Free obstetric care in

Haiti

Making pregnancy safer for mothers and newborns

“With the implementation of the SOG project we have seen a total change in women’s behaviour towards the use of services. Women were not coming to the hospital, as they could not afford the fees. Women are now coming from all over the district as far as three to four hours away.”

– Lamarre Anthonese, nurse midwife, Port-Salut referral hospital

What is the SOG project?Targeted at some of Haiti’s poorest and most vulnerable women, the Free Obstetric Care project (Soins Obstétricaux Gratuits, or SOG) offers free assisted childbirth and consultations to those who cannot afford to pay.

Since its launch in 2008, the project – led by Haiti’s Ministry of Public Health and Population and supported by the Canadian International Development Agency (CIDA), the Pan American Health Organization (WHO/PAHO), and the EC/ACP/WHO Partnership1– has already produced remarkable increases both in assisted births and the number of women attending prenatal consultations.

This booklet looks at the impact of the project after its launch in 2008. Following the devastation caused by the January 2010 earthquake, the project will need to rebuild – but its record, documented in these pages, makes a compelling case not just to reestablish but to extend it to the whole country. Indeed, the experience of the SOG project demonstrates how free obstetric care can help to build the future health of women and newborns across Haiti.

“Women who do not have the funds to seek care at a hospital must give birth at home. Without fail, the financial barrier is one of the most important reasons for the high rate of home births.”

– Dr Serge Louissaint, Directeur du Département Sanitaire, Les Cayes

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Why do women need free services?Haiti is the poorest country in the Western hemisphere. More than two thirds of its people live on less than US$ 2 per day, so most women simply cannot afford maternity care. Such poverty lies behind alarming numbers of maternal and newborn deaths that, even before the earthquake, were the highest in the Americas: around 2900 women die every year from causes related to pregnancy and childbirth2 and 62 infants per 1000 live births do not survive their first year of life3 .

Most poor women are forced to give birth at home, assisted by unskilled helpers, as they cannot pay for a safe birth at a health facility. A 2007 study4 showed that 76% of women in Haiti’s South Department would opt for birth at home rather than in a health facility. Lack of money was the most cited reason to explain this unfortunate choice, which brings increased risk of death for the mother and the baby. About 65% of women said they found institutional birth too expensive. Removing the cost therefore seemed an obvious way to increase their use of such services.

How does the project work?Haitian health institutions are paid to offer pregnant women free childbirth and care before and after birth. Fifty institutions across Haiti have been selected to take part in this project based on the quality of their services. Support nationally comes from CIDA and WHO/PAHO, while the EC/ACP/WHO Partnership provides targeted funds for the project’s work in Port-Salut and Aquin that we highlight here.

Key elements of the project include: payment to health facilities for pregnancy, birth and postpartum services; refunds to pregnant women of transport costs; and payment to traditional birth attendants who accompany pregnant women to the health institutions for birth. Facilities are only reimbursed if they send for approval a standardized record of the care given to each woman. As well as providing important verification that the project is achieving its aims, this Perinatal Information System (SIP) – developed by WHO/PAHO/CLAP/SMR5 – is used to monitor performance.

The project is part of wider efforts to reduce maternal and neonatal mortality in Haiti, to increase access to health services, and to improve the capacity of institutions to provide quality care. In Port-Salut and Aquin the EC/ACP/WHO Partnership is also supporting the rehabilitation and equipment of health institutions, training of health providers and the provision of medical supplies and essential drugs.

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“This is my first child and I attended two prenatal consultations at the hospital. I did not have problems during pregnancy but I had complications in childbirth and am happy I delivered at the hospital. At home the baby could have died.”

– Merise Merita, 19 years old, Port-Salut

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Dominican Republic

Hinche

Jacmel

Jeremie

Gonaives

Miragoane

Les Cayes

Cap Haitian

Fort Liberte

Port de Paix

Port-au-Prince

Aquin

Port-Salut

Data Source: United Nations Stabilization Mission in Haiti (MINUSTAH GIS), UNFPA, PAHOMap Production: Public Health Informationand Geographic Information Systems (GIS)World Health Organization

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoeveron the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

© WHO 2010. All rights reservedMap produced: 28 January 2010, 11:00 GMT

0 20 4010 Kilometers–

* It is not known whether data is unavailable or if noprimary health facilities exist for these communes.

" Capital city# Major town or city2008 estimated population coverage (total)

Less than 15 00015 000 - 30 00030 000 - 45 00045 000 - 60 000More than 60 000None/ not known*

Haiti Communes: Average population covered, per primary health facility

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The UCSSituated in the South Department of Haiti, the Unités Communales de Santé (UCS) of Port-Salut and Aquin are public health institutions bringing together health-care providers, local authorities and community groups. They serve populations of 85 000 (Port-Salut) and 120 000 (Aquin) people who live scattered throughout the local mountainous region. Each UCS includes several health facilities such as dispensaries and health centres, spread across its area, and each is linked to a referral hospital (Hôpital Communautaire de Référence).

Women with birth complications can get emergency care at the referral hospitals of Port-Salut and Aquin. However as the operating theatres in these hospitals are only open part time, the Departmental Hospital in the regional centre, Les Cayes, takes referrals when necessary.

How is the community involved?In Port-Salut and Aquin, people from the community have been recruited to support women through pregnancy, childbirth and after. They offer answers to questions such as: How can I prepare for childbirth? Why should I give birth in a hospital? Who takes care of my other children when I am in hospital? When and how should I go to the hospital?

These community health agents also serve on committees – “maternal mortality surveillance committees” – that connect communities to health institutions. The committees can tell the hospital about births that could be complicated, pass on women’s views about the quality of care and follow up on supply shortages. Thus they can speed up response to emergencies and reduce delays in transferring pregnant women to clinics.

Such community participation – widely seen as vital to improving maternal and newborn health – has been promoted by the project in Port-Salut and Aquin, via the local health units (Unités Communales de Santés or UCS), that coordinate health services in each area (see box below).

An important part of the project has been the advocacy campaign to promote it. WHO/PAHO and its partners have worked hard to raise national political support for a policy of free childbirth care. They have also sought to increase the use of services by promoting the benefits of hospital birth and boosting public awareness of free services in some hospitals.

“We have used every possible means of communication to spread the message as far as possible to also reach the people who live in the most remote areas of the districts. So far the rate of institutional births remains very low compared to the rate of home births. But nevertheless we have made a big step forward towards an increased number of births in health facilities.”

– Dr Joseph Yves Domercant, UCS Director, Port-Salut

“I live three hours away from the referral hospital of Port-Salut by motorbike taxi. I gave birth to my first two children at home and had never used the services before. I came to the hospital for a prenatal consultation after hearing about the free services for pregnant women on the radio. Money has always been a problem for me and coming to the hospital had meant spending a lot for the services, transport, medicines etc…”

– Paula Ferdinand, 26 years old, 8 months pregnant

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What has the project achieved?The success of SOG in Port-Salut and Aquin is clearly shown in the sharp rise in the number of women using maternal and neonatal health services. An initial evaluation of the project6 nationally reveals that:

Progress on maternal mortality appears encouraging. Early figures suggest a ratio of 135 per 100 000 in project areas after SOG implementation versus 630 per 100 000 nationally.

Since the introduction of the SOG in Port-Salut, a six fold increase of antenatal care visits was observed. In Aquin, three times more antenatal care consultations were carried out.

Institutional childbirth in more than half of the participating institutions increased by 62% compared with the previous year.

30% of the women that gave birth in SOG institutions had had their previous birth at home.

Progress on response to emergencies also appears encouraging – measured by a caesarean section rate of 9% compared with 3% nationally.

83% of women using the services said they were satisfied with the assistance they received.

The SOG project has encouraged women of different ages and socio-economic backgrounds to seek institutional care for the first time regardless of the number of previous pregnancies. Most say the main reason they have opted for institutional care this time is because it is now free. They also acknowledge the higher quality of care they and their newborns receive at the hospital.

The Perinatal Information System (SIP) gives a much more accurate picture of the situation in Port-Salut and Aquin than the periodic surveys done previously. Its success has prompted national health authorities to approve implementation of the system for all Haiti’s public maternity services.

“Some women are used to giving birth helped by untrained matrons. This is mainly a problem of education. With the committee we will have to show the women why it is much better to give birth at a hospital than at home.”

– Alabre Odesse (right), community health agent, Maternal Mortality Surveillance Committee, Port-Salut

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What are the next steps?The project’s success suggests that funds to strengthen Haiti’s health services should be redirected and extra funds should be made available for free obsteric care. The surge in women using services in the project areas shows how much progress can be made simply by removing fees. Many more women can be reached as other formidable obstacles to accessing healthcare such as poor roads, infrastructure and lack of transport are addressed.

The project underlines how community involvement – backed by investment in improved facilities and trained staff – can ensure that free obstetric care in Haiti reaches the poorest and most vulnerable women. As well as supporting women, community members can communicate with health institutions and shape the development of better and more responsive services.

Spreading the benefits of the project across Haiti, to its most remote parts, demands a national policy of free obstetric care. Its record also backs the case for a national scheme of social protection in health and future programmes to develop enough skilled staff and suitable facilities.

Of course the immediate priority for Haiti is to restore basic health services including obstetric care. WHO/PAHO’s appeal launched in February 2010 aims to raise US$ 21 million both to do this and to strengthen responses to life-threatening emergencies. Reactivating and expanding the SOG project – with more drugs, equipment, services, facilities and mobile clinics to reach displaced women – will be an essential part of these efforts.

After the earthquake, Haitian women and newborns need the project more than ever – and its achievements above show just how much they will be helped with properly targeted, free services. But as important as the statistics are the voices of the women and of the health workers on the ground featured in this report – voices that speak of the project’s success and the way free obstetric care can save and change lives. As Haiti recovers after the earthquake, providing free obstetric care will be one of the cornerstones for rebuilding women’s health.

“Where we have succeeded, in my opinion, is to put forward the idea that in a country where 70% of the population lives under the poverty line, it is not possible to talk about health and especially maternal health, without talking about free services.”

– Dr Carlos Gril, WHO/PAHO Adviser in Reproductive Health, Haiti

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AcknowledgementsThe creation of this booklet was made possible through funding under the EC/ACP/WHO Partnership, and the full support and assistance from WHO/PAHO Haiti throughout the field research.

Photos and initial text were provided by Monika Piskorek and Stéphane Grandvaux who travelled across Haiti and interviewed women and health staff are involved in the project or who used the free services.

Amit Srivastava has finalized the text of this booklet and the graphic design has been done by Duke Gyamerah.

Special thanks go to all the personnel at the referral hospitals of Port-Salut and Aquin, the members of the maternal mortality surveillance committees and the women interviewed for their time and participation.

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“It is good to see so many women coming to the hospital. The hospital added an extra day for prenatal consultation to allow us to see all the women. Since the beginning of the SOG project the number of consultations almost quadrupled.”

Dr Labady Ledon, Aquin referral hospital

1 European Community/African, Caribbean and Pacific Group of States/World Health Organization Partnership – a tripartite agreement signed between the three partners and national ministries of eight countries, including Haiti, to support accelerated actions for reaching Millennium Development Goal 5.

2 Plan Stratégique National pour la Réforme du Secteur de la Santé 2005-2010.

3 Ministère de la Santé Publique et de la Population, République d’Haïti, Port-au-Prince, 2005.

4 Enquête Mortalité, Morbidité et Utilisation des Services, EMMUS IV, Ministère de la Santé Publique et de la Population, République d’Haïti, Port-au-Prince, 2006.

5 Divers J, Joseph JR, Napoléon W. Etude sur les déterminants du choix des femmes habitant le Département du Sud sur la motivation à accoucher chez elles ou dans les institutions de santé. OPS/OMS, Haïti, 2007.

6 The data are up to November/December 2009 as the monitoring has been interrupted by the earthquake in January 2010.

References

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