says is still missing, frankly, is money. Direct United States government funding around the world for HIV/AIDS is 8.5 billion dollars this year. For maternal health, it's only half a billion.
ANN STARRS: It's increasing, the allocations for maternal health and for family planning. But it's not where we need to be. Globally, the estimates are that we need probably around $25 billion per year to really address the needs of family planning, maternal health and newborn health. Where we are right now is at about half of that figure.
HINOJOSA: But there are signs things are starting to change. Just a few weeks ago, Secretary of State Hillary Clinton announced increased funding for international maternal health efforts.
SECRETARY OF STATE HILLARY CLINTON: "We have pledged new funding, new programs and renewed commitment to achieve Millennium Development Goal five, namely a two thirds reduction in global maternal mortality."
HINOJOSA: And the United Nations Secretary General and other world leaders are also signaling a renewed commitment. Starrs says the stakes couldn't be higher: world wide, a woman dies in pregnancy or childbirth every minute... devastating losses for families and communities.
ANN STARRS: The estimate is that the lost productivity from the deaths of women and newborns in pregnancy and childbirth comes to $15 billion a year. Women are the ones who do a lot of the work, particularly in agriculture. For older children, particularly for girls, the impact is huge. If a woman dies from complications of childbirth You can bet that that girl's going to be pulled out of school and brought home to play mom. She's going to have to go fetch the water, to cook, to take care of the younger siblings, to do all the things that her mother did do. So it's huge when a woman dies. Families often get destroyed.
HINOJOSA: How do you, in fact, change a cultural perception about women, about childbirth—about a gender, essentially?
ANN STARRS: If you really wanna change cultural values and cultural perceptions around women, around—around women's roles and around pregnancy and childbirth, the first thing you need to do is look at education, and education for girls and women, and help families and communities see that an educated girl, an educated woman, is able to do a lot more for her family and community.
HINOJOSA: As we've seen in both our programs in Haiti, there was promise there, things were moving in the right direction. But if giving birth in Haiti was already hard, now it's going to be even harder. An estimated 200,000 women in Haiti are currently pregnant.
ANN STARRS: Women are having babies in Haiti right now. How are they having them? They're having them at home, on the streets, in—under trees, if they're lucky, in field hospitals that have been set up in tents. I think if you're optimistic, you look at what's happening in Haiti and you say, "Well, the country's been devastated. It's almost like things have been wiped out. So, maybe we can look at this as an opportunity to rebuild in a way that is thoughtful, that is constructive, that can set the—set the basis for long-term solutions."
HINOJOSA: An hour after our midwife trainees visit the small village and educate its traditional birth attendant, the earthquake strikes. They survive, but the main midwives training school in the capital is devastated. In Jeremie, Bette Gebrian and the Haitian health foundation are now coping with the arrival of thousands of homeless and injured people coming by boat from port au prince. But they haven't given up on assisting women giving birth: there have been a dozen since the quake, including Camsueze, the woman whose mother cried when she came to the center of hope to give birth. Just today, she had a baby boy. With so much of Haiti now in ruins, the pioneering women we have introduced you to tonight will increasingly become the brain trust to ensure a future for Haiti's mothers, and their children.
FRANCENETTE DEFONCE: When you have a woman who is carrying a baby, that's something very grand. I respect that very much. I believe that if you can save 2 lives, that's more than winning.
BRANCACCIO: in the aftermath of Haiti's earthquake, a debate has emerged over whether the country should try to restore its destroyed institutions, or start from scratch. And over what role the international community should play. This goes further than health care issues, we're talking about the way the whole country works. Weigh in with your point of view on our feedback forum. Pbs.org is your starting point. And that's it for NOW. From New York, I'm David Brancaccio. We'll see you next week.
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