Haiti has the highest maternal mortality rate in the Americas. Where female sexuality is taboo and abortions illegal, it all happens clandestinely, and in the worst possible health conditions.
PORT-AU-PRINCE — She came alone this morning at the crack of dawn. She winces in pain when she sits, after Dr. Jean-Edouard Viala, chief of the obstetrics department in Haiti's state university hospital, welcomes her in his office.
The doctor takes her hand, calls her "chérie," and speaks in Creole. Sandrine is 25 years old but has the voice of a frightened little girl. She's in shock. She doesn't know that upon her arrival she was categorized as an "IIA," for "interrupted induced abortion."
Dr. Viala is used to it by now.
In a given week, he typically sees 20 young women just like Sandrine. Though one in four have suffered from spontaneous recurrent miscarriages, most of them come after having an illegal abortion. Too often, they are forced upon the women, which is precisely what has happened to Sandrine.
She recounts her story in a whisper, tears rolling down her cheeks. She had been unemployed and had been in a relationship for a year with a 60-year-old man, probably married, who was financially supporting her family. When she realized she was pregnant, she was happy. One day, though, she felt feverish and the old man took her to the doctor's office. There, she was told the baby was not healthy, and she was sent to see another physician. This "colleague" injected something into her body, so that "the baby could feel better," and she passed out right away.
Hours later — she doesn't know how many — she woke up bathed in her own blood, and with her feet up in the stirrups. All she knows is that her lover is gone, and her baby too. Her file says she has iron deficiency, suffers from deep vein thrombosis and from a serious infection that needs medical attention.
A few days later, Sandrine is sitting in the obstetrics department common room, eating some sort of gruel her aunt brought her. The hospital doesn't have the financial means to feed its own patients. She's wearing a long loose T-shirt through which the IV stuck in her arm is visible. She's looking at other women around her, all with their newborn babies. Sandrine looks away through the window.
The previous day, Dr. Viala received a mother and her 14-year-old daughter. The girl did not understand why she wasn't having her period anymore. He performed an ultrasound and let her listen to her baby's beating heart. The teenage girl was 20 weeks pregnant. When he asked who the father was, she said, "The father of what?"
An estimated one in seven women in the world has an abortion during her lifetime. In Haiti, abortion is strictly illegal under article No. 262 of the criminal code, an article passed in 1835! It specifies that abortion is punished with a lifetime jail sentence for the patient as well as for anyone (intermediaries, doctors, pharmacists) who helps abortion patients. In reality, that law is never enforced. From time to time, legal proceedings are launched, but most of them are dismissed.
Dr. Vladimir Larsen, president of the Haitian association for gynecology and obstetrics, is fed up with this hypocrisy. Haiti has the highest maternal mortality rate in the Western Hemisphere, with 530 maternal deaths per 100,000 children born, at least a fifth of them linked to abortions. Early pregnancies often happen one year after the first periods, as young as 12 or 13 years old.
Like other doctors and nurses whose job is to take care of the sick and suffering, Dr. Larsen fights every day against religious bigotry, evasion and male chauvinism — all in a country where extreme poverty doesn't leave much room for progress.
"Having this many maternal deaths is not something we can tolerate," he says. "The same goes for all the sexual assaults that are too frequently the cause of unwanted pregnancies. "We find ourselves in front of young girls or young women who are often badly distressed emotionally — and, when having gone through illegal abortions, are often physically in poor shape. This cannot go on anymore. We can't keep silent. We have to end this cruelty."
Around the Port-au-Prince hospital, dozens of white-and-green pop-up drugstores await customers. You go up a few steps and find yourself facing a barred counter from which there is no way of seeing the face of the man in front of you. Behind him, the dispensary looks dark. He can be suspicious and even aggressive when someone asks him if he has any Cytotec. This drug, produced by the pharmaceutical lab Pfizer, is the more common name for the Misoprostol drug, designed to treat ulcers.
But, in Haiti, as in many other countries where abortions are illegal, Cytotec is often used to terminate a pregnancy. On the Internet, many false prevention campaigns feature the drug as a way to help young women in distress. If the pharmacist is obliging, he will sell one pill of Cycotec for between 50 and 100 Haitian gourdes (around $2). Depending on the prescription, a patient must take between eight to 12 pills, a costly "cure" in a country where the median income is around $2.50 a day.
Rogue pharmacists will then send the patient to take the back alley that runs along the building, where there are chickens and stray dogs, until they reach a hidden door. There, in an air-conditioned room, people in nurse-looking outfits are waiting. They tell the patient the appropriate dosage of the drug and suggest they return for a $100 to $120 curettage in the illegal clinic. Any sudden movement causes panic, and jittery patients will be asked to promptly leave the clinic.
Cytotec is applied both vaginally and orally, with Toro (energy drink), or with wine, beer or pineapple juice. Every doctor has seen the consequences of these cocktails: a destroyed uterus, perforations, significant bleeding and, sometimes, even infertility.
Despite these risks, street vendors still sell this drug without ever being investigated. Sometimes, everything "works out."
A secret with God
Questions about abortions have multiplied, particularly regarding the use of Cytotec. Dr. Myrna Eustache, head of the POZ association, an NGO working with AIDS patients, talks about one of her patients, Emily. She is unemployed and divorced, a mother of two girls aged 20 and 18.
Emily herself is 38, and when she found out that she was pregnant again, with a new boyfriend, she feared he would beat her. So one morning, without having eaten anything, she swallowed two tablets of Cytotec, and at night, put another two into her vagina. Three hours later, she was bleeding. Her OB told her the "egg had gone away." Emily then went to church and asked for forgiveness. "It was my secret with God," she says. "Now I know he's forgiven me and everything is fine."
Dr. Eustache says Emily got lucky. "Most often, I see 13-year-old girls whose abortions were performed by complete quacks," she says. "That is a crime. Abortion shouldn't be a taboo in Haiti anymore."
According to the sociologist and women's right activist Danièle Magloire, who has long been fighting violence against women, abortion and birth control are among the central paradoxes of Haitian life. "You have to take into account social background and tradition of a patriarchal society," she says. "When you have the financial means, then you can have an abortion, and no one will ever find out."
An IUD can be purchased abroad and inserted for more than $300 in a secret practice. Hospitals can also insert IUDs previously purchased, for a lower price, though people may find out. Indeed, in Haïti, female sexuality itself is still taboo. "Below the waist, a woman's body belongs to her husband," locals are fond of saying.
A variety of relationship statuses exist in the country, marriage not being very popular. Magloire says one of them is called the "placage," or common-law marriage not formally registered with the state but widely accepted by society. Another is the "viv avek," or living together, which doesn't require permanent cohabitation.
"In reality, Haitian women live according to serial monogamy principles while men are openly polygamous," Magloire explains.
A high number of abortions is easy to understand in a country where women rarely use contraception, except when men ask them to (only 36% of Haitian women use birth control compared to 68% and 95% for Dominican and Colombian women). Religious and obscure beliefs prevent society from widely embracing the use of birth control.
What about condoms? Again, people in the country spread the idea that condoms were the cause of HIV. And priests claim they even promote sex. Meanwhile, birth control pills are regarded as a vile sin by many members of the religious community, according to which, only God can decide upon the number of children a woman can bear.
"To many young people, abortion has become a method of birth control," Magloire says.
The sociologist also says that women in Haiti don't have control over their own sexuality: "Men take control over everything, whether it's birth control, pregnancy, or even sexual intercourse. Women don't have the right to say "No," and face financial blackmail," she explains. "Men refuse to lose control of their partner's sexual activity."
So, women have to look out for themselves — as they have done since slavery, when women didn't want to bring future slaves into this world. Outside of the city, people don't always have access to medical facilities, and they use traditional medicine to avoid giving birth to "a fatherless baby." Everything is done based on beverages with banana tree roots, logwood bark, lemongrass leaves.
After the apocalypse
Jan. 12, 2010, 4:53 pm. Haïti barely survived the apocalypse. The earthquake left more than 200,000 dead and 300,000 injured. Around 1.5 million people were left homeless. About 40% of the population of Port-au-Prince wound up in camp sites. A few months later, a cholera epidemic hit the country, infecting some 700,000 and killing 8,000.
In this country of 10 million, many international and humanitarian organizations come to help. In temporary camp sites, the lack of privacy is startling. Children, teenagers — orphans sometimes — are left unattended. To feed their family, women, widows, depend on the good will of the men handing out food aid.
Some have reported that this situation has caused a rise in sexual assaults. Doctors certainly see too many young pregnant girls coming their way.
Four years have passed since the earthquake, and even now, 150,000 people are still living in camp sites. In the maternity ward of Isaïe-Jeanty, in Port-au-Prince, facility heady Raymond Fleurimont recounts that a 19-year-old girl, who had just given birth, simply got up and walked out of the building a few days ago, leaving her newborn baby behind on the delivery table.