Traditional Midwives, Tetanus Immunization, and Infant Mortality in Rural Haiti

1. Traditional Midwives, Tetanus Immunization, and Infant Mortality in Rural Haiti Krista Pfaendler GHIG Journal Club December 6, 2004 Berggren et al. Tropical Doctor, 1983. Vol 13, 79-87.

2. Parturition Around the World in 1978 • 2/3 of the world’s babies are born at home, attended by a traditional birth attendant (TBA) • Home birth environment is often characterized by prevalence of infections and poor sanitation • In rural Haiti, TBAs known as matrones perform 80% of deliveries • Maternal mortality rates are high (367 deaths/100,000 live births)

3. Background on Haiti • Occupies western 1/3 of Hispaniola • 5 million people • 11,000 square miles • Haitians take pride in the fact that they defeated French forces in 1804, becoming the first Negro republic in the world

4. Haiti and the Artibonite Valley • The Artibonite Valley is the region served by Hôpital Albert Schweitzer, located in Deschapelles

5. Home Birth in the Artibonite Valley • Thatch-covered homes with packed earth floors, mud walls, little furniture • Mat on the floor serves as a bed • Most deliveries occur on the mat, with the mother in a squatting or semi-seated position and husband or relative supporting • TBA or a trusted grandmother will be called in when labor becomes intense

6. Midwives/TBAs • Believe in letting nature take its course • May administer teas and potions to ease pain • Rarely perform vaginal or rectal exams • Often very perceptive about early signs of obstructed labor • Willing to help transport patient to modern facility if delivery will be difficult • Under-utilization of maternity beds • Of estimated 3600 deliveries per year in Artibonite Valley, less than 10% took place in maternity unit that has the capacity to conduct at least 20% of deliveries

7. Delivery • Marshal F.N. Advances in Pediatrics (1968): • At delivery, “the baby usually falls on dirt, whether in a house or outside, and later lies on a straw mat beside the mother. It is likely that the soil and climate conditions, and modes of human and animal living in Haiti foster the accumulation and widespread distribution of tetanus bacilli.” • Difficult to get a basin of clean water and enough fuel to bring it to a boil before the delivery

8. Umbilical Cord Care • Cut with an old or new razor blade, a knife, a sharp piece of glass, or scissors • Tied with rags, thread, old string, or grass • Powdered or crushed charcoal, burned strands of the straw bed mat, nutmeg, or candle grease may be applied to the stump before a patch of cloth is applied as a dressing

9. Neonatal Tetanus • Neonatal tetanus derived from umbilical cord contamination affected 10-20% of Haitian newborns in rural areas lacking health programs • Tetanus spores contaminate umbilical cord at the time it is cut or dressed after delivery • Symptoms usually appear the third day • Baby stops nursing, becomes progressively more rigid, develops an arching of the whole body and experiences painful convulsions • Fatality rate of 70-100%

10. Postpartum Traditions • Placenta is traditionally buried beneath the doorway at the site of a birth • Voodoun ceremonies sometimes accompany the celebration of a birth • Smoke from a fire must ascend in front of the closed doorway behind which the mother and baby must stay in the dark for at least one week

11. Traditional Beliefs Affecting Neonatal Health • Colostrom must be discarded • Yellow color looked upon with great suspicion • Milk is not considered good for the baby until it is white • Mother must eat only white foods • Large doses of castor oil might be given to newborns to “clean out” the “unhealthy” meconium stools

12. TBA Advice to Mothers • TBAs must not enter the yard where the mother cooks while she is pregnant • Advice given in offhand manner in marketplace or while washing clothing • TBAs fear being blamed if the baby is malformed or if the delivery goes badly • TBA gives advice for week(s) after delivery and is the most important educator during the immediate postnatal period • Receive a $1-2 for their services

13. Jacmel Region TBAs • 70% more than 49 years old • 50% had practiced for 10-19 years • Nearly 50% conceived the idea of becoming a TBA in a dream or from a spiritual experience • Nearly 1/3 report having learned the profession from one or more family members who passed on the tradition

14. Jacmel TBAs • Most perform about one delivery per month • Illnesses treated in newborns: gastrointestinal problems (44%), respiratory problems (36%), and tetanus (35%) • 87% thought that a doctor could do better with difficult deliveries • Majority thought it would be a good idea for a doctor to come to their village and discuss their role

15. Service Coopératif Inter-Américain de la Santé Publique (SCISP) • Designed program for training in 1948 • Each midwife equipped with a metal box containing enema equipment, plastic or rubber apron, basins, tongs, cotton dressings, soap, nail brush, scissors, and umbilical cord tie • Trained in use of cleaned and boiled equipment

16. HAS Retrospective Study of Neonatal Tetanus Deaths in Rural Haiti

17. Hôpital Albert Schweitzer • Found tetanus to be the first cause of infant deaths in 1967 • Did not have a maternity unit at the time, but continued some features of SCISP program once the program lost funding • Undertook mass immunization program and revision of the program for TBAs after a retrospective evaluation

18. Review of Program for TBAs • Scissors from midwife kits were collected and replaced with sterile cord-cut packets • 1 razor blade lightly oiled with mineral oil and tightly wrapped in aluminum foil; 2 umbilical cord ties; 1 gauze dressing for the umbilical cord; 2 large safety pins and a belly band • Boiling water is a luxury; boiling for >20 minutes rarely achieved • Providing packets free of charged proved less expensive than coping with complications due to unsterile cord-cutting techniques • By 1968, program only reached 36 midwives on a regular basis (<1/3 of the midwives in the Artibonite Valley)

19. Modification of TBA Training • Record established on each TBA including attendance to establish who needed equipment or further education • “Tetanus Baby” movie made locally in the Creole language by the HAS staff, using a local TBA to play the leading role • Depicts preparation for rural home delivery, role of TBA, and importance of follow up • Shown in clinics and at monthly TBA meetings • Ticket system devised to evaluate number of deliveries accomplished • Battery-run transistor radio offered to each TBA whose tickets showed that she had referred 50 newborns into the hospital for BCG vaccinations

20. Results of HAS Program • Rapid decline in neonatal tetanus admissions during the first period after 1968 • Increased demand for care of umbilical cord stump at HAS • More than 3000 cord cuts annually • Documentation of the annual number of deliveries per midwife • 3300 annual deliveries in the Artibonite Valley by more than 200 midwives, each attending about a dozen per year • Voluntary increase in number of TBAs trained • 36 midwives trained in 1967; 175 in 1970

21. Neonatal Tetanus Deaths in Rural Haiti

22. Implications of HAS Program • Intensive education did not result in more utilization of trained midwives but in referring more midwives for training • Increased demand for cord cut services at outpatient clinic rather than increased use of nearby maternity unit • Midwives cooperated actively in the immunization campaign in marketplaces • Most important outcome: elimination of neonatal tetanus through immunizing all women

23. 1990 HAS District Census • District Population: 180,000 • Women of childbearing age: 45,000 • Pregnancies: 6,000 • 120 TBAs reported attending 3,000 births • Pan-American Health Organization estimated maternal mortality: 340/100,000 • (Remember that it was 367/100,000 in 1978)

24. HAS Reproductive Statistics 1994 • 5000 prenatal visits logged about 30% of pregnant women received prenatal care • Minimum of 3 visits suggested with most receiving no more than 2 • 3-4 tubal ligations per month • 1-2 vasectomies per year

25. HAS Labor Statistics 1994 • Prior to maternity ward establishment: • 8 maternal deaths in hospital • 82 pregnancies with abortive outcomes • 53 eclampsia and obstructive labor • 1.4% C-sections • Maternity service established at HAS in 1995

26. Hôpital Albert Schweizer 2003 • District Population: 258,249 • Women of childbearing age: 62,238 • 831 women admitted in 2003 • 71-107 women admitted monthly • 773 deliveries • 393 vaginal, 380 C-section • 4995 OB/GYN visits to outpatient clinics

27. Maternal Morbidity and Mortality 2003 • Maternal morbidity: • Mother with single liveborn (393), pregnant state incidental/abdominal delivery (339), threatened labor (183), severe pre-eclampsia (72), C-section (41), mild or unspecified pre-eclampsia (27), unspecified essential hypertension (23), anemia unspecified (22), early onset of delivery (21), convulsions (20) • Maternal mortality: • 7 maternal deaths (0-3/month)

28. Neonatal Morbidity and Mortality 2003 • Neonatal morbidity: • 87 infections specific to perinatal period • 40 disorders relating to preterm infants • 24 unspecified severity of birth asphyxia in liveborn infants • Neonatal mortality: • 31 neonatal deaths (0-6/month)

29. HAS Maternal Care 2003 • Helped increase to 31% the use of modern contraceptive methods by women of reproductive age • Provides at least 3 prenatal visits to 60% of the pregnant women in the district • Started using Nevirapine to reduce risk of mother-to-child transmission of HIV

30. Tetanus Today • Responsible for 14% (215,000) of neonatal deaths globally (WHO, 1998) • Maternal tetanus is responsible for more than 5% of maternal deaths (Fauveau, 1993) • Estimated 90,000 women die annually from puerperal infections caused by unclean delivery practices (WHO, 2000) • UNICEF, WHO, UNFPA Goal: Elimination of maternal and neonatal tetanus by 2005 • Still not eradicated from 57 countries, including Haiti