Helping Haitian women give birth at home

This article about why Haitian women prefer to give birth at home despite high mortality rates was based on a study at University Hospital of Mirebalais. The medical staff at Hispañola Health Partners (HHP) made similar observations in the remote Southeast Department and now supports home births assisted by local matwòn (traditional birth attendants) with field visits by a registered nurse/midwife to assure the health of mother and child. The original article by Claudy Junior Pierre can be read in French at https://bit.ly/3jK9XOZ.

A 21- year-old woman rests in bed with newborn child after giving birth attended by her local matwòn in her mountain home outside rural Marge-Joffrey in the Haitian Sud Est region. Hispanola Health Partners has partnered with the region’s matwòn to provide home visits by a trained birth attendance to make sure mother and baby have no complications.

Haiti has the highest maternal mortality rate in the Western Hemisphere, at 359 maternal deaths per 100,000 live births, an increasing trend. The country made a commitment to reduce the number of maternal deaths per
100,000 live births to 70.

But despite a small amount of progress, it has been unable to live up to its promises of reducing maternal mortality by 75 percent in 2015, according to the Millennium Development Goal.

Hence the desire to identify and act on the major causes of this high mortality rate.

Pregnancy is not an illness, so it is almost inconceivable that a woman will die giving birth. Health professionals in Haiti have a certain mastery in the care of pregnant women capable of guaranteeing, in the vast majority of cases, a delivery without risk to mother and child. Where the shoe pinches is that 63 percent of Haitian women give birth at home. To solve this problem, a study carried out at the University Hospital of Mirebalais proposes to identify the barriers and the facilitators that explain, on the one hand, the
refusal to give birth in one of the best hospitals in Haiti, and on the other hand, the factors that encourage the choice to give birth at home.

The work of matwòn: a strong argument in the choice to give birth at home

Local matwòn gather at Hispanola Health Partners for a six-week training session in safe birth practices delivered by HHP’s skilled birth attendant Ruth Lafleur. The matwòn are paid to attend the class, which meets once a week and has fostered a partnership between them and the clinic’s medical staff.

In an article published in 2020 by the scientific journal “BMJ Global Health,” women gave their top five reasons for home childbirth. “Women appreciate the comfort and care provided by birth attendants at home,” reveals this retrospective study, conducted between May and December 2017. “Participants’ descriptions suggest that matwòn take on a companion role (i.e., a trusted companion who supports a person on their journey), providing both physical and emotional support to women during childbirth at home.”

In general, matwòn are members of the family. As one study participant put it, “Women are more comfortable at home because they know and are used to people who touch their stomachs and give them massages. This familiar atmosphere is more than support for women.”

… In addition, the matwòn know the culture and traditional practices in Haiti. According to the participants, the choice to give birth at home is linked to the fact that traditional midwives provide a holistic practice outside the realm of standard obstetrics.

Ronnie, a matwòn whose knowledge was passed on by an elder, has been assisting the home births of Haitian women in the remote Southeast region since the 1960s.

“In some cases, it involves brewing teas to give women who are in labor a boost,” say the women who took part in this study. “The matwòn boils orange leaves, after which she mixes different types of leaves, then she puts a leaf called fobazin in it, boils it and gives it to the pregnant woman to drink. If you lack strength during labor, tea will help you,”

A traditional, self-taught birth attendant or matwòn gathers lemon grass in the hills above Marre-Joffrey, Haiti to make tea for his pregnant clients. The matwòn, who locals call Ronnie, has been doing this work since the 1960s.

Women also referred to the prayers and rituals associated with childbirth. “One of these rituals involves the care of the placenta after birth. The matwòn digs a hole and buries the umbilical cord. Afterwards, she gives you a hot bath with papaya leaves and some ginger tea to drink. Sometimes the matwòn makes a hole in front of the bed and puts the placenta in it. Sometimes she burns the rest of the baby’s umbilical cord after having tied it up and says prayers,” said a woman who had many experiences with matwòn.

Lack of respect for hospital staff

The women interviewed for this study reported feeling mistreated by hospital staff during labor and delivery. They condemned the fact that the staff do not tolerate noise or screaming during childbirth. The staff even make jokes about the suffering of the sick, the women said. …

Some staff members even spank women who refuse to follow directions during labor. The experience is traumatic, perhaps explaining why some women refuse to return to the hospital after a first experience.

Ruth Lafleur, a registered nurse and skilled birth attendant at Hispañola Health Partners in Southeast Haiti, shows a young mother who has just given birth at home how to breastfeed her newborn child. Because women in labor in this mountainous region can’t access the services of a hospital and prefer to give birth at home with a matwòn. Lafleur provides training for the self-taught matwòn and visits their clients at home to make sure mother and child are in good health. She says she decided to train to be a skilled birth attendant after witnessing the cruel treatment of laboring women by nurses in a hospital where she was working.

One woman in the study went so far as to contrast the intimacy of home births with her experience in the hospital, noting that the staff made fun of her pain and ridiculed her.

“When I give birth at home, nobody sees me, whereas in the hospital people laugh at you. The house is better (laughs!).”

Other women said they were judged by staff because of their physical appearance. They reported that nurses pay attention to women’s clothes and make fun of them because they look poor. “Nurses are generally disrespectful of the poorest, humiliating them for not wearing clean clothes. Some women do not have enough financial means. Others are afraid because of the shame and humiliation of the caregivers.”

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Ruth Lafleur, a trained birth attendant (top photo) and Ronnie, a traditional matwon or midwife, (bottom), raverse the rugged terrain of Southeasht Haiti making follow-up visits to women who haven birth at home. Lafleur, an employee of Hispanola Health Partners based in nearby Mare-Joffrey, has partnered with Ronnie and other local matwon to train them in safe birth delivery practices and check in with their clients to make sure mother and child are doing well.

Other factors raised by the study participants included the problem of infrastructure; distance and geographic access; the hidden costs associated with a hospital birth, including preparing for the arrival of a newborn; and the lack of space and beds at the hospital.

Despite these difficulties, 70 percent of the women consulted at the University Hospital of Mirebalais antenatal clinic as part of this study chose to give birth there because of the complications that can arise from a home birth. Hospitals need to increase their reception capacity, standardize care, and improve the conditions raised by the women as being obstacles to childbirth in a hospital environment.

Regarding matwòn, the researchers believe “They could be an important bridge between biomedical and socio-cultural approaches to care, encouraging women to adopt evidence-based practices before and after birth.”

A traditional matwòn or midwife, Ronnie, walks arm in arm with Ruth Lafleur, a trained birth attendant employed by Hispañola Health Partners, after visiting a mother and her newborn in the mountains of rural Southeast Haiti.

This can help women overcome a dilemma of choosing between receiving physical and emotional support from birth attendants during home births or receiving modern obstetric care in facilities equipped to treat possible complications during childbirth.

The study concludes that collaboration between the matwòn and trained midwives at the facility level can improve the use of health facilities by women.

The study concludes that collaboration between the matwòn and trained midwives at the facility level can improve the use of health facilities by women.

In the rural Southeast, Hispañola Health Partners has concluded that collaboration between the matwòn and professional staff at a local health care facility can improve healthy outcomes for both mother and baby even when the birth is at home.

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Researchers Maxi Raymondville, Carly A. Rodriguez, Aaron Richterman, Gregory Jérôme, Arlene Katz, Hannah Gilbert, Gregory Anderson, Jean-Paul Joseph, Molly F. Franke and Louise C. Ivers took part in this study, which was published in August 2020.