Bringing Healthcare to Mothers in Haiti

For nearly 60 years, HAS has been an international model for health care, disease prevention, and education in the developing world. HAS is committed to fulfilling its promise to provide high quality healthcare to those who are most in need.

Maternal and child health services account for nearly 60% of all services provided by Hôpital Albert Schweitzer Haiti (HAS), among both hospital and community services. With this emphasis on maternal and child health, HAS aims to improve maternal and child survival rates in Haiti, which are among the lowest in the world. 

Children cannot be healthy if their mothers are not healthy. HAS therefore views pediatric healthcare and maternal healthcare as closely, indeed inextricably related. From Cesarean sections for high-risk deliveries in the hospital, to community-based education about various topics including breastfeeding, nutrition, and prenatal warning signs, HAS strives to meet the healthcare needs of mothers and children in the Lower Artibonite and adapt to the changing public health situation through a wide variety of health services. Not only does HAS provide extensive education for patients about reproductive health, encourage and ensure skilled antenatal care for women, we work with mothers and children intensively until a child turns five in order to promote optimal health for women and their families. The hospital specializes in treating serious and complicated illnesses, saving thousands of lives per year with medication and surgeries. Much of the services performed in community services is preventive; by screening children for malnutrition and administering all required vaccines to children under five years, for example, our staff also saves lives by stopping potentially fatal illnesses before they even start. 

This report details HAS’s major maternal and child health service outputs from 2013. The year was quite busy at HAS, with patient volumes in virtually every maternal and child health service higher than in 2012. Community health workers, nurses, and doctors stretched themselves more than ever in order to treat, refer, and prevent illnesses for these vulnerable patient populations, as well as for all patients.

INPATIENT PREGNANCY AND MATERNAL CARE

While most routine prenatal care at HAS is performed in community health centers (known at HAS as “dispensaries”) and mobile clinics, the main hospital’s OB/GYN services specialize in high-risk obstetrics. Neonatal care is provided by the Department of Pediatrics, headed by Dr. Maurice Toussaint, pictured below. If clinicians in the community discover a potential pregnancy complication, such as high blood pressure that could indicate the onset of preeclampsia—pregnancy-induced hypertension that could lead to fatal consequences for mother and baby if untreated—the woman will be referred to the hospital for the remainder of her prenatal care and delivery. As awareness grows through education about warning signs in pregnancy, and the reputation for HAS’s maternity care remains one of the strongest in Haiti, the demand for high-risk obstetrics services is on the rise at HAS. In 2013, due to rising acuity of cases, the occupancy rate averaged 150% in the maternity ward. That this number is even higher than last year’s 118%—already well  over capacity—indicates the rate at which expectant mothers are coming to HAS with increasingly complicated cases of conditions such as preeclampsia, placenta previa (a major cause of antepartum hemorrhage), and peripartum cardiomyopathy (weakened heart function surrounding pregnancy). Patients are also staying longer in the hospital, to ensure full recovery from high-risk deliveries.

 Below is an overview of the hospital’s OB/GYN service numbers in 2013:

• 5,405 consultations in the hospital’s OB/GYN clinic; comparable to 2012’s 5,622 OB/GYN clinic consultations.
• 1,165 women admitted to the OB/GYN ward, slightly more than 2012’s 1,068 admissions.
• 1,021 deliveries in the hospital, an 11.7% increase over 2012’s 914 births. Mothers deliver their babies at the hospital when their pregnancy is considered high-risk or if a home birth could be life-threatening.
• 329 of hospital deliveries performed via C-sections, due to the high-risk nature of these pregnancies, compared to 280 C-section in 2012.
• 34% of all hospital deliveries in 2013 were performed via C-section, compared to 30% in 2012.
• C-sections in 2013 represent a nearly 20% increase over 2012. This increase has created added pressure on the OBGYN surgical and nursing staff.

PREGNANCY AND MATERNAL CARE IN THE COMMUNITY

Community health centers and mobile clinics are a fundamental part of the integrated community services network. HAS runs four community health centers (two in valley areas, two in mountainous areas of the hospital’s service area), with an average of 76 mobile clinics per month throughout the service area. Both of these components of community care provide primary and preventive care services, including those specific to maternal health, such as pre- and postnatal consultations and family planning and reproductive health. They are located even in the most remote corners of the service area to ensure that quality health care is accessible to our patients, who may live up to eight hours’ walking distance from the main hospital.

Community health workers play an important role in maternal health by encouraging women in their communities to attend regular prenatal exams at the nearest community health center or mobile clinic, teaching them about important milestones and warning signs during pregnancy and motherhood, and conducting post-natal home visits. Community health workers and health center staff deliver hundreds of education sessions at health posts and health centers every month.

Below are some of the major community-based maternal health activities from 2013:

• 8,464 prenatal consultations among the four community health centers and an additional 1,115 consultations in 70-80 mobile clinics per month. Both are increases compared to 7,518 and 606 consultations respectively in 2012. The number of pregnant women in HAS’s service area fluctuates at any given time between 3% and 9% of the female population between 15-49 years (approximately 37,000 women).
• 1,524 births were recorded in the community, all of which were assisted by a skilled birth attendant (in most cases, an HAS-trained traditional birth attendant, matrone).  This number represents a 9% increase over 2012’s 1,392 registered community births
• 1,292 postnatal consultations total at the four community health centers (dispensaries), and an additional 152 in mobile clinics, which average between 70 and 80 per month. These are similar to the 2012 numbers:  1,320 and 121 respectively.
• 1,077 postnatal home visits, conducted by community health workers, occurred in 2013. 87% of these were done within 3 days of delivery. Although in 2012 there were 1,331 visits, 80% of them were done within 3 days of delivery, significantly less than the 2013 number.
• 20,362 family planning and reproductive health consultations occurred for women among the community health centers and mobile clinics, a 12% increase compared to 18,199 consultations performed in 2012. By offering reproductive health education and services on a voluntary basis, we ensure to the best of our ability that all women will have access to excellent reproductive health care. We expect that our efforts to raise awareness have caused more women and girls to seek information in recent years. 
• 891 4-month supplements of Vitamin A were distributed to breastfeeding mothers in 2013, slightly lower but still comparable to 2012’s distribution of 971 doses. Infants whose breastfeeding mothers receive supplemental vitamin A have stronger immune systems, decreased rates of night blindness, and reduced risk of infant mortality.
• 783 similar supplements of iron (folic acid) were distributed to women. This was 89% less than last year (7,085 doses in 2012) due to a stock-out problem in 2013. (Keeping adequate stocks of iron supplements was a challenge for HAS in 2013, or more supplements would have been distributed.) Iron is crucial to prevent anemia, which in pregnancy could increase the risk of hemorrhage and sepsis during childbirth and is implicated in 20% of maternal deaths worldwide.
• Nearly 10,000 people per month reached with crucial health education—about 84% of whom were women. Most education sessions, delivered mainly by community health workers and community health center staff, deals with maternal and child health themes such as breastfeeding, nutrition, pre-natal warning signs, reproductive health, vaccination, and many more important health topics. This level of service remained fairly constant between 2012 and 2013. 

CHILD HEALTH

Pediatric patients represent a significant portion of the hospital patient base. Over half of the available beds are reserved for the various pediatrics wards (pediatric surgery, general pediatrics, nutritional rehabilitation, pediatric isolation, and neonatal intensive care). Additionally, the general pediatrics clinic and the pediatric surgery clinic combined make pediatrics the second busiest hospital outpatient clinic division, behind internal medicine. In 2013, children represented 33% of all admissions, but nearly 50% of total patient days, indicating that their cases are often complex and require them to stay in the hospital for a considerable length of time. The children who are admitted to the hospital for care often suffer from serious, even life-threatening health conditions, including severe, acute malnutrition, infectious illnesses such as diarrheal diseases and upper respiratory infections, and injuries or conditions that require surgery and rehabilitation. Ward admissions in 2013 showed notable trends compared to 2012; while most decreased in volume, there were considerable increases in pediatric surgery and neonatal intensive care admissions.

The following are the main hospital pediatric service numbers from 2013:

• 7,970 consultations in the hospital’s general pediatrics clinic, and an additional 1,558 in the pediatric surgery clinic—increases in both cases, compared to 7,225 general pediatrics and 1,115 pediatric surgery clinic visits in 2012.
• Admissions to the various pediatrics wards included:
• 774 to pediatric surgery, a 27% increase from 2012’s 609, which fits with the overall trend in increased demand for surgical care at HAS.
• 2,015 to general pediatrics (17% lower than 2012’s 2,437 admissions).
• 186 to nutritional rehabilitation, a notable decrease compared to 2012’s 257, potentially due to earlier detection and treatment of malnutrition in the community thanks to screening efforts.
• 6 to pediatric isolation, a reduction of more than half from 2012, when there were 14 admissions. Pediatric isolation is usually due to a diagnosis of AIDS and/or tuberculosis.
• 624 to neonatal ICU, a 12% increase from 556 in 2012.

Community health centers, mobile clinics, and community health worker activities emphasize child health in a variety of ways. Pediatric primary care consultations in community health centers and mobile clinics are high volume, and preventive health activities, particularly for children under 5 years old, are the focus of child health activities in the community. From nutrition screenings to immunizations to distribution of vitamins and deworming medication, most activities are targeted to reduce child mortality, particularly in the “first 1,000 days” from conception to age two when children are the most vulnerable. During this critical time period, proper nutrition and health can profoundly impact a child’s ability to grow, learn, and live a full and productive life. In 2013, we maintained or increased service levels for most child health activities in comparison to 2012, indicative of the true and continued need for these services.

 Below is an overview of 2013’s main community child health activities:

• 22,177 general pediatric consultations total among the four community health centers and an additional 5,620 pediatric consultations among 70-80 mobile clinics per month. This represents a sizable increase compared to the 2012 community health center total pediatric consultations (18,453), and a slight increase compared to the 2012 mobile clinic consultations (4,145).
• 16,562 immunizations were administered in 2013, including all vaccines required by the Haitian Ministry of Health (known as MSPP): diphtheria, pertussis, and tetanus; measles and rubella; polio; and tuberculosis. The overall total doses of these vaccines administered was less than in 2012 (19,117), partially due to the fact that starting in May, 2013, a new vaccine (pentavalent) was introduced to HAS’ immunization program. This is a five-in-one vaccine that protects children from diphtheria, pertussis and tetanus (thus replacing the former diphtheria, pertussis, and tetanus vaccine), hepatitis B and Haemophilus influenzae type b (Hib), which causes pneumonia and meningitis. From May to December, 2013, 2,692 doses of the pentavalent vaccine were administered.
• 1,989 children 5 and under received all of their vaccines; 1,733 (87%) of these children were under one year old. This is nearly the same number as in 2012 (2,058).
• 102,082 children were screened for malnutrition in 2013, nearly 9,000 per month (comparable to 2012 numbers). At this rate, we estimate that we are covering at least 96% of the children in our service area with regular nutrition screenings.
• 589 children were treated for malnutrition at one of the 6 outpatient nutrition treatment sites, compared to only 488 in 2012. The higher number could be due to the fact that we have been finding and treating cases of malnutrition earlier through regular screening.
• 25,195 4-month doses of Vitamin A were distributed to children between 6 months and 6 years, 8% higher than 2012’s 24,314. This is important for preventing entirely avoidable yet potentially debilitating childhood blindness.
• 15,491 doses of Albendazole (deworming medication) were distributed to children with diarrhea, an easy and effective way to prevent malnutrition and even death due to diarrheal disease. This is in line with 2012’s distribution of 15,971.

THE IMPACT OF HAS ON CHILDREN AND FAMILIES

The HAS high-risk obstetrics (OB/GYN) ward is increasingly one of the busiest wards at HAS. Known throughout Haiti for its excellent work in helping women deliver safely despite life-threatening pregnancy complications, HAS’s OB/GYN ward always has a specialist on call ready for emergency cases. Alisma and her family are just one story that illustrate the countless ways HAS helps families in Haiti.

Last February, 26-year-old Alisma went into premature labor seven weeks before her due date—an already high-risk situation compounded by the fact that she was expecting triplets. Alisma's local clinic referred her to the only place for miles around that could help her: HAS. Alisma was rushed by ambulance to the hospital in Deschapelles, where Dr. David Jean-Louis, the obstetrician on call, managed her care, helping her and her infants through a safe, natural delivery.