A skilled midwife working in rural Haiti, Esthère Louis knows all too well the dangers mothers can face when giving birth. It seems to be a fact of life that nearly everyone in the island nation knows a woman who has died or lost a baby during childbirth. "As a midwife, you are there so that you can help patients in need," Louis said. "You’re there to save them."
Haiti’s maternal death rates are by far the highest in the Western Hemisphere. A woman in Haiti has a one in 90 lifetime risk of dying during childbirth, 16 times higher than a woman’s risk in the United States. Infant mortality is also extremely high compared to other nations. Out of every 1,000 children born in Haiti, 59 will die before their first birthday. In the United States, that number is just five.
It's for this reason that Haitian women and their families often view birth with conflicting emotions: joy at the prospect of new life and fear that the worst may happen.
But it doesn’t have to be this way. Maternal and infant deaths are largely preventable, according to the World Health Organization. Research has proven that skilled care before, during, and after childbirth can save the lives of women and newborn babies, yet not enough Haitian women are able to access this critical care when they need it.
That's where Louis comes in. She is one of 95 skilled birth attendants who have graduated from a yearlong training program called Midwives for Haiti (MFH). In the classroom and through hands-on practice, women like Louis learn to become skilled birth attendants in line with the WHO’s global standards.
In addition to traditional labor and delivery support, trained midwives screen pregnancies for risks, treat infections that could complicate labor or affect the baby’s health, and teach about nutrition and warning signs of pre-eclampsia — a treatable condition that is the major killer of expectant mothers in Haiti. The services these midwives provide seem basic but can be life-saving.
And so far, it's working: MFH graduates now care for tens of thousands of women each year in five hospitals and 13 birthing centers across Haiti. The nonprofit even opened its own birthing center in a rural region of the country last November.
MFH communications director Summer Aronson said training midwives has a ripple effect on the communities in which they live.
"Investing in mothers and skilled birth attendants pays off," Aronson said. "These programs not only save lives, they transform them."
And compassionate, high-quality care from dedicated professionals like Louis will help more women in Haiti enter motherhood with joy instead of fear. Ahead, inspiring photos show how Haiti's midwives are empowering mothers and transforming their communities.
Caption were provided by Midwives for Haiti. In this photo, skilled birth attendant Juslene Regulus holds a newborn during her rounds in the hospital ward.
The seeds of Midwives for Haiti were planted 13 years ago by American nurse and midwife Nadene Brunk. Visiting Haiti as part of a medical team, she said she was struck by the lack of resources and care available to pregnant women. She was also determined to keep coming back.
Brunk started out by recruiting a group of medical volunteers back home who would travel to Haiti to provide midwifery services and training on a rotating basis. As the group of volunteers became more of a fixture in the local community of Hinche, a city on Haiti’s central plateau, word spread about the classes they were teaching.
Initially, volunteers started with little more than a blackboard under a tree, but the fledgling teaching program soon evolved into a more formalized curriculum. The MFH education model is also based on an understanding of local culture, language, and practices.
Four Haitian teachers are supported by visiting medical volunteers, mostly from the U.S.; some MFH graduates, like Louis, also stay on to pass their skills on to new students.
Caption: A pregnant mother is carried into the hospital by several men while another young mother waits for postpartum counseling before being discharged. The seriously ill woman had been driven by car over an hour because she had experienced sharp headaches and seizures — signs of eclampsia, a potentially fatal disease of pregnancy and the number one killer of pregnant women in Haiti. Fortunately, medications suppressed her seizures, and labor was induced. She was able to give birth to a healthy daughter and recover.
The Midwives for Haiti model is part of a larger global movement toward task shifting, the practice of training local people to take on skilled caregiving responsibilities in areas where there is a lack of access to healthcare. For example, community health workers without a medical degree might be taught to provide basic healthcare services in rural areas where there are no doctors.
According to Lyn Middleton, PhD, a regional nursing advisor at Columbia University’s International Center for AIDS Care and Treatment Programs, task shifting is effective, but success still hinges on proper training and oversight.
"There is increasing research to show that task shifting is a viable option for improving access to primary healthcare services," Dr. Middleton said, "[but] those being trained to provide these services [must be] well trained and supervised over time."
Caption:Haitian women need and want skilled medical care. They also gain strength from their faith and seek spiritual care, according to Midwives for Haiti.
Haiti is currently meeting only 10% of its need for skilled birth attendants. And an optimistic scenario predicts only 37% of the need will be met by 2030. That's why Brunk said she is motivated by the urgent need to train more women quickly.
"We have to come up with creative ways to educate more [midwives] faster and to equip them to live and work near the women who need them most," she said. "Until then, mothers will continue to die unnecessary deaths."
Even with the limitations it faces as a small nonprofit working on an enormous problem, MFH is determined to increase its reach within Haiti and make the greatest impact possible.
Caption: Two pregnant women wait for turns with the local skilled birth attendant. Many women give birth at home with localmatròns (traditional birth attendants) because of the difficulties in transportation and costs of going to the hospital.
Midwives for Haiti's founder said she is passionate about ensuring the midwives are able to apply their training in practice.
"Educating midwives is not enough," Brunk said. "We also need to deploy them where women live and work and in places of referral that would otherwise not have enough skilled staff."
Of the current class of 30 students, eight have jobs waiting for them when they graduate, mostly with other healthcare nonprofits working in underserved areas.
According to Aronson, "Helping students find jobs upon graduation is often the hardest part…but we work very hard to create partnerships and network with the [Haiti Ministry of Public Health] and other NGOs throughout the country.”
The salary for a skilled birth attendant in Haiti is about $4,100 per year.
Caption: Yvanese, a Midwives for Haiti student, completes paperwork while two mothers spend time with their newborns. Midwives for Haiti students and graduates have earned a good reputation for the compassionate, skilled care they provide; they manage more than 200 births a month at this hospital.
It is estimated that there are only 400 obstetricians working in Haiti, which has a population of over 10 million people. That’s approximately one obstetrician for every 12,500 women. The shortage of highly skilled physicians is partially due to a phenomenon known as "brain drain," where ambitious, skilled professionals leave their home countries for more money and better opportunities abroad.
"Brain drain" is certainly not unique to Haiti. However, Haiti has faced exceptionally difficult circumstances, including natural disasters like the catastrophic 2010 earthquake that destroyed much of the country's infrastructure and hit the already small healthcare workforce hard.
Yet despite the difficult circumstances in which they work and the promise of a higher salary abroad, once midwives graduate from MFH’s program, they stay. All but two graduates are still in Haiti, and 92% are employed as midwives in high-need communities across the country.
Caption: A skilled birth attendant offers the mother the chance to hear her baby’s heartbeat during a prenatal exam in a rural clinic setting.
As part of the country's progress toward achieving the U.N.'s Millennium Development Goals, Haiti has cut its maternal mortality rate in half since 1990, and infant mortality is falling by about 3% per year, according to UNICEF reports.
However, Haiti still has the highest birthrate in the Western Hemisphere, and much work remains to be done to strengthen the healthcare workforce.
The newly announced Sustainable Development Goals present a new challenge for the next 15 years. And while continued investment from international organizations like the U.N. is important, it's grassroots efforts that are really needed to create lasting change.
Caption: Two young friends begin their long walk home after receiving prenatal care at the newly opened Carrie Wortham Birth Center in Cabestor, a remote community. The birth center closes a critical gap in care for the mothers and families of Cabestor by providing 24/7 access to skilled birth attendants and a safe, clean space for prenatal, delivery, and postnatal care.
In Haiti, most women deliver their babies at home — the Journal of Midwifery & Women’s Health reported that just 36% of mothers gave birth at healthcare facilities in 2012. The main barriers are distance and cost, as well as the availability of trained professionals. Even if women live close to a hospital, some are unlikely to go if they do not feel safe there, or as if they will be treated well. Giving birth in a facility under the care of a skilled birth attendant — such as a doctor, nurse or midwife — gives women and their infants better chances of survival, since the birth attendant is able to recognize complications and provide basic emergency and neonatal care.
However, it is unlikely that all women will be able to deliver their babies at a clinic or hospital, and this is where midwives can be especially helpful, by expanding access to care by reaching women in rural areas.
MFH runs a mobile prenatal clinic that takes services directly to rural women. The Mobile Prenatal Clinic program cares for more than 500 women per month in 20 villages. It also provides emergency transport, which helped 25 rural mothers give birth safely in 2014.
Caption: Two matròns role-play assisting childbirth. Matròns attend an estimated 75% of deliveries in Haiti, most of which are outside of medical facilities. For mothers living in rural areas without access to medical facilities, matròns are crucial.
Upon completion of the Midwives for Haiti course, graduates receive a certificate of advanced training from the Haitian Ministry of Health that makes them eligible to work at any facility in the country as a skilled birth attendant.
Women who give birth at home are often aided by matròns, lay birth attendants whose childbirth practices are traditionally passed down through generations. They are highly trusted in their communities and are driven by the same sense of love and responsibility to women as other midwives, but do not generally have formal medical education. It is estimated that 75% of births in Haiti are attended by matròns.
Brunk explained that many of these matròns wanted to take Midwives for Haiti's course. So in 2012, MFH began providing training for them; this program now has more than 120 graduates and has trained 50 matròn trainers to keep the cycle going.
Caption:A crowd of Haitian nurses packs the entrance to the area where Midwives for Haiti will interview prospective students. One important question was, "Why do you want to be a midwife?" In Haiti, one hears profoundly different answers to this essential question: "Too many women die in childbirth.""Babies die.""I want to help the suffering.""I want to save lives."
Despite the challenges, Midwives for Haiti is defined by optimism. Its mission is specific to Haiti, but the vision of safe motherhood for all is inherently universal.
"Women are women everywhere," Brunk said. And women everywhere can identify with the need for safe pregnancy and childbirth for mothers and babies regardless of where they’re from, she added.
As for Louis, she is determined to continue to provide compassionate service, culturally sensitive care, and high-quality education for her fellow midwives in Haiti.
She hopes that the MFH midwife-training program will continue to grow and "have the capacity to take on more students," she said, "because the school is very important — it means that many women who would have died will not die."
Learn more about Midwives for Haiti here.
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