PORT-AU-PRINCE, Haiti — 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, far from any hospital, the midwife frantically tried to get the baby out by smacking Aristide in the rear.
Giving birth is dangerous business for poor mothers in Haiti, the nation with the highest maternal mortality rate in the Western Hemisphere. Some 630 of every 100,000 women died of pregnancy-related causes in 2006 — more than five times the Latin American and Caribbean average, according to the United Nations.
“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, known by its French initials MSF, for Médecins Sans Frontières.
Experts say matters have improved over the last few decades, thanks to free maternal care at some hospitals and the work of non-governmental organizations such as MSF and the Central Plateau-based Partners in Health. MSF recently moved to a larger facility after two and a half years in a building so cramped that doctors could not walk around some patients’ beds.
But the needs are far greater in a country of nearly 10 million, with the highest birthrate in the Western Hemisphere — almost 36 births per 1,000 people.
Maternal health is one of the issues that 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 earlier this month.
Haiti faces as much as a $100 million shortfall in its national budget this year. It is struggling once again to meet the most basic health needs after large-scale emergency spending following four destructive storms in 2008.
In the meantime, hospitals with maternity wards are few and overtaxed. Even public ones charge fees for medicine and beds. But many pregnant women exhaust what little money they have paying taxi fare to the hospital.
So some, like Aristide, simply give birth themselves at home, or with the help of untrained midwives who administer medicine care using leaves made into tea, oil or paste.
MSF’s hospital has about 66 beds and averages 1,000 deliveries a month. At the old facility, women lay on rows of beds, 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.
“War zone conditions,” 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.”
Jean-Francoise Marie Lucet was the next to start shouting in the delivery room one January day. 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.
The hospital focuses on emergency births. In Haiti, that most often means 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 the disorders are seen all over the world, the incidence rates are much higher in Haiti — 14 in every 2,000 pregnancies, compared to 1 in 2,000-3,000 pregnancies in the U.S., according to the National Institutes of Health.
Because eclampsia and pre-eclampsia are caused by pregnancy, the only cure 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.
During last fall’s peak birth season, nine months after Carnival, doctors at Port-au-Prince’s main public hospitals were on strike for better work conditions. Suddenly MSF had 80 women in labor at a time, with some giving birth on the floor.
One woman in the throes of an emergency died before doctors, caught up with other life-threatening emergencies, could attend to her, Lai said.
Just a few blocks away, deep in the Cité Soleil slum, things are different. Women depend on local midwives who, unlike those at the hospital, are untrained and generally unprepared to deal with 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 outskirts of Cité Soleil, the decision on where to give birth comes down to the time of day and how much money they happen to have 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.