by Eva Lathrop, MD, MPH

Originally Published: © 2010 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins.

When I arrived in Haiti 10 days after the earth- quake, dear friends recounted this past Christ- mas, 2009, as being the first in their lifetimes that Haiti actually felt calm and promising. They told the story wistfully and with a tinge of regret, as if feeling foolish for thinking that Haiti was coming in to good times.

The glimpse of this had allowed them to hope and hope big. Two weeks later, everything changed and changed for everyone. Haiti is widely known to be the poorest country in the western hemisphere and the only least-developed nation in the region.1 How- ever, Haiti has recently achieved a measure of polit- ical stability that brought with it improved security, a tiny increase in employment, a more reliable food supply chain, and a tentative but positive interest on the part of the global development community. The earthquake struck January 12, 2010, and has threatened to rewind decades of all of Haiti’s progress. There is not a corner of coastline or a valley amid the mountain ranges that is untouched by this. The damage at the epicenter is visibly jarring and measured by buildings toppled and bodies heaped. The damage to the rest of the country is insidious and initially invisible, but the fabric of the country is frayed and threatens to unravel completely. The global response to rescue and recovery has been swift, and if it endures with depth and sustainability, and if the most vulnerable populations, women and girls, are kept at the center of the rebuilding effort, then Haiti has the chance to emerge stronger and safer.

I have worked as a health volunteer with Konbit Sante: Cap-Haitien Health Partnership in the north- ern part of Haiti for several years, and, in the days after the earthquake, I returned to the city of Cap- Haitien, where our project is based and our colleagues have become family over the past 9 years. As we passed the 2-week mark after the earthquake, it became evident it was the right thing to do to travel to Haiti in response to the disaster and to go to the north, away from the epicenter, to a place where we, as trusted partners of the public health system, could be immediately effective in response to the collateral damage the earthquake caused to the community and the displaced victims seeking refuge.

The immediate needs of food, water, shelter, and management of severe injuries initially took prece- dent over other health care–related issues. While these critical steps must be prioritized to protect survivors in the first days after an emergency, wom- en’s health is often marginalized in their wake, and placing reproductive health high on the list of prior- ities also felt urgent. In calmer times, Haiti’s maternal health statistics are dismal; the maternal mortality ratio is estimated at 670 maternal deaths for every 100,000 live births,2 70% of deliveries are at home without skilled attendants, 18% of sexually active women of reproductive age use a modern method of contraception, with an estimated unmet need for family planning at 60%.3 Haiti has faced a series of natural disasters in recent history, but none as grave as this, none as costly as this, and none that has threatened to displace reproductive health to a low priority position as much as this one.

Obstetrical emergencies, gender-based violence, unintended pregnancies, and human immunodefi- ciency virus transmission all increase in complex emergency settings,4 and assessing the displaced pop- ulation for their experiences with and potential risk for these complications quickly became integrated into our larger assessment strategy. Unattended deliv- eries have reportedly increased. Access to emergency obstetrical care has become even more challenging for women displaced to a region largely unknown to them. The tenuous family planning supply chain has been broken and an increase in unintended pregnan- cies will likely surface.

OBSTETRICS & GYNECOLOGY

I was grateful for the opportunity to speak with women who traveled north seeking safety and was stunned by their openness and willingness to share private and intimate details of their experiences. I will never claim to understand what they have been through or understand the magnitude of the impact this disaster has had, but the individuals, the names, clothes, voices, and faces transformed this from a series of numbing numbers impossible to grasp to a tangible, unique tragedy for each person I spoke to. Remarkably, most of the women I worked with were eager to tell me what they had been through—as if the telling of the story puts it officially on the record of time, as if by voicing their experience, it will count and publicly be remembered. But all of the voices were flat, and all of the faces were drawn. Everyone was exhausted, hungry, thirsty, and afraid, and they answered, “Koman ou ye? (How are you?), with a shaky, “M’vivant” (I am alive). Before the earth- quake, when I asked about someone, an assessment of one’s wellness was, “Li manje” (She eats). Now it is “she is alive.” Everybody had their own story of tragic loss, escape, survivor guilt, and sheer, raw grief. The sadness was palpable, and the losses were unimaginable.

So many of the women I spoke with found it difficult to have any hope for the future. The young women and girls who were seeking a coveted education in Port au Prince, the one that was going to give them the opportunity to rise out of poverty, know that the chance is lost. They have nothing and own nothing but what they had the moment the earth- quake struck: no money, no documents, and no photos. They are moving to rural towns with distant relatives who likely are already stretched beyond what they can bear. Households that had eight people and enough food for five now may have 15 people and no additional support with the arrival of earth- quake victims. It is only a matter of time before they are at risk for trafficking or becoming Restaveks, the Creole phrase for indentured servants. The school girls were still in the uniforms they were wearing January 12, 2010; the same uniforms that once were crisp and clean and worn with matching ribbons decorating their braids. They were the symbol of Haiti’s future and are now dirty and torn. Their ribbons are gone. Some people have lost everyone they know. The stories I heard are few, and to know that there are millions more is impossible to grasp.

There is no one in Haiti who has escaped impact from the earthquake. While the displaced seek refuge through a largely unorganized migration, the host community absorbs the growing population and individuals bear the pressure of supporting larger house- holds. Our assessment of earthquake impact in the poorest neighborhoods in the area demonstrated that most families are absorbing displaced people, all are struggling with the increase in the cost of food, and the sudden interruption of financial support some were receiving from family in the capital. Community access to health services has become an increasing challenge because health centers are more under- staffed and undersupplied than usual and families have even less money to pay the meager fees. People know that the little support they received as a com- munity before the earthquake, such as food aid, vaccine campaigns, and family planning supplies, will all be shifted to the relief efforts in the south. Perhaps assessing the community for these potentially harmful losses will allow program support to continue in the immediate aftermath of the earthquake and avoid adding to the already staggering number of victims, but no one I spoke to felt assistance would come soon. Despite this, they still managed to smile, share small moments of hope, and find strength to persevere. It was remarkable and humbling. It was a privilege to be among them.

Usually I bring my baby with me to Haiti, but this time I left her home. Her gift to Haiti was donated breast milk used to feed tiny orphans, and her small contribution made me feel better about being apart from her. I struggled with missing her, with the guilt of leaving her, and the guilt of having her still. I spoke with several women who lost a child or lost all of their children and I wondered whether I had the right to miss her. How could I miss her when “li vivant, li manje, li secure” (she is alive, she eats, she is safe)? It was staggering to me that these women could survive after such profound losses. After hearing their stories, I stopped thinking about my daughter and began to feel nothing when I looked at her picture. It fright- ened me how disconnected I had become.

As Haiti begins the long recovery after the earth- quake, it has the opportunity to place reproductive health in the center of the rebuilding framework and the chance to lift itself out of the quagmire of devas- tating maternal health statistics. Now is the time to improve access to quality care in the face of obstetrical emergencies through the development of referral systems between communities, health centers, and tertiary facilities, and to strengthen local capacity to provide services. Now is the time to integrate miso- prostol into the strategy for postpartum hemorrhage prevention and management by dissemination of education and medication to health facilities and women in communities where the majority of deliveries remain unattended. Now is the time to promote high-quality care services after abortions and to im- prove social marketing strategies to increase access to contraception.5 Now is the time.

The global community has and will continue to provide massive support to Haiti. Specialists in repro- ductive health can contribute by partnering with organizations that have long-term commitments to Haiti, a stake in Haiti’s recovery, and a willingness to collaborate with the Ministry of Health in building a public system that can assure quality services.6 Those who have the requisite skill set of technical expertise, appropriate language ability, an understanding of Haiti’s cultural and political context, and a strong conviction that Haiti can emerge better from this will be invaluable assets to the rebuilding efforts. But it is by tapping into the capacity of Haitians themselves to lead and build that sustainable change will be possi- ble. Witnessing the generosity of Haitians toward Haitians has been the most compelling thread in the story; the beautiful young volunteer spoon-feeding a displaced girl who was nearly catatonic with shock and grief, cradling her head, and rubbing her cheek slowly, encouraging her to eat. She stayed with her and provided her the only comfort she had in weeks. As the country focuses on rebuilding from the ground
up, placing the improvement of women’s health and status at the center of that effort is paramount. It is a great piece of unfinished business and as the country tries to recover, we must pay special attention to women and girls. It is this that will allow Haiti to recover over time.

REFERENCES
1. United Nations Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries, and the Small Island Developing States. Available at: http:// www.unohrlls.org/en/ldc/related/62. Retrieved February 10, 2010.
2. United Nations Children’s Fund. Haiti at a glance. Available at: http://www.unicef.org/infobycountry/haiti_statistics.html. Retrieved February 10, 2010.
3. Ministere de la Sante Publique et de la Population and Macro International. Haiti demographic and health survey 2005, preliminary report. Available at: http://www.measuredhs.com. Retrieved February 10, 2010.
4. Medecins Sans Frontieres. Refugee health: an approach to emergency situations. Oxford (UK): Macmillan Publishers Ltd., 1997.
5. Ministry of Health Uganda, Family Health International. Inte- grating community-based distribution of DMPA into existing health systems. Brief 4. January 2007. Available at: http://www.fhi.org/en/RH/Pubs/servicedelivery/cbd_dmpa/brief4.htm. Retrieved March 20, 2010.
6. Kidder Tracy. Recovering from disaster—partners in health and the Haitian earthquake. N Engl J Med 2010;362:769.