by Julie Mann, PIH midwife and nurse
The rain had fallen hard the night before. The narrow footpaths crisscrossing central Haiti were slippery with mud, making it even more difficult for 25-year-old Naromie Axilian (not her real name), now 39 weeks pregnant, to climb up and down the many mountains that lie between her hut and the health center. After eight hours of walking, Naromie arrived late in the evening at the new Boucan Carré hospital, where she laid down her blanket on the cold, hard earth alongside other waiting patients and slept restlessly until the clinic opened the next morning.
This was Naromie’s first visit to the Boucan Carré hospital. The midwife performed a physical exam and some routine tests, including for syphilis and HIV. Naromie was told to return the following day for her test results. Unable to make the long trip home only to return again the next day, she spent another night sleeping outside the clinic. With the dawn of the next morning, Naromie learned she was HIV-positive.
Naromie was born and raised in a small village in Haiti’s Central Plateau. She lived with her parents, sister, and two brothers in a one-room hut with a dirt floor and a thatched roof. Like most people in rural Haiti, Naromie’s family practiced subsistence farming. She attended school for only three years before being forced—due to lack of money for books, uniforms, and fees—to stop and find work. She began selling rice, oil, and other food staples at the local market. Her family continued to struggle economically, particularly after a devastating bean crop, and Naromie was sent to Port-au-Prince to find work. Lonely and in unfamiliar surroundings, Naromie met a young man with whom she had her first and only sexual encounter. Upon learning that Naromie had become pregnant, he abandoned her and took all of the money she had been saving. Panicked and alone, Naromie returned to her home village.
Unfortunately, Naromie’s story is all too common in rural Haiti, where women face myriad obstacles and dangers that heighten their vulnerability to disease and poverty. Due to economic hardship, many of the women we serve at our Partners In Health (PIH)/Zanmi Lasante (ZL) clinics in the Central Plateau were obliged, as young girls, to leave school and find work, often far from home, where they were coerced—directly through physical force or less directly as a consequence of the desperation engendered by their dismal straits—to enter into exploitative sexual relationships. This repeated pattern results in a high incidence of unwanted pregnancies and sexually transmitted infections (STIs), including HIV.
While sweeping political, social, and economic reforms are needed to alleviate the senseless suffering and injustice on a grand scale, PIH/ZL is taking small but important steps towards breaking this crushing cycle by providing comprehensive, free health care—obstetrical and gynecological care, family planning services, and testing and treatment for STIs and other illnesses—for these vulnerable women through the Proje Sante Fanm—Women’s Health Project in Haitian Creole.
Perhaps the gravest risk to Haitian women’s health and well-being is, simply, becoming pregnant. Due to lack of access to doctors, midwives, and nurses, among other factors, Haitian women are forty times more likely to die from pregnancy-related complications than are women in the United States. At PIH/ZL, we ensure that women can give birth safely by making available high-quality prenatal, intrapartum, and postpartum care by trained obstetrical providers. Each Zanmi Lasante site in the Central Plateau has a fully functioning women’s health clinic staffed by a well-trained, college-educated Haitian midwife. Additionally, there are four full-time obstetrician/gynecologists who cover all six sites.
In addition to our trained clinicians, PIH/ZL also relies on matrons, traditional birth attendants, to help women deliver babies at home. Matrons are men and women with no prior formal training who have nonetheless been identified by their community as capable of helping in the delivery of babies. PIH/ZL has long recognized the invaluable services provided by these experienced and accessible matrons, and offers trainings and monthly review sessions to train the matrons to identify complicated or high-risk pregnancies that need to be referred to a clinic or hospital. PIH/ZL also supplies matrons with birthing kits containing gloves, gauze, vitamin A, soap, a scrubbing brush, a razor blade, a plastic drape, and string to clamp the umbilical cord to help protect the matrons, mothers, and newborns from infection. The partnership between PIH/ZL clinicians and matrons ensures that pregnant women receive the safest and most efficient obstetrical care possible in rural Haiti, inside and outside the clinic.
Gynecological problems in Haiti range from straightforward urinary tract infections and perimenopausal symptoms to life-threatening breast masses and sexually transmitted infections. Aggressive screening and treatment of STIs is one of our top priorities. A recent study performed by our Boston and Haiti-based staff found that the rate of STIs in the Central Plateau is alarmingly high, with nearly 20 percent of new patients presenting to Zanmi Lasante’s women health clinics with at least one STI (Smith Fawzi et al., 2004). When certain STIs go untreated, not only is the rate of transmission of HIV elevated up to tenfold, but women are also at greater risk for impaired fertility and other potentially fatal consequences. Additionally, pregnant women with untreated STIs are at risk for preterm delivery, miscarriage, and neonatal complications such as blindness and pneumonia. At Zanmi Lasante clinics, every pregnant, symptomatic, or at risk woman is counseled, tested, and, if necessary, treated using algorithms that reflect the local epidemiology. Every woman is encouraged to have her partner tested and treated as well, so as to avoid re-infection. In the future, we hope to perform another study to evaluate the effectiveness of this aggressive and comprehensive effort to reduce STIs.
In this upcoming year, PIH/ZL is committed to expanding the women’s health program by improving our ability to detect and treat cervical and breast cancer. For many years, palliative care was all we had to offer women who presented with advanced breast cancer. We are now working with a team of radiographers and specialists to bring a mammography machine to Haiti and are also training local staff to perform better clinical breast exams, read mammograms, do biopsies, and provide treatment when needed. Cervical cancer is the most common cancer for women in developing countries, and in recent years many women have presented to our clinics with very advanced, invasive disease. Zanmi Lasante does not currently have the capacity to perform routine Pap smears, but one of our goals for 2005 is to bring Pap smear screening to all of our sites. Countless lives will be saved when we are able to offer comprehensive cervical and breast cancer screening and treatment.
Family planning, one of the most effective ways of reducing maternal mortality, is another essential component of our women’s health program. When women are counseled, educated, and provided with contraceptive options, they are more likely to delay childbearing, have fewer children, and reduce their risk for obstetrical complications. For over 14 years, PIH/ZL has been offering free condoms and other contraceptive methods, and at each of our sites there is a fulltime nurse with specialized training in the provision of sex education and reproductive health counseling. Additionally, for women who decide they do not want to get pregnant again, we offer permanent sterilization through tubal ligation.
Despite a high patient volume at our family planning clinics, there are many women who, unable to make the long journey, are not benefiting from the education, counseling, and care we offer. To address their needs, two years ago Zanmi Lasante piloted a program in Cange to train and mobilize a new category of community health workers who specifically promote family planning and women’s health issues. These ajans fanm travel throughout the countryside, teaching women and men about STIs (including HIV) and contraceptive methods, distributing condoms and oral contraceptives, and referring pregnant women and others to the clinics. The ajans fanm are proving to be an indispensable component of our women’s health efforts, and we hope to expand the program to all of our sites this year.
Preventing Mother-to-Child Transmission of HIV
One of the most pressing problems we face in our women’s health program is the transmission of HIV from pregnant women to their newborns. In rural Haiti, approximately 5 percent of all women attending prenatal clinics are infected with HIV. If these women receive no antiretroviral therapy during pregnancy, their chance of transmitting the virus to their infant at birth is 30 percent.
Zanmi Lasante recognized very early on that averting vertical transmission of HIV must be a top priority in our efforts to curb the epidemic. In 1995, we began providing HIV-positive pregnant women with zidovudine, which resulted in a 10 percent drop in the rate of vertical transmission.
Zanmi Lasante currently offers every pregnant woman seen—about 10,000 a year—HIV counseling and testing. (The number of women who choose not to be tested is almost nil.) Women found to be HIV-positive are counseled and provided with a small monthly stipend to cover basic nutritional needs and monthly travel costs to the clinic. They are also paired with an accompagnateur, a community health worker who will deliver and observe antiretroviral therapy twice daily. Combination therapy—exactly what HIV-positive pregnant women in the United States receive—is extremely effective in preventing vertical transmission of the virus from mother to infant. (In the United States, vertical transmission is now almost nonexistent.)
When women present to clinic too late in their pregnancy for ART alone to be effective, we are able to perform cesarean sections and other surgical interventions in our three fully-equipped operating rooms. Again, this is equivalent to the care HIV-positive pregnant women receive in the United States. After birth, because of the high risk of HIV transmission through breastfeeding, we also urge all HIV-positive mothers to formula feed, and, through the PMTCT program, give them the means to do so safely.
Zanmi Lasante’s capacity to provide comprehensive, high-quality health care has been instrumental in reducing the rate of mother-to-child transmission of HIV to less than two percent in the areas we serve, and we are continuing to improve on these successes through education, screening, and treatment. In November 2004 we piloted an inexpensive PCR test—now used throughout the developed world—that has enabled us to more rapidly diagnose HIV in infants.
Until recently, high costs, sophisticated laboratory requirements, and the need to refrigerate test samples made viral testing prohibitively expensive in resource-poor settings; we were constrained to using antibody testing to determine a baby’s serostatus, a method that is not definitive until an infant is at least 18 months old (the maternal HIV antibody, which passes from mother to child via the placenta, can last in the child’s system for up to 18 months). The new test yields reliable, stable, and noninfectious samples that are easily shipped to Europe for lab processing. Confirming an infant’s serostatus within one to four months of birth allows us to provide more timely treatment and follow-up for the few infants who do contract the virus from their mother. Additionally, it is a profound relief for parents to know the serostatus of their child so much sooner.
The services offered through Zanmi Lasante’s women’s health program are saving countless lives in the Central Plateau. Were it not for PIH/ZL’s expansion to the commune of Boucan Carré, where we revitalized what had been a dilapidated, poorly staffed, and underutilized health clinic, Naromie would have had no place to seek prenatal care, learn her HIV status, and deliver her baby safely. More likely than not, she would have died from AIDS or from obstetrical complications. Thanks to the generous support of PIH’s donors, Naromie’s story continues to unfold.
After learning of her diagnosis, the Zanmi Lasante team—midwife, physician, nurse, and social worker—offered Naromie counseling, provided her with social support, and arranged for further testing. While PIH/ZL provides antiretroviral therapy to all pregnant HIV-positive women as a matter of course, there was concern that, in Naromie’s case, ART alone would not be enough. The extent of her immunosuppression indicated that her HIV infection had progressed to full-blown AIDS, and she was very close to her due date. After much discussion, Naromie was taken to Zanmi Lasante’s main hospital in Cange, where a cesarean section was performed.
Today, Naromie is the mother of a healthy, HIV-negative, 18-month-old boy. Through the PMTCT program, she was given infant formula and taught how to boil water and clean bottles in order to feed him safely. Naromie and her baby return to the health check-ups and family planning counseling. In addition to receiving daily directly observed ART from an accompagnateur, she participates in a social support group for women infected with HIV. Through Zanmi Lasante’s social assistance program, Naromie, in good health, is now employed as a cleaning woman at the Boucan Carré hospital where her life was saved.
This article first appeared in PIH’s Winter 2005 Newsletter.